Triaging in a Major Disaster: Haiti Earthquake Case Study

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Haiti Earthquake

On January 12, 2012, the country of Haiti was hit by a catastrophic 7.0 magnitude earthquake that changed the lives of people living across the nation. The earthquake struck inland before 5pm and was approximately 25 kilometres west of Haiti’s capital Port-au-Prince1. It was estimated that as many as 3 million people had been affected by the earthquake2. The estimated death toll was over 220,000 and many more significantly injured at the time2. The widespread destruction and damage throughout Port-au-Prince and elsewhere severely damaged or destroyed vital infrastructure including hospitals, communication systems and air, sea, and land transportation facilities3. Many countries responded to this massive disaster by dispatching rescue and medical personnel, and supplies. In the aftermath of the devastating Haitian earthquake, medical teams had stumbled upon difficult ethical decisions due to the medical needs far exceeding the accessible resources. The medical providers in this situation speculated when and how they should limit treatment for existing patients currently under their care, or reserve resources for new casualties who were additionally in need of medical care4. Thus triage systems needs to be readily available and prepared for all types of major disasters and incidents.

Overview

Haiti is the third largest Caribbean nation with 27,750 square kilometres of land5. Haiti’s population during 2010 was 9,896, 000 with just under a million of whom live in the capital city, Port-au-Prince5. Prior to the earthquake Haiti World Health Organization estimated that only 43% of the target population acquired the recommended immunisations and disease was very common, along with extreme poverty, political unrest, violence and weak infrastructure5. Additionally, it is the poorest country in the Western world. When it comes to poverty and health in the country, the earthquake has Haiti left in a poorer and desperate economic condition than before.

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World Health Organisation defines disaster as a “serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources.”6 In Haiti, the strong and destructive 7.0 magnitude earthquake shocked the region and its people. The U.S Geology Survey reported with as many as 59 aftershocks with a magnitude of 4.5 or greater from the period of 12th January 2010 to 23rd February 20101. The Haiti earthquake occurred at a fault that runs right through the boundary region separating the Caribbean plate and the North America plate1. These plates are enormous rocky chunks that cover the planet and fit one another like a gigantic jigsaw puzzle. The movement (the slipping along the two plates) is vigorous and there is friction between the North American Plate and the Caribbean Plate. Pressure then is built up amongst the two plates until it is set loose as an earthquake. The earthquake occurred at shallow depth thus meaning the seismic waves have to travel a minor distance through the earth crust to reach the surface so maintain more of their energy1. The overall annihilation of infrastructures caused numerous people in Haiti to sleep outdoors on mattresses, in their cars, because their homes had been demolished, or they feared standing structures would not endure aftershocks3. Although buildings and homes were ruined, the numbers of injuries and deaths were rising.

Acute medical emergencies

The International Federation of Red Cross and Red Crescent predictable as many as 3 million people had been affected by the earthquake and thus the appeal for humanitarian aid7. Rescue efforts began in the immediate aftermath of the earthquake, Haitians took recover efforts into their own hands with able-bodied survivors extracting the living and the dead from the debris of the countless structures that had collapsed8. Most of the people who survived the earthquake had injuries ranging from “open fractures, established compartment syndromes, spinal fractures with paraplegia, multiple dirty, open wounds, and many closed fractures.”9 The most common injury was primarily major musculoskeletal injuries as well as a large amount of disparagingly wounded patients impending or established sepsis due to neglected wounds. 9 In regards to other injuries it was proven fatal if any patient with head, chest, or abdominal injuries9. Due to the limited resources and poor facilities that remained, medical personnel had to develop and utilised a triage system to prioritise treatment and management as well as to maximize the use of scarce medical supplies.

A problem that that clinicians faced was patients with open wounds and infection10. Several patients had critical infections with obvious dead tissue often requiring amputation, the highest priority for surgical debridement, as well as hours of operation, united with anticoagulation and close continuations check-ups to retain the muscle flap from thrombosis10. Whilst the treatment is essential and lifesaving, the number of patients required amputation led to major problems as disability is poorly accepted in Haiti therefore a number of patients of patients refused the surgery as they were afraid of amputation or departed the hospital despite knowing that the alternative was probably death9, 10. The difficulty in this case was determining how to allocate limited treatment, time and other resources between existing patients and potential patients not yet under care.

Incident triage system

In the result of the overwhelming Haitian earthquake, nations from all over the world sent personnel, medicines, equipment, and other aid to Haiti. In particular, one medical team of 16 members was dispatched to Hospital St. Nicholas, in St. Marc roughly 128 kilometres from Port-Au-Prince. The medical team with the help of local volunteers developed a structured Triage scheme:9

  • A Surgery today to save life
  • B Surgery today to save limb
  • C Surgery as soon as possible for wounds
  • D Surgery when possible for closed fracture
  • E Evacuate when able
  • F Observe

The triage scheme implemented by these medical professionals fairly simple as triage category’s A, B, C and D is self-explanatory with initial urgency being specified to septic patients9. Patients who were category ‘E’ were clinically stable, as well as being adequately perfused and hydrated were hoped to be evacuated when possible9. However, the medical team stated that its first helicopter flight did not happen till 11 days after the earthquake.

The patients who were Category “F” would have remained the utmost priority for care in diverse situations but, in this circumstance, these patients had major complications that were outside the teams capability to treat or whose treatment would be too resource needy9, 11. These individual’s clinical conditions were an ethical dilemma for the medical team as perhaps the most difficult decision in clinical medicine. Although the care of these patients would be considered as being the highest priority in a standard medical setting however, in the disaster scale event, it is too time consuming and will also prevent the team from treating other patients. In order to provide life-saving aid the team established a principle, to maintain hydration, use antibiotics, and provide pain relief, and offer cherishing to those who were triaged not to receive surgical treatment9. This method allows each and every patient to deserve the compassionate and sympathetic care without aggravating the wellbeing of those with a likely to live.

In Haiti, clinical judgment and the restricted obtainable resources determined how triage and treatment may occur and eventually impacted every patient’s chance of survival. At the time improvisation and innovation were crucial when providing care. One study of the triage system adopted during the Haiti earthquake, by emergency response team from Stanford Hospital in a third-world disaster is “done by everyone and anyone able to recognise victims in need of help.”11 It is essential, in disaster triage, providing life-saving aid is the ideal main emphasis as well as focusing exclusively on the individual’s injury and the implementing the method of care. The Stanford team prioritised patients to their own instincts and beliefs in this case patients who needed the most attention at the time. One nurse from the Stanford emergency response team states that it was problematic and different to use and practice the disaster triage principles as they would rarely use it in the United States11. Another factor that arose for medical professions was the lack of documentation and history taking when dealing with vast amounts of patients11. Due to circumstances these patients being faced in a third-world country, knowing that numerous of those who died would have survived or would have an increased chance of survival if they had been accessible.

Current international major incident triagesystems

The definition of triage is ‘to sort or sieve’12. In medicine, it is the process of organising patients in the categories of priority for treatment and evacuation. Although there are different forms that triage may operate at, overall the main purpose is to provide the right patient with the right care at the right time and place.

The triage tool which originated in the UK, Major Incident Medical Management and Support System (MIMMS), utilises the ‘sieve and sort’ of several physiological parameters to identify the priorities for treatment12. This triage system uses colour coding scheme to easily determine the different expectant category. The triage priorities and levels are separated into four different colours: Red (Immediate – Life threatening), Yellow (Not Immediate – Required medical intervention within 2-4 hours), Green (Minor Injuries – Not life threatening) and Blue (Deceased or limited resources to save patient)12. When it comes to sorting the priority of a patient, further information must be obtained by recording Glasgow Coma Score (GCS), Respiratory Rate and Systolic blood pressure12. This information provides an accurate and assists with documentation of patients records. When implanted into a disaster situation, this triage would be reliable as well as fast, structured and easy to use.

Recommendations for the country’s incident triage system

Haiti being one of the worlds the poorest country in the Western world may not have the readily available resources in disaster conditions. Although, method of allocating scarce resources was not reasonable, the country should have implemented the MIMMS triage tool throughout their disaster plan. The triage tool is fast, easy and reliable which provides maximal treatment to prioritised patients. As strategic disaster response become more regular, it is likely the study of disaster response would increase thus providing perceptions into disaster epidemiology that may guide response patterns in these circumstances.

Conclusion

Due to minimal resources triaging patients in Haiti was no simple task. The earthquakes devastated the lives of many and prompt that triaging in a major disaster needs to be improved to a standard. As triage remains at large the most vital tool for medical team’s disposal when dealing with major incidents and/or disasters.

References

1.USGS USGS. Magnitude 7.0 – HAITI REGION. 2013 [cited 2014 2 October]; Available from: http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#details.

2.O’Connor MR. Two Years Later, Haitian Earthquake Death Toll in Dispute. Columbia Journalism Review. 2012.

3.ROMERO S, LACEY M. Fierce Quake Devastates Haitian Capital The New York Times. 2010.

4.Hoppes E. In the Wake of Tragedy: Medical Ethics and the Haiti Earthquake. Wake Forest University Center for Bioethics, Health & Society, Documentary Film Program, 2011.

5.Division LoC-FR. COUNTRY PROFILE: HAITI. 2006.

6.WHO WHO. Definitions: emergencies. 2008.

7.Inc. CI. Red Cross: 3M Haitians Affected by Quake. 2010 [cited 2014 4 October]; Available from: http://www.cbsnews.com/news/red-cross-3m-haitians-affected-by-quake/.

8.Cooper A, CNN. Haitians dig themselves out as quake damage slows outside aid. 2010 [cited 2014 4 October]; Available from: http://edition.cnn.com/2010/WORLD/americas/01/14/haiti.earthquake/index.html.

9.Smith RM, Dyer GSM, Antonangeli K, Arredondo N, Bedlion H, Dalal A, et al. Disaster triage after the Haitian earthquake. Injury. 2012;43(11):1811-5.

10.Eyal N, Firth P. Repeat triage in disaster relief: questions from haiti. PLoS currents. 2012;4:e4fbbdec6279ec. Epub 2012/11/13.

11.Camacho-McAdoo G. Triage following a Natural Disaster: A Haitian Experience. Journal of Emergency Nursing.36(4):385-7.

12.Smith W. Triage in mass casualty situations. Western Cape Department of Health and Division of Emergency Medicine, University of Cape Town and Stellenbosch University, 2012.

Haiti Earthquake

On January 12, 2012, the country of Haiti was hit by a catastrophic 7.0 magnitude earthquake that changed the lives of people living across the nation. The earthquake struck inland before 5pm and was approximately 25 kilometres west of Haiti’s capital Port-au-Prince1. It was estimated that as many as 3 million people had been affected by the earthquake2. The estimated death toll was over 220,000 and many more significantly injured at the time2. The widespread destruction and damage throughout Port-au-Prince and elsewhere severely damaged or destroyed vital infrastructure including hospitals, communication systems and air, sea, and land transportation facilities3. Many countries responded to this massive disaster by dispatching rescue and medical personnel, and supplies. In the aftermath of the devastating Haitian earthquake, medical teams had stumbled upon difficult ethical decisions due to the medical needs far exceeding the accessible resources. The medical providers in this situation speculated when and how they should limit treatment for existing patients currently under their care, or reserve resources for new casualties who were additionally in need of medical care4. Thus triage systems needs to be readily available and prepared for all types of major disasters and incidents.

Overview

Haiti is the third largest Caribbean nation with 27,750 square kilometres of land5. Haiti’s population during 2010 was 9,896, 000 with just under a million of whom live in the capital city, Port-au-Prince5. Prior to the earthquake Haiti World Health Organization estimated that only 43% of the target population acquired the recommended immunisations and disease was very common, along with extreme poverty, political unrest, violence and weak infrastructure5. Additionally, it is the poorest country in the Western world. When it comes to poverty and health in the country, the earthquake has Haiti left in a poorer and desperate economic condition than before.

World Health Organisation defines disaster as a “serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources.”6 In Haiti, the strong and destructive 7.0 magnitude earthquake shocked the region and its people. The U.S Geology Survey reported with as many as 59 aftershocks with a magnitude of 4.5 or greater from the period of 12th January 2010 to 23rd February 20101. The Haiti earthquake occurred at a fault that runs right through the boundary region separating the Caribbean plate and the North America plate1. These plates are enormous rocky chunks that cover the planet and fit one another like a gigantic jigsaw puzzle. The movement (the slipping along the two plates) is vigorous and there is friction between the North American Plate and the Caribbean Plate. Pressure then is built up amongst the two plates until it is set loose as an earthquake. The earthquake occurred at shallow depth thus meaning the seismic waves have to travel a minor distance through the earth crust to reach the surface so maintain more of their energy1. The overall annihilation of infrastructures caused numerous people in Haiti to sleep outdoors on mattresses, in their cars, because their homes had been demolished, or they feared standing structures would not endure aftershocks3. Although buildings and homes were ruined, the numbers of injuries and deaths were rising.

Acute medical emergencies

The International Federation of Red Cross and Red Crescent predictable as many as 3 million people had been affected by the earthquake and thus the appeal for humanitarian aid7. Rescue efforts began in the immediate aftermath of the earthquake, Haitians took recover efforts into their own hands with able-bodied survivors extracting the living and the dead from the debris of the countless structures that had collapsed8. Most of the people who survived the earthquake had injuries ranging from “open fractures, established compartment syndromes, spinal fractures with paraplegia, multiple dirty, open wounds, and many closed fractures.”9 The most common injury was primarily major musculoskeletal injuries as well as a large amount of disparagingly wounded patients impending or established sepsis due to neglected wounds. 9 In regards to other injuries it was proven fatal if any patient with head, chest, or abdominal injuries9. Due to the limited resources and poor facilities that remained, medical personnel had to develop and utilised a triage system to prioritise treatment and management as well as to maximize the use of scarce medical supplies.

A problem that that clinicians faced was patients with open wounds and infection10. Several patients had critical infections with obvious dead tissue often requiring amputation, the highest priority for surgical debridement, as well as hours of operation, united with anticoagulation and close continuations check-ups to retain the muscle flap from thrombosis10. Whilst the treatment is essential and lifesaving, the number of patients required amputation led to major problems as disability is poorly accepted in Haiti therefore a number of patients of patients refused the surgery as they were afraid of amputation or departed the hospital despite knowing that the alternative was probably death9, 10. The difficulty in this case was determining how to allocate limited treatment, time and other resources between existing patients and potential patients not yet under care.

Incident triage system

In the result of the overwhelming Haitian earthquake, nations from all over the world sent personnel, medicines, equipment, and other aid to Haiti. In particular, one medical team of 16 members was dispatched to Hospital St. Nicholas, in St. Marc roughly 128 kilometres from Port-Au-Prince. The medical team with the help of local volunteers developed a structured Triage scheme:9

  • A Surgery today to save life
  • B Surgery today to save limb
  • C Surgery as soon as possible for wounds
  • D Surgery when possible for closed fracture
  • E Evacuate when able
  • F Observe

The triage scheme implemented by these medical professionals fairly simple as triage category’s A, B, C and D is self-explanatory with initial urgency being specified to septic patients9. Patients who were category ‘E’ were clinically stable, as well as being adequately perfused and hydrated were hoped to be evacuated when possible9. However, the medical team stated that its first helicopter flight did not happen till 11 days after the earthquake.

The patients who were Category “F” would have remained the utmost priority for care in diverse situations but, in this circumstance, these patients had major complications that were outside the teams capability to treat or whose treatment would be too resource needy9, 11. These individual’s clinical conditions were an ethical dilemma for the medical team as perhaps the most difficult decision in clinical medicine. Although the care of these patients would be considered as being the highest priority in a standard medical setting however, in the disaster scale event, it is too time consuming and will also prevent the team from treating other patients. In order to provide life-saving aid the team established a principle, to maintain hydration, use antibiotics, and provide pain relief, and offer cherishing to those who were triaged not to receive surgical treatment9. This method allows each and every patient to deserve the compassionate and sympathetic care without aggravating the wellbeing of those with a likely to live.

In Haiti, clinical judgment and the restricted obtainable resources determined how triage and treatment may occur and eventually impacted every patient’s chance of survival. At the time improvisation and innovation were crucial when providing care. One study of the triage system adopted during the Haiti earthquake, by emergency response team from Stanford Hospital in a third-world disaster is “done by everyone and anyone able to recognise victims in need of help.”11 It is essential, in disaster triage, providing life-saving aid is the ideal main emphasis as well as focusing exclusively on the individual’s injury and the implementing the method of care. The Stanford team prioritised patients to their own instincts and beliefs in this case patients who needed the most attention at the time. One nurse from the Stanford emergency response team states that it was problematic and different to use and practice the disaster triage principles as they would rarely use it in the United States11. Another factor that arose for medical professions was the lack of documentation and history taking when dealing with vast amounts of patients11. Due to circumstances these patients being faced in a third-world country, knowing that numerous of those who died would have survived or would have an increased chance of survival if they had been accessible.

Current international major incident triagesystems

The definition of triage is ‘to sort or sieve’12. In medicine, it is the process of organising patients in the categories of priority for treatment and evacuation. Although there are different forms that triage may operate at, overall the main purpose is to provide the right patient with the right care at the right time and place.

The triage tool which originated in the UK, Major Incident Medical Management and Support System (MIMMS), utilises the ‘sieve and sort’ of several physiological parameters to identify the priorities for treatment12. This triage system uses colour coding scheme to easily determine the different expectant category. The triage priorities and levels are separated into four different colours: Red (Immediate – Life threatening), Yellow (Not Immediate – Required medical intervention within 2-4 hours), Green (Minor Injuries – Not life threatening) and Blue (Deceased or limited resources to save patient)12. When it comes to sorting the priority of a patient, further information must be obtained by recording Glasgow Coma Score (GCS), Respiratory Rate and Systolic blood pressure12. This information provides an accurate and assists with documentation of patients records. When implanted into a disaster situation, this triage would be reliable as well as fast, structured and easy to use.

Recommendations for the country’s incident triage system

Haiti being one of the worlds the poorest country in the Western world may not have the readily available resources in disaster conditions. Although, method of allocating scarce resources was not reasonable, the country should have implemented the MIMMS triage tool throughout their disaster plan. The triage tool is fast, easy and reliable which provides maximal treatment to prioritised patients. As strategic disaster response become more regular, it is likely the study of disaster response would increase thus providing perceptions into disaster epidemiology that may guide response patterns in these circumstances.

Conclusion

Due to minimal resources triaging patients in Haiti was no simple task. The earthquakes devastated the lives of many and prompt that triaging in a major disaster needs to be improved to a standard. As triage remains at large the most vital tool for medical team’s disposal when dealing with major incidents and/or disasters.

References

1.USGS USGS. Magnitude 7.0 – HAITI REGION. 2013 [cited 2014 2 October]; Available from: http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010rja6/#details.

2.O’Connor MR. Two Years Later, Haitian Earthquake Death Toll in Dispute. Columbia Journalism Review. 2012.

3.ROMERO S, LACEY M. Fierce Quake Devastates Haitian Capital The New York Times. 2010.

4.Hoppes E. In the Wake of Tragedy: Medical Ethics and the Haiti Earthquake. Wake Forest University Center for Bioethics, Health & Society, Documentary Film Program, 2011.

5.Division LoC-FR. COUNTRY PROFILE: HAITI. 2006.

6.WHO WHO. Definitions: emergencies. 2008.

7.Inc. CI. Red Cross: 3M Haitians Affected by Quake. 2010 [cited 2014 4 October]; Available from: http://www.cbsnews.com/news/red-cross-3m-haitians-affected-by-quake/.

8.Cooper A, CNN. Haitians dig themselves out as quake damage slows outside aid. 2010 [cited 2014 4 October]; Available from: http://edition.cnn.com/2010/WORLD/americas/01/14/haiti.earthquake/index.html.

9.Smith RM, Dyer GSM, Antonangeli K, Arredondo N, Bedlion H, Dalal A, et al. Disaster triage after the Haitian earthquake. Injury. 2012;43(11):1811-5.

10.Eyal N, Firth P. Repeat triage in disaster relief: questions from haiti. PLoS currents. 2012;4:e4fbbdec6279ec. Epub 2012/11/13.

11.Camacho-McAdoo G. Triage following a Natural Disaster: A Haitian Experience. Journal of Emergency Nursing.36(4):385-7.

12.Smith W. Triage in mass casualty situations. Western Cape Department of Health and Division of Emergency Medicine, University of Cape Town and Stellenbosch University, 2012.

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