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Post-Earthquake Injuries Treated at a Field Hospital --- Haiti, 2010

On January 12, 2010, a 7.0-magnitude earthquake struck Haiti, resulting in an estimated 222,570 deaths and 300,000 persons with injuries. The University of Miami Global Institute/Project Medishare (UMGI/PM) established the first field hospital in Port-au-Prince, Haiti, after the earthquake (1). To characterize injuries and surgical procedures performed by UMGI/PM and assess specialized medical, surgical, and rehabilitation needs, UMGI/PM and CDC conducted a retrospective medical record review of all available inpatient records for the period January 13--May 28, 2010. This report describes the results of that review, which indicated that, during the study period (when a total of 1,369 admissions occurred), injury-related diagnoses were recorded for 581 (42%) admitted patients, of whom 346 (60%) required a surgical procedure. The most common injury diagnoses were fractures/dislocations, wound infections, and head, face, and brain injuries. The most common injury-related surgical procedures were wound debridement/skin grafting, treatment for orthopedic trauma, and surgical amputation. Among patient records with documented injury-related mechanisms, 162 (28%) indicated earthquake-related injuries. Earthquake preparedness planning for densely populated areas in resource-limited settings such as Haiti should account for injury-related medical, surgical, and rehabilitation needs that must be met immediately after the event and during the recovery phase, when altered physical and social environments can contribute to a continued elevated need for inpatient management of injuries.

The UMGI/PM field hospital was established on January 13, 2010. During the first 9 days, the hospital functioned in the United Nations compound in two storage tents capable of holding up to 250 patients. Initially, the facility had approximately 12 volunteer staff members and no critical-care units or organized operating rooms. After 9 days, the hospital moved to a four-tent facility on the grounds of the Port-au-Prince airport, approximately 3.7 miles (6.0 km) from the city center; 17 critical-care beds and three fully organized operating rooms were added. The hospital was staffed by 220 volunteers from the United States and Canada serving rotations of 5--7 days. All supplies were donated directly or bought with privately donated funds, and transported from Miami to Haiti via weekly charter flights. Medical records were established and maintained by the volunteer clinical staff, but few records were kept during January 13--22. A retrospective medical record review and data abstraction of all available field hospital inpatient records from the period January 13--May 28 was conducted at the UMGI/PM headquarters in Miami, Florida. May 28 was the last date for which records were available for abstraction before the field hospital closed and transitioned to a permanent facility.

In June 2010, UMGI/PM and CDC staff members abstracted data from paper-based medical records into an electronic database with the following variables included for analysis: sex; age; dates of injury, admission, and discharge; type and mechanism of injury; all diagnoses (including those not injury-related); surgical procedures; and patient disposition. Dates of injury, admission, and discharge were used to assess changes in injury patterns over time and to calculate length of stay. For 75 patient records in which date of discharge was not recorded, the date of last entry in the medical record was used as a proxy for discharge. Assessing readmissions or calculating injury severity using anatomical scoring systems was not possible because of incomplete documentation. Injury diagnoses were grouped using categories of a modified mass casualty surveillance instrument.* Earthquake-related injuries were defined as diagnoses for which the medical record 1) documented the date of injury as January 12, 2010, 2) recorded in the medical history that the injury was related to the earthquake, or 3) described a mechanism reasonably consistent with an earthquake-caused injury.Injury cases were defined as injuries in patients with any of the following diagnoses: fracture; post-traumatic wound infection (both primary and postsurgical infections); head, face, or brain injury; burn; crush; or other injury. All injury diagnoses for which the medical record did not suggest earthquake-related injury or specify mechanism were defined as "injury other." A patient could have more than one diagnosis or surgical procedure. Patient disposition variables included discharge to a residential setting (e.g., home, tent, or internally displaced persons camp), discharge to another medical facility (including a rehabilitation facility), or death.

From January 13 to May 28, 2010, a total of 581 patients with medical records available were admitted to the field hospital with an injury diagnosis; of these, 162 (28%) had earthquake-related injuries (Table). Among all injured patients, 333 (57%) were male, and median age was 24 years (range: 1 day--96 years). Patients aged 15--24 years accounted for 22% of patients, more than any other 10-year age group. Median length of stay for patients with earthquake-related injuries and patients with other injuries was 13 days (range: 1--87 days) and 6 days (range: 1--83 days), respectively. The majority of earthquake-related injured patients sought care during the first 4 weeks of the response, after which an increase in the proportion of patients with "injury other" was observed (Figure).

The most common injury-related diagnoses were fractures/dislocations, wound infections, and head, face, and brain injuries. The most common surgical procedures were wound debridement/skin grafting, treatment for orthopedic trauma, and surgical amputation. Among patients with earthquake-related injuries, the most common mechanisms recorded were cut/pierce/struck by an object and crush (Table). Approximately three fourths of injured patients were eventually discharged to a residential setting, 12% were transferred to other medical or rehabilitation facilities, and 3% died (Table). During the study period, 788 inpatients had only non--injury-related diagnoses, of which the most common included infectious diseases followed by cardiac/respiratory conditions.

Reported by

G Hotz, PhD, E Ginzburg, MD, G Wurm, MD, V DeGennaro, MD, D Andrews, MD, Miller School of Medicine, Univ of Miami, Florida. S Basavaraju, MD, V Coronado, MD, L Xu, MD, T Dulski, MPH, Div of Injury Response, National Center for Injury Prevention and Control; D Moffett, PhD, J Tappero, MD, Health Systems Reconstruction Office, Center for Global Health; M Selent, DVM, EIS Officer, CDC.

Editorial Note

Earthquakes in resource-limited geographic areas can result in substantial morbidity and mortality because of inadequate engineering, building construction, transportation infrastructure, and search and rescue capabilities (2). These factors were magnified in the Haiti earthquake because of limited economic resources, the earthquake's magnitude and epicenter's proximity to Port-au-Prince, and destruction of much of the already limited health-care infrastructure (3). The World Health Organization (WHO) and Pan American Health Organization (PAHO) have formulated guidelines for the use of foreign field hospitals after sudden-impact disasters and divide the response into three phases: 1) early emergency medical care (the first 48 hours); 2) from day 3 to day 15; and 3) the last phase, which might continue for ≥2 years (4). UMGI/PM's field hospital functioned in all three phases.

Two observations related to the patterns and proportions of injuries in this report might be relevant to future sustained responses through reconstruction phases. First, the UMGI/PM field hospital experienced an initial surge of patients, consistent with previous events (5--6). However, the hospital also experienced a sustained number of earthquake-related and other injuries during phases 2 and 3. In addition to readmissions (e.g., because of wound infections), an explanation for the sustained number of earthquake-related injuries several weeks after the earthquake might be delayed access to health-care and transfers of patients with earthquake-related injuries from other hospitals. Many other injuries during phases 2 and 3 might have been earthquake-related but not direct results of earthquake-related shaking on January 12. Examples include motor vehicle--related or violence-related injuries attributed to damaged roads or prisoner escapes from damaged prisons (7). Second, earthquake-related injuries in resource-limited areas, especially extremity fractures and dermatologic injuries, can require orthopedic and plastic surgical interventions requiring highly skilled medical staff. The severe orthopedic injuries, amputations, and skin-related surgeries can require long-term rehabilitation services, including prostheses. Given the inability of the health-care infrastructure to provide services, rehabilitation activities might be undertaken by field hospitals, resulting in prolonged patient stays, which can place strains on facilities.

The findings in this report are subject to at least three limitations. First, as reported in previous earthquakes, characterization of earthquake and non--earthquake-related injuries relied on incomplete and often inadequate documentation (8). Thus, some actual earthquake-related injuries might have been misclassified as "injury other." Second, incomplete record keeping during the first 7--10 days of the field hospital operations might have resulted in an underestimate of total earthquake-related injuries and deaths reported. Finally, this hospital rapidly evolved into a tertiary referral center, to which numerous patients with complex injuries and medical conditions were referred. Thus, the findings in this report might not be generalized to other hospitals operating in Haiti after the earthquake but likely represent conditions requiring more specialized care.

To enhance health-care delivery, disaster preparedness should include pre-event coordination by organizations planning to prepare for an immediate surge and subsequent sustained number of injuries. Earthquake preparedness planning for densely populated areas in resource-limited settings such as Haiti should account for injury-related medical, surgical, and rehabilitation needs that must be met immediately after the event and during the recovery phase, when altered physical and social environments can contribute to additional and sustained numbers of injuries.

Acknowledgments

This report is based, in part, on contributions by A Trujillo, A Quintero, L Sosa, J Rezendes, and A Gustitus, Miller School of Medicine, Univ of Miami, Florida.

References

  1. Ginzburg E, O'Neill WW, Goldschmidt-Clermont PJ, et al. Rapid medical relief---Project Medishare and the Haitian earthquake. N Engl J Med 2010;362:e31--3.
  2. Gutierrez E, Taucer F, De Groeve T, et al. Analysis of worldwide earthquake mortality using multivariate demographic and seismic data. Am J Epidemiol 2005;161:1151--8.
  3. CDC. Rapid establishment of an internally displaced persons disease surveillance system after an earthquake---Haiti, 2010. MMWR 2010;59:939--45.
  4. Guidelines for the use of foreign field hospitals in the aftermath of sudden-impact disaster. Prehosp Disaster Med 2003;18:278--90.
  5. Macintyre AG, Barbera JA, Smith ER. Surviving collapsed structure entrapment after earthquakes: A "time-to-rescue" analysis. Prehosp Disaster Med 2006;21:4--17.
  6. Roces MC, White ME, Dayrit MM, Durkin ME. Risk factors for injuries due to the 1990 earthquake in Luzon, Philippines. Bull World Health Organ 1992;70:509--14.
  7. Berg L-A. Crime, politics and violence in post-earthquake Haiti. Washington, DC: United States Institute of Peace; 2010. Available at http://www.usip.org/publications/crime-politics-and-violence-in-post-earthquake-haiti. Accessed December 23, 2010.
  8. Bulut M, Fedakar R, Akkose S, et al. Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake. Emerg Med J 2005;7:494--8.

* Available at http://emergency.cdc.gov/masscasualties/bombingform.asp.

Medical history documentation might include, for example, the physician writing "found in rubble." A mechanism reasonably consistent with an earthquake-related cause might include, for example, "injured by wall of bricks falling on patient."


What is already known on this topic?

Moderate and severe earthquakes frequently result in substantial mortality and an initial surge of complex injuries such as fractures, skin injuries, and amputations.

What is added by this report?

This report describes the experience of a field hospital operating for 5 months in a tent facility after a severe earthquake. In addition to an initial surge of patients, this hospital experienced a sustained high number of patients with earthquake-related and non--earthquake-related injuries lasting several months.

What are the implications for public health practice?

Planners and field hospitals engaging in long-term post-earthquake response in resource-limited settings should account for the injury-related medical, surgical, and rehabilitation needs of survivors immediately after the event and during the recovery phase, when altered physical and social environments can contribute to additional and sustained numbers of injuries.


TABLE. Sex, age distribution, length of stay, diagnoses, surgical procedures, injury mechanism, and disposition status of injured inpatients at a field hospital after an earthquake --- Port-au-Prince, Haiti, January 13--May 28, 2010

Characteristic

Earthquake-related injury

Other injury

Total

No. (%)

No. (%)

No. (%)

Total no. of patients with injury diagnoses

162 (27.9)

419 (72.1)

581 (100)

Sex

Male

74 (45.7)

259 (61.8)

333 (57.3)

Female

85 (52.5)

151 (36.0)

236 (40.6)

Unknown

3 (1.9)

9 (2.1)

12 (2.1)

Total

162 (100)

419 (100)

581 (100)

Age group (yrs)

<1

2 (1.2)

21 (5.0)

23 (4.0)

1--5

14 (8.6)

35 (8.4)

49 (8.4)

6--14

30 (18.5)

67 (16.0)

97 (16.7)

15--24

41 (25.3)

88 (21.0)

129 (22.2)

25--34

31 (19.1)

73 (17.4)

104 (17.9)

35--44

16 (9.9)

56 (13.4)

72 (12.4)

45--54

8 (4.9)

36 (8.6)

44 (7.6)

≥55

16 (9.9)

38 (9.1)

54 (9.3)

Unknown

4 (2.5)

5 (1.2)

9 (1.5)

Total

162 (100)

419 (100)

581 (100)

Length of stay (days)

<3

27 (16.7)

156 (37.2)

183 (31.5)

4--7

24 (14.8)

86 (20.5)

110 (18.9)

>7

111 (68.5)

176 (42.0)

287 (49.4)

Unknown

0

1 (<1)

581 (100)

Diagnoses for injured patients*

Fracture/Dislocation

88 (54.3)

139 (33.2)

227 (39.1)

Wound infections/Abscess

60 (37.0)

109 (26.0)

169 (29.1)

Head/Face/Brain injury

15 (9.3)

89 (21.2)

104 (17.9)

Burn

3 (1.9)

37 (8.8)

40 (6.9)

Crush injury

41 (25.3)

9 (2.1)

50 (8.6)

Other

69 (42.6)

158 (37.7)

227 (39.1)

Total

276 ---

541 ---

817 ---

Surgical procedures for injured patients

Plastic/Skin graft/Incision and drainage/Wound debridement

76 (46.9)

147 (35.1)

223 (38.4)

Orthopedic

42 (25.9)

54 (12.9)

96 (16.5)

Amputation

21 (13.0)

24 (5.7)

45 (7.7)

Neurologic and spine

9 (5.6)

13 (3.1)

22 (3.8)

Gastrointestinal

0

12 (2.9)

12 (2.1)

Other

4 (2.5)

11 (2.6)

15 (2.6)

Total

152 ---

261 ---

413 ---

Injury mechanism

Cut/Pierce/Struck

41 (25.3)

17 (4.1)

58 (10.0)

Crushed

34 (21.0)

4 (1.0)

38 (6.5)

Fall

9 (5.6)

21 (5.0)

30 (5.2)

Burn

2 (1.2)

23 (5.5)

25 (4.3)

Vehicle injury

0

106 (25.3)

106 (18.2)

Assault/Violence-related

0

30 (7.2)

30 (5.2)

Other

1 (0.6)

6 (1.4)

7 (1.2)

Unknown

75 (46.3)

212 (50.6)

287 (49.4)

Total

162 (100)

419 (100)

581 (100)

Disposition

Residential setting

132 (81.5)

317 (75.7)

449 (77.3)

Transfer to other medical facilities

18 (11.1)

53 (12.6)

71 (12.2)

Died

0

17 (4.1)

17 (2.9)

Other/Unknown

12 (7.4)

32 (7.6)

44 (7.6)

Total

162 (100)

419 (100)

581 (100)

* A patient might have had more than one diagnosis.

A patient might have had more than one surgical procedure.


FIGURE. Number of patients admitted to a field hospital with earthquake-related injuries and other injuries, by week --- Port-au-Prince, Haiti, January 13--May 28, 2010

The figure shows the number of patients admitted to a field hospital with earthquake-related injuries and other injuries, by week, in Port-au-Prince, Haiti, during January 12-May 28, 2010. The majority of earthquake-related injured patients sought care during the first 4 weeks of the response, after which an increase in the proportion of patients with other injuries was observed.

Alternate Text: The figure above shows the number of patients admitted to a field hospital with earthquake-related injuries and other injuries, by week, in Port-au-Prince, Haiti, during January 12-May 28, 2010. The majority of earthquake-related injured patients sought care during the first 4 weeks of the response, after which an increase in the proportion of patients with other injuries was observed.



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