On the Ground in a Crisis Zone

Family Medicine Training Crucial in Responding to Haiti Disaster, Say FPs

February 01, 2010 03:35 pm Barbara Bein

Mark Crouch, M.D., a first-year resident at the In His Image Family Medicine Residency in Tulsa, Okla., is at the beginning of his family medicine career. Douglas McKeag, M.D., the retired chair of the Indiana University School of Medicine's Department of Family Medicine in Indianapolis, is at a turning point in his long career. Yet, despite these differences, the two share a common heritage and a mutual calling.

Recently returned from separate medical service experiences in earthquake-shattered Haiti, both of these family physicians said their broad-based training -- though gained decades apart -- equipped them well to care for the many injured Haitian people they encountered during their trips.

FPs' Training Well-suited to Caring for Disaster Victims

According to Mitch Duininck, M.D., program director at In His Image, family medicine training is distinguished both by its wide range of knowledge and skills and by its focus on caring for people of every age in the context of their families and communities. In a disaster situation, he told AAFP News Now, family physicians are well able to treat fractures, dislocations, wounds, infections, pain, multisystem problems, and other acute and chronic problems that can encompass medical, surgical and psychological components.

Family physicians also are good at multitasking -- doing triage, supervising personnel and organizing impromptu clinics, said Duininck. They have skills in leadership and in negotiating with patients, families and other care providers, and are sensitive to cultural and spiritual issues.

Family Medicine Residents Hit the Ground Running

Three days after the Jan. 12 earthquake, Crouch and three other In His Image family medicine residents -- Nick Carroll, D.O.; Sujan Joshi, M.D.; and Kwabena Boakye, M.D. -- joined forces with a team from the Rappha Medical Center in St. Joseph, Mich. They flew to the airport near Port-au-Prince, the Haitian capital, and then moved on to a Salvation Army clinic near a soccer stadium around which 10,000 homeless families had set up makeshift tents.

Crouch and his fellow family physicians set to work treating hundreds of patients with broken bones and wounds incurred from falling bricks and debris. They treated acutely injured trauma patients, a number of them with partially severed hands and feet.

After two days, the team started treating more pediatric patients and patients with infectious diseases, including malaria and dysentery. Some patients had respiratory infections from smoke and dust inhalation. Many also had severe stress reactions.

"People would have shortness of breath, anxiety," Crouch told AAFP News Now. "We felt six to 10 aftershocks while we were there."

In fact, the family physicians experienced the 6.0-magnitude quake on Jan. 20 that, according to Crouch, "set our team's hearts aflutter and we started identifying with our patients. We realized what the stress was like for them."

During their five days at the clinic, the team treated between 200 and 300 patients a day -- a total of 1,300 people. Crouch said the training of a family physician is well-suited for disaster medicine.

"It's important to have that experience when you walk into a situation like this," he said. "Having the bulk of our team in family medicine was helpful because we could triage. We treated several women who were pregnant. Because we had family physicians, they could see obstetric patients, pediatrics patients and help people deal with the stress and anxiety of the earthquake."

Still, when walking into a health crisis of such massive scale, said Crouch, it's next to impossible to predict what lies ahead.

"You never know what you're going to see," he said. "We went thinking we'd set broken bones and fill wounds out. But we had a lot of infectious disease, we delivered five babies, and we had one (premature infant) who we treated like a neonate."

A second team of In His Image residents left for Haiti on Jan. 22, and a third team left on Jan. 29.

Long-time Doc Is First-time Disaster Response Recruit

Meanwhile, McKeag -- who teaches in the Indiana University School of Medicine family medicine department, serves as director of the university's Center for Sports Medicine, treats patients and conducts research -- was recruited by his neighbor, a fireman, to join a medical response team.

McKeag agreed enthusiastically and enlisted another family physician, Gaylen Kelton, M.D., former associate chair of the same family medicine department. For McKeag, this was his first personal experience with disaster medicine.

"There's been such an overwhelming response from all sectors," he told AAFP News Now. The media portrayed this as a disaster of gigantic proportions. (Haiti) wasn't that far. I did have the time. This was something I had looked at in the past -- with Hurricane Katrina and the (Pacific Rim) tsunamis -- but I had too many responsibilities."

The family physicians bought their own plane tickets, flew into the Dominican Republic capital of Santo Domingo, and drove west to a United Nations- and International Red Cross-operated camp in the Haitian border town of Jimeni. A U.S. Army helicopter airlifted injured persons from Port-au-Prince to the camp, McKeag said.

McKeag worked all day; Kelton relieved him at night. McKeag said he treated patients with broken bones in every conceivable place in their bodies, as well as a 1-month-old infant with a scalp injury and an 18-month-old boy whose legs had to be amputated. There were many such amputations because of injuries caused by crashing cement.

CDC Has Resources for Treating Haiti Evacuees, Returning Relief Workers

The CDC has developed resources for physicians who will treat Haitian evacuees or returning relief workers in their local communities.

The resources provide information on infectious diseases, such as dengue, diphtheria, hepatitis, malaria and typhoid, that persons arriving from Haiti may present with.

The CDC Web site provides regular updates(www.cdc.gov) about the agency's response to the Haiti earthquake.

"We saw things we had never seen before. There was no X-ray, no radiology, no imaging, so our work was done by sight," McKeag said.

"You have to be on the ground to see this," he added. "I am very proud of being a family doctor. In a disaster you have everything happen. There's no rhythm to it. It changes by the hour. You need someone masterful at triage, someone who is comfortable with the life cycle, from early on until late.

"Even though we didn't deliver any babies, we had pregnant women there. You had to know your infections and diseases. I was comfortable dealing with fractures."

McKeag said his sports medicine experience, specifically in treating concussions, proved particularly useful in caring for Haitian victims who suffered severe head trauma in the quake, he said.

After a long career in patient care, teaching, administration and research, McKeag said his first experience in disaster response changed his thinking, and he would like to see family medicine and its trainees get more involved in global health.

His five days in Haiti were a life-changing experience, McKeag said. "Family medicine needs to be in a situation where (family physicians) can do rapid response. We can do an awful lot -- with our continuity of care and our knowledge base, it's time to reevaluate this discipline as a way to get involved in global health and train our trainees in some kind of response."