Stories from Haiti; The Medical Division: Ronan talks priorities

After two weeks spent treating Haitian earthquake victims aboard a U.S. Navy-owned hospital ship, Dr. Laurence Ronan returned to Boston last Friday. A physician at Massachusetts General Hospital, Dr. Ronan is the director of the Thomas S. Durant, MD, Fellowship in Refugee Medicine program, and is a member of a disaster response team that deploys to catastrophes all over the world. What the Savin Hill resident saw in Haiti last month has topped them all.

This week, as he prepares to return to the Caribbean in a matter of days to help coordinate long-term medical care for thousands of victims, Ronan talked to the Reporter about the scenes he witnessed and the great need for the world to keep its gaze focused on an island nation that has lost some 200,000 people — and counting— to this devastation.

Ronan was deployed aboard the USNS Comfort, a massive non-commissioned ship that is owned by the Navy and crewed by civilians. It can house some 2,000 patients, doctors, and support staff. The floating 1,000-bed hospital

has already reached capacity, Ronan said, and the chief problem that he and other officials are trying to solve is how to rotate patients in and out to keep up with the overwhelming demand for care.

“Who should be in acute care [aboard the Comfort]?” Ronan asked.
“That’s what’s going on back on shore. Do you maximize treatment for someone who can actually have limb salvage versus someone you can support, but can’t fix. If a person is paralyzed or burned, they will occupy a bed for weeks or months. That’s the decision that’s going on right now.

“There is a huge pressure on our resources down there— for the NGOs [nongovernmental organizations] and the military – to transfer people depending on what their contacts are in the U.S.” said Ronan. “If you now ask us to focus on the one [this particular senator] wants transferred, it’s a Sophie’s choice. What about the 40,000 other people who have that problem. Who should come to the U.S.? Why does Larry Ronan get to do that and [someone else] does not. Do we want people on the ground figuring that out themselves?

“It’s not an intellectual discussion. If you say this person goes and this one doesn’t. I have to say to that patient or their family, ‘Sorry.’ It’s not so easy. It’s a terrible position for our country and for the Haitian people.”

The situation on the ground remains chaotic, despite improvements Ronan said he has seen over the last two weeks. New injuries are coming into field hospitals caused by post-earthquake conditions: Children are being burned in makeshift camps where kerosene and charcoal fires are used for heat and cooking; car accidents are occurring as people try to move around a city still strewn with debris and refugees. Then, of course, there are the hundreds of thousands of injured victims of the temblor and its aftershocks— men, women, and children whose chances of recovery have been seriously compromised by the lack of effective medical care in-country. Only four small hospitals that existed before the Jan. 12 quake are still operating in Port-au-Prince.

“The people who died in the initial earthquake died from crush injuries. Most people haven’t been recovered. They are still inside the buildings,” said Ronan. “Then, there are people who have been rescued by international teams. There are 132 documented cases of that. But, then there are a lot more people saved by Haitians who took their relatives and neighbors out themselves and we don’t have that number.

“The people who survived had crush injuries: femur fractures, tib-fib [tibula-fibula], feet crushed, upper extremities, head injuries— all from heavy stuff coming down on top of them. Those people who got care, they would cast them. But then there were those with open wound injuries and they didn’t get fixed right away. They’ve got infected wounds and those tend to require amputation. There are a whole group that are septic and sick because they got that infection. And that’s what is taking a lot of people’s lives.”

A major problem going forward, Ronan said, is how to care for the tens of thousands of amputees and parapalegics spawned by the disaster. Haiti had no infrastructure in place prior to Jan. 12 to handle post-operative care, physical therapy, and the like. Ronan is urging federal officials to invest in building those facilities now to handle the demand. He believes at least 10-15 permanent long-term care facilities will be needed in the coming months.

“Whatever we do, do it in Haiti,” is Ronan’s advice. “We need to go to the countryside and find ways we can build Haiti, pour money into Haiti. It needs to survive this and come out of it as whole as we can make it.”

The medical facilities in and around Port-au-Prince that were destroyed “need to be stood up and supported and we need to throw resources into them to have them come back to what they were before,” Ronan urged. “Secondly, there are hospitals in [other Haitian cities]. They are two hours away by road and they have good standard of care with Haitian and Americans, but are overwhelmed by the numbers. They need to be supported and stood up as well.

“Then there are also things Haiti has never had: the sub-acute facilities needed to help people going forward. The current thinking right now is that the [U.S.] Air Force will stand up a 250-bed facility about 4-5 miles outside the [Port-au-Prince] Airport in an area barren right now. That will be a sub-acute facility for patients with recent amputations who don’t have to take up resources of the hospital. That’s a whole new concept for Haiti that will require a huge amount of help from U.S. and we need to help get all these specialists in immediately and on the ground.

“You’re going to need 10-20 of those facilities in the next few months,” Dr Ronan said.