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Dermatology Aboard the USNS COMFORT: Disaster Relief Operations in Haiti After the 2010 Earthquake
Derma tology Aboard t h e U S N S COMFORT: Disaster Relief Operations in Haiti After the 2010 Earthquake Kenneth Galeckas, MDa,b,* KEYWORDS Haiti Dermatology Disaster relief Planned humanitarian assistance mission
nations in Central and South America and along the Pacific Rim. In addition, these ships are on perpetual standby as part of the national response to natural disasters, both in the United States and abroad. Recent disaster-related missions have included deployments to New Orleans after Hurricane Katrina and to Indonesia after the 2004 tsunami. Although most missions render humanitarian assistance or disaster relief, the Comfort also provided combat medical support for Operation Desert Shield and Operation Desert Storm. In this instance, most of the reporting personnel received less than 24 hours notice to prepare for deployment, get to Baltimore, and report aboard. The Comfort set sail on January 16, 2010, with more than 1000 medical and support staff. It arrived in Port-au-Prince and was receiving her first patients within 7 days of the earthquake. Commissioned in 1987, the Comfort’s capabilities are impressive. It was originally built and launched as an oil tanker, the SS Rose City, in 1976. At 892 feet, almost as long as an aircraft carrier, it boasts a 50-bed trauma emergency room, 12 operating rooms, a 20-bed recovery room, a 30-bed intensive care unit, 400
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government. a Department of Dermatology, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA b Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA * Department of Dermatology, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address: [email protected] Dermatol Clin 29 (2011) 15–19 doi:10.1016/j.det.2010.09.004 0733-8635/11/$ e see front matter. Published by Elsevier Inc.
derm.theclinics.com
On the 12th of January 2010, Haiti was struck by a 7.0 Richter magnitude earthquake that devastated its already fragile capital region. Approximately 230,0001 people died either immediately or during ensuing weeks, mostly due to acute trauma. Countless others suffered significant lifeor limb-threatening injuries. As a part of the United States’ response to this tragedy, eventually named Operation Unified Response (OUR), the United States Navy deployed hundreds of physicians and other medical response individuals on the USNS Comfort, a US Navy hospital ship based in Baltimore, Maryland. OUR was a military joint task force operation that was augmented by both governmental and nongovernmental organizations (eg, US Agency for International Development, Project HOPE, and Operation Smile). Our mission was to bring urgently needed medical and logistical support to the region. I had the distinct privilege to serve as the dermatologist for this mission. The Comfort (Fig. 1) is one of two Mercy class hospital ships operated by the US Navy. The Comfort and its West Coast counterpart, USNS Mercy, participate in biennial humanitarian missions that bring health care to many developing
Galeckas
16
Fig. 1. The USNS Comfort, at anchor off Portau-Prince, Haiti, February 2010.
intermediate-care beds, 500 minimal-care beds, and full radiologic and laboratory support. For this mission, the ship was staffed with many medical and surgical subspecialty physicians (Table 1).2 OUR was designed as a disaster relief operation. This mission’s purpose was distinctly different from a carefully planned humanitarian
assistance mission (HAM). HAMs are preceded by site visits in an effort to efficiently coordinate care once the Comfort arrives on schedule at a particular location. On typical ship-based HAMs, the dermatologist goes ashore to set up clinics that have been announced to the local population. Usually, these announcements encourage hundreds of people to seek care. In this way, there is a virtually endless stream of patients and the care that is provided is limited only by time and supplies. The Haitian earthquake destroyed nearly all of Port-au-Prince’s piers; thus, the Comfort anchored farther out in the harbor, which in turn made helicopters and small boats necessary to transfer patients. Because of the orthopedic nature of many injuries, transportation of patients required stretchers and many stretcher-bearers. As such, helicopters and small boats filled quickly with seriously injured patients, thereby limiting my ability to obtain transportation to land. When traveling to local hospitals, our teams of physicians and support staff were assigned security escorts, thereby adding another layer of
Table 1 Breakdown of physician/staff specialties aboard USNS Comfort for Operation Unified Response Haiti USNS Comfort for OUR Haitid2010a Physician Staff Anesthesiology Cardiology Critical care Dermatology Develomental pediatrics Emergency medicine Emergency medicine (pediatrics) Endocrinology (pediatrics) Family practice Gastroenterology General surgery Infectious disease Internal medicine Nephrology Neurology Nonphysician Clinical Staff Dentist Nurse anesthetist Family nurse practitioner Medical/surgical nursing a
11 1 3 1 1 5 1
1 2 2 3 1 12 1
1 4 1 2 2 2 2 1
Neurology (pediatrics) Neurosurgery Obstetrics/gynecology Opthalmology Oral/maxillofacial surgery Orthopedic surgery Orthopedic surgery (pediatrics) Otolaryngology Pediatrics Plastic surgery Psychiatry Radiology Urology Vascular surgery Wound care
3 13 3 165
Optometry Clinical psychology Social worker Wound care nurse practitioner
2 2 2 2
1 4 1 1 4 2 1 1
Includes volunteer nonmilitary staff augmentees. Data from Amundson D, Dadekian G, Etienne M, et al. Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian earthquake. Ann Intern Med 2010;152(11):733e7.
Dermatology Aboard the USNS COMFORT logistical complexity. In the 2 months after the earthquake, the crowds were peaceful and were welcoming, likely the result of the general goodwill cultivated from the Comfort’s previous missions to Haiti, most recently as part of Operation Continuing Promise in the spring of 2009. The Comfort and other US Navy ships delivering humanitarian assistance have been frequent visitors to Haiti for many years. As a testament to the US Navy’s previous efforts, Haiti’s Ministry of Health specifically requested the Comfort to be dispatched to Haiti after the earthquake. As the initial surge of trauma waned over several weeks, I was able to go ashore and make several trips to local hospitals, orphanages, and schools that had been converted into makeshift clinics. My first trip ashore was to a local children’s hospital as part of a team that had a mission to establish a relationship with the staff and see how we could be of service. Knowing I was a dermatologist, the hospital’s doctors showed me several patients with scabies, head lice, and tinea capitis. Those conditions were commonplace and likely exacerbated by overcrowding and chronic sanitation issues. Because of my limited opportunity to go ashore, I quickly developed and disseminated a protocol on how to send teledermatology consults to the Comfort to help assist local physicians with difficult dermatologic cases. Every time a medical team went ashore, I sent along copies of my teledermatology protocol to be distributed to the local health workers. Because the e-mail address was disseminated widely, my services as a dermatologist were called on often. For most teledermatology cases, the diagnosis was straightforward. The major
hurdle was whether or not the consulting clinician had appropriate medicines to treat the patient. Dermatologic complaints encompassed approximately 25% of all acute visits to the Comfort’s sickbay, which is a 6-bed shipboard clinic that provides care for the large crew (more than 1200 people at times). Most patients presented with allergic and/or irritant contact dermatitis or dermatophyte infections. The tinea infections seen among the ship’s crew were brought aboard by most patientsdflaring as a result of the long hours, heat, and humidity. There were scattered cases of acne, eczema, warts, and psoriasis. There were several cases of phototoxicity from doxycycline, the antimalarial prophylaxis of choice. Doxycycline was preferred over atovaquone/proguanil (Malarone) or chloroquine because the once-a-day dosing made it easy for ship’s company to take at daily muster. For me, the most interesting cases were the incidental diagnoses of several Haitian patients who were admitted with earthquake-related traumatic injuries. Below are the stories of two such individuals: Patient #1: I was asked to see JD, an approximately 9-year-old boy (aged based on dental examination), for skin lesions (Fig. 2A). This young boy was abandoned by his parents and left on the doorstep of an orphanage shortly after the earthquake. An orphanage volunteer brought him to the ship to treat what was thought to be a traumatic eye injury. His right eye appeared quite swollen with overlying erosions and ulcerations. I found that he was malnourished and clearly suffered from a developmental or neurologic disability. Skin examination was significant for abundant
Fig. 2. (A, B) Nine-year-old boy with XP phenotype. Note the distinct photogradient (B).
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18
Galeckas widespread hyperkeratotic pigmented papules scattered on all sun-exposed areas with a distinct photogradient. Double-covered areas showed minimal to no damage (see Fig. 2B). Physical examination showed a xeroderma pigmentosum (XP) phenotype. Biopsy of three hyperkeratotic lesions showed pigmented actinic keratoses. On clinical examination, his eye “injury” was noted to be a solid mass. Biopsy confirmed squamous cell carcinoma, prompting enucleation by an oculoplastic surgeon. After 12 days of postoperative convalescence on the Comfort, JD was discharged to a local hospital with the ultimate goal of engaging the Xeroderma Pigmentosum Society for assistance with subsequent care (www.xps.org). Patient #2: DL was a 7-year-old boy admitted for treatment of a femur fracture. I was consulted for evaluation of skin lesions. He was not accompanied by family on board, which was commonly the case with many of our pediatric patients. On examination, DL was suspicious, hesitant, and uncooperative. I deduced, via a Creole translator, that his skin lesions had been present for a “long time,” that that they were getting worse, and they seem to spread with scratching. His sister was affected by similar lesions. He also stated that he is often teased at school because of his skin problem. There were many hypopigmented flattopped papules scatted about his face, arms and trunk, some in linear arrangements (Fig. 3A). My clinical diagnosis was flat warts. Biopsy of a representative lesion on his dorsal hand revealed the classic smoky-blue cytoplasm seen in virally infected keratinocytes, typical of epidermodysplasia verruciformis (EDV) (see Fig. 3B). Having a similarly affected sibling was consistent with the diagnosis of this autosomal recessive disorder. I also suspected untreated or undiagnosed HIV infection, which subsequent ELISA testing confirmed.
Accompanied by a complete package of information, and after stabilization of his femur fracture, he was discharged to a local hospital. The accepting physicians have been made aware of his diagnosis and plan to run HIV testing on his sister. Happily, DL’s father, missing since the earthquake, was located and the family has been at least partially reunited. The memory of these two cases will stick with me for the rest of my career. I had to reconcile the fact that after these children were discharged from the Comfort, it is unlikely that they received the care that I am accustomed to providing in the United States. Unfortunately for both of these patients, they are among countless individuals with chronic undiagnosed medical conditions who have been born into a society with, at best, a struggling medical infrastructure. I am hopeful that local medical care and access to subspecialties will improve as the international community continues its effort to rebuild Haiti. Questions remain. If the diagnosis of XP had been identified earlier, would protective measures have led to a better outcome? Will this boy succumb to his first melanoma? For the boy with EDV, would antiretroviral therapy have averted the development of socially disabling facial lesions? Without our intervention, when would he have eventually learned that he was HIV positive? Now, with a known underlying diagnosis, perhaps he will not receive well-intentioned but inappropriate treatments. For both patients, how in the world will they practice sun safety in Haiti? With XP, as well as the increased cutaneous carcinogenicity associated with EDV, photoprotection is paramount to long-term survival. I was happy to hear that JD has been sent to the United States and is currently living with a family that has another child with XP. Dr Kenneth Kraemer of the National Institutes of Health,
Fig. 3. (A, B) Seven-year-old boy with HIV-associated EDV, (A) clinical (B) histopathology
Dermatology Aboard the USNS COMFORT a pioneer in XP research, was instrumental in coordinating JD’s follow-up care. Although I chronicled only two patients here, 1000 patients were admitted to the Comfort in its first 7 weeks in Haiti and each patient has a unique story. Even as the Comfort’s mission concludes, the work to rebuild Haiti will continue for years. I encourage all physicians to volunteer their skills to the various volunteer organizations that participate in such humanitarian assistance or disaster relief operations. As echoed by countless clinicians who have been come before me and have been involved in similar endeavors, I have gained as much, if not more, than I gave.
ACKNOWLEDGMENTS The author would like to sincerely thank Dr Scott Norton for his generous advice, mentorship, and editorial assistance.
REFERENCES 1. USAID Haiti Fact Sheet. July 11, 2010. Available at: www. usaid.giv/helphaiti. Accessed September 17, 2010. 2. Amundson D, Dadekian G, Etienne M, et al. Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian earthquake. Ann Intern Med 2010;152(11):733e7.
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nations in Central and South America and along the Pacific Rim. In addition, these ships are on perpetual standby as part of the national response to natural disasters, both in the United States and abroad. Recent disaster-related missions have included deployments to New Orleans after Hurricane Katrina and to Indonesia after the 2004 tsunami. Although most missions render humanitarian assistance or disaster relief, the Comfort also provided combat medical support for Operation Desert Shield and Operation Desert Storm. In this instance, most of the reporting personnel received less than 24 hours notice to prepare for deployment, get to Baltimore, and report aboard. The Comfort set sail on January 16, 2010, with more than 1000 medical and support staff. It arrived in Port-au-Prince and was receiving her first patients within 7 days of the earthquake. Commissioned in 1987, the Comfort’s capabilities are impressive. It was originally built and launched as an oil tanker, the SS Rose City, in 1976. At 892 feet, almost as long as an aircraft carrier, it boasts a 50-bed trauma emergency room, 12 operating rooms, a 20-bed recovery room, a 30-bed intensive care unit, 400
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government. a Department of Dermatology, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA b Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA * Department of Dermatology, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address: [email protected] Dermatol Clin 29 (2011) 15–19 doi:10.1016/j.det.2010.09.004 0733-8635/11/$ e see front matter. Published by Elsevier Inc.
derm.theclinics.com
On the 12th of January 2010, Haiti was struck by a 7.0 Richter magnitude earthquake that devastated its already fragile capital region. Approximately 230,0001 people died either immediately or during ensuing weeks, mostly due to acute trauma. Countless others suffered significant lifeor limb-threatening injuries. As a part of the United States’ response to this tragedy, eventually named Operation Unified Response (OUR), the United States Navy deployed hundreds of physicians and other medical response individuals on the USNS Comfort, a US Navy hospital ship based in Baltimore, Maryland. OUR was a military joint task force operation that was augmented by both governmental and nongovernmental organizations (eg, US Agency for International Development, Project HOPE, and Operation Smile). Our mission was to bring urgently needed medical and logistical support to the region. I had the distinct privilege to serve as the dermatologist for this mission. The Comfort (Fig. 1) is one of two Mercy class hospital ships operated by the US Navy. The Comfort and its West Coast counterpart, USNS Mercy, participate in biennial humanitarian missions that bring health care to many developing
Galeckas
16
Fig. 1. The USNS Comfort, at anchor off Portau-Prince, Haiti, February 2010.
intermediate-care beds, 500 minimal-care beds, and full radiologic and laboratory support. For this mission, the ship was staffed with many medical and surgical subspecialty physicians (Table 1).2 OUR was designed as a disaster relief operation. This mission’s purpose was distinctly different from a carefully planned humanitarian
assistance mission (HAM). HAMs are preceded by site visits in an effort to efficiently coordinate care once the Comfort arrives on schedule at a particular location. On typical ship-based HAMs, the dermatologist goes ashore to set up clinics that have been announced to the local population. Usually, these announcements encourage hundreds of people to seek care. In this way, there is a virtually endless stream of patients and the care that is provided is limited only by time and supplies. The Haitian earthquake destroyed nearly all of Port-au-Prince’s piers; thus, the Comfort anchored farther out in the harbor, which in turn made helicopters and small boats necessary to transfer patients. Because of the orthopedic nature of many injuries, transportation of patients required stretchers and many stretcher-bearers. As such, helicopters and small boats filled quickly with seriously injured patients, thereby limiting my ability to obtain transportation to land. When traveling to local hospitals, our teams of physicians and support staff were assigned security escorts, thereby adding another layer of
Table 1 Breakdown of physician/staff specialties aboard USNS Comfort for Operation Unified Response Haiti USNS Comfort for OUR Haitid2010a Physician Staff Anesthesiology Cardiology Critical care Dermatology Develomental pediatrics Emergency medicine Emergency medicine (pediatrics) Endocrinology (pediatrics) Family practice Gastroenterology General surgery Infectious disease Internal medicine Nephrology Neurology Nonphysician Clinical Staff Dentist Nurse anesthetist Family nurse practitioner Medical/surgical nursing a
11 1 3 1 1 5 1
1 2 2 3 1 12 1
1 4 1 2 2 2 2 1
Neurology (pediatrics) Neurosurgery Obstetrics/gynecology Opthalmology Oral/maxillofacial surgery Orthopedic surgery Orthopedic surgery (pediatrics) Otolaryngology Pediatrics Plastic surgery Psychiatry Radiology Urology Vascular surgery Wound care
3 13 3 165
Optometry Clinical psychology Social worker Wound care nurse practitioner
2 2 2 2
1 4 1 1 4 2 1 1
Includes volunteer nonmilitary staff augmentees. Data from Amundson D, Dadekian G, Etienne M, et al. Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian earthquake. Ann Intern Med 2010;152(11):733e7.
Dermatology Aboard the USNS COMFORT logistical complexity. In the 2 months after the earthquake, the crowds were peaceful and were welcoming, likely the result of the general goodwill cultivated from the Comfort’s previous missions to Haiti, most recently as part of Operation Continuing Promise in the spring of 2009. The Comfort and other US Navy ships delivering humanitarian assistance have been frequent visitors to Haiti for many years. As a testament to the US Navy’s previous efforts, Haiti’s Ministry of Health specifically requested the Comfort to be dispatched to Haiti after the earthquake. As the initial surge of trauma waned over several weeks, I was able to go ashore and make several trips to local hospitals, orphanages, and schools that had been converted into makeshift clinics. My first trip ashore was to a local children’s hospital as part of a team that had a mission to establish a relationship with the staff and see how we could be of service. Knowing I was a dermatologist, the hospital’s doctors showed me several patients with scabies, head lice, and tinea capitis. Those conditions were commonplace and likely exacerbated by overcrowding and chronic sanitation issues. Because of my limited opportunity to go ashore, I quickly developed and disseminated a protocol on how to send teledermatology consults to the Comfort to help assist local physicians with difficult dermatologic cases. Every time a medical team went ashore, I sent along copies of my teledermatology protocol to be distributed to the local health workers. Because the e-mail address was disseminated widely, my services as a dermatologist were called on often. For most teledermatology cases, the diagnosis was straightforward. The major
hurdle was whether or not the consulting clinician had appropriate medicines to treat the patient. Dermatologic complaints encompassed approximately 25% of all acute visits to the Comfort’s sickbay, which is a 6-bed shipboard clinic that provides care for the large crew (more than 1200 people at times). Most patients presented with allergic and/or irritant contact dermatitis or dermatophyte infections. The tinea infections seen among the ship’s crew were brought aboard by most patientsdflaring as a result of the long hours, heat, and humidity. There were scattered cases of acne, eczema, warts, and psoriasis. There were several cases of phototoxicity from doxycycline, the antimalarial prophylaxis of choice. Doxycycline was preferred over atovaquone/proguanil (Malarone) or chloroquine because the once-a-day dosing made it easy for ship’s company to take at daily muster. For me, the most interesting cases were the incidental diagnoses of several Haitian patients who were admitted with earthquake-related traumatic injuries. Below are the stories of two such individuals: Patient #1: I was asked to see JD, an approximately 9-year-old boy (aged based on dental examination), for skin lesions (Fig. 2A). This young boy was abandoned by his parents and left on the doorstep of an orphanage shortly after the earthquake. An orphanage volunteer brought him to the ship to treat what was thought to be a traumatic eye injury. His right eye appeared quite swollen with overlying erosions and ulcerations. I found that he was malnourished and clearly suffered from a developmental or neurologic disability. Skin examination was significant for abundant
Fig. 2. (A, B) Nine-year-old boy with XP phenotype. Note the distinct photogradient (B).
17
18
Galeckas widespread hyperkeratotic pigmented papules scattered on all sun-exposed areas with a distinct photogradient. Double-covered areas showed minimal to no damage (see Fig. 2B). Physical examination showed a xeroderma pigmentosum (XP) phenotype. Biopsy of three hyperkeratotic lesions showed pigmented actinic keratoses. On clinical examination, his eye “injury” was noted to be a solid mass. Biopsy confirmed squamous cell carcinoma, prompting enucleation by an oculoplastic surgeon. After 12 days of postoperative convalescence on the Comfort, JD was discharged to a local hospital with the ultimate goal of engaging the Xeroderma Pigmentosum Society for assistance with subsequent care (www.xps.org). Patient #2: DL was a 7-year-old boy admitted for treatment of a femur fracture. I was consulted for evaluation of skin lesions. He was not accompanied by family on board, which was commonly the case with many of our pediatric patients. On examination, DL was suspicious, hesitant, and uncooperative. I deduced, via a Creole translator, that his skin lesions had been present for a “long time,” that that they were getting worse, and they seem to spread with scratching. His sister was affected by similar lesions. He also stated that he is often teased at school because of his skin problem. There were many hypopigmented flattopped papules scatted about his face, arms and trunk, some in linear arrangements (Fig. 3A). My clinical diagnosis was flat warts. Biopsy of a representative lesion on his dorsal hand revealed the classic smoky-blue cytoplasm seen in virally infected keratinocytes, typical of epidermodysplasia verruciformis (EDV) (see Fig. 3B). Having a similarly affected sibling was consistent with the diagnosis of this autosomal recessive disorder. I also suspected untreated or undiagnosed HIV infection, which subsequent ELISA testing confirmed.
Accompanied by a complete package of information, and after stabilization of his femur fracture, he was discharged to a local hospital. The accepting physicians have been made aware of his diagnosis and plan to run HIV testing on his sister. Happily, DL’s father, missing since the earthquake, was located and the family has been at least partially reunited. The memory of these two cases will stick with me for the rest of my career. I had to reconcile the fact that after these children were discharged from the Comfort, it is unlikely that they received the care that I am accustomed to providing in the United States. Unfortunately for both of these patients, they are among countless individuals with chronic undiagnosed medical conditions who have been born into a society with, at best, a struggling medical infrastructure. I am hopeful that local medical care and access to subspecialties will improve as the international community continues its effort to rebuild Haiti. Questions remain. If the diagnosis of XP had been identified earlier, would protective measures have led to a better outcome? Will this boy succumb to his first melanoma? For the boy with EDV, would antiretroviral therapy have averted the development of socially disabling facial lesions? Without our intervention, when would he have eventually learned that he was HIV positive? Now, with a known underlying diagnosis, perhaps he will not receive well-intentioned but inappropriate treatments. For both patients, how in the world will they practice sun safety in Haiti? With XP, as well as the increased cutaneous carcinogenicity associated with EDV, photoprotection is paramount to long-term survival. I was happy to hear that JD has been sent to the United States and is currently living with a family that has another child with XP. Dr Kenneth Kraemer of the National Institutes of Health,
Fig. 3. (A, B) Seven-year-old boy with HIV-associated EDV, (A) clinical (B) histopathology
Dermatology Aboard the USNS COMFORT a pioneer in XP research, was instrumental in coordinating JD’s follow-up care. Although I chronicled only two patients here, 1000 patients were admitted to the Comfort in its first 7 weeks in Haiti and each patient has a unique story. Even as the Comfort’s mission concludes, the work to rebuild Haiti will continue for years. I encourage all physicians to volunteer their skills to the various volunteer organizations that participate in such humanitarian assistance or disaster relief operations. As echoed by countless clinicians who have been come before me and have been involved in similar endeavors, I have gained as much, if not more, than I gave.
ACKNOWLEDGMENTS The author would like to sincerely thank Dr Scott Norton for his generous advice, mentorship, and editorial assistance.
REFERENCES 1. USAID Haiti Fact Sheet. July 11, 2010. Available at: www. usaid.giv/helphaiti. Accessed September 17, 2010. 2. Amundson D, Dadekian G, Etienne M, et al. Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian earthquake. Ann Intern Med 2010;152(11):733e7.
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