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Disaster Management, Triage-based Wound Care, and Patient Safety: Reflections on Practice Following an Earthquake

Empirical Studies

Disaster Management, Triage-based Wound Care, and Patient Safety: Reflections on Practice Following an Earthquake

Abstract

  Triage is the process of prioritizing patient care based on need and available resources. Clinicians in wound clinics triage daily because time and resources never seem to be sufficient. The triage concept is taken to an extreme when a disaster strikes — the clinical goal of patient care transforms from the individual patient to providing the greatest good for the greatest number of patients. Situational awareness of system resources is of paramount importance in a disaster.

Planning for surge capacity while simultaneously attending to patients who require immediate attention is a must. The recent earthquake in Haiti provided an opportunity to test those skill sets. Scores of clinicians volunteered their time and expertise, elevating wound care to the status of a clinical division. The experience of providing quality wound care despite a myriad of situational limitations suggests that busy wound clinics can learn valuable lessons from the realm of disaster management. The rate of under- and over-triage in wound clinics can be reduced by utilizing commonly collected outcomes and operational data. Patient safety improves when the hierarchy is flattened, communication is open, checklists are used, debriefings are held, and teamwork is encouraged. Reflecting on the working conditions in Haiti, it is clear that patients and clinicians benefit when success is measured by patient outcomes instead of individual accomplishments.

Potential Conflicts of Interest: none disclosed  

 On January 12, 2010 at 4:53 p.m., an earthquake rated at 7.0 on the moment magnitude scale struck Haiti 16 miles east of the country’s capitol, Port-au-Prince. By January 20, at least 52 4.5-rated aftershocks had occurred. More than 230,000 people died, 300,000 were injured, and more than 1 million were made homeless.

  Almost as quickly as the disaster struck, medical and relief teams began to mobilize to provide assistance. The first teams to arrive encountered total chaos, facing many wounded, few supplies, and nonexistent sanitary conditions. Reports began to emerge of numerous amputations performed out of necessity in nonsterile locations with minimal equipment. Military support was necessary for both security and logistical reasons. Through Project Medishare, the University of Miami (Miami, FL) organized a makeshift tent hospital on the grounds of the airport at Port-au-Prince. As supplies and volunteers arrived, the tent hospital expanded into a small medical compound with an emergency department, pharmacy, orthopedic unit, pediatric unit, central supply department, and outpatient wound clinic with a procedure area. Medical volunteers from all fields were organized for 1 week deployments. My team was deployed on February 7, 2010, a little more than 4 weeks after the quake. My years of medical, surgical, and leadership training did not adequately prepare me for the experience.

  The medical teams were organized into a hierarchical system, not unlike at a university, with a chief medical officer (CMO) in charge of the division chiefs of five independent clinical units: orthopedics (surgery), pediatrics, internal medicine, anesthesia, and wound care. Our wound team treated up to 60 inpatients and 20 outpatients per day while providing emergency department consults. Clinical work began at 7 a.m. and frequently ended late in the evening. Food was limited, beds were uncomfortable cots, and the Fahrenheit temperature was in the 90s. Portable toilets, rare showers, marginal food, and lack of sleep completed the picture.

  Given the above scenario, I would have anticipated chaotic clinical care, poor outcomes, multiple errors, and a hostile working environment. In addition, I was uncertain how teams of clinicians from various locations and backgrounds would coalesce into the hierarchical healthcare system required in a triage-based situation. But communication, collaboration across disciplines, and teamwork were held in high regard. I probably communicated more with colleagues over 7 days than I would within a month at my home institution.

  At home, we hear about medication errors, surgical mishaps, poor personal relationships among medical staff, and reports of overall unsafe healthcare delivery in our facilities. We are constantly reminded about Office of the Inspector General (OIG) investigations into overuse of advanced products and procedures. House-staff officers are paralyzed when the CT scan machine goes down or lab test results are not available for morning rounds. Yet in this makeshift hospital with limited supplies, we were able to work in unison with a common goal — patient care — with good outcomes.

  What follows is a report on my experiences and a brief review of disaster management and the patient safety movement to which appropriately trained wound care clinicians can add tremendous value. After describing a set of clinical concepts as they relate to a disaster situation, I use these constructs to create a parallel process for wound care in general and the situation I encountered in Haiti specifically. In closing, I will describe outcomes from the experience and highlight both the positive and negative lessons learned. It is my hope that, moving forward, disaster management and patient safety committees will include more wound care clinicians among their membership.

Disaster Management

  Historically, much of what we know about wound care comes from military conflict. The French military surgeon, Ambroise Pare, developed dressings to manage battlefield wounds that did not induce pain.1 During World War I, Alexis Carrell and Henry Dakins helped design dressings with antimicrobial functions.2 Rapid transport and Mobile Army Surgical Hospital (MASH) units became the norm during the Korean war.3 Recently, Operation Iraqi Freedom improved our ability to care for complex wounds caused by the tremendous number of lower extremity injuries from improvised explosive devices (IEDs).4 These battlefield concepts and innovations have not always transferred to the chronic wound community; similarly, in most cases the use of advanced wound dressings, physical therapy wound modalities, and wound bed preparation techniques have not moved from wound care to the trauma arena. However, although differences between the training, goals, objectives, and types of practitioners are clear (see Table 1), the two fields began to cross-pollinate with the increased use of negative pressure wound therapy, pulsed lavage, and the introduction of bioengineered scaffoldings and new debridement tools.5 The main difference between mass casualty and routine healthcare management is the scale of the problem. With mass casualty, the number of cases outstrips existing resources. Cases can be similar but patient volume results in inadequate time for evaluation and planning and may lead to clinical rationing.

  Triage (see Table 2). The concept triage — “to sort” — is thought to have been created by Napoleon’s battlefield surgeon, the Baron Dominique Jean Larrey.6 On initial evaluation, an immediate decision is required that will place the patient into a treatment category, with important ramifications.

  Five well-accepted triage categories are described in the disaster literature.7 The first decision is a dichotomous choice focused on whether immediate treatment is needed. Laboratory testing, radiographs, and the like do not play a role at this phase of the process. In a disaster situation, the receiving unit does not know the ultimate number of incoming patients and resources have to be carefully appropriated. The immediate category describes patients with life-threatening injuries who require urgent treatment; once stabilized, these patients can be designated to another category. The delayed category describes trauma patients who require medical intervention but are currently hemodynamically stable so a delay in treatment will not result in diminished outcomes. Patients in this category receive minimal acceptable care in order to stabilize them; however, constant monitoring is required to ensure they do not deteriorate and require immediate care. The walking wounded refers to the minimally injured who are often the first to arrive at the triage center. Their numbers can overwhelm a local hospital and their arrival is often the first signal that a local disaster has occurred. As with the delayed group, they must be constantly monitored to ensure they do not deteriorate. Patients in the expectant category — ie, alive but unlikely to survive their injuries even if extensive treatment were provided — often cause clinicians the most emotional difficulty. The knowledge that diverting large amounts of resources to these patients will result in many more patients dying who could have been saved does not make this decision easier. These patients need to be kept comfortable and should be monitored in case their status improves. Patients presenting without pulse or spontaneous respirations are assumed dead and resuscitation efforts are not started.

  The triage officer. The triage organization is hierarchical — the triage officer is at the highest point in the chain of command. Experienced and knowledgeable physicians or nurses usually serve as triage officers. The triage officer does not provide direct patient care so it is important to recognize that if the center has a shortage of either nurses or physicians, assigning one of them the role of triage officer will further deplete the critical mass of available clinicians. Communication skills, leadership ability, decision making, and a keen sense of situational awareness are essential qualities for a successful triage officer.

  Under- and over-triage rates. The accuracy of triage decisions is determined by examining under-triage or over-triage rates. Under-triage occurs when a critical patient is assigned to the delayed category. Over-triage is when a noncritical patient gets treated as an urgent case, inappropriately diverting scarce resources. The goal is to provide the greatest good to the greatest number of patients, which is significantly different than ordinary clinical practice when each clinician focuses on the individual patient in front of them. Under and over-triage rates are intimately related — a move toward one will result in a reduction of the other. The clinician’s reflex is a tendency to over-triage; over- and under-triage both are problematic.

  Data utilization. Evaluating disaster records after the event is important to improve the triage process. One parameter, the critical mortality rate, is determined by dividing the number of deaths in critically injured persons by the total number of critically injured patients. This evaluation of the level of triage and the overall effectiveness of the triage process is more accurate than looking at an overall death rate of all patients seen, which of course would be significantly lower.8

Disaster Management: Wound Care Implications (Non-disaster Situation)

  If the definition of mass casualty involves the number of cases that outstrips existing resources, I would argue that mass casualty occurs every day in a busy wound center. Wound care patients require extensive staffing to assist with transfers and to provide complex dressing changes, patient education, social service assessments, and assistance obtaining the ordered dressings and durable equipment. Standard clinician/patient outpatient clinic ratios, which are frequently applied by hospital administration to the wound care program, are completely inadequate to provide comprehensive care. When staffing is limited, it may be impossible to perform the full diagnostic evaluation required to make an accurate initial triage decision. This leads to significant under- and over-triage decisions. Unlike disaster preparedness activities, where practice efforts and real disaster outcomes are used to improve processes, many wound care centers do not utilize their outcomes data to change practice.

  Triage. When clinical volume outstrips resources, the clinician often utilizes standard minimally acceptable care even in actually urgent (under-triage) cases or applies advanced therapeutic options (biological skin substitutes) for cases that would have responded to standard of care (over-triage). Clinical pathways need to emphasize the importance of the initial visit with regards to establishing an accurate diagnosis and an appropriate level of situational awareness concerning the acuity of the clinical situation. Only then can the wound clinic combine the delayed and minimal categories into maintenance and follow-up clinic visits with more visits per day booked, potentially utilizing physician extenders and other healthcare practitioners.

  Thus, the wound care field could borrow from the disaster management process by improving the initial “sorting” of cases. As presented in Table 2, wound care patients could be placed into categories similar to those created for mass casualty. The most pressing initial decision is whether the patient requires urgent treatment — ie, hospitalization. Most wound clinics tend to have patients return for follow-up visits without making an accurate initial decision concerning the level of clinical acuity and a sound presumptive diagnosis of wound etiology. For example, a patient with a diabetic foot infection and systemic signs of infection is better served with triage to the inpatient setting. A patient with a nonhealing, postoperative abdominal wound with considerable soft tissue necrosis and odor also is best served with an inpatient admission, along with surgical debridement, imaging, and antibiotics when indicated rather than frequent, ineffective office debridements. Once initial care is rendered, the patient can be downgraded to the minimal category and followed weekly in the outpatient wound center. A treatment plan for palliative patients in the expectant category could include less frequent visits and clearly defined goals and objectives of care that the clinician, family, and patient have discussed thoroughly and agree to follow.

  Substantial clinical resources, time, and money frequently are wasted on the “nonsurvival” category. In wound care, nonsurvival often refers to a limb, but also could mean a wound that cannot be healed. When a nonambulatory, cognitively impaired, poorly nourished patient presents from the nursing home with critical limb ischemia and extensive soft tissue loss, successful limb salvage is highly unlikely. More importantly, it could be debated whether any treatment outside of amputation should be performed. Of course, patient wishes, family concerns, and cultural and religious considerations all have to be reviewed before making any decision but the clinical reality must remain at the forefront of the discussion. Although this scenario may seem obvious, treatment is known to continue without a real dialogue regarding the true goals of care and expected outcomes in a myriad of less definitive clinical situations. Such an approach would be considered inappropriate in the disaster world but should be considered equally inappropriate in the wound care community.

  The triage officer. The wound clinic medical director could and should act as triage officer. Clearly, staff members of many clinics have expertise in diagnosis and disease pattern recognition as well as triage skills. In practice, we often ask each member of the clinical team to play all positions on the team. It may be time to reconsider this model and emulate post-disaster analysis within the wound community.

  Data utilization. Although many clinics collect data, few utilize the power of these data with regularly scheduled outcomes assessments. Healing rates often are discussed but not unlike in the disaster field, they may not accurately reflect the effectiveness of the team. The critical mortality rate has implications for the wound care field. For example, if the healing rate was calculated by taking the number of healed patients from a population that could achieve healing and comparing it to the ratio of patients that healed from a group considered difficult to heal, we would see a more accurate reflection of the clinical effectiveness of the team. This concept also underscores the absence of accurate categorization methods — ie, risk stratifying and wound severity index scoring — that plague our ability to compare centers.

  Training. Another problem in the field of wound care is the absence of a formal residency program and didactic content agreement. Most clinicians work in outpatient settings and do not have the experience of treating truly sick patients; therefore, they have a tendency to over-triage. The dichotomous decision of treatment yes or no was something I learned in my vascular fellowship when my trainer, Dr. John Sloan, would say, “Bill, is this patient sick? Yes or no.”

Disaster Management: Haiti

  The process utilized in Haiti was similar to a classic disaster triage system. Each day began with a meeting outside of the sleeping tent for all members of the clinical team (see Figure 1). The CMO used a megaphone to speak to the 100 or so clinical volunteers and reviewed the events of the prior day, presented any issues that arose overnight, and updated everyone on the anticipated clinical events for the coming day — eg, the number of beds available, transfer options, scarce resource issues, incoming volunteers and their backgrounds, and any major political issues. General announcements were made and questions from the crowd were addressed. Immediately after, the CMO and the division chiefs met in the command tent to discuss each clinical service. The most critical patients were reviewed and decisions about the need to transfer and the potential receiving institutions were discussed in detail. Operating room volumes, intensive care beds, critical supplies, and manpower issues were addressed across the teams. Following this meeting, each division chief met with his/her respective clinical teams who had already started rounding and treating patients to update them on the issues.

  Having this knowledge at the start of the day greatly influenced how we would triage. Patients were brought to the medical compound and initially seen in the emergency department (ED). If they had a wound, a member of the wound consult team was called. The chief of the service made the initial decision to admit, manage as an outpatient, or send directly to the operating room. Bed utilization, discharging to outpatient, and the scheduling of wound procedures could be carried out with confidence. Understanding the resources available each day increases each team member’s situational awareness and allows the day to be planned in the most efficient manner. When a case in the ED had to go straight to the operating room, the chief of wound care would physically find the chief of surgery and the two would agree on the plan and timing of the procedure. Anesthesia was brought in and medicine would provide the best medical clearance that could be provided given the little history and testing available. The process continued in a cyclical fashion every day utilizing the same techniques in a consistent, reproducible fashion. Almost 12% of patients received dressing changes in an operating room environment (see Table 3). The chiefs of service also have to plan for possible major swings in capacity — in trauma terminology, surge capacity. For example, almost 60% of all dressing changes were performed at the bedside (see Table 3); however, the use of an anesthesia-staffed procedure tent accounted for 30% of dressing changes to facilitate provision of time- efficient treatments and maximal patient comfort. Thus, if we were without an anesthesiologist in the wound tent for the day, only simple dressing changes or painless negative pressure wound dressings changes would be scheduled. Also, every team member carried a hand-written patient list that was updated at the end of every working day with a complete sign out from all team members (lists were hand-written because there was only one functional printer and few laptops). Laboratory testing was minimal, radiographs consisted of one filmless x-ray machine, and patient charts consisted of clipboards with sticky notes and a collection of papers in no specific order. Patients were numbered in rows but at night families would move their loved ones around the tent so previous patient location was suspect by morning.

  A total of 60 patients with 105 wounds (1.75 wounds/pt average) were seen on either a daily or every-other-day basis during my 7-day rotation (see Table 4). Wounds presented in many locations but the majority was localized on the thigh, leg, and foot (see Table 4). Almost 80% of the wounds seen were traumatic or postoperative (see Table 3).

  Despite the dire conditions, the generosity of many corporate donations allowed the wound team to maintain a high level of advanced wound care therapy. Our team had access to negative pressure wound therapy (V.A.C. Therapy® KCI, San Antonio, TX), MIST® Therapy System (Celleration, Inc., Eden Prairie, MN), and Ultraviolet Light (Dermawand National Biological Corp, Beachwood OH). Although decades of literature support the use of moist healing and advanced therapy, it has been well described that the most common dressing order in US based hospitals is wet-to-dry saline. However, of the 105 wounds we managed in Haiti, 68 (65%) were treated with advanced therapeutics or moist dressings and 16 (35%) wounds were treated with gauze-based therapy (see Table 5).

Patient Safety

  Awareness of patient safety issues increased considerably following publication of the Institute of Medicine’s report, To Err is Human,9 which stated that between 44,000 and 98,000 deaths occur per year due to medical errors. Adverse events are divided into preventable and nonpreventable. Nonpreventable events include those that occur when everything is done correctly and can be attributed to the patients underlying condition. Errors are usually defined as acts of commission (doing something wrong) or omission (not doing the right thing). Errors that do not result in an adverse event are referred to as near misses.10 A previous approach to medical errors was to assign blame and focus on the so-called “sharp end” of care (ie, the end user — eg, the surgeon in a transplant case) rather than to evaluate the process and system.

  In the past several years, systems thinking has supplanted the blame game and helped elevate the science and methodology of the patient safety initiative.11 A classic model frequently used in the assessment of organizational accidents is known as the Swiss cheese model of James Reason.12 This theory posits that a single, sharp-end error resulting in harm is a rare event. More frequently, an error occurs when a series of layers fails to protect the individual from harm. You can visualize this by imagining a number of pieces of Swiss cheese lined up, each representing a layer of an organization. Only when all the holes of the cheese align could an error proceed unimpeded through the holes and result in an adverse event. The last person to interact with the patient ends up with the immediate effect, causing many to misdiagnose this temporal relationship as causality.

  When root cause analysis is applied, errors can be categorized in many ways. Vincent13 discussed institutional, organization and management, work environment, team, individual staff members, the task, and the patient as parts of a potential framework for categorizing the root cause analysis of errors. In addition, considerable attention has been devoted to assessing the difference between “slips” and “mistakes” in medicine. To wit: Conscious behavior is what we do when we pay specific attention to a task, as if doing something new. Automatic behaviors occur with little thought; initially, such tasks may have been difficult and required conscious effort but with repetition and time proceed as if we are on autopilot and are easy enough to allow us to multitask. Automatic behaviors open the door for “slips” to occur. Mistakes also may arise from incorrect choices based on inadequate knowledge, lack of experience or training, incomplete data or information, or by applying the wrong set of rules or protocols to a clinical decision.

  Several methods can be employed to deal with slips and mistakes, including read-backs, checklists, building in redundant systems, and standardization and simplification of orders and protocols. Airline pilots participate in crew resource management programs that include flattening of the hierarchy, open communication, checklist programs, debriefings, error reporting, and programs designed to improve teamwork. Organizations committed to error reduction focus on structure, process, and outcomes — a priority issue is to reduce random variation in practice.

Patient Safety (Non-disaster Situation): Wound Care Implications

  Wound care was brought into the center of the patient safety movement when the Centers for Medicare and Medicaid Services (CMS) introduced the concept of never events.14 The development of a pressure ulcer not present on admission is among the never events for which the CMS will not pay additional fees (ie, if this condition added to the hospitalization or increased the resources and cost of care).15 The Agency for Health Care Research and Quality (AHRQ) has listed patient safety indicators they consider surrogate markers of quality. Previously the “sharp end” of care with regards to pressure ulcer formation was to blame the nursing staff; physicians abdicated themselves from any responsibility for pressure ulcer development. As systems thinking began to permeate the medical field, it became obvious that the problem included multiple layers of the organization and also included the presence of a much sicker patient population with increasing risk factor rates.

  The concept of medical slips is an important consideration in wound care. We open the exam door and see a 65-year-old woman with an irregularly shaped wound on the medial ankle above the malleoli with hyperpigmentation and subconsciously assign a diagnosis “venous ulcer.” Subsequent laser Doppler and laboratory testing is ordered to confirm our immediate suspicions. An experienced clinician will be correct most of the time. When high patient volumes, interruptive phone calls, and a complication in the other exam room are added, this puts the clinician on autopilot and slips may occur. It is hard to maintain a constant state of heightened alertness when most cases are routine. This is where redundant systems, checklists, and protocols can be most useful. Clinicians argue that protocols and checklists are not needed for such easy cases but it is precisely in those cases that the majority of slips occur. These concepts tie nicely into the previously discussed triage system and could provide a new paradigm for daily wound clinic operations.

Patient Safety: Haiti Experience

  In Haiti, with a new clinical team, inadequate charting and testing, overwhelming patient volumes and substandard living conditions, healthcare delivery followed a different paradigm. The following clinical vignettes exemplify some of the reasons why.

  A nurse who has been assigned 25 patients is starting IVs and responding to ongoing screams of pain from patients who were hungry and tired. She is asked by a physician, “Could you help us get this patient some more medication? We need to do a procedure now.” The nurse answers, “Sure!”

  A physician with 20 scheduled procedures (and none of them are finished) is approached by an OR tech, who says, “Doctor, they need you in the OR to check out an open amputation to see if they should vac or flap. Can you come help?” The doctor answers, “Sure!”

  A physical therapist who has changed the twelfth negative pressure dressing of the day, with alarms beeping constantly in her ears due to the inconsistent supply of electricity, is asked by the medic, “Could you come to the procedure tent? We can’t fix the vac there.” The physical therapist answers, “Sure!”

  I heard a great deal of “Sure,” “Sure,” “Sure” while in Haiti. And there was something else that I personally did not anticipate: Physicians asking nurses for help and advice. Military medics were helping physical therapists, who in turn were helping medical assistants, and so on. “I’ll go get it,” “I have one of those,” “I know where those are,” “I saw one just like that yesterday,” “Let me help you.”

  Patient safety requires a sense of responsibility, accountability, and team work. The situation in Haiti provided this while simultaneously limiting personal distractions such as family responsibilities, hobbies, and general activities of daily living. It appeared that few slips occurred due to the sense of team work and a heightened sense of involvement. As the clinical scenarios above demonstrate, it was not that distractions did not occur, it was simply that the overwhelming desire to help the patients and each other allowed clinicians to return to their original task without losing concentration.

  Interestingly, the fact that humans are distractible is a survival mechanism. A machine will continue on with its repetitive task as the building in which it is housed is burning to the ground. The best methods for minimizing slips is to build in redundancies and checklists. This was accomplished with the multiple sign-in and sign-out procedures followed in Haiti. Although the patient safety concept is well documented, a quantifiable method of measure would need to be in place to ensure actual safety goals were met in Haiti. These measuring methodologies need to be incorporated into standard operating policies for future relief teams so various safety techniques can be measured, validated, and implemented into future training courses.

Discussion

The clinicians and volunteers who sought to help after the earthquake in Haiti developed, out of necessity, a triage system that enabled rapid clinical decisions to be made on complex cases with limited information. The daily morning camp meeting, division chief meeting, individual team meeting, and nightly signout are all actions we have engaged in at some time in our training but over the years may not have maintained. Patient volume, inadequate reimbursement, burnout, administrative duties, and lifestyle are all reasons we have, over time, failed to maintain processes that ensure safe patient hand-offs, safety net procedures, cross check policies, and checklists in our daily practices. Certainly the situation in Haiti gave everyone a common cause and sense of purpose. It also can be said that a disaster naturally selects for a particular type of clinician and, therefore, the situation is biased. The results of their actions speak to the power of collaboration.

  What did we feel we achieved? Despite (or perhaps because of) the realities of disaster management in Haiti, clinicians and volunteers the wound care outcomes achieved may be attributed to the following:

Positive observations.
1. Clinicians were under a heightened sense of situational awareness due to the gravity of the situation, fear, excitement, and a sense of doing good. This observation led to increased concentration even for tasks assumed to be mundane. No task seemed too small or insignificant; this eliminated some of the “auto-pilot” mentality discussed in prior sections of this paper.
2. Clinical status and titles were not important. Despite the hierarchy required in a command center model in a disaster, at the operational level, tasks were assigned and completed based on urgent need and available personnel, not who has an advanced degree or more experience. Who performed which task was not as important as making sure the task was performed. The structure of reporting up the command chain was also based on central decisions of leadership and expertise and not the historical hierarchy of traditional medical care.
3. You had to rely on your team members. The work could not be accomplished without every one doing his/her part. Teams self-monitored and performed corrective action plans for those team members that could not or did not want to pull their load.
4. When you did not know how to do a task, you asked. No judgments were made; the information was simply transferred to you from someone who knew the answer.
5. Success was measured by patient outcomes not individual accomplishments.
6. The isolation from family and friends was difficult but allowed for intense bonding among clinical team members. This created a sense of teamwork and “family” that focused on patient care and helping each other to a much greater level than is experienced in our day-to-day practices. Nonmilitary clinicians get a small glimpse of this during residency but it is not often carried over into subsequent practice settings.
7. Complications, poor outcomes, and patient loss were analyzed on a system level, not an individual clinician level.

Negative observations.
1. Not all clinicians were able to break from their mental model of “The doctor is in charge” and “This is how I do it back home.”
2. Tendency to over-use the anesthesia tent for dressing changes due to efficiency and patient comfort can lead to “over-triage.”
3. Over involvement in the patients, hospital and “situation” led to many clinicians not taking care of themselves. Dehydration was common and many clinicians simply forgot to eat for many hours at a time.
4. The lack of medical records and minimal documenting became a convenient reason not to document important notes.
5. Although wounds were improving, the absence of photographic documentation and longitudinal follow-up may falsely create the sense of positive outcomes without evidence of the ultimate goal — ie, healing. Each team relied on surrogate endpoints due to limited time on the rotation.

Conclusion

  Based on the literature, military/disaster management practices, and our experiences in an earthquake-ravaged country, I propose:
1. All wound clinicians interested in disaster volunteering should take a course in mass casualty or disaster preparedness. The concepts triage and command center and the hierarchical military-like chain of command may not be tolerable for some clinicians. We experienced several clinicians who were unable to adjust to being told to perform certain tasks or procedures. Private practice autonomy can become a way of life and this abrupt change back to feeling like a resident or trainee was a hard transition for some clinicians. Clinical practice in a triage environment with an emphasis on overall good for the population also can create internal conflict for clinicians not familiar with the concept. Interested persons should consider the American College of Surgery course available at www.facs.org/trauma/disaster/dmep_course.html.
2. During the immediate postdisaster period, the majority of wounds are surgical and traumatic. Clinicians with little or no acute care or surgical experience might want to consider volunteering several weeks to months after the initial event. We experienced the early development of pressure ulcers during our stay and have heard back from subsequent teams that rehabilitation and chronic care needs became the most prominent need after we left.
3. Wound clinicians should gain experience in team building by joining multidisciplinary teams within their clinical sites. Courses in conflict management and leadership at the graduate level would be an advantage in these situations.
4. Clinicians need to volunteer through organized networks like Project Medishare. Although they are well-intentioned, clinicians often simply “show up”at disaster scenes. This occurred in New York City at the World Trade Center disaster. Without a structured program and organization, trying to ascertain the credentials and expertise of various “walk-ins” at a disaster scene becomes chaotic. In fact, these volunteers often create more confusion than help. A central organization can assess the needs at the scene and help appropriately deploy the needed expertise without duplication and waste.

  Per my experiences in Haiti, if clinicians recognized a hierarchy of planning and preparation that embraced an attitude of teamwork, likely their institutions would run better, patient satisfaction would improve, and high quality would be the norm. As we develop future wound care curricula, it is my hope that patient safety and disaster preparedness and management are included topics. It should not have taken an earthquake to shake us up to the fact that as healthcare providers, we are members of a team, and despite the fact we are humans who make errors, we are fortunate to be in the healthcare field where we can offer assistance and hope to people in need.

Acknowledgments

  There is a group of people, some I invited to join, some joined at the scene, without whom an article such as this would not be possible. I would like to personally thank Claudia Lee, MS, PT (my friend, colleague, and crutch); Stu Donnenfeld, RN (best home health nurse ever); Lisa Corbett, APN (if all APNs were like you, physicians all would be out of business); Kenny Gruber (professional volunteer, humanitarian, beautiful person — the common thread for us all); Anna Margarita Guerra Dumont, DO (outpatient wound clinic, boundless energy); Colin Briton, US Army Medic (our military security force!); Justin Dumont (Radar O’Reilly); Mary Duna, RN (peds nurse); Rachel McDonald, RN (peds nurse 2); Dr. Tom Rusing (procedure room, overall great guy); Sarah Sanford, RN (cot-mate of our team and friend); Barbara Bates- Jensen, RN,PhD (commander in chief!); John MacDonald, MD (the brain child of all things wound care international); and Rob Kirsner, MD, for his tremendous efforts in coordinating the hundreds of volunteers that applied to Project Medishare via the University of Miami and the score of surgeons, nurses, therapists, and medics whose names I either can’t place or don’t have room to mention. Thank you all. Lastly, to the people of Haiti, in our efforts to help you in crisis, we are the ones who likely benefitted the most. It is our hope that our efforts in some way made a difference.

Dr. Ennis is a Professor of Clinical Surgery, Chief Section Wound Healing and Tissue Repair, University of Illinois at Chicago, Chicago, IL. Please address correspondence to William Ennis, DO, MBA, University of Illinois at Chicago, Section of Wound Healing and Tissue Repair, 820-840 S Wood Street, 3rd Floor, Suite 376, Chicago IL 60612; email: w.ennis@comcast.net.