Problem: If EPs wait for big organizations to act, they will miss their real need.
As soon as I saw the scale of disaster in Haiti I knew I wanted to respond. But because I was on the West Coast, I was unprepared to respond to the Navy’s call to join the USNS Comfort. I then wasted a week looking for another group, finally joining Team Rubicon, an NGO that had only been formed the week prior by people like me who just wanted to do something.
Take Home:
If you want to be able to respond in the first wave of relief, have a relationship with a team of like-minded individuals or an organization that is ready to respond on a moment’s notice.
Problem: With infrastructure gone, first responders can be a burden to the host country.
The first element of Team Rubicon was made up of former military medics and firefighters. They carried their own tents, food, and gear, enough to last for a week. Being first, they lacked equipment and meds, especially narcotics, to handle many cases that they saw. Only when the second element arrived, a week later, did the team have the needed meds and equipment.

Take Home:
Have a relationship with a supply chain that will provide the needed meds, including narcotics, on short notice.

Problem: Relief efforts are really expensive.
Team Rubicon wisely committed from the beginning to publishing their activities on the web, thus raising much needed cash in a very short period. But their initial response was done out of their own cash. Regardless of what VISA says in their advertisements, banks and ATMs were not functioning during the disaster. During the initial days of the deployment the team routinely spent up to $1000/day on a variety of unforeseen needs. Getting home was another problem. While the military opened up humanitarian flights and other NGOs operated flights, Team Rubicon had a logistics person working this issue every day.

Take Home:
Team members must have access to and be willing to carry large sums of cash. You must also reserve cash and a plan for getting home.

Problem: Having a contact once you arrive at ground zero.
Having a local contact that can be trusted is absolutely imperative. Team Rubicon members made contact with a Jesuit brother named Jim Boynton through one of the team members who had attended a Jesuit high school. Brother Jim made the contact with the local Jesuit mission in Haiti. Lacking such a connection, the team members might have found themselves camping in a location where security was an issue. Moreover, contact with the base at home is crucial. Current technology allowed members to stay in touch through satellite phones and internet uplinks.

Take Home:
Build a list of contacts for places you are willing to go. The more information the better as communication may be limited in a disaster. Religious NGOs are good contacts for this. They commonly have the trust of the locals and basic facilities from which to work. Also, be prepared with reliable communication, whatever the cost.


Problem: Sometimes there is no one to whom to refer serious cases.
First responders found themselves handling crush injuries and open fractures with no hope of immediate follow-up by surgeons. Many field amputations were performed by physicians who had never done such procedures. Even when orthopedic surgeons began arriving they were quickly overwhelmed and soon out of orthopedic appliances. When the USNS COMFORT arrived on station, there were 1200 patients waiting to be air lifted to tertiary care. Needless to say it didn’t happen over night.

Take Home:
Plan on bringing supplies to clean wounds, splint the worst kinds of open fractures, provide prophylactic antibiotic coverage, and pain control for several days. Then develop priorities for handling once secondary help begins to arrive.

Problem: Doctors and nurses flee local hospitals, leaving them unattended.
Jake Wood, the leader of Team Rubicon, was a former Marine and is currently a firefighter EMT. Nevertheless, at one point early on he was the highest-trained individual on site at the University Hospital.

Take Home:
First responders who are simply offering to “help” may need to step up and lead, at least for a time, if the local professionals have fled, been killed, or incapacitated by the situation.

Problem: How do I keep from making enemies of the locals?
On my first trip to Haiti some years ago I felt very threatened by the locals. This time they seemed very warm and accepting of Americans. However, as it became known that many people had received amputations of limbs and children had been evacuated with few documents, many became more suspicious. Most situations were resolved with better communications, but taking time with each patient and not seeing them as just part of the larger picture remained a challenge. Our group, many being former military, had very functional military clothing. But wearing it made us look like we were foreign invaders. American firefighters are always proud to wear tee shirts emblazoned with uber-American catch phrases, but these are unintelligible to the locals and insulting to many foreigner aid workers. I found that by wearing scrub tops, or a lab coat, even dirty ones, I was easily recognizable as a doctor, a universal symbol of aid, and given respect and assistance.

Take Home:
Don’t allow yourself to get caught up with the thought that you can do anything just because it’s a disaster. People still require, and deserve, communication. Laws still apply, and you are still a foreigner. Just ask Laura Silsby. Also, identify yourself readily as a caregiver so that others will know to come to you and will assist you.

Problem: How do you integrate with all the other people wishing to help.
The hospital where I took more urgent patients was staffed by American doctors, nurses and paramedics, along with a French contingent of the same. There was constant criticism and bickering between the two groups. Eventually, the French cordoned off their area and told the Americans not to touch their patients or even go in the tents with their patients. This lead to much confusion in the post-op care process. One patient even died from neglect. Even Doctors Without Borders made it clear that they didn’t want help from physicians not affiliated with their organization.

Take Home:
Be prepared to work with organizations from around the world with different medical standards and differing views of Americans. Knowing multiple languages always helps.

Problem: How do you know when to go home?
It was clear from the first day that Haiti’s medical needs would go on for a long time. And yet, there came a clear point when it seemed that the larger organizations were in place, doing good work, and the immediate crisis was moving into a new, sustained phase. Even though we knew that a second wave of infection and malnutrition was around the corner, we had to face the fact that the time for our little group of emergency care givers was over. Leaving Haiti was like walking out of the ER with the waiting room still full. You just have to trust the next shift.

Take Home:
Coming full circle, you have to remind yourself that the emergency medicine portion of a disaster does come to an end, giving way to others with more assets.


# Mark, Outstanding After Action ReportJeff 2010-03-03 21:08
Splendid observations and possible solutions. Chile happened too soon, but we will get it figured out
# Asa Church 2010-03-04 00:38
Although I am not a doctor, I was fascinated to read your lessons learned. It's great to turn a great act of mercy toward others into a learning lesson for us. Thanks to Logan for linking this article to the EPMonthly Twitter account. I followed it here!
It is terrible to hear about the bickering between various aid groups but I am naive to be surprised.
# Medical Logistics Officer/Team Leader, TR2Gary Cagle 2010-03-08 02:00
Hey Mark,

I am in the DR, and will fly home tomorrow!!

When I get back, we have a lot to talk about...in the meantime, your AAR is one of the most succint, detailed, and yet to the point that I have read.

Talk to you in a day or so...

# RN, Team Rubicon 2Dee Spina 2010-03-12 02:41
I concur with Gary. Well written and to the point. I have mixed thoughts however on the military aspect. Not because of my affiliation but for safety reasons. We never know when things will get out of control, I believe the "uniformed" members help stave that off. Also, the day we departed, the local police refused to let us go the airport. Everyone else driving through - not us. If Gunny had not flashed his military ID and made his "presence" known, I don't know what would have happened at that street corner.
Lastly, thank you for touching on a subject that was so dear to me. Just because it's a distaster, doesn't give us the right to just rush in and do whatever without communication. I always (with a translater) asked permission to touch and provide care. I truly believe the Haitian people appreciated that. Not to mention it is the ethical and moral thing to do. I have to do it here, so I have to do it there....period.
Thanks for listening. Hope to see you again soon.


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