College of American Pathologists
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  Lab turns field hospital into one that’s more real


CAP Today




May 2010
Feature Story

Anne Ford

David M. Andrews, MD, had been running the laboratory of the University of Miami/Project Medi­share field hospital in Port-au-Prince for all of two days when the girl with the clenched jaw arrived. Like many of the Haitians being seen in the hospital at that point—a few weeks after the Jan. 12 earthquake—she was not there to be treated for wounds from the quake. Instead, the 14-year-old presented with a gaze defect and decorticate posturing, in addition to the tightened jaw.

The University of Miami clinicians who saw her, a neurosurgeon and an infectious disease specialist, consulted Dr. Andrews, who is associate professor of clinical pathology and director of the special coagulation laboratory at the university. Each had come to him separately to say they had an unusual case and were not sure what it was. It “kind of looks like tetanus,” he recalls one of them saying. The three came together to discuss the puzzling case. Performing a lumbar puncture was an option, but doing an LP in the field setting was risky. Dr. Andrews “nudged” the clinicians into performing the procedure, he says, believing that the benefits of better diagnostic insight into the girl’s condition, which the new lab made possible, would outweigh the risk.

Given the conditions, the clinicians could hardly be blamed for worrying about subjecting a young girl to a risky diagnostic intervention. In the 200-bed field hospital that the University of Miami Miller School of Medicine set up (now administered primarily by Project Medishare) on the grounds of the Port-au-Prince airport shortly after the earthquake, volunteers sleep on cots in a giant tent, potable water is at a premium, and on at least one occasion, oxygen regulators have had to be hastily assembled from spare parts.

But despite their improvised surroundings, Dr. Andrews and the other pathologists who continue to volunteer in rotation at the field hospital have been able to drastically improve care for the Haitians treated there. With the help of technologists and companies that have donated laboratory equipment and supplies, pathologists are helping to treat not only patients with acute earthquake-related trauma but also “everything from complicated pregnancies to abscesses to encephalitis,” Dr. Andrews says.

Take the case of the girl with the clenched jaw: “We were able to spin her crystal-clear CSF down, look under the microscope, and see a lot of lymphocytes, which, in combination with her clinical symptoms and other laboratory results, pointed to a viral picture,” he says. “It just completely illuminated her diagnosis. They treated her, and she got better.”

The University of Miami has been active in providing medical care in Haiti since long before the recent quake. In 1994, two physicians from the medical school—Barth Green, MD, professor and chair of the Department of Neurological Surgery, and Arthur Fournier, MD, professor and vice chair of the Department of Family Medicine and Community Health—founded Project Medi-share, a nonprofit affiliated with the University of Miami’s Global Institute that provides health care services to orphanages, schools, and communities throughout Haiti.

So when the recent major quake hit, “there was an almost immediate mobilization,” says Richard Cote, MD, professor and chair of pathology. “It was within a week that some infrastructure actually began to be built. It eventually resulted in a tent complex that housed an operating facility, inpatient and outpatient facilities, and the accommodations of the volunteers there. And it was at about that time that I began to ask: ‘Well, what’s happening with pathology?’”

“What I was concerned about,” he continues, “was that there was extensive trauma surgery and care of trauma victims going on, without any pathology backup. You couldn’t even get a hematocrit or a urinalysis, let alone a chemistry panel, CBC, or anything having to do with an infection. The only laboratory services available were on the USNS Comfort, the Navy hospital ship, that was located in the harbor shortly after the earthquake. So we started to mobilize.”

Dr. Cote recruited the help of former CAP president Thomas Sodeman, MD, University of Miami’s chief of laboratories and vice chair of pathology, who immediately began requesting donations of equipment and supplies from several companies that make laboratory instruments suitable for use in field conditions. Chempaq, Olympus, Abbott, BD, Roche, Hemocue, Inverness, and BioImagene all responded with generous donations. “The companies were very, very good,” Dr. Sodeman says. “They recognized the problem, they responded appropriately, and we were able to get together the equipment and the donations. They contributed probably close to a quarter of a million dollars in products and reagents.”

The first University of Miami pathology team to deploy consisted of Dr. Andrews and medical technologist Juan Garcia. The two arrived in Haiti via a Medishare flight about three weeks post-quake with 45 boxes of equipment and supplies. “After we landed, they wheeled up the stairs to the airplane, and the pilot said, ‘We’ll need some help getting the luggage off the plane,’” Dr. Andrews remembers. “All the passengers got into a chain, and we passed luggage down to be loaded into the back of a truck.” The Port-au-Prince airport looked nothing like he had ever seen. “The first thing you see is nothing but military people from many different countries. There’s this giant fissure splitting the terminal—this jagged crack running from the roof to the floor.”

Once they got to the field hospital, Garcia and Dr. Andrews set up the laboratory in a spare corner of a tent that housed pediatric patients. “What we did was to set up a microscopy station with basic stains and a laboratory testing station that could provide basic chemistry panels and renal function and hematology results and urinalysis,” Dr. Andrews says. “Tissue and tumor biopsy, things like that—those were not the issue at the time. What was needed were the basic laboratory tests.” Everything was improvised. “There were some carpenters down there who cut us a tabletop out of plywood. We duct-taped the plywood to a couple of examination tables, and that became our microscopy station.”

Before leaving for Haiti, Dr. Andrews had strategized with Dr. Sodeman about the type of equipment that would work best in the country’s high temperatures. “Having limited air conditioning and no running water—that eliminates 99 percent of laboratory products that could be used,” Dr. Sodeman says. However, the field hospital was equipped with fairly reliable electricity and refrigeration, allowing for the use of point-of-care or POC-like devices, such as the i-Stat analyzers and cartridges that Abbott donated.

Abbott manager of customer services Jeannie Stephens-Newbert says the company was delighted to be able to assist the university’s efforts by supplying devices that work well in field conditions. “The i-Stats were used extensively after Hurricane Katrina” in New Orleans, she points out. “In a disaster relief situation, they’re absolutely perfect because they’re small, handheld, and battery-operated. The cartridges are also small, you don’t need a lot of blood sample, and you get your results displayed immediately on the screen.”

Best of all, the i-Stats could be easily cooled, Dr. Andrews says. “It’s very hot in Haiti, and a lot of the instruments have temperature ranges in which they operate. Above a certain temperature, they just don’t run. We had these cool packs, the kind of things you get when you ship a Styrofoam container. We were rotating cool packs between the freezer and the instruments. We were able to keep the instruments cool by putting the packs next to them, and that saved us.” With those packs, they were able to generate results consistently.

At the time that Dr. Andrews arrived, “the vast majority of patients were earthquake-related injuries, typically orthopedic injuries,” he says. “Many patients had amputations or significant orthopedic repairs with external fixation.” Over the course of his initial 12-day stay, the patient demographic shifted to include conditions and illnesses that were either not related or indirectly related to the earthquake; after all, “people get sick when they don’t have their normal, life-sustaining shelter, food, and water,” Dr. Andrews points out.

He remembers, for example, the case of a 19-year-old woman who had lost both her parents in the earthquake, and who was brought into the hospital malnourished and dehydrated with “rip-roaring pneumonia and a full-blown case of depression,” he says. “I was able to get a beautiful Gram stain of her sputum, and she responded to antibiotics, but then her disposition became a major problem because she was so depressed. She didn’t break her leg, but [her condition] was earthquake-related. She was eventually treated and discharged.”

Another case involved a young woman who presented with a grossly enlarged knee. The field hospital’s orthopedic surgeon “opened her knee, and he found a tumor mass and was able to give us a piece,” Dr. Andrews says. “I did a touch prep of the tissue, and got some beautiful images by holding my digital camera to the ocular of the microscope. I sent them to Miami—the hospital had very limited Internet bandwidth—and they made it to Boston, to one of the leading bone and tissue pathologists in the country, Andrew Rosenberg, who helped make a diagnosis of osteosarcoma.” (Andrew Rosenberg, MD, is professor of pathology at Harvard Medical School.)

Sustaining Dr. Andrews’ spirits throughout all of this was the knowledge that having a functional laboratory “was transformational to the practice of the hospital,” he says. Before the laboratory was up and running, “the question of whether someone was in renal failure was, ‘Well, are they urinating or not?’ If they were trying to decide whether someone was anemic, they would just look at their mucosal membranes and decide yes or no.” Coming into those conditions, “we had a huge impact on the level of care right away.”

Two of the university’s clinicians who were volunteering in the field hospital at that time agree. “The lab turned a field hospital into more of a real hospital,” says James D. Guest, MD, PhD, associate professor of neurological surgery. Before the laboratory was set up, he says, “every decision that was made was made on clinical judgment. But there are certain issues that can’t be resolved at all using clinical judgment.” Among the conditions made diagnosable by laboratory results, he says, were renal failure stemming from crush injuries, tuberculosis, and malaria.

Another grateful University of Miami clinician is Eddie Island, MD, director of pediatric liver and GI transplantation. “You can check a patient’s pulse, look at their eyes and fingers, but it’s really not the same as having a number to hang your hat on,” he says. “The institution of these very basic tests made a tremendous impact in terms of the care we could provide.” He appreciated, too, what he calls Dr. Andrews’ “on-the-spot service”: “Obviously there was no computer system where results could get put into. As soon as he had a result, he would go and find the physician who was interested in it. It was a lot of good old-fashioned communication.”

About halfway through his initial stay in Haiti, Dr. Andrews was asked to become the field hospital’s chief medical officer for the remainder of his time there. “It was an honor,” he says. “I used to joke that in Haiti, resources are used creatively, and an interesting manifestation of that is how the pathologist becomes the chief medical officer in a hospital. But it was a wonderful experience.” In his role as CMO, his chief duty was to coordinate patient transfers, which sometimes entailed petitioning the government for a humanitarian visa so that a critically ill patient—such as the Haitian teenage boy who was diagnosed with an aggressive leukemia—could be flown to the U.S. for treatment.

Dr. Andrews has made more trips to Haiti since then, and so have many volunteer pathologists and laboratorians from the United States and Canada. The question now is when and how the field hospital will transform into a permanent, brick-and-mortar facility. “The hospital cannot remain as a tent hospital on the grounds of the airport permanently,” he says. “If an airplane struck the hospital, you’d have two disasters. And a tent hospital in the rainy season is going to be severely compromised.”

Meanwhile, the University of Miami Department of Pathology has implemented a longer-term strategy to support pathology in Haiti. A telepathology unit donated by digital pathology solutions company BioImagene will be set up, “so that we can provide real-time consultation for biopsies and cytologies that are performed in Haiti,” Dr. Cote says. “That, we believe, will be really an outstanding resource.” He would also like to see the university eventually provide U.S.-based training opportunities for Haitian pathologists and pathology trainees.

The physicians who have donated their time and services to the field hospital find themselves reflecting on what Dr. Island calls “a very intense and profound experience.”

Actually, he says, “the most telling experience wasn’t a medical experience. There was a six-year-old child who had devastating wounds to her lower extremities, and she was coming in for wound care. When it was time for us to care for this child, it was her father who picked her up out of the cot and brought her into the procedure room. He waited until the procedure was done, and then he runs back to her cot area and dusts it off as best he can so his child can have a clean place to lay down and recover. To me, in the middle of all this chaos, that was one of the most telling sights that I observed—how people go to great lengths to do the right thing.”

Anne Ford is a writer in Evanston, Ill.

In addition to those mentioned in the story, the following University of Miami Department of Pathology residents, medical technologists, staff, and faculty members were deployed to Haiti or assisted in the relief effort: Timothy Cleary, PhD; Douglas Karsch; Clara Milikowski, MD; Jay Radtke, MD; Naomi Montague, MD; Charles Glenn, MD; Maria Coll; Marlene Perez; Sarita Paulino; and Ashley Smith (Baptist Hospital). Many volunteers from numerous other institutions throughout the U.S. and Canada have served in the field hospital laboratory.


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