The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response

Ofer Merin, M.D., Nachman Ash, M.D.,
Gad Levy, M.D., Mitchell J. Schwaber, M.D.,
and Yitshak Kreiss, M.D., M.H.A., M.P.A.
New England Journal of Medicine
03 March '10

Within 48 hours after the massive earthquake that struck Port-au-Prince, Haiti, on January 12, the government of Israel dispatched a military task force consisting of 230 people: 109 support and rescue personnel from the Israel Defense Forces (IDF) Home Front Command and 121 medical personnel from the IDF Medical Corps Field Hospital. The force's primary mission was to establish a field hospital in Haiti.

We landed in Port-au-Prince 15 hours after leaving Tel Aviv and began to deploy immediately. The first patients arrived at our gates and were admitted even before the hospital was fully built, within 8 hours after our equipment arrived. In its 10 days of operation, the field hospital treated more than 1100 patients.

Our mission was to extend lifesaving medical help to as many people as possible. The need to manage limited resources that fell far short of the demands continuously presented us with complex ethical issues. Every mass-casualty event raises ethical issues concerning the priorities of treatment, but the Haiti disaster was exceptional in several ways. Haiti is a poor country with minimal civil facilities, and the earthquake's destruction of infrastructure left millions of people homeless and hundreds of thousands in need of medical assistance. When we arrived, there was no functioning authority coordinating the distribution of the available medical resources. We were faced with the challenge of establishing an ethical and practical system of medical priorities in a setting of chaos.

Our hospital was designed to contain 60 inpatient beds, including 4 in the intensive care unit (ICU). It had one operating room with a single table. In view of the initial absence of functioning nearby medical facilities and the dire need for medical services, we extended our hospitalization capacity to its maximum of 72 patients and added a second operating table.

Under normal circumstances, triage involves setting priorities among patients with conditions of various degrees of clinical urgency, to determine the order in which care will be delivered, presuming that it will ultimately be delivered to all. After the Haitian earthquake, however, it was impossible to treat everyone who needed care, and thus the first triage decision we often had to make was which patients we would accept and which would be denied treatment. We were forced to recognize that persons with the most urgent need for care are often the same ones who require the greatest expenditure of resources. Therefore, we first had to determine whether these patients' lives could be saved.

Our triage algorithm consisted of three questions: How urgent is this patient's condition? Do we have adequate resources to meet this patient's needs? And assuming we admit this patient and provide the level of care required, can the patient's life be saved?

In the first days of our deployment, most of the patients we saw had recently been removed from the rubble. The majority had limbs that were compromised by open, infected wounds. Untreated, open fractures meant infection, gas gangrene, and ultimately death. Clearly, the sooner after injury the patient received medical attention, the better his or her chances of survival. Late-arriving patients who already had sepsis had a poor chance of survival. But there was no clear cutoff time beyond which patients could not be saved; each case had to be evaluated individually.

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