After-Action Report

January 22, 2014
Fatal motor vehicle collision
Aquin, Département du Sud, Haïti

Scene of fatality - Route National 2, Département du Sud, Haiti

Scene of fatality – Route National 2, Département du Sud, Haiti (Jan. 22, 2014)
Photo: M. McGee ©Trek Medics Intl 2014

Complied by:
Michael McGee, M.Ed., EMT-B
Project Coordinator
Trek Medics International
mmcgee@trekmedics.org
February 11, 2014
 
With participation from:
l’Équipe Communautaire pour le Réponse aux Urgences (ÉCRU)
Haitian Resource Development Foundation (HRDF)
Aquin Hospital

Download the pdf version here

Note: In an attempt to maintain coherence and continuity of effort in addressing the lack of emergency medical care in Haiti, this after action report has adapted content and format from the report, “After-Action Review for January 16, 2012 Port-au-Prince Mass Casualty Incident”, co-authored by International Medical Corps, the Haitian Ministry of Health (MSPP), and Haiti State University Hospital (HUEH) department of emergency medicine. This report was written following the Delmas 33 mass-casualty incident that claimed 29 lives and resulted in over 50 more injured on January 16, 2012, in Port-au-Prince, Haiti.

* * * * *

Introduction to After Action Reports
The completion of an After Action Report (AAR) is a standard process in improving emergency and disasters response, most frequently completed within 90 days of an incident. To the extent possible, After Action Reports should be developed jointly by all relevant stakeholders and should emphasize improvement of emergency management and systems at all levels.

After Action Reports serve to:

  • Document response activities
  • Analyze the current emergency and disaster care systems
  • Identify problems and successes during emergency operations
  • Propose measures to counteract problematic elements and mitigate future disasters

 

Disclaimer
Due to the limited scope of the incident described herein, the objective of this AAR is to detail the events and obstacles that regularly inhibit effective emergency medical response in the Southern Department (Département du Sud), described within the context of a single incident involving the death of Obeld Dorival on January 22, 2014. It should also be noted that, in some cases, and owing in part to the fractious and chaotic nature of emergency response and transport in Département du Sud, bystanders, eyewitnesses and clinical professionals at times expressed an unwillingness to answer questions for fear of punitive actions that, while ambiguous in their explanation, were felt to be real. To respect the wishes of those interviewed, this report does not include names when anonymity was requested.

* * * * *

INCIDENT BACKGROUND

On January 22nd, 2014, at approximately 5:00 A.M., local time, a motor vehicle collision occurred between a small pickup truck and a large dump truck on National Route #2, approximately one mile east of the city limits of Aquin, Haiti. Traveling in the pickup were four people, the driver and passenger sitting in front, and Obeld Dorival (the deceased) and another passenger sitting on the gunwales of the bed of the pickup.

The exact nature of how this accident occurred is still unclear as reports from eyewitnesses at the scene, and from individuals involved in removal of the vehicle vary. Some at the scene of the accident report that the dump truck pulled eastward onto National Route #2 without looking; others report that the dump truck was stationary in the middle of the road. There is also speculation that the vehicles may not have been appropriately lighted – given the date and time of the accident, it would have still been dark.

Photos of the pickup truck taken post-incident indicate that the front passenger-side of the pickup struck the side of the dump truck. The front end of the pickup sustained significant damage, and the roof of the cab seemed also to have been impacted. However, the passenger compartment itself showed limited signs of intrusion. As a result of the impact, according to bystanders and friends of the deceased, the driver and passenger sitting in front and one of the two riding in back sustained mild, non-critical injuries. However, Dorival fell from the gunwale of the truck bed where he was sitting and struck his head on the ground.

Photo: M. McGee ©Trek Medics Intl 2014

Photo: M. McGee ©Trek Medics Intl 2014

* * * * *

DISCUSSION OF RESPONSE BY LEVEL

I. COMMUNITY FIRST AID

Summary of Response
Vehicles passengers and bystanders were on-scene to provide the initial response. Eyewitnesses to the collision helped rescue the injured. It is unclear the extent to which the community members provided first aid according to evidence-based guidelines.

Conclusions
The current status of first aid knowledge and training known to community members is unclear; as are the means by which existing emergency medical response organizations in Aquin can be alerted.

Recommendations

  • Perform a Knowledge, Attitude and Practice (KAP) study of access to emergency care and first aid in Département du Sud
  • Provide increased community emergency response training

 

* * * * *

II. DISPATCH

Summary of Response
Efforts made to reach out to existing, established community responders – including the local Croix Rouge, Protection Civile, Équipe Communautaire pour le Réponse aux Urgences (ÉCRU), or police – were not reported. Due to the comparatively isolated location of the incident, it is also unclear as to eyewitnesses’ perception regarding the ability to alert these organizations via telecommunications.

Conclusions
Département du Sud lacks a unified and well-publicized emergency dispatch system.

Recommendations

  • The Government of Haiti (GOH) should work with national telecommunications providers and local emergency response agencies to establish a unified emergency line for police, fire and medical
    • This unified number should be heavily publicized through a sustained community outreach and media campaign
    • The coordination center should have a system to disseminate information to local emergency response agencies in their respective catchment areas
    • Requests for emergency assistance can then be transferred to local agencies
  • All medical dispatch should be unified under one agency in the Ministry of Health (MSPP), specifically the National Ambulance Center(CAN)
    • CAN should be the only agency in charge of the medical dispatch center, with the ability to accept and triage calls, and to then forward this information to local jurisdictions
    • There should be a MSPP designee in charge of emergency medical dispatch and triage
    • CAN should have the contact information for, and be in regular contact with, all available response agencies and/or personnel

 

* * * * *

III. EMERGENCY TRANSPORT

Summary of Response
No local emergency medical responders were on-scene to transport. Witnesses at the scene of the incident transported Dorival to Aquin Hospital – approximately 10 minutes away from the scene of the collision. The decision to transport was made based on proximity to the nearest clinical facility. It is uncertain how much time elapsed between the accident and their arrival at the hospital.

Conclusions
Triage and transport decisions in Département du Sud are made on an individual and ad hoc basis. There is no unified system for hospital notification.

Recommendations

  • There should be a unified call list for all hospitals, with a number that is always available in case of patient transport
  • Emergency personnel should have a system and equipment to alert receiving hospitals of incoming patients
    • They need phones and/or radios to do this
  • Hospitals should have a phone available 24-7 to receive such calls

 

* * * * *

IV. HOSPITAL-BASED CARE

Summary of Response
Dorival was first treated at Aquin Hospital. Because the incident occurred within relative proximity of Aquin hospital, transport decisions were made based on distance, and without knowledge of available capabilities. Upon arrival at the hospital, Dorival was seen by the Haitian Medical Director,[1] Dr. Pierre-Richard Lessage. In a follow up discussion after the incident, Dr. Lessage reported that Dorival arrived in critical condition. According to Dr. Lessage, he and hospital staff provided the care that they could with the resources at their disposal. However, Dorival ultimately needed a more advanced level of care not available at the Aquin hospital, or in any other hospital in the Département du Sud.

Conclusions
Aquin Hospital provided emergency care to the patient to the best of their capabilities.

Recommendations

  • A minimum standard of care should be available within all clinical facilities regularly attending to patients with time-dependent medical conditions
    • Refurbishment of emergency care facilities with emergency care equipment should be undertaken to meet minimum standards of emergency medical care[2]
  • A future triage and dispatch system should be able to better distribute patients to receiving hospitals so that facilities receive patients corresponding to their capacity
  • Clinical facilities should improve their coordination with pre-hospital providers
    • Clinical facilities should have improved equipment for communication with pre-hospital providers
    • Clinical facilities should develop disaster drills and incorporate local emergency response agencies into these drills
    • Aquin Hospital should serve as a center for excellence for training pre-hospital providers in Département du Sud
    • Aquin Hospital should pilot the training of Tap-Tap drivers and other community members to improve access to emergency care networks

 

* * * * *

V. INTER-FACILITY TRANSFER

Summary of Response
Due to limited capabilities, Dorival was referred to the Médecins Sans Frontières (MSF) emergency care facility in Léogâne, approximately 2 hours and 30 minutes from Aquin, to receive a higher level of care. The vehicle used for this transport was privately owned, as the local hospital does not have any emergency transport capabilities.

Upon arrival at the MSF facility in Léogâne, Dorival was turned away for undeclared reasons. According to some of the first responders interviewed for this report, this may have been because he had already been provided basic care at another facility. They elaborated that in their experience transporting patients to this facility and others, they will often remove any bandages or IVs that the patient already has from other facilities for fear of not receiving care. It is unclear how accurate these claims are.

A further conversation between a first responder from Aquin and an employee from the MSF facility in Léogâne reported that the facility’s services are currently being scaled back. Therefore, it is likely that the specialists needed to treat Dorival may not have been present, or that they may not have had the capacity to receive another patient with his status at that time.

Dorival was subsequently transported to the State University Hospital in Port-au-Prince (HUEH). It is uncertain why this hospital was selected – whether they were directed there by those at the MSF facility, or if they made this transport decision on their own – and why no other hospitals in between were considered. Shortly after his arrival at HUEH, Dorival died sometime around 9:00 AM in the morning.

Conclusions
There is a lack of communication and coordination between referring and referral facilities in Haiti for patients with critical, time-dependent conditions. Patient transfers are left to unskilled drivers when appropriate medical transport vehicles with proper equipment and staffing are unavailable. There is no uniform protocol for deciding to initiate an inter-facility transfer or providing palliative care in instances of perceived medical futility.

Recommendations

  • MSPP should establish guidelines for inter-facility transport in Haiti
    • There should be a universal phone list for facilities
    • Facilities should be available for contact 24-7
    • Facilities should be called and accept patients before transport
    • Protocols should be established to assist clinical providers in decision-making regarding medical futility
  • Facilities should have trained drivers available 24-7 to carry out transfers using appropriate vehicles
    • Transfer protocols should be established to dictate drivers’ actions during transport

 


[1] Aquin Hospital has two Medical Directors, one Haitian and one Cuban

[2] See World Health Organization’s Guidelines for Essential Trauma Care and Integrated Management for Emergency and Essential Surgical Care (IMEESC) for low-cost/high-impact improvements

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