Stories From the Field:

TYPHOON HAIYAN

Mass General Supports Typhoon Haiyan Recovery Efforts with Project HOPE

A second team from Massachusetts General Hospital has been deployed to support medical relief efforts in the Philippines. This periodically updated blog from the team chronicles their work at the Tapaz District Hospital in the province of Capiz with Project HOPE.

January 22, 2014

Tuesday was spent at the clinic. We did more training on the portable ultrasound with prenatal visits. We continued our teaching on handwashing after the team had installed a bunch of CalStat containers around the clinic area. Finally, [the Rotation 3 leadership] were able to get a deeper understanding of this area and the flow of healthcare by interviewing the head of the midwives and the head of social service.

On the island of Panay, there is the province of Capiz. Within Capiz, there is the municipality of Tapaz. Tapaz is divided into barangays. This word is derived from the Spanish word barrio - neighborhood. There are 58 barangays in Tapaz. The health system is government run. Our clinic and hospital is under provincial control. The physicians who staff it don’t live in Tapaz but come in to do 48-hour shifts and then leave. There is little continuity of care and the doctors are not invested in the hospital. Patients have to pay for their care.

The central Tapaz clinic is under municipal control and is much better resourced. There is only one physician, but there are 17 midwives, and even more nurses. A lot of the care is free. Next door to the clinic is the mayor’s office. There is also the department of social welfare and development, DSWD. There are two social workers in the Tapaz municipality.

When we asked the municipal leadership about their biggest challenges, they said quite simply: disasters. There are always little disasters – storms, etc. with local damage and then people will request aid. But Typhoon Yolanda affected the whole municipality. Everyone was affected. Everyone had damage or had family members who were severely affected. 

On Wednesday, we had an outreach clinic at the elementary school, “Candelaria”.  We saw, collectively 623 patients and 300 to pediatrics! Again, most of the visits are for primary care and prenatal checks. Most of the women we saw had delivered their babies at home.

January 20, 2014

We did a clinical outreach at a very poor elementary school called Taslan. We set up the same stations in different school rooms as we did last week – peds, adults, dental, circumcision, and as a new twist - hair cutting. The circumcisions and hair cutting were done by the ever-present army.

We collectively saw 450 patients with more than half being pediatric cases. In a sad little classroom with no electricity, or lights, we did a bunch of prenatal checks and a lot of primary medicine. While most people came out of curiosity and with chronic, low-grade complaints (headache, dizziness, back pain, abdominal pain, chronic skin ulcers/rashes), we also saw some extraordinary illness. We were all struck by how many people had very serious, uncontrolled hypertension (diastolics over 100) – in about 32% of the adult patients. This is a public health crisis.

January 17, 2014

On Friday, we had clinic and hospital time for half the team while the other half journeyed 2 hours to Iloilo, the biggest city on Panay, to find CalStat containers for our project on hand washing and other supplies. We made a CalStat/Purell-type hand washing station with 2/3rds isopropyl alcohol and 1/3 hair gel. Then, the team went over to the clinic and hospital and put them up all over the place.

A bunch of people came to the hospital’s emergency room after being hit by a gravel truck. They were stuffed into a local small bus called a jeepney. A jeepney is what you'd get if you crossed a jeep with a bus. Jeepneys are the main mode of public transportation in most towns, and are used for both local and long-distance transport in the Philippines. Everyone got thrown into the road.  Saw lots abrasions and swollen heads. One woman was seen for being “nervous” after falling in the road.

Day 5 ended with an amazing hike with two soldiers for security up to a mountain area that they thought was safe. We emerged up on a volcanic lake ringed by mountaintops that looked like teeth. Lots of green and randomly interspersed roofs form houses that had blown off in the typhoon.

The volcanic lakeside had tons of caribou munching of delicious looking for vegetation.

January 13, 2014

Note: Rotation 3 with Project HOPE arrives in Philippines. Updates are from Rotation 3 Team Leader

After dropping our gear at the house, we went straight to the San Antonio school where a clinic had been set up. We spent 3 hours seeing patients.  The other Project Hope volunteers who were already on the ground, had been working for a few hours already. The system they set up was as follows: patients come into the first classroom and get an initial assessment (what is your chief complaint, blood pressure check), then into next classroom where there were 3 separate desks set up with a clinician and another Project HOPE volunteer who was a native speaker. From our arrival to the end of the clinic, we saw 235 patients were seen - 134 adults. Most of the people had cough and runny nose and headache as their main complaints. I did not think any of them had infections and wondered if there was something in the environment.  These people are very weathered.

January 3, 2014

Doctors and nurses went to the hospital and clinic to assist in care again today.  Our staff started clinic early in order to prevent patients from waiting in the small, congested waiting area. The team taught TB isolation to the local doctor and the chief physician today. One of the challenges facing the local team is limited availability to tuberculin testing to perform the Tine Test, meaning they have to rely on X-rays for diagnosis. 

The team also revisited San Miguel-Ilwod today to ensure there was adequate space for our outreach. So, two outreaches will be back-to-back, Jan 6th, Garcia and Jan 7th, San Miguel-Ilwod, then Rotation 2 will begin to exit and Rotation 3 will begin arriving.

January 2, 2014

Rotation 2 worked at the rural hospital and clinic.  A total of 72 patients were seen today. Our doctors and nurses were the only staff at the clinic, running it the entire day, seeing adults and children. Please note that the numbers may be misleading as this was a Thursday – local market day - and school is still out (possibly a reason why we saw more children). Also, note census at the hospital dropped from 34 to 17 over New Years, even ICU patients were discharged – families were insistent in taking their patients home.
January 1, 2014

Rotation 2 returned to Iloilo for pharmaceutical supplies and to shop for the day. A few stayed behind to work on inventory and to enjoy the peace and quiet of the house. Rotation 2 was invited to a New Year's Day Family Reunion next door and the group enjoyed karaoke to finish out the evening.
December 31, 2013

For New Year’s Eve, Rotation 2 took a ride into Iloilo today for a boat ride around the islands and a lazy day on the beach of Iloilo.  The groups treated themselves, the drivers and security to Starbucks while in town.  The trip was a major hit with the group and definitely a morale booster.

December 29, 2013

The team continues to pitch in at the local clinic and hospital, and we have been working with local staff to identify potential areas for further in-service trainings for the local staff. The team also completed two medical outreaches over the past 4 days. The first clinic saw >350 patients over the course of 6 or 7 hours on a very sunny Friday. Our second mobile clinic saw just over 230 patients on a rainy Sunday. As with the first outreach, the patients were mostly in good health; a few people presented with heartburn and infections, and multivitamins were distributed liberally. Project Hope will be scouting additional barangays for two more outreach clinics in the next week.

We are beginning to shift our focus to long-term planning for Project Hope in the Tapaz district. The goal is to develop health delivery capacity in the region in conjunction with the existing infrastructure, eventually handing over the project to the local community.

December 23, 2013

The final members of Team Bravo arrived in Tapaz without incident. The team was met by the Team Leader and oriented to the field location and clarified in-country rules and regulations. The team broke into groups to work at both the hospital and clinic. We also scouted two sites for mobile medical outreach for the coming weeks and identified local schools in San Nicholas and Katipunan as appropriate. The community leaders are enthusiastic for our arrival and staffing at the mobile clinic site will be both Project Hope and local hospital/clinic staff.

The Project Hope team was also invited by the community to attend a Christmas party for persons with disabilities. Team members were asked to give impromptu speeches with were very well received by the local community.

December 20, 2013

The second (Bravo) deployment with Project HOPE has begun with the arrival of the new team leader. Our first few days on the ground have largely spent getting a feel for the day-to-day activities of the medical volunteers, learning how the house is run, and having early discussions on future phases of the mission in Tapaz.

Twelve new volunteers arrive tomorrow and the final departures of the Alpha as well. We are planning onboarding activities for Saturday and hopefully a trip to the local hospital on Sunday afternoon. We will also have a briefing meeting on Sunday night before we start medical work on the mission objectives. We will likely keep close to the hospital and clinic in Tapaz for the first week while laying the groundwork for several mobile clinics in the outlying barangays over the following two weeks.

Nutrition has again been voiced as a concern for the local populations we visit during the mobile clinics. Because neither acute malnutrition nor underlying food insecurity have been quantitatively determined, surveillance will be a priority for the Bravo volunteers. We also hope to leverage our contacts with the World Food Programme to advocate for additional food resources for our region.

December 19, 2013

The first team with Project HOPE has returned back to Boston and the Massachusetts General Hospital. A second team is now in the field and will be updating this blog as telecommunications allow.

December 17, 2013

The fifth and final medical outreach was an incredible success; everything was left “on the field.” Nearly 200 patients were treated, bringing the total patient count well over 1,000 during the course of our team’s outreach efforts.

Our mental health team met with elementary school teachers to discuss disaster experiences and reactions, with each person volunteering a personal story and tearful support from all in our group. In response to our previous concerns about malnutrition in some of the areas around Tapaz, UNICEF has delivered 150 sacks of rice, 1 kilo per student per day, infant feeing kits and Dignity Kits, cookware and family necessities.

December 16, 2013

Today resumed the extensive medical outreach mission; this was the fourth of five planned rural outreach missions. This operation took place in barangay Artuz, the most remote location Project Hope has visited to-date. The mountainous roads were narrow, large enough for only a single vehicle to pass at a time, with sharp ravines on either side of the road way. Almost none of the road was paved or improved; the rented vans did an excellent job following existing ruts up the steep incline.

The site of operations was yet another elementary school. The typhoon’s destruction was most prevalent here, as there is little abatement from the elements and very exposed. Additionally, it is extremely difficult to transport repair materials and supplies in this mountain community. The team was met by approximately 100 villagers and the school principal led a prayer before we began offering medical evaluations, thanking God for our presence in their village – in her words we were the answer to their prayers, we were “their hope.”

The people of Artuz have many of the same disease of those found in the United States such as hypertension, diabetes mellitus, asthma and tuberculosis. We also observed some cases of malnutrition, presumably due to the destruction of crops from the typhoon. Children <5 were measured using the mid-upper arm circumference (MUAC) scale to diagnose malnutrition. Project Hope provided medical consultation, wound care, OB evaluations, and medicine distributions in similar fashion to the previous outreach missions. In all, more than 300 patients were seen.

In the evening Peggy and Melissa went to the Tapaz Clinic to give them some supplies. They also held an in-service training on using bag valve masks for resuscitating both adult and pediatric patients. The nurses were very pleased with the training and the new equipment for the clinic.

December 14, 2013

Members of the team visited four surrounding hospitals with functioning operating rooms to gain a better understanding of the standards of care used in the region and to provide feedback to our partners on upgrades needed for the OR at the Tapaz District Hospital.

December 13, 2013

Our third outreach effort began with a wonderful greeting upon our arrival to the Cristina Barangay elementary school. Kindergarteners were singing ‘We Wish You a Merry Christmas’. With some seasoned help from the clinic, our physician saw over 85 patients. He is now known by all as “Santa Claus.”

We continued to establish and operate a wound care and critical care area. In addition to some very ill patients, wound debridement and burn dressings were also common. We also worked in the pharmacy, at barangay Christina outreach, over 317 patients were seen and 99% received meds from the pharmacy. It was a very busy day. Chief complaints varied from dizziness, cough, runny nose, fever, pain, loss of appetite, inability to sleep, back pain & joint pains. Some of these complaints are recent but some have been going on for months or years.

December 12, 2013

Last evening, we held a disaster-focused psychiatric training with our group. It had excellent participation and was well received.

This morning, some of the team met with the head of the Social Welfare Department and reviewed the records to see if concerns about food insecurity are credible. Although no claims or requests from local social representatives for more food have been made, NGO agencies involved with food security are welcome in the region.

Our team also met the headmaster of the Central School, pre-school thru 12th grade. 68% of their students have returned after the Typhoon. After introductions and orientation to disaster psychiatric issues, 14 head teachers from area schools were invited to talk about their experiences and school situations.

Members of the team also reviewed the anesthesia equipment at the hospital and believe that additional parts would be needed to fix some of the machines.

The team leaders traveled to Roxas City to send updates to the Global Disaster Response team in Boston and personal messages to family and friends for the entire team. They spent the majority of the day at the Capital Building Command Center, where Canadian military forces, UN aid workers, Red Cross volunteers, and local government agencies were working together to organize outreach programs across the Philippines in response to the Typhoon. We made contacts for local food and shelter clusters, who may be better equipped and prepared to respond to the critical need in these areas, in tandem with our medical outreach efforts.

Some of us went to a barangay clinic with the midwives to assist with prenatal checkups. Once a month, the midwives visit each town to monitor the pregnancies and aide any persons who are unable to make the trip to the hospital. It was approximately a 45-minute drive up the mountain through rough terrain.  Most of the people here use motorcycles for transportation. As women draw closer to their due date they are unable to drive to the town clinic, so it is important to have these smaller clinics available.  Each time a woman becomes pregnant a paper chart is written. Her vital signs, weight, EDC and fundal-height are recorded. The fetal heart tones are also recorded. The patient takes home the chart and returns it the following month. The Midwife keeps a list of the pregnant woman and monitors closely those who do not come to their checkups.  When Typhoon Yolanda hit on November 8th many of these records were destroyed. The new records are based on mom’s recollections.

The clinic was recently built. It is constructed out of cement block. The interior is clean and bright but has only limited equipment.  We were able to donate nine electronic Litman stethoscopes so the midwives will be able to hear fetal heart tones.

December 9, 2013

All of the MGH team traveled to Iloilo City to utilize high speed internet and acquire supplies for Tuesday’s outreach.

In general, team morale is extremely high – the team is well integrated and complimentary in personalities and professional capabilities. One week down, two weeks to go. Mission is proceeding smoothly, continuing to stay within the mission statement and accomplish critical objectives.

December 8, 2013

The focus of today was preparing for the outreach planned for Tuesday and Wednesday. As a group, along with the rest of the Project Hope volunteers, the MGH team worked to sort 120 boxes of medical supplies. The boxes were separated into 3 groups: supplies going to the Hospital, clinic, and to the outreach.

After sorting, the boxes were loaded into vans and 2 Philippine military trucks. We then helped to deliver the supplies to the clinic and hospital - everyone was so grateful. The team also helped to suture a facial laceration from a motorcycle accident with local anesthetic.

After freshening up, the entire Project Hope team was invited to a Christmas celebration for the kids of all the barangays.

Finally, all boxes were opened and the medicines and supplies were sorted in preparation for Tuesday’s outreach.

December 7, 2013

The MGH team dedicated Saturday to the construction of the temporary roof covering over the emergency room, patient area, and laboratory space at the Tapaz District Hospital. During the rain patients are often found holding their umbrellas inside the waiting room due to the damaged roof caused by Typhoon Yolanda. Utilizing UNICEF tarps and some locally purchased materials, the MGH team and two local workers covered the roof in order to prevent water from leaking onto patients and staff - this was listed as a top priority by hospital administration and staff. With tools and supplies costing less than 2,000 pesos (or approximately $50 US dollars) the roof was repaired with seven hours of labor. The hospital chief physician and nursing staff were visibly appreciative of the effort; numerous “thank-you’s” and good will wishes were exchanged. Umbrellas are now left at the door.

A member of the team was warmly greeted by the nurses and staff who participated in the disaster stress group and introduced to their children as Santa Claus, so they helped distribute gifts from the trolley the whole staff wheeled to each patient in the hospital. There was much laughter for all.

December 6, 2013

The Chief Medical Officer of the hospital requested we do a stress relief program for hospital staff, which combined didactic presentation of emotional and behavioral aspects of disaster combined with participants discussing his and her experiences, behavior and emotional responses during the typhoon and now. Mutual recognition and support of all was effective and, in the CMO’s words, “enlightening.” All felt this was effective and satisfying. Our Filipino team member and the Chief Nurse translated several dialects and assisted the presentation to the 40 participants.

The MGH team continued to treat patients in the minor surgical procedure room. Today’s focus was on wound care. A 7 year old male patient received second degree burns from contact with a motor vehicle exhaust pipe. MGH staff brought antibiotic cream and burn relief gel, items which are otherwise unavailable here at the hospital. By utilizing MGH staff and equipment, treatment is provided to patients nearly, or in some cases completely free of charge - an obvious, noticeable benefit the community. A crudely dressed wound from a recent c-section procedure was cleaned and dressed, and multiple foot injuries incurred from local infrastructure repair were treated, cleaned, and dressed.

Final measurement and material procurement was performed in order to emplace a temporary roof patch on the emergency room. This was described by the chief nurse and hospital administrator as the number on infrastructure priority. At this time, patients are exposed to inclement weather when seeking consultation or assistance from the emergency room. Our intent is to provide an immediate, effective, but temporary measure to alleviate this problem while awaiting more permanent repairs.

Our Filipino colleagues continue to serve as the interpreters for different team members, patients, families, and staff. Today, the team started with celebrating the birthday of the lady who has breast cancer and poor prognosis. During the celebration, the lady stated that “this is the best day of my life.”

Thursday is Market Day, a day that the people from the various barangays (part of the municipality) come to town to shop and to see the doctor. The clinic was full of patients when they arrived then directed to the hospital. The patients that were seen were dressing changes or prescriptions to be picked up until the doctor arrived for “consultation”.  As at the hospital their supplies are limited and supplies brought by our staff were utilized ie; sterile gauze and triple antibiotic ointment for dressing change. The hospital staff is highly trained and very resourceful; they effectively utilize the limited supplies they have.

December 4, 2013

Wednesday was very busy, the clinic was filled. Starting with motorcycle accident, the MGH team did initial screening, triage and evaluations along with clinic staff. As the local municipal health officer was away, all patients would have to be sent on to the hospital. The MGH team was asked to fill in which he did with staff understanding there would be a low threshold for hospital referral. The usual quota of 30 patients was exceeded, 40 patients being seen!  The patients are initially triaged by the nurses with most severe cases first, the elderly second, minor injuries and complaints last. We were all pleased.  20% of visits were related to symptoms or injuries due to the Typhoon others were cough, fevers, motorcycle accidents, burns and pre- and post-natal care.

A cursory examination of the hospital roof, especially over the emergency room where patients wait while exposed to the elements and weather, was conducted by the MGH team. After climbing the roof, it was apparent that a temporary “tarp” covering was in place to retard the influx of rain. The entire roof appeared to be in disrepair, and it is recommended that professional or local contracting services could be utilized to make interim repairs while awaiting government support. This would, at least, improve the morale of patients and hospital health care workers, who are, at present, remain exposed to rain during inclement weather while awaiting consultation with physician; in some cases, patients bring umbrellas into the hospital to keep dry.

The MGH team spent time going around the different departments of the hospital together with the Chief Nurse. As the Project Hope representative requested the team to find out what their “wish list” is, the Chief Nurse was more than willing to tell us what they were. Their central supply room is bare. Od sewing machines make surgical drapes, gauze and sheets. Old Foley catheters are used as tourniquets. The EKG machine is non-functional. The only equipment in the ICU is an oxygen tank. There is one charge nurse & one medication nurse with several “casual nurses” (similar to the per diem nurses) to care for patients. The medication nurse prepares all medications ahead of time and nurses use a simple kardex plan. As the team went thru all the different wards, they were able to talk with each patient and their families. They were very open to talk about their experiences and challenges during and after the typhoon. There were several children admitted with asthma, fever and diarrhea. All the patients in the men’s ward came in with cough or asthma attacks as chief complaints but after talking to them, all admitted to be being smokers since they were kids. One of the Project Hope volunteers is a Palliative Care Nurse and has offered to give an in-service on palliative care to the nurses, who were highly receptive to this. Continuing medical education opportunities are rare at the hospital. The nurses are very receptive to any educational instruction that the MGH team can offer.

December 3, 2013

The MGH team headed to Tapaz District Hospital in the province of Capiz, Philippines. Our team of 6, along with other Project Hope volunteers toured the hospital with Chief Nurse and met with the Director of the hospital. Tapaz District Hospital is a 25-bed secondary hospital that serves an average of 25 patients but can scale as high as 50 in crisis situations. Services include Internal Medicine, Family Medicine, Obstetrics, and Emergency and Trauma Care. Due to Typhoon Haiyan, patient volumes have surpassed capacity and seriously depleted hospital supplies.

The first day focused on seeing clients with lacerations, puncture wounds, and minor trauma. One of our team is from Iloilo, Philippines and speaks the dialect. He has become our interpreter. One specific case involved a male farmer in his late forties who incurred a severe foot laceration while “tilling soil.” The resulting wound required debridement, irrigation, and eight sutures to adequately approximate the edges and close the wound.  A clean dressing, a week long course of oral antibiotics and analgesics as required were provided; the patient was instructed to return in one week for follow-up and make every effort to “keep the wound clean.”

At the clinic, the MGH team met and talked with staff, oriented to clinic procedures, and got to know a bit about each other. We were invited to join staff for lunch at a local restaurant, which they hosted, being so grateful for our coming to help. They then took us for a walk to the main square and shopping area.