Editor’s note: On September 6, 2017, Hurricane Irma ripped through a string of small Caribbean islands, with the eye passing over Barbuda, damaging approximately 95 percent of the buildings on the island. Surgeons from nearby Puerto Rico rushed to the rescue. Two weeks later, on September 20, Hurricane Maria made landfall in Puerto Rico, devastating the U.S. commonwealth and killing 499 people. This article recounts surgeons’ efforts to respond to both natural disasters.
The roar of the turboprop engine faded as Ramón K. Sotomayor, MD, FACS, a general surgeon and surgical oncologist, was preparing to disembark from the plane. He was among a group that included one surgeon, one emergency room physician, and one intensive care unit physician assembled through an initiative of the HIMA-San Pablo Hospital System, Caguas, Puerto Rico, to assist in the aftermath of Hurricane Irma, which devastated the islands of St. Thomas, Tortola, Barbuda, and a number of other Virgin Islands just a few days earlier.
Hurricane Irma moved over the northern Caribbean in early September as the strongest Atlantic basin hurricane ever recorded outside the Gulf of Mexico and the Caribbean Sea. While the eye of this super storm was projected to pass through Puerto Rico, most of the winds stayed to the north, and it felt more like the tropical storms to which islanders had grown accustomed. The northern Lesser Antilles, however, did not fare as well. Islands like Barbuda experienced 95 percent devastation to all infrastructure, and for the first time in more than 300 years, no human inhabitants remained on the island after the permanent evacuations.
Caribbean people, however, are resilient. For as long as can be recounted in written and verbal tales, the region suffers an economic setback each time a big storm passes through. Unlike large developed nations, the smaller islands have limited disaster recovery funds and even more limited crisis and emergency management plans—but in the words of a past-Prime Minister of Barbados, “It is the special character of a people who have survived and risen above slavery and indentureship, racism and the exploitation of colonization, and limited economic resources.”*
As soon as the storm left the region, medical teams from Puerto Rico were on the move to aid their island brothers and sisters. “As the plane banked over the island, it was heartbreaking to see,” said Dr. Sotomayor, who has treated patients in the British Virgin Islands through a collaborative partnership. “I had seen the islands many times from the air before, but this time it was different. The usual lush greenery was missing. One of the main clinics on the island of Bougainville was destroyed and the other one, Peebles Hospital, was running on a generator.” One of the local surgeons, Marjorie Yee-Sing, MB, BS, FACS, who has practiced in Tortola for some time, introduced Dr. Sotomayor to a number of patients. After reviewing their charts and examining them, he decided to airlift two of them for care at a tertiary center in Caguas.
Meanwhile, in Puerto Rico, Bolívar Arboleda-Osorio, MD, FACS, the author of this article, was taking care of a 74-year-old woman who had been flown in from St. Thomas. When she arrived in the emergency room (ER), she was noncommunicative. Initially, the ER team thought a neurologic baseline condition could be part of the problem because she arrived without relatives or a copy of her records from St. Thomas, but after ruling out any anatomic neurologic problem, we proceeded with her surgical care.
We knew she had abdominal pain for a week prior to her transfer to Puerto Rico. A computed tomography scan revealed a major process in her ascending colon, and we proceeded with an exploratory laparotomy. Intraoperative findings revealed the patient had necrosis of the posterior wall of the ascending colon, and a right colectomy with ileotransverse anastomosis was performed.
The hardest part was being unable to communicate with the patient or any relative. I managed to talk to her sister-in-law once via a military phone to explain her condition, but communication from St. Thomas was minimal, and no flights were leaving the island. After a week in the intensive care unit, the patient started recovering. It wasn’t until more than a week later she was able to communicate and finally understood what happened and why she was in HIMA-San Pablo Hospital.
What is unfortunate about this story is that during her recovery, a second storm—Hurricane Maria, a deadly Category 5 storm—directly hit the island of Puerto Rico.
Hurricane Maria roared mightily in the early hours of Wednesday, September 20, 2017. Having experienced Hurricanes Frederic (1979—Category 4), Hugo (1989—Category 5), Marilyn (1995—Category 3), Hortense (1996—Category 4), Georges (1998—Category 4), and many others in the past five decades, the 3.4 million residents of the Commonwealth of Puerto Rico thought they were adequately prepared with plywood, storm shutters, water, and batteries. With sustained winds of 155 miles per hour, the monster hurricane tore through the southeastern coast as it traversed the island. No other hurricane had had similar wind force since Hurricane Okeechobee (locally known as Huracán San Felipe) in 1928.†
On Thursday, September 21, the whole landscape had changed for the island of Puerto Rico. The El Yunque—the only tropical rainforest in the U.S. National Forest System—looked like a barren landscape, much like an early winter scene in New England when the trees are bare, waiting for the first snow. The majestic, weather-beaten fort of El Morro, however, survived mostly unscathed, keeping true to its purpose, in my observation, of defending the Spanish port city of San Juan from enemies.
The more modern buildings in San Juan, as well as the electrical and communication systems of the island, were decimated. More than 80 percent of the electric grid was destroyed, posing a major problem for all Puerto Ricans—and most notably health care, education, and emergency services. Hurricane Maria had created a humanitarian crisis at a time when Puerto Rico was the strongest supporter of its fellow island nations still reeling from the damage now of two storms.
“We are working with the emergency generator right now, and we have been able to get one of the operating rooms (ORs) running for the major trauma patients,” said Andrés Guerrero, MD, FACS, chief of surgery at Hospital HIMA San Pablo-Caguas, the day after the hurricane hit. Dr. Guerrero had been taking care of a 58-year-old gentleman who had been transferred from St. Thomas during the previous hurricane two weeks earlier. “He arrived with a small bowel obstruction after receiving an exploratory laparotomy in his home island and thank God was improving. We were in the process of preparing him to go back to St. Thomas when this happened.”
A week after Hurricane Maria, the situation was not much better. The electric grid was down in about 75 percent of the country and eight major hospitals in the island had to close. A number of dialysis units, home care centers, and other smaller health care facilities have closed as well. This is something I had never experienced in my 34 years as a physician. Our hospital was overloaded with patients who were transferred in from other institutions that fared worse than us. The OR was back to nearly fully functional status by the beginning of October, but the number of emergency cases we saw as late as December was incredible because such a large number of other hospitals have closed. In fact, during the first two weeks, the number of emergency cases at the hospital tripled. The dedication of our surgeons and all our staff is something to be proud about. We would have never in our wildest dreams thought that in such a short time we would go from being the rescuers to the rescued.
Relief efforts continue
On October 17, 2017, a surgical team from Operation Giving Back of the American College of Surgeons arrived in Puerto Rico to offer assistance in surgical care. At press time, no visiting surgeons remain on the island, as the assessment determined that the need was mostly for supplies and infrastructure rather than manpower. Caribbean people are a resilient people and we will continue to find purpose, gratefulness, and even joy in our most vulnerable time.
*Caricom.com. Resilience of Caribbean people will determine success or failure—former PM Arthur. March 27, 2015. Available at: http://caricom.org/communications/view/resilience-of-caribbean-people-will-determine-success-or-failure-former-pm. Accessed December 18, 2017.
†Fritz A. Puerto Rico has a long history with tropical storms. None of them were like Hurricane Maria. Washington Post. September 19, 2017. Available at: www.washingtonpost.com/news/capital-weather-gang/wp/2017/09/19/puerto-rico-has-a-long-history-with-tropical-storms-none-of-them-were-like-hurricane-maria/?utm_term=.ee0a11ee3c1c. Accessed December 18, 2017.