There I was, landing in a town cut off from the outside world by Mother Nature. The distinct sound of the Black Hawk’s four rotors broke through the thin air while horses ran freely and stunned children watched, amazed by the sight of a 12,000-pound machine slowly hovering and touching down on a wet field. For their mothers and fathers, this was a glimmer of hope. Despite all this, it was difficult to ignore the degree of destruction that surrounded us.

How My Journey Began

Dr. Trivino assisting in the resuscitation of a patient in cardiac arrest.
PHOTOS: Julian Trivino

On Sept. 21, 2017, I was sitting in conference at Florida Hospital when I got a text from one of my attendings: “Would you be interested in going to Puerto Rico [PR] next week?” The worst natural disaster on record had just struck the island of PR, and there were people in need of immediate medical attention. “YES!” I replied. I wanted to be on that island at all costs.

Many of my attendings at Florida Hospital had trained in PR, and although they had lived in the continental United States for many years, their hearts still remained on the island. Following Hurricane Maria, it was evident to them that there were discrepancies between the reports from the media and from physicians whom they had trained with on the ground. While the media reported improvements following the aftermath, the limited communication received by our team portrayed a picture of an island with incredible need for medical relief, supplies, and support. Due to power outages on more than 95 percent of the island, there was limited communication between hospitals, physicians, citizens, and the outside world, leaving the overall health of the Puerto Rican people in question.

As I boarded that flight, I left behind the mainland and any doubt regarding the reason I had chosen this specialty. I was born to do this. My heart filled with joy; my body, with excitement. As my colleagues—Katia Lugo, MD; Alfredo Tirado, MD, FAAEM; and Jorge Lopez, MD, FACEP, from the Florida Hospital emergency department and my fellow resident William Kotler, MD—and I arrived in PR with a plane full of supplies, we began to appreciate the challenges the island faced. From the plane looking down, a stream of lights stretching approximately two to three miles shone brightly, surrounded by darkness—a line of cars waiting to fill up with gas. Some cars had been there for more than 48 hours. The streets were otherwise empty due to a 7 p.m. curfew. Tons of rental cars were available due to the mass exodus from the island, but there was no gas. We caught a ride from an airport employee to our hotel, having to leave all of our supplies behind for the time being. At the hotel, we were met by locked doors and security, as the concern for looting became more prevalent with each passing day. In the hotel, we were greeted by staff ecstatic to see US physicians arriving.

Dr. Lugo, Dr. Tirado, Dr. Kotler, and Dr. Lopez inside the US Customs and Border Patrol plane that transported the team to Puerto Rico.
PHOTOS: Julian Trivino

The next day, we spent much of our time establishing provisional medical licenses to practice in PR. The PR Department of Health (DOH) had moved its headquarters to the convention center in San Juan; it had become a military fortress. Military personnel with automatic weapons surrounded the building. There we made contact with Norma Torres, the assistant to the secretary of the DOH. Through her, we were granted provisional licenses #001–004. She informed us that a nearby hospital in Aguadilla, which supported the entire northwest corner of the island, was on the brink of closing, and the PR DOH needed personnel to assess the current situation of the hospital and likely stay to work for a few days. Communication lines were down, so updates were being relayed to the DOH by townspeople making their way to San Juan in search of assistance.

At the Hospital

We arrived in Aguadilla the next morning as the sun was rising. The hospital sits adjacent to the ocean, and despite the level of surrounding destruction, it remained a beautiful sight. We were shown to the office of the medical director where hospital leaders were discussing shutting down the hospital within two hours. They were concerned about the lack of diesel fuel and potable water as well as their overworked staff.

As the medical director took us into the emergency department, one of the patients being held there went into cardiac arrest. There was only one physician for 30 beds, and she was busy tending to another critically ill patient. The medical director immediately sprung into action and started CPR. Our team and the remaining staff worked for more than 15 minutes to successfully resuscitate the patient. Within a matter of 10 minutes, we had walked into the emergency department, resuscitated a patient, and established rapport with the staff. Although the emergency department was hemorrhaging morale, our arrival lifted the spirits of nurses, techs, and other physicians who had been praying for help.

The emergency department in Aguadilla had no air-conditioning, and temperatures were 91–97°F at all times. The air was humid and smelled of disease. After just one hour in the emergency department, my scrubs were soaked and sticking to my body. We faced challenges I had never experienced in the United States. The first was managing septic patients with fevers of 103–106°F in a room that was only a few degrees cooler. We were short on antibiotics, normal saline, ice to pack axillas, central lines, and IV tubing. There were no imaging capabilities, only plain radiographs, without a radiologist to read images. To transfer a patient to a trauma center, we had to use our satellite phones and attempt to establish a connection while pointing the antenna to the clearest spot in the sky. With the help of Florida Hospital, within two days, we had a shipment sent on a private plane with many of the needed supplies. In addition to the Florida Hospital shipment, we received aid from the Federal Emergency Management Agency and continued support from PR DOH. After spending three days in Aguadilla, Ms. Torres asked us to return to San Juan for our next mission. They had heard via people coming from Aguadilla that the hospital had been stabilized.

Helping in Other Areas

Dr. Trivino reads a C-spine X-ray while outside the Aguadilla hospital in Puerto Rico.
Julian Trivino

The PR DOH began to hear of other towns in dire need of supplies, personnel, and acute care. Many of those with chronic illnesses were decompensating. Many had been out of medications since the hurricane began, and those with limited medications had no place to refill them. For many who lived on insulin, the lack of power and the heat and humidity had ruined their remaining insulin. Many pharmacies were having problems issuing medicines, as power outages limited their ability to contact insurers to verify and authorize prescriptions. We reached out to Florida Hospital for a temporary solution. They sent insulin and several commonly prescribed medications. Ms. Torres asked us to try to reach as many towns as we could, assess their needs, deliver medications, and treat anyone we could. Our travel was limited, as the road conditions were poor; driving at night was treacherous.

The solution to that problem arrived. Antonia Novello, MD, surgeon general during President George H.W. Bush’s administration, was a friend of one of the leaders of our group, Dr. Lopez. She came to join our team efforts. With her collaboration with the PR DOH and the U.S. Army, we were granted access to the 101st Airborne Division, who flew us to several hospitals throughout PR. We found needs similar to those seen in Aguadilla. On more than one occasion, care providers were forced to place acutely sick patients in ambulances and transfer them, without any notification, through harsh terrain and dangerous roads. Dr. Lugo and Dr. Novello came across an orphanage where kids were out of food and water. By the next day, with the help of the 101st Airborne, they had crates full of water and food.

After three weeks in PR, our team had been able to reach 28 towns and deliver medications, supplies, food, and water and provide medical care to thousands of patients. However, we did more than that. We lifted the spirits of the people of PR. The sight of joy and hope as we landed in desolate towns is now permanently embedded in my memory. It is a tribute to the simple truth that what we do as emergency physicians matters. I am grateful and honored to be part of this family and would never choose a different specialty.

Dr. Trivino is chief resident in the emergency medicine residency at Florida Hospital in Orlando.