The US Navy hospital ship USNS Comfort played an integral role in the initial phases of Operation Unified Response–Haiti following the devastating earthquake that struck near Port-Au-Prince, Haiti, on January 12, 2010. Deployed to Haiti from its home in Baltimore, Maryland, just 4 days after the earthquake, the USNS Comfort would become the region's primary tertiary casualty receiving center for 6 weeks. The pathology and laboratory department staff onboard the ship helped support the mission and experienced unique mass casualty/disaster relief scenarios while underway. This article reviews the accounts of the core laboratory, microbiology, anatomic pathology, and blood bank divisions on the USNS Comfort from the chaotic first few weeks to the final patient discharge 40 days after Operation Unified Response–Haiti began.

At 4:43 pm Eastern Standard Time on January 12, 2010, an earthquake measuring 7.0 on the Richter scale hit the island nation of Haiti. The epicenter occurred approximately 25.7 km west of the nation's capital, Port-Au-Prince, a city of 2 million people. The earthquake resulted in approximately 230 000 deaths and an additional 300 000 injuries. Additionally, there was near total devastation of the Haitian health care infrastructure. Four days later the USNS Comfort, a US Navy hospital ship docked in Baltimore, Maryland, was mobilized, and on January 19 began seeing earthquake-related patients as part of Operation Unified Response–Haiti (OUR-H). The USNS Comfort, anchored off the coast of Port-Au-Prince, was quickly able to provide tertiary-level medical care for the most critically wounded patients. Unlike other recent earthquake relief efforts, such as Iran in 2003 and Kashmir in 2005, there were minimal evacuations to other land-based facilities in Haiti, a result of the nation's geographic isolation. This resulted in the USNS Comfort being the primary trauma facility for evacuation of life- and limb-threatening injuries. During the ensuing 40 days, the crew of the ship would process 1056 admissions, perform 843 surgical procedures (including 669 trauma-related extremity procedures), conduct more than 3600 radiographic studies (including 626 computed tomography scans), and reach a maximum inpatient census of 411 patients. This article tells the story of the experiences of the clinical and anatomic laboratory teams as they provided clinical support on the USNS Comfort's disaster relief mission in Haiti.

The USNS Comfort laboratory staff embarked from Baltimore, Maryland, on January 16 with 30 US Navy active-duty personnel assembled from multiple Navy medical treatment facilities across the country. All personnel were given between 24 and 72 hours to pack their personal belongings, travel to Baltimore, and assemble on the ship. The USNS Comfort is designed to function maximally as a 1000-bed patient-trauma facility with a 50-bed casualty receiving area, an 80-bed intensive care unit, 12 functioning operating rooms, and a 20-bed Postanesthesia Care Unit. The laboratory department that supported this capability during OUR-H was separated into 6 distinct divisions: core laboratory, microbiology, cytology, histology, morgue, and blood bank. Although all 6 divisions fell administratively under the same medical director, they were staffed by individuals with specific skill sets in each area who were chosen by the Navy's medical leaders shortly after January 12 to deploy for this disaster-relief mission. The core laboratory team consisted of a medical director, who also functioned as the sole pathologist on the ship; a laboratory officer, acting in the capacity of a laboratory manager; and 16 laboratory technicians. Although a microbiologist was not on the mission, 4 microbiology technicians, working in conjunction with an infectious-disease specialist primarily assigned to the internal medicine service, handled the extremely busy and complex microbiology section. The anatomic pathology sections were fortunate to have 1 experienced technician who was certified in both histology and cytology and thus able to manage both areas by himself. He also served as the morgue technician. Although no postmortem examinations were performed during the deployment, the morgue was heavily used during the first 3 weeks of our 40 days of clinical operation. The final division, and arguably, the most significant during a surgically intense mission, was the blood bank. It was staffed by 1 blood bank officer or manager and 6 blood bank technicians. These 30 individuals made up the complete laboratory/pathology staff which worked 24 hours a day, 7 days a week, in a combination of both mass casualty and tertiary medical facility scenarios for 40 days.

One of the busiest areas of the entire ship during the first weeks of OUR-H was the core laboratory (Figure 1). Nestled one deck above the casualty-receiving areas and the main operating rooms, the core laboratory was somewhat secluded from the main patient-intake areas, but nevertheless was just as chaotic. In the laboratory, like all departments on a ship, there is maximum use of the limited space available. Although not as well equipped as many land-based tertiary care facilities, the USNS Comfort is able to provide appropriate laboratory support with automated equipment for analysis of blood chemistries, hematology, serology, and urinalysis. The workhorses of the laboratory were the 2 Vitros 5,1 FS chemistry analyzers (Ortho-Clinical Diagnostics, Piscataway, New Jersey), 2 Vitros ECiQ analyzers (Ortho-Clinical Diagnostics), and 2 Ac•T 5 Diff CP Hematology analyzers (Beckman Coulter, Brea, California). Starting on January 19, 2010, and extending to February 27, 2010, when the final Haitian inpatient was discharged from the USNS Comfort, the core laboratory performed 3402 diagnostic tests (not including microbiology tests). These tests were broadly distributed into 4 general categories (Figure 2). The most common chemistry test performed was the basic metabolic panel, composed of sodium, potassium, carbon dioxide, chloride, blood urea nitrogen, creatinine, and glucose, and it was ordered 877 times. The primary hematology test ordered was the complete blood cell count, run 1250 times. As would be expected when entering a mass-casualty scenario, the volume of specimens received in the laboratory rapidly approached maximum capacity. During the first 48 hours of continuous medical operations, 184 patients, almost all with critical, trauma-related injuries, were admitted and 344 laboratory tests were performed. The daily volume of tests performed remained greater than 100 tests per day for 21 of the first 22 days of the mission with a maximum of 224 tests on Saturday, January 23.

Figure 1.

The core laboratory onboard the USNS Comfort.

Figure 1.

The core laboratory onboard the USNS Comfort.

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Figure 2.

This graph illustrates the relative percentages of core laboratory tests performed from January 19, 2010, to February 27, 2010, onboard the USNS Comfort (n  =  3402).

Figure 2.

This graph illustrates the relative percentages of core laboratory tests performed from January 19, 2010, to February 27, 2010, onboard the USNS Comfort (n  =  3402).

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Human immunodeficiency virus seroprevalence in Haiti is 2.2%.1 The infectious disease physician and clinical laboratory team, working together on the hospital ship's Infection Control Committee, discussed the best approach to evaluate for the presence of this infection at the outset of the mission. Given that the ship had limited quantities of rapid human immunodeficiency virus test kits (OraSure Technologies, Inc, Bethlehem, Pennsylvania), it was decided not to screen every patient that came onboard. Rather, testing was limited to those patients with a high clinical suspicion of human immunodeficiency virus infection as well as USNS Comfort staff who were exposed to high-risk blood and body fluids. Fifty-eight rapid human immunodeficiency virus tests were performed with only 1 patient testing positive. No confirmatory testing was performed because of lack of availability.

Malaria is endemic in Haiti and the USNS Comfort core laboratory had the ability to perform malaria testing using the rapid BinaxNOW malaria kit (Binax, Inc, Scarborough, Maine). Testing on the ship was limited to those patients with a strong clinical suspicion for infection. One patient was diagnosed with Plasmodium falciparum infection (46 total tests performed by the hospital laboratory). The patient had a high parasitic load, and gametocytes were present in the peripheral blood smear during light microscopic evaluation. Despite aggressive medical intervention, the patient died from clinical cerebral malaria. Although there were more than 1000 people working aboard the USNS Comfort, all of whom were taking prophylactic antimalarial medication, there was not 1 documented case of malaria (as of the last day of the mission) among the staff and crew.

The injuries sustained as a result of the earthquake were primarily extremity fractures, with many open fractures exposed to the environment. Orthopedic surgeons on the USNS Comfort performed 669 extremity surgical procedures, including 122 femur fracture repairs. Twenty-one patients were admitted with previous amputations that had been done at field hospitals in Port-Au-Prince, Haiti, in the days leading up to Comfort's arrival. These types of injuries, in conjunction with the lack of a public sanitation system in the aftermath of the earthquake, lent themselves to infections.

A total of 725 patient specimens were submitted to the microbiology laboratory for culture; of these, 266 (36.7%) recovered at least 1 organism. According to the guidelines from the Clinical and Laboratory Standards Institute,2 all isolates were identified by both manual biochemical testing and automated procedures with the use of the MicroScan AutoSCAN-4 (formerly Dade Behring Diagnostics [now Siemens Healthcare Diagnostics Inc], West Sacramento, California). The microbiology technicians performed more than 300 antibiotic-susceptibility reports manually, using the Kirby-Bauer technique, including phenotypic confirmation of extended-spectrum β-lactamase production using clavulanic acid.

Cultures submitted to the microbiology laboratory were classified into 7 different categories: wounds, blood, cerebrospinal fluid, urine/stool, respiratory, surveillance, and other. Wound cultures were primarily taken from debrided soft tissue and bone, purulent drainage from abscesses, and swabs of amputated extremities. Many wounds were infested with various worms and maggots, including 2 wounds from 2 separate patients' faces that recovered multiple Cochliomyia hominivorax screw worm larvae. There were 209 blood cultures performed (>90% of which were aerobic) using a single BD BACTEC 9050 blood culture analyzer (Becton Dickinson, Franklin Lakes, New Jersey). Of those, 46 cultures (22%) were positive for aerobes with 4 (2%) being polymicrobial. Of 160 urine cultures, 37 (23%) were positive for bacteria, with the most common isolate being Escherichia coli, occurring mostly in catheterized patients. Five of the 12 isolates of E coli (42%) were confirmed extended-spectrum β-lactamase producers, and of the 4 isolates of Klebsiella pneumoniae in urine, 3 (75%) were confirmed extended-spectrum β-lactamase producers. Multidrug-resistant Acinetobacter baumannii infection appeared early in the mission, and the presumed index patient contracted meningitis while at a shore-based facility. Following diagnosis of that index patient, surveillance cultures of the groin were taken from patients in the intensive care units, and 8 patients were deemed to be clinically infected with the organism.

Parasitologic analysis of stool included trichrome staining as well as serologic enzyme-linked immunosorbent assay microplates for Campylobacter, Cryptosporidium, Giardia, Shiga toxin, and E coli. There was one case of a young child passing the helminth Ascaris lumbricoides in feces.

The anatomic pathology laboratory and gross pathology room played a relatively small role in this mission. The compact gross pathology room was equipped with a single Tissue-Tek VIP 5 tissue processor (Sakura, Torrance, California), a Cryotome cryostat (Thermo Fisher Scientific, Waltham, Massachusetts) for potential intraoperative frozen sections, and other standard histology equipment, including a water bath and microtome to prepare glass slides from formalin-fixed, paraffin-embedded tissue (Figure 3). Hematoxylin-eosin staining was performed on all cases, and a small cadre of special stains (periodic acid–Schiff, Gomori methenamine silver, acid-fast bacilli, and Fite) were available at the request of the pathologist. No immunohistochemical staining was available. As previously mentioned, most surgical cases involved orthopedic trauma repair and amputations with no clinical diagnostic dilemma. In addition to the 21 patients who had amputations before arriving on the USNS Comfort, another 37 patients underwent primary limb amputation while onboard. Several of these 58 amputees underwent multiple revisions, resulting in 64 of the 113 anatomic specimens (57%) being extremity soft tissue and/or bone. The distribution of cases by anatomic site is indicated in the Table. Although only 6 placentas were received in pathology, including 1 twin placenta, there were a total of 9 children (8 deliveries) born on the USNS Comfort. Three malignant-tissue diagnoses were made during the mission, including an infiltrating ductal carcinoma of the breast, a chondroblastic osteosarcoma of the femur, and an orbital squamous cell carcinoma in a patient with xeroderma pigmentosum.

Figure 3.

The USNS Comfort anatomic pathology gross room.

Figure 4. The blood bank on the USNS Comfort.

Figure 3.

The USNS Comfort anatomic pathology gross room.

Figure 4. The blood bank on the USNS Comfort.

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Surgical Pathology Caseload on the USNS Comfort During Operation Unified Response–Haiti 2010

Surgical Pathology Caseload on the USNS Comfort During Operation Unified Response–Haiti 2010
Surgical Pathology Caseload on the USNS Comfort During Operation Unified Response–Haiti 2010

The cytology service generated 8 Papanicolaou tests, 1 urine cytology, and 32 cerebrospinal fluid cases. The laboratory was equipped with a single ThinPrep 2000 processor (Cytyc, Marlborough, Massachusetts) and one trained cytotechnologist. Seven of the 8 Papanicolaou tests (87.5%) were negative for dysplasia, with 1 test (12.5%) revealing atypical squamous cells of undetermined significance. On cytologic evaluation, 2 of the 32 cerebrospinal fluids tests (6%) showed markedly increased neutrophils, consistent with meningitis. These were eventually confirmed with microbiologic cultures and included 1 case of Acinetobacter baumannii meningitis.

The USNS Comfort has a morgue facility onboard capable of storing 23 bodies. A total of 33 bodies were kept in the morgue for varying lengths of time between the first death on January 21 and the last on February 13. Twenty-nine of the bodies were patients who died while onboard the USNS Comfort, and the remaining 4 were brought already deceased to the ship from other sites solely for the purpose of keeping the body stored in the morgue. Most of the deaths were related to trauma and secondary infections that occurred as a direct result of the earthquake. Acinetobacter meningitis following trauma (1 case, USNS Comfort received the patient already infected), cerebral malaria caused by Plasmodium falciparum infection (1 case), and a suspected case of pulmonary embolism in a patient recovering from polytrauma (1 case) were also causes of death on the mission. Given that approximately one-third of the patients seen on the mission were pediatric patients, it is not surprising that 13 of the 29 deaths onboard (45%) were children younger than 18. The bodies of those who did not have identified family members onboard with them were kept in the morgue for 72 hours while the Haitian Ministry of Health attempted to locate family members on shore. If the Ministry of Health was unable to identify the family within 72 hours, the procedure was to transport the bodies via boat or helicopter to a Ministry of Health–established site in Port-Au-Prince, Haiti, with a temporary morgue facility. For those deceased with family onboard the USNS Comfort, the body and family were brought back to Port-Au-Prince, Haiti, via boat or helicopter and, through coordination with the ship's Patient Administration Department and nongovernment organizations, such as United States Agency for International Development, they were returned to their villages or towns. No postmortem examinations were performed during OUR-H because of an agreement reached with the Haitian Ministry of Health.

The USNS Comfort has a robust blood bank with the capacity to store 5000 fresh and frozen units of packed red blood cells (RBCs) in 8 blood-storage Revco refrigerators (Thermo Fisher Scientific Inc, Waltham, Massachusetts) and 8 ultralow (−80 degrees) freezers (So-Low Environmental Equipment Co, Inc, Cincinnati, Ohio) (Figure 4). The blood bank can also house fresh frozen plasma and cryoprecipitate and has a platelet incubator designed to hold 10 apheresis platelet units. The ship left Baltimore, Maryland, on January 16 with 49 units of RBCs, 20 units of fresh frozen plasma, 2 viable units of cryoprecipitate, and no platelets. A supply lifeline was quickly established with the Armed Services Blood Program Office in Falls Church, Virginia, and it was able to keep the ship supplied with a variety of blood products via air transport throughout the mission. The blood bank staff was also able to deglycerolize 46 units of frozen RBCs for transfusion using the 5 ACP-215 deglycerolizing machines (Haemonetics Corp, Braintree, Massachusetts) in the blood bank. For the first time in USNS Comfort history, and at the request of the trauma surgeons, platelets were brought onboard, stored, and used intraoperatively. Platelets have a shelf life of only 5 days, which indicates the efficient manner in which they were transported from the donor site in the United States to the USNS Comfort deck, a process involving multiple stops, which was routinely completed within 48 to 72 hours. For the mission, 177 type and crossmatch and 60 type and screen tests were performed. In addition, 348 units of RBCs, 16 units of fresh frozen plasma, 12 units of platelets, and 1 unit of cryoprecipitate blood products were transfused in 36 days with no documented transfusion reactions. During the first 21 days of OUR-H, an average of 14 units of RBCs were transfused daily, with the maximum number of RBC transfusions in a single day being 27 on January 21 (Figure 5).

Figure 5.

Units of red blood cells (RBCs) transfused daily on the USNS Comfort from January 20, 2010, to February 24, 2010 (n  =  348).

Figure 5.

Units of red blood cells (RBCs) transfused daily on the USNS Comfort from January 20, 2010, to February 24, 2010 (n  =  348).

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Figure 6.

USNS Comfort in Haiti during Operation Unified Response 2010.

Figure 6.

USNS Comfort in Haiti during Operation Unified Response 2010.

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In the aftermath of the Haitian earthquake, the USNS Comfort was quickly activated and within 7 days was functioning as the primary tertiary care referral center in the area (Figure 6). This was an unprecedented disaster relief mission for the hospital ship in terms of volume and acuity of critically injured patients. For the clinical providers to adequately and appropriately manage this mass casualty scenario for several weeks, the anatomic and clinical pathology departments needed to provide rapid and accurate clinical support. Faced with the unique challenges of a floating hospital, the laboratory staff used their knowledge of specialty and equipment, improvisation, and a tireless spirit to assist in providing the highest level of care to earthquake victims treated on the USNS Comfort.

The authors would like to recognize the entire USNS Comfort medical team for their extraordinary efforts and cooperation throughout OUR-H. Their spirit and teamwork inspired the laboratory team to keep providing support despite many agonizing days and sleepless nights. A special thanks to Jeff Stancil, PhD, MPH, Navy entomologist, for his work on helping to identify specific microbiology cases and to the USNS Comfort Public Affairs Office for their photographs and edits. We would also like to thank those at the Armed Services Blood Program Office; the Naval Air Station, Jacksonville, Florida; the USS Fort McHenry, the USS Bataan, and the USS Carl Vinson; the Naval Hospital Guantanamo Bay, Cuba; the Naval Medical Center, Portsmouth, Virginia; Armed Services Blood Bank Center, Bethesda, Maryland; and the National Naval Medical Center, Bethesda, Maryland, for their invaluable contributions to our mission's success.

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Author notes

From the Departments of Pathology (Dr Hussey, Messrs Dukette and Dunn, and Ms Evans), Internal Medicine (Dr Gleeson), and Urology (Dr Donahue), National Naval Medical Center, Bethesda, Maryland; and the Laboratory, Naval Medical Center, Portsmouth, Virginia (Ms Oakes).

The authors have no relevant financial interest in the products or companies described in this article.

Competing Interests

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, nor the US Government.