VIIth AMHE VISIT TO Justinien University Hospital
November 3 – 7, 2014
Louis J Auguste, MD, FACS
For the seventh time in the past five years, the Association of Haitian Physicians Abroad (AMHE) sent a team of 30 medical volunteers to Justinien University hospital, located in Cap-Haitien, the second largest city of Haiti. Justinien Hospital is also the second largest public hospital in the country with 250 acutes beds and a staff of 44 physicians and 119 nurses. It represents a referral center for a catchment area of nearly one million people, including not only the inhabitants of the North, North-East, and North-West provinces of Haiti, but also the undocumented Haitian workers in the Northern parts of the Dominican Republic and the islands of the Bahamas and Turks and Caicos, who do not have access to medical care while living in these countries. Justinien Univesity Hospital provides teaching and formation to 123 young Haitian physicians in the specialties of Anesthesia, Dentistry, Emergency Medicine, Family Medicine and Internal Medicine, General Surgery, Obstetrics and gynecology, Ophthalmology, Orthopedics, Pediatrics and Urology. Unlike other medical missions sponsored by International Non Governmental Organizations or other “charitable” organizations that are mainly focused on providing direct patient care, therefore competing with and weakening the local medical workforce, the goals of the AMHE is to work with the local health care providers and upgrade their knowledge base and their skills, through lecture series, seminars, technical workshops, advanced courses in Trauma management and acute cardiac care and the donation of teaching material including, textbooks, magazines, DVDs and CDs.
Thus over the past year, the organizing committee has been working to gather a diverse team of board-certified specialists and instructors, taking into account their respective availability and coordinating the effort with the medical and administrative leadership at Justinien Hospital. The group, this year, included all the specialties that had previously been involved in the program. In addition, we had the privilege of adding a geriatrician, a dental surgeon, an infectious disease specialist and a pathologist. In total, the group included the following members:
|Patricia Armand, CRNA||Nurse Anesthetist||North Shore/LIJ Health System|
|Evan Auguste||Support Team||New York University|
|Louis J Auguste, MD||Surgical Oncology||North Shore/LIJ Health System|
|Louis J Auguste||IT/Tele-pathology||CookieSmart Enterprises|
|Macsie Auchter, RN||OR Nursing||North Shore/LIJ Health System|
|Sara Beague||Dental Hygiene||Private Practice, Elmont, NY|
|Thomas Beague, DDS||Dentistry||Private Practice, Elmont, NY|
|Akinwumni Carons, MD||Urology||North Shore/LIJ Health System|
|Maxime Coles, MD||Orthopedics||AMHE-CEC|
|Alix Dufresne, MD||Cardiology||Interfaith Hospital, Brooklyn, NY|
|Sharon Deans, MD||Obstetrics and Gynecology||Health Plus|
|Marie Garnes, MD||Pediatrics||NY Hospital of Queens, NY|
|Howard Gusik, MD||Geriatrics||North Shore/LIJ Health System|
|Christopher Hartmann, MD||Urology||North Shore/LIJ Health System|
|Kristen Jacobs, MD||Pathology||South Bend Medical Foundation|
|Neffirte Larkin, RN||OR Nursing||Elmhurst Medical Center, NY|
|Patrick Lecorps, MD||Orthopedics|
|Hubert Leveque, MD||ENT|
|Anne Lihau N’Kanza, MD||Trauma Surgery|
|Todd Mailly, MD||Orthopedics||Hartford Hospital|
|Paul Nacier, MD||Gastro-Enterology||Kingsbrook Jewish Hospital, NY|
|Julie O’Keefe, RCT||Cyto-pathology technician||South Bend Medical Foundation|
|Loronne Paul Chery||Support Team||North Shore/LIJ Health System|
|Danielle Pigneri, MD||General Surgery||Guthrie Clinic, Sayre PA|
|Kaitlin Poeth, MD||Infectious Diseases||North Shore/LIJ Health System|
|Jean-Berbard Poulard, MD||Colo-rectal Surgery||Queens Hosp. Center, Jamaica, NY|
|Robin Warshawsky, MD||Radiology||North Shore/LIJ Health System|
|Dany Westerband, MD||Trauma Surgery||Johns Hopkins Health System, MD|
|Michael Ziegelbaum, MD||Urology||North Shore/LIJ Health System|
Given the expertise available, an extensive educational program was elaborated, featuring our traditional Advanced Trauma Course, a seminar on infectious diseases, instruction on electro and echocardiography, training in Tele-pathology, journal clubs and a total of 45 lectures. Encouraged by the turnout last year at our women’s health screening, we wanted to duplicate the accomplishment and perhaps do more, since we had now a pathologist and a cyto-pathology technician in our ranks. Given the recent ravages of Chikungunyia in the Caribbean Basin, the endemic presence of Hepatitis and Helicobacter Pylori in the region, as well as the threat of EBOLA in the western hemisphere and given that our group included an infectious disease specialist and a gastro-enterologist, we set up the seminar in the middle of the week, with the hope that it would attract not only the Justinien Staff, but all the physicians of the surrounding localities or other health facilities. The entire program was communicated to the Chief administrator, the medical director, the director of formation and the president of the Committee of Interns and Residents at Justinien Hospital.
Finally, in preparation to that visit which enjoys a great deal of support in the community, equipment and materials were collected from different sites within the NS-LIJ Health System, from Elmhurst Hospital and from several charitable individuals, including members of the team. We have to thank the NS-LIJ Health System who allowed us to use the storage facility at the Center for Advanced Medicine as a staging site for the shipment of all these supplies and to Mr. Greg Eversley, who picked up the items from all the different sites, packaged them and worked with the shipping companies to facilitate the transport of more than 2,000 lbs of supplies from New York to Cap-Haitien, Haiti. The container arrived at destination ahead of us. So all was set for a successful mission starting on Monday November 3, 2014.
Unfortunately, that was counting without Mother Nature, which elected to dump on Cap-Haitien, during four days torrential rains, as I had never seen before. This resulted in disastrous flooding in and around the low-lying areas of the City. Houses were partially submerged. Cars were stranded. Streets were impassable. Half of the team planned to take advantage of the newly inaugurated international airport and to travel directly to Cap-Haitien. However, American Airlines cancelled the scheduled flights on Sunday, Monday and Tuesday, and the team members so affected had to scramble to find alternative ways to reach their destination. Some of them were on their first trip to Haiti. Therefore, we spent the first two days of the trip, trying to locate them, making sure they were safe and that they were picked up at the airports. By the end of the second day, the team was complete, but our schedule had to be completely revised. The screening for cervical and breast cancer was the most impacted and instead of the 400 women we had last year, we were able only to screen 73 women. The pathology team who was ready to educate the resident staff on the tele-pathology program, instead had to catch up reading the cytology slides, 35 of them were interpreted on site in a small pathology lab set up and equipped with the material and reagents that were all shipped ahead of time. The Advanced Trauma Course had to be delayed by two days, causing a major inconvenient for Drs. Westerband and Coles who were supposed to leave town on Wednesday. Furthermore, the hospital consisting of several separate pavilions, we had to run under the rain from one area to the other. Nevertheless, after the cordial welcome offered by the Chief Administrator, Dr. Jean Geto Dube, the Medical Director, Dr. Jean Coq, Dr. Jean Lenic Joseph of the Medical Service, as well as the Medical and Surgical Chief Residents, the members of the group that were already on site started working from the first day in their respective services, although the conditions were difficult.
Bedside rounds were conducted daily in Medicine, Obstetrics and Gynecology, Pediatrics, Surgery and Urology and for three days in Orthopedics. We provided consultations in the outpatient clinics and reviewed the patients that were scheduled for surgery during the week. Overall, we gave 21 lectures, including:
- Nutrition in the surgical patient
- All you need to know about Anal Fissures, fistulae, hemorrhoids etc…
- Classification and Management of Cardiac arrhythmias
- Sudden death in Young Athletes
- Delirium, Dementia and Depression in Geriatric patients
- Principles of geriatric Pharmacology and pharmacotherapy
- Interpretation of Plain Chest X-Ray
- Approach to Sonography
- Introduction to Body CT Scans
- Hepatitis A, B and C
- H. pylori infestation
- Clostridium difficile Infection
- Dengue, Chikungunya and Yellow Fever
- Update on the Ebola Fever
- Repair of Vesico-Vaginal Fistula
- Management of Urethral Stricture
- Posterior Urethral Valve in Pediatrics
- Management of Renal stones
- Post-Partum Hemorrhage
- The Management of Ankle Injuries
We conducted a journal Club with the surgical residents during which we discussed: Early enteral Feeding following intestinal surgery and the NESQIP program for reduction of post-operative infections.
In addition, Drs. Westerband, Lihau N’Kanza, Coles and Pigneri, all certified ATLS instructors provided a full Advanced trauma Course to 11 residents in Surgery, Anesthesia, Orthopedics and Pediatrics. We anticipated 20 participants, but the new first-year residents in surgery, recently appointed by the Ministry of Health had not arrived yet.
We performed 17 surgical procedures including
- 1Resection of a recurrent Wilm’s tumor in a 10-year-old girl
- 1 Open reduction and internal fixation of a proximal and sub-trochanteric femoral fracture
- 1 Open reduction of a 3-month old mal united distal femur fracture with bone grafting
- 3 Trans-Urethral Prostatectomies
- 1 Inguinal Hernia in a 7 year old girl
- 1 excision of a right groin mass, which turned out to be a Dermato-fibrosarcoma protuberans
- 1 excision of a left axillary mass
- 1 Closure of Colostomy
- 1 Colostomy for Anal Imperforation
- 1 Sub-cutaneous mastectomy for gynecomastia
- 1 repair of an umbilical hernia
- 1 Exploration for a gunshot Wound of the Abdomen
- 1 Ureteroscopy and stent placement
- 1 Cesarean Section
- 1 Marsupialization of a Bartholin cyst
The complex orthopedic procedures were carried out thanks to an agreement between the Haitian Ministry of Health and the SIGN Group who has been providing intra-medullary rods and other orthopedic equipments to most of the Hospitals in the country, with the stipulation that pre and post-operative radiographs be done, free of charge to the patients. Prior to his departure from Justinien, Dr. Coles and his two colleagues discussed the issue with Dr. Dubé, since the non-compliance to this requirement may constitute a deal breaker.
Dr. Hubert Leveque provided much needed help in the ENT service and diagnosed significant pathologies of the buccal cavity, the larynx and the neck. Fine needle aspiration biopsies were carried out and processed immediately. Unfortunately, these lesions were beyond the scope of surgical treatment and were referred to Dr. Jean-Gilles in Port-au-Prince to facilitate the subsequent management of these patients.
For the first time in five years, the team included a Dental surgeon and a dental hygienist, Dr. and Mrs. Thomas Beague. Going into Justinien, they did not quite know what to expect. They worked side by side with the two dentists on staff at the Hospital for four long days. More important, they were able to appraise the status of Dentistry and Oro-Facial Surgery in Cap-Haitien. They have promised a donation of material and equipment to the Service. In addition, they will know better how to prepare for the next visit in a year.
The entire team enjoyed the imaging support provided by Dr. Robin Warshawsky, radiologist, who had a great impact of the mission. Indeed, in addition to the lectures, she gave to the medical staff, she performed 33 sonographic examinations on the breasts, the pelvis, the abdomen, the head and neck and facilitated the care of the obstetrical, urology, pediatric, surgical and medical patients. Her examinations also helped in the decision making regarding several trauma patients. We thank the Sonosite Company, who lent the portable sonogram machine to us, for the duration of the trip.
Finally, the pathologist, Dr. Jacobs and the cyto-pathology technician Julie O’Keefe provided a service that has not been available at Justinien Hospital, the last pathologist left Cap-Haitien in the 1960s. Over the abbreviated course of the mission, they assisted in the cytologic evaluation of breast masses, a neck ulcer, endometrial lesions, tonsillar neoplasm. They lectured the Medical technology students on the preparation of cytology slides and about the importance of cytology in the screening of women for cervical neoplasms. We moved one step closer to Tele-Pathology as they worked with Louis J. Auguste II who is investigating how cytology slides can be used for Tele-Diagnosis. They brought back to their Lab 38 and interpreted additional slides and the two solid specimens of renal neoplasm and the right groin tumor. Over all, they diagnosed five previously undetected cases of cervical cancer, confirming once more the high prevalence of cervical cancer in the country. The pathology reports on the two solid tumors were communicated to the respective services in Cap-Haitien. One patient will require a reexcision of the right groin tumor, while steps are being taken to refer the young patient with the recurrent Wilm’s tumor to St Damien Hospital in Port-au-Prince for systemic adjuvant chemotherapy.
Now, four weeks after the mission, it is fair to say that despite the adverse conditions, many lives have been touched. Patients have received care that they probably would not have received otherwise. The young physicians have probably had a chance to discuss approaches to diseases, different from theirs and we hope that these discussions have opened their minds and perhaps raised the level of their practice. As to the members of our team, they all came out moved by the experience. Some had previously participated in medical missions in other countries, but for many, this was the first exploration of a medical world with limited resources and devoid of all the technological advances, they have become accustomed to. They were unanimous in expressing the desire to return and to continue the work that was started five years ago in this corner of Haiti.
More important than our own feeling, we were interested in finding out how the young Haitian physicians in training felt about our presence. A survey was quickly put together and was distributed to the first 100 interns and residents that were seen in the confines of the institution. We received 60 responses that have been tabulated. We are happy to share the results with you.
Fifty percent of the responders were interns, 42% were residents and 8 % were attending. The larger group came from the Internal medicine Service (30%), followed by Surgery (22%), Orthopedics (15 %) and pediatrics (10%). The ratio of males to females was 1.5:1. Half of the group was participating in an AMHE mission for the first time. This was the second experience for 28 %, the fourth for 4 % and the third for 2 %. Seventeen percent for a reason or another stated that they did not participate, although all of them at least participated at least in the bedside rounds. Eighty percent felt that the presentations were made at the right level, while 2 % felt the level was too high and 2 % felt that it was too low. Forty-eight percent had no difficulty understanding a presentation in English. Twenty-nine percent benefitted from the English presentation, although they were difficult to understand. As stated before, 17 % did not attend the conferences and did not offer any opinion about their levels or their understandability. Thirty-five per cent of the responders felt that these academic missions were essential to their formation, while 65 % thought they were useful. Asked how many visits of the AMHE, they would like to receive per year, 42 % said 4, 24 % said 3, 31 % said 2 while 2 % said six and 2 % said one.
Finally the questionnaire queried about ways to improve the education of the interns and residents as well as ways to increase the impact of the AMHE on their formation. The responses were diverse and it was impossible to have any significant statistics. However, some felt that there was a lack of structure in the formation they receive at Justinien. Several responders complained about their salaries and the accommodations at the hospital. Several felt that they were autodidacts and 20 % complained of the lack of participation of the local attending physicians in their formation. A few felt that the attending physicians themselves needed to attend refresher courses. They complained also about the lack of ancillary services, advanced technology and laboratory facilities. More than 30 % of the responders would like to have the opportunity to spend a period of observation abroad in the US or in Canada. This issue is pretty much on the mind of the AMHE leaders and even before we left the United States, the discussion had already started between Dr. Kernizant of the SIMACT group, Dr. Nacier of the AMHE Foundation, Brooklyn Hospital and other interested parties. It is very likely that the exchange program that used to bring residents frm the State University Hospital and Justinien Hospital to the Brooklyn Hospital in New York for a period of three months will resume in the near future.
At the time of our debriefing, Dr. Dube advised us that the Hospital budget was very limited and that they depended largely on the fees collected from the operating room, the laboratory, the pharmacy and the radiology lab. The operating room could not keep its doors open, if it were not for the fees collected from the patients. Yet, they have to care for the patients brought in emergently who requires an intervention without any delay. This leaves no margin at all to do the multiple projects that are sorely needed throughout the institution, like for example a new roof for the operating room, a ceiling lamp for the third operating room, an expansion of most of the pavilions which are overcrowded. Every time, the AMHE brings supplies and materials to Justinien, it alleviates the pressure on the budget, but it would be desirable to have these shipments more on a regular basis, so that they can be counted on. Dr. Poulard noted that some of the repairs may be minor and easily done. Indeed, he showed that the ceiling light that was not working in one of the ORs needed only a bulb. He has since purchased a couple of bulbs and shipped them to Dr. Dube. We asked Dr. Dube to have a wish list of projects that he would like to see funded. The list will be reviewed by the AMHE and the Global Health Committee of the North Shore/LIJ health System and we will see how we can cooperate in this endeavor.
Meanwhile, we thank Drs. Dube, Coq, Roney, Joseph, Leconte, Barella, Pierre-Louis, Turenne, Bendson, Joseph and all the other interns, residents and attending physicians who greeted us with open arms and worked side by side with us to make this trip a success despite all the climatic disruptions. The surgical residents gave us a beautiful plaque in recognition to our contributions to their formation and education. This plaque will have a special place on my wall among other certificates, citations and awards accumulated over the years.
We appreciated very much the delicious lunches provided daily at the hospital. All the participants who had never experienced Haitian cuisine fell in love with it and learned rapidly the “ri ak pwa,” “Lambi creole,” “bannann peze” etc… The group still managed to take an afternoon to go and visit our national treasure on top of the Bonnet-à-l”Eveque Mountain, our unique Citadelle and everyone came back to the US satisfied with their trip. We all look forward to the next AMHE visit at the Justinien University Hospital.
This is also an opportunity to thank all the members of the AMHE, the staff at North Shore/LIJ Health System, the Global Health Committee of the NS/LIJ Health System, Haiti Shipping Lines who facilitated the transportation of the medical goods to Cap-Haitien, all the individuals who believed in our efforts and who have contributed their time, their effort and their money to the extent of their abilities. My most sincere gratitude will go also to all the volunteers who left the comfort of their homes and spent their own money and time to try to make a difference in this little corner of our planet. In moments like these, we can really feel ONE, ONE with our fellow human beings whoever and wherever they may be.