Vth AMHE Medical Mission to Justinien University Hospital
Cap-Haitien, Haiti
Advanced Trauma Care Management at the State University Medical School
Port-au-Prince, Haiti
November 10 – 17, 2012

“Dissatisfaction and Discouragement are not caused by the lack of things, but by the lack of vision.”

For the second time in this year 2012, the strongest yet contingent of AMHE delegates took part in the Vth Medical Mission of the Association to Justinien University Hospital.  As previously stated, the philosophy behind this program is to:
-    To cooperate with the local resources
-    To support the national system with learning material, medications and much needed equipment
-    To empower the Haitian health care professional to practice better medicine, so that the level of care for the Haitian patient can be raised and this impact may last beyond our physical stay in the country.
With these principles in mind, immediately after our last visit in February 2012 to Justinien Hospital, we began preparing our next trip. That preparation included the selection of a convenient date, the recruitment of volunteers and the collection and shipment of supplies. The project met with an unprecedented enthusiasm and in no time, we were able to assemble the largest group of volunteers so far, that came from eight different states. We selected the second week of November, representing a window between the presidential election and Thanksgiving.

In keeping with our previous observations, we wanted to continue to address the inordinate number of casualties resulting from road accidents and acts of violence by developing a program of “Advanced Trauma Care Management Course” in Haiti.  After a dry run in February 2012, we wanted to start expanding the program and provide certifications to interested individuals all over the country. After discussion with our experts in the matter, we also had a vision that eventually the Haitian Ministry of Health could mandate this course for all individuals involved in acute care in Haiti. During the AMHE Annual Convention of July 2012, we had further discussions with Dr. Ginette Lubin, current president of the Association Medicale Haitienne (Haitian Medical Association) and Dr. Claude Surena, outgoing president of the AMH. The then Dean of the State University of Haiti School of Medicine showed a lot of interest in integrating this trauma course in the curriculum of the graduates about to go on to their social service assignments.

Preparations were therefore initiated to provide this formation both in Port-au-Prince and in Cap-Haitien. An Ad Hoc committee was created and included Drs. Dany Westerband, Anne Lihau-N’Kanza, Maxime Coles, George Angus and Earvin Douyon. These individuals were all instrumental in making this project a reality.  Dr. Westerband contacted an administrator of the American College of Surgeons, who donated to the project and shipped directly to the Medical School in Port-au-Prince 50 ATLS textbooks, while Dr. Golden collected used ATLS textbooks from the North Shore LIJ Surgical residents to be donated to the course participants in Haiti.  Dr. Westerband also drafted the curriculum of the course, while Dr. Lihau-N’Kanza was in charge of selecting, purchasing and/or leasing the manikins needed for the courses.  In a conference call, the ideal number of participants for each site was agreed upon and this was communicated to the Dean Jean-Claude Cadet, MD in Port-au-Prince and Dr. Guerline Roney in Cap-Haitien. These two physicians also took on the task of reserving an appropriate venue for the courses in these locations.

On the other side, Drs. Dufresne and Thelusmond designed the curriculum for the Resuscitation and Acute Cardiac Management Course.  They purchased the BLS/ACLS textbooks and an EKG machine, as well as a cardiac defibrillator that was obtained through the efforts of Drs. Jean-Claude Compa, Bordes Laurent, Roger Belzie and Francois Brutus.  Both machines were donated to the Justinien Hospital at the completion of the course.

In addition, Dr. Ziegelbaum and I solicited material contributions and monetary support for the project from multiple donors. With the valuable assistance of Carol Olsen, RN of the Smith Institute of Urology, we accumulated six pallets worth of medical equipment and material.  Dr. George was of great help in organizing the shipment and coordinating the pickup with Pilot Freight Company.  Unfortunately, hurricane Sandy delayed the pickup of the merchandises that were shipped down to Cap-Haitien via the Haiti Shipping Lines.  Thus, the pallets were not in Cap-Haitien at the time of our arrival.

We also collected $7250.00, which helped to partially cover the bills for the EKG machine, the instructional materials for the Cardiac Course, the lease of the Trauma manikins and the shipment of these items to Haiti.
Here, we would like to recognize:
Drs. Frantz and Nicole Pierre
Dr Ronald Sanon
Dr. John B. Chang
Dr. Evelyne Moise
Dr. Prosper Remy
Dr. Frantz Moise
Dr. Alan Efron
Dr. B. Marie Ward
Dr. Fritz Apollon
Mrs. Lila Deitelzweig
Dr. Kettly Michel
Dr. Linda Bastien
Dr. Mario Saint-Laurent
Dr. Jean-Robert Desrouleaux
Mrs. Ghislaine Stephen, RN
Dr. Jean-Bernard Poulard
Dr. Lionel Lefebvre
Dr. Charles Coren
Dr. Laurie Levine
The OB/GYN practice of Goldstein, Kusnitz and Trufelli
Ms. Eunice Skelly
Dr. Alan Abramson
Dr. David C. Levine
Jerry Hirsch, CPA
Mr. and Mrs. S. Freedman
Zita Ruskin-Becker
Carol Smolinsky

We are still looking for more donations to pay for the transport from Miami to Cap-Haitien.

The news of our arrival in Cap-Haitien was greeted with excitement both by the leadership at the hospital and the residents of the different services.  The residents were encouraged to submit a wish list of lectures.  We received requests from General Surgery, Internal Medicine and Urology and all the participants agreed to meet these demands. In addition, I wanted to introduce for the first time the concept of Journal Clubs in the education of these residents, as a way to develop a critical approach of the medical literature and to maintain up-to-date medical knowledge.  Dr. Golden was given the responsibility to select and discuss appropriate articles, while this task was assigned to Dr. George in Urology and Dr. Surapaneni for Internal Medicine. The respective services in Haiti also selected a group of surgical cases to be performed during our stay. The Academic program was thus established and shared with all involved stateside and in Haiti.

Lastly, the most difficult task consisted in booking this large group on Flights from the US to Port-au-Prince and from Port-au-Prince to Cap-Haitien as well as reserving lodging both in Port-au-Prince and Cap-Haitien.  Drs. Margarett Osselyn-Abraham and Ghislaine E. Auguste got the ground transportation covered in Port-au-Prince as well as the hotel reservations for the trauma instructors. Dr. Roney was up to the task as well with the arrangements in and out of Cap-Haitien.  Despite last minute cancellations and last minute additions to the group, as well as unanticipated developments in Cap-Haitien, we were all set and ready to go a week before the pre-determined date of departure on November 10, 2012. Or so we thought, until the unexpected showed its ugly face.

Dr. Dufresne was injured in a car accident.  Dr. Lihau N’Kanza’s mother-in-law passed away on November 8, 2012, but this incredible family agreed to postpone the funeral until Anne returned from her mission in Haiti. To top it off, on the eve of our departure, we received news of torrential rains and neighborhood flooding in Cap-Haitien as well as possible anti-governmental rioting, causing one of our members to defect.  As the night was approaching, we had to contact the people on the ground in Cap-Haitien and exchange e-mails with every member of the group who was still in the US.  This wonderful and dedicated group of physicians and nurses were unflappable and decided to forge full speed ahead, except for a preliminary halt in Port-au-Prince in order to reevaluate the situation in Cap-Haitien.  The text message from Dr. Andrew Tyan still remains engraved in my memory:”Why should we turn our back, when they need us the most”.

The Advanced Trauma Course in Port-au-Prince
Thus, by Sunday November 11, 2012, the trauma team, including Maxime Coles, MD, Anne Lihau-N’Kanza, M.D., Erwin Douyon, MD and later on Dany Westerband, MD was on the ground in Port-au-Prince, inspecting the venue and ready to start the course the following day, while the rest of the team flew to Cap-Haitien.  Finally, the mission seemed set to go on as scheduled. Only to find out that there had been a death during a hazing ceremony at the State School of Law and Economics and the students were enraged. They set up barricades to block access to their school, ipso facto blocking access to the medical school juxtaposed to the Law School.  That did not deter our trauma instructors who were guided around the obstacles and eventually made it to the auditorium of the medical school. The course was set afoot, albeit with some significant delay and a significant reduction in the number of attendees.  In the middle of the course, a mob of 20 to 30 angry Law students all of a sudden entered the classroom and demanded that one of the instructors who had been photographing scenes of the demonstration delete his pictures.  Cooler heads prevailed and the course resumed. As the group switched to the practical sessions with the dummies, another angry mob rushed the practice tables, with the clear intention to disrupt what they believed to be an exam. This time, the assistant dean intervened and defused the situation.  The next day, the mob of Law students tried to break in and smash the instructors’ laptops. Again, the vice-dean had to calm the situation. From then on, the course went on without a hitch.  The participation and the interest were deemed extraordinary and 35 certificates of attendance were distributed at the end of the course to 4 attendings, 6 residents and 25 interns. The team of instructors is extremely grateful to Dean Cadet and vice-dean Vilsaint as well as Mrs. Alexandre and the other members of the staff who were of tremendous help during the program. Thanks to them, the participants were treated to nice collations during the coffee breaks and two copious lunches. We want to express our gratitude to them for making the experience successful despite unexpected and difficult circumstances.

Traveling to Cap-Haitien / Visit to the Citadelle
Meanwhile, the bulk of the team landed in Cap-Haitien in the middle of the day, under a still cloudy sky, but the situation was clearly not as bad as was reported by the news outlets.  Still the mud patches and the piles of debris and garbage were evident. We all took residence at the Auberge du Picolet and those who wished to do so, rushed immediately to visit the formidable Fortress CITADELLE located at about 30 minutes from the City. We barely managed to finish exploring it and did not have a chance to visit the Ruins of the Sans-Souci Palace, due to darkness.  At the hotel, a delicious welcome dinner was awaiting, courtesy of Drs.  Jean Geto Dubé and Guerline Roney.

Welcome to Justinien and Surgery Program
By the following morning, we went to Hopital Justinien and met the Chief Administrator, Dr. Jean Geto Dubé, le Medical Director Dr. Jean Coq and the Director of Formation, Dr. Yverl Zephyr. After a particularly warm greeting, we were given a tour of the Hospital by the Medical Director and eventually injected into our respective services.  At that time only, I found out that the academic schedule had been rearranged.  All the 18 cases of surgery that were prepared for us had to be done during the first three days, because the surgeons and the residents would be busy with the trauma course during the last two days of our stay.  That was a difficult task, given the delays in the OR suite of two (and a half) operating rooms and the inescapable daily cancellations due to the ever unpredictable cesarean sections. Nevertheless, we managed to complete most of the anticipated number of cases.  They included:
-    An examination under anesthesia of a case of Imperforated Anus
-    A parotidectomy
-    A laparotomy for a Malignant GIST Tumor of the stomach
-    An excision of a recurrent Wilm’s Tumor of the abdominal wall
-    A below knee amputation for diabetic gangrene
-    A modified radical mastectomy
-    An excisional biopsy of a breast mass
-    A repair of a large inguinal hernia
-    An excisional biopsy of a right arm biceps tumor
-    An excisional biopsy of a right groin mass
-    Two Unilateral Hydroceles
-    One bilateral Hydrocele
-    A scheduled gastrectomy and additional breast biopsies could not done for lack of time available on the schedule
As a result, the academic sessions could not get started.  By the third day, it was imperative to at least carry out the journal club.  Dr. Golden did an outstanding job, with a detailed PowerPoint presentation that was moderated by Dr.  Loubeau. It led to some serious discussions with the surgical residents and interns.  Dr. Jasmin also presented a lecture on Traumatic Colon Injuries.  I never had a chance to present my lecture on Management of Retroperitoneal hematomas, Duodenal and Pancreatic Injuries, but downloaded the slides for the residents.

Advanced Trauma Course in Cap-Haitien
The same day, three of the instructors arrived in Cap-Haitien, minus Dr. Maxime Coles who had another engagement. The Advanced Course on Management of Trauma was given during the last two days of the week, in the Conference Suite of the Auberge du Picolet, with practice sessions on the TRAUMA MAN manikins. Everyone had a chance to perform a pericardial tap, a crico-thyroidotomy, a tube thoracostomy and a peritoneal tap and lavage.  The audience was attentive and included:
-    Two surgeons
-    Three surgical chief residents
-    One senior surgical resident
-    Two Orthopedic residents
-    One intensivist
-    One anesthesiology resident
-    Three nurse anesthetists
-    A pediatrician
-    Two internists
-    Two Family Medicine Residents
They all successfully achieved the goals of the course and were awarded a certificate of completion of “Le Cours Avancé de Prise en Charge des Traumatisés” de l’AMHE.

Internal Medicine/Cardiology Program
Advanced cardiac Care Course
Following a parallel schedule, our two cardiologists conducted ward rounds with the resident and the attending staff every morning.  During the first two afternoons, they provided an advanced course on the management of different cardiac events, with detailed instructions on the diagnosis and the control of diverse types of arrhythmias. There were 16 attendees, including residents and attending staff.  They performed a large number of echocardiograms, providing information heretofore unknown to the staff.  When the news got out that they were in town, patients came from several adjacent towns and villages for consultations. Our cardiologists also traveled to the Sacred Heart Hospital in Milot, run by CRUDEM. They were able to make a significant difference in the care of all these patients. On the third day, Dr. Tyan gave a two-hour lecture to the medical staff on “How to read a plain Chest X-Ray and plain Abdominal Films.” The residents and interns in medicine also had a Journal club during which they discussed a series of articles selected by Laalitha Surapaneni, MD, our medical resident.  Again, the interest, judged by the questions, was extremely elevated.  The rest of the week continued on the same high note, with participation in the outpatient clinics.

Urology Program
For the first time, the delegation included two urologists.  Their arrival was eagerly anticipated and they made a huge impact on the service. Dr. George delivered several lectures on “Interpretation of a Urinalysis”, “Testicular Carcinoma” and “Prostate carcinoma.” On the third day, he carried out the journal club, which was very successful and stimulated the interest of the students, resident and attending alike. The two urologists participated in the outpatient clinics and diagnosed a large Renal carcinoma. They took care of an impressive operative list as well and besides performing the three large hydroceles mentioned above, they did
-    Correction of bilateral Uretero-Pelvic Junction Stenosis in a 3-year old
-     a suprapubic prostatectomy
-    A nephrectomy
-    A correction of a urethral stricture
The success of their visit was quite evident when the Urology staff organized a separate farewell reception for them. In addition, the entire staff of interns and residents came to the hotel and made sure they were photographed with the two stars of the week. I would not be surprised if they asked for autographs.

Obstetrics and Gynecology
Our two gynecologists arrived only in the middle of the week, but made their presence felt.  Dr. Guillaume presented a lecture on “Anovulatory Menstrual Cycles.” They assisted the residents during a cesarean section and performed a hysterectomy for large myomas.

In the operating room, Dr. Livingstone was a pillar of support and managed some difficult unstable patients despite the lack of the minimum that he would have expected in an operating room, such as intravenous hydralazine or Beta-Blockers for my parotidectomy patient, whose systolic blood pressure rose to nearly 200 as she was weaned from the anesthetic agents.  He ran four cardiac arrest codes during the week being successful in three instances. He also lectured the anesthesiology resident and the CRNAs on various techniques of nerve blocks.

Still in the Operative Suite, our two nurses progressively inserted themselves in the system and talked about a different approach to operative nursing.  They talked about proper identification of the patients, pre-operative time out, the importance of having nurses scrub on the cases and a better management of the stocks. Mrs. Guerrier, the OR Head nurse, explained to them that after completing a peri-operative nursing course in France, she tried to implement some changes, but it was very difficult to get the other members of the staff or the administration to cooperate. Therefore, she stopped trying. The idea of counting instruments and sponges before and after surgery was ridiculed by the surgical residents who claimed that there had never been a case of retained sponge in a patient.  Interestingly enough, on the last day, I saw a slide presentation of films from the director of Radiology at Justinien and low and behold, there it was, a case of retained lap pad in a Justinien patient. Obviously, the effort needs to be pursued.

Dr. Patricia Loubeau delivered a masterful and thought provoking lecture at the Justinien School of Nursing, entitled: “Social Marketing and Public Health” that was well received.

All was not smooth however at Justinien Hospital. The pediatric residents were on strike.  Their list of grievances included the need of:
-    A working suction machine
-    A nebulizer for asthmatic children
-    An emergency cart stocked with appropriate medications
-    A warming table for neonates and primies
-    Surge protectors for the incubators that keep getting damaged by daily power surges at the Hospital
Obviously, there are always two sides of a story. The other side is that the residents went on strike despite the fact that the administration has been doing its best to improve the care at the Pediatric Service, by allocating more money for oxygen tanks, examining cloves etc…  We are hoping that the two sides will sit down face to face and work out their differences. Meanwhile, our medical resident Dr. Surapaneni spent the better part of the week helping the interns in pediatrics.  She also took the time to establish an inventory of all the material and supplies in stock in Pediatrics.  This cache contained useful medications, instruments and supplies.  Their existence was unsuspected. The stock was itemized and some of it was delivered to the other services where they were needed. Mrs. Michele Jasmin, an experienced NICU nurse, gave strong support to the pediatric staff during these trying moments.

Debriefing and Suggestions
Finally, on the last day of the Mission, several members of the AMHE team sat down with Dr. Dubé, at his request for a debriefing.  We expressed to him our gratitude for making this visit possible, first by supplying a mini-bus for our transportation from the airport to the hotel and for the daily trip to and from the Hospital, second by providing us with a delicious lunch every day at the hospital, as well as a lunch for the individuals attending the TRAUMA course. We then had a frank discussion about the obstacles he deals with at the helm of the largest health care facility of the North of the country.

One of the main issues affecting the hospital is the lack of revenues.  As the contributions from the Ministry of Health are insufficient to cover the operating costs of the institution, the administration has to generate an income that traditionally comes from the pharmacy, the clinical laboratory, the radiology division and the morgue.  Dr. Dubé reported that until recently the hospital was losing nearly 40% of the income derived from the pharmacy.  One of the common schemes was carried out by hustlers who would hang around the pharmacy and whenever a patient would present with a prescription, they would intercept it, obtain an exoneration from the administration and pocket the cost of the drug.  The hospital has to resort to charging the patients for everything, from the simplest lab test to a flat fee for the use of the operating room suite. Even then, the patients who can afford to pay for their care manage to get their fees waived through their connections.  Thus, only the patients without a connection must pay for everything or risk not to receive any care.  Under Dr. Dubé, a valiant effort is being made to clean up and improve the finances of the hospital.  This has not gone over well, since he is being vilified both in the hospital and across town by those who used to profit from these shady deals.

We suggested that every employee of the hospital be given an ID badge, as a sine qua non condition to circulate within the hospital. That measure along with the hiring of security agents would limit access for the undesirable hustlers, allow better control of the staff and restrict the excessive flow of individuals who crowd the hospital daily. Dr. Dubé informed us that they were exactly in the process of issuing two types of badges, a green one for the employees of the Ministry of Health and a red one for the employees under contract.  We hope that these policies will be firmly enforced and eagerly await the results.

We also remarked on the decrepit appearance of several pavilions of the hospital, which are still as they were in 1925, when the Red Cross undertook the last major overall of the hospital. For example, the OR Suite with two regular rooms and one minor surgery room is clearly inadequate to meet the needs of the different surgical services.  There is no ceiling scialytic light in the minor surgery room, no functioning anesthesia machine, an electric cautery or a suction machine that would allow to convert that room into a regular Operating room.  We also discussed the bad state of the leaky roof.  We suggested that if there were a cost estimate for the roof, the AMHE would consider taking on such limited repair programs.  Dr. Dubé informed us of an expected grant from the World Health Organization/Pan American Health Organization earmarked to improve Gynecological services that will be used in part to add a second floor to the OR suite and expand the operative capacity of the hospital.

Next, we addressed an issue that has been in the forefront of our preoccupations from the days of the first AMHE visit, that of the respect of human dignity in the facility.  Once again, we observed patients being uncovered in the middle of the wards, under the gawking eyes of visitors and other patients of the opposite gender I must add, since male patients are often hospitalized in the Women’s ward, when the Men’s ward is filled.  I observed a female patient being wheeled from the pre-operative examining room to the operating room with her chest totally uncovered.  These repeated observations convinced us that there was a desensitization to the notion of human dignity.  This observation applies to everyone from the porter to the attending physicians, including the nurses and the residents.  Dr. Dubé replied that there was a need to address that issue both in medical and nursing schools and to have a discussion with all the employees as well.  We feel that this issue must be revisited at every opportunity and must be considered a quality improvement parameter.

Connected to the same matter, we observed patients lying in beds with dirty sheets on the wards and a patient who had bled vaginally before a cesarean section being asked to lie on a cover that was heavily stained with her blood.  The porter changed the sheet when we protested, but we feel that this attitude connotes a lack of respect for a fellow human being.  We were told that the Hospital had no sheets and that the patients were responsible for bringing sheets from home, because of unending stealing of the sheets that used to be provided by the hospital.  We repeated the offer made last year by Dr. Jean-Bernard Poulard to donate a supply of bed sheets and covers, offer that can be revisited provided the hospital makes an effort to control the distribution, the laundry and the preservation of these sheets.

Finally, we decried the lack of participation of the surgical residents in this opportunity that was given to them to participate in rare operations such as a parotidectomy that I performed with one of the attending at Justinien or the hydroceles that Dr. Ziegelbaum performed with Dr. Romain, one of the North Shore/LIJ surgical residents.  Even though, a hydrocele is considered a common, run of the mill procedure, we know that there is always something to be learned when the procedure is being done by a surgeon with a different approach, even if it is just to compare techniques.

Overall, we believe that the Vth AMHE Medical mission to Haiti was a success. We have now 53 new physicians certified in the administration of advanced care to trauma victims and 16 new physicians capable of managing cardiac emergencies, in addition to whatever medical resources were already available in the country.  We introduced the concept of Journal Club in the Justinien residency curriculum as a tool for developing critical learning and for updating medical knowledge, instead of repeating traditions passed from one generation to the next, even if they may no longer be relevant.  Finally, we presented a dozen of lectures, which is a far cry from our previous series or from our prepared list for this visit, but as I mentioned earlier, an unexpected change in the schedule prevented us from delivering all the lectures requested by the residents.

We sincerely thank Dr. Florence Guillaume, Dr. Raymond, Dr. Jean-Claude Cadet, Drs. Dube, Coq, Roney, Joseph, Zephyr, Desir, Cyril and Carmelle Leconte, Barella, Damas, Compere, as well as all the residents from the different services for their cooperation and for opening up their door to an honest discussion about the present and future health of our compatriots.  We also want to include Dr. Ginette Riviere Lubin and Dr. Claude Surena for facilitating the communications. We hope to be able to extend the Trauma and cardiac training programs to other parts of the country and eventually form local educators that will diffuse this knowledge to the entire nation. To share our knowledge with compassion and respect is and will remain our motto, until every single Haitian woman, man or child can obtain decent health care.

At last, I have to mention the ultimate kindness of Dr. Roney who presented every single member of the team with a gift, a product of the local arts and crafts.  This gesture touched us, since we felt that thanks were due to her and her team.  It is no surprise that every single member of the AMHE Team reported that he or she had a great experience and pledged to return next year.



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