VIth AMHE Visit to Justinien University Hospital
November 16 – 23, 2013

If you are kind, people may accuse you of ulterior motives.  Be kind anyway. .. The good you do today may be forgotten tomorrow.  Do good anyway. Give the world the best you have and it may never be enough. Give your best anyway. For you see, in the end, it is between you and God. It was never between you and them anyway…
Mother Theresa.

For the fourth year in a row and for the sixth time, the AMHE, true to its by-laws to promote health in the Haitian Community both at home and in the Diaspora organized a mission to the Justinien University Hospital, the main health facility of the second city of Haiti.  As before, the goals of the mission were not to compete with the local physicians or the local institutions but rather to strengthen them and support all their efforts to bring health to a community of nearly half a million individuals. Indeed the catchment area for Justinien Hospital includes not only the city of Cap-Haitien and its surrounding localities but also the entire North, Northeast, Northwest, the islands of the Bahamas and the border zone of the neighboring Dominican Republic because the Haitians living there illegally are precluded from receiving any form of medical care locally.  Mindful also of the notion that repetition is key to retention, we were committed to reiterate our message and our teaching in order to bring about lasting changes.

In this endeavor, we have been lucky to share our views and convictions with a few members of the AMHE.  We are also happy to see a growing support for this program within my institution, the North Shore/LIJ Health System.  Two departmental chairs, convinced of the positive impact of these missions on the formation of the young residents, have supported their desire to be part of the AMHE missions.  Finally, colleagues and co-workers have volunteered either to join the group or to participate in the collection of items, material and equipment for Justinien Hospital.

Thus, once we had selected the third week of November 2013 for this mission, we rapidly assembled a team of 25 physicians and nurses, the largest and the most diversified group to participate in this program. We extend a personal note of thanks, both on behalf of the AMHE and of the Haitian people to the following individuals for being so generous of their time, their talent and their hard-earned money.

Anesthesiology
John Downey, MD………….San Francisco, CA
David Livingstone, MD………….North Shore/LIJ
Michelle Villanueva, CRNA………….North Shore/LIJ
Cardiology
Alix Dufresne, MD………….AMHE/Interfaith Hospital, Brooklyn, NY
Louis Herve Thelusmond, MD………….AMHE/Coney Island Hosp., Brooklyn, NY
ENT
Hubert Lévêque, MD………….AMHE/Santa Barbara, CA
Infectious Diseases
Arthur Luka, MD (Second Year Fellow)………….North Shore/LIJ
Informatics
Louis Auguste, BA………….London, UK
Nursing
Macsie Auchter, RN………….North Shore/LIJ
Danielle Colwell, RN………….North Shore/LIJ
Patricia Delyra, RN………….North Shore/LIJ
Nadege Lanoue, RN………….North Shore/LIJ
Gerald Surprise, RN………….North Shore/LIJ
Obstetrics and Gynecology
Sharon Deans, MD………….Garden City, NY
Orthopedics
Maxime Coles, MD………….AMHE/Pittsfield, ME
Radiology
Gail Phillips, MD………….PROMEDICA, Lake Success, NY
Andrew Tyan, MD (3rd Yr Resident in Radiology)………….Minneapolis, MN
Surgery
Louis J. Auguste, MD (Oncology and General)………….AMHE and North Shore/LIJ
Amie Kraus, MD (4th year Surgical resident)………….North Shore/LIJ
Jean-Michel Loubeau, MD (Vascular and General)………….AMHE/Larchmont, NY
Nelson Rosen, MD (Pediatric and Trauma)………….North Shore/LIJ
Dany Westerband, MD (Trauma and Critical care)………….AMHE/Suburban Hosp., Bethesda, MD
Urology
Raymond Paul-Blanc, MD………….AMHE/Mansfield, MA
Simpa Salami, MD (4th Yr Resident in Urology)………….North Shore/LIJ
Nikhil Weingangar, MD(Chief Resident in Urology)………….North Shore/LIJ
Michael Ziegelbaum, MD………….North Shore/LIJ

The team initially included a pathologist and the entire mission was structured around her presence, given the difficulty in obtaining any kind of cytologic or histo-pathologic  biopsy results in Haiti.  Unfortunately, she had to abort her trip at the last minute, due to health concerns.   On the other side, during the last week that preceded the trip, three additional individuals joined the team: Samuel Broaddus, MD and Lars Ellison, MD, both from the State of Maine who were in Haiti to attend the first Joint Haitian American Urology Conference, sponsored by the AMHE and the American Urological Association, as well as Brigit Downey who volunteered to work side by side with her husband Dr. Jon Downey.

Having completed the roster of participants, it was time now to build our agenda and academic curriculum around the expertise available and the needs prevailing at Justinien Hospital.  First, we had to present for the third time our emergency management courses, i-e the advanced trauma and the Advanced cardiac life support courses, which we have pledged to continue to offer as long as we have the instructors available.

Second, we wanted to continue the Journal Club series, which we have been trying to institute as an important piece of the education system for the residents at Justinien.  The responsibility of organizing these discussions was entrusted to the Surgery, Urology and Infectious disease residents and fellows of North Shore LIJ.

Thirdly, we wanted to maximize the impact of the participation of Dr. Nelson Rosen in this mission. Indeed, he was not only the first pediatric surgeon to join us, but also he was doubly qualified as a trauma surgeon and a specialist of Ano-Rectal malformations.  Indeed, as a member of the Reserve Army Medical Corps, Dr. Rosen did several tours of duty in Iraq and for the past few years, he has been the director of Pediatric Trauma at Long Island Jewish Medical Center.  As a bonus, Dr. Rosen completed his fellowship in Pediatric Surgery at St-Justine Hospital in French Canada, therefore he spoke and understood French well. Thus, not only did he work as an instructor for the Advanced trauma Course but we organized a symposium on Ano-Rectal malformations, discussing the embryology and anatomical classification of these malformations as well as the best techniques for correcting them.

Fourthly, as a pathologist, signed up for the mission, this opened the door to immense possibilities. Not only we could obtained biopsies and immediate pathology reports as we have not seen in Cap-Haitien in over 40 years, but also we saw the possibility of initiating the Tele-pathology program. Louis Auguste, Jr, who created a web-based platform for tele-pathology, travelled from London to organize the technical part of the program, while our pathologist would assume the task of training the residents and physicians of HUJ in the preparation of cytology slides. Assured of her participation, we also organized a screening session for Cervical and Breast cancers that was advertised and promoted on the local television channel and radio station.  Unfortunately, on the eve of our departure, the pathologist had to cancel her trip due to an unexpected illness, causing the collapse of a whole section of our program. We had to scramble to revise our plans and save what we could save. As a consolation, the pathologist obtained that a Lab in New York interpret 400 Pap smears for us.

On another positive side, we have to acknowledge the support of the entire North Shore/LIJ Health System.  This effort was coordinated by Carol Olsen, RN who, despite her own health concern, contacted all the hospitals in the system and requested donation of medical supplies and materials.  She also secured for us a spot in the CFAM (Center for Advanced Medicine) depot, which was a staging area for collection of supplies, packaging and shipping of all the material collected. All the nurses in the Operating Room at LIJ collected unused supplies, sutures, gauze pads, gloves, gowns, drapes, etc… Our thanks also to the group of nurses anesthetists at LIJ who contributed to a fund that was used to purchase additional material that had been requested by the staff at Justinien Hospital.  Altogether, we collected 4296 lbs or about 2.15 tons of material and equipment that included: Endo-tracheal tubes, naso-tracheal tubes, chest tubes, naso-gastric tubes, Foley catheters, Gauze, Laparotomy pads, electric loop for LEEP procedures, a suction machine, a colonoscope, a microscope, glucometers, spinal needles, Vision testers, surgical instruments, suture materials, prosthetic meshes, a baby warmer etc…  This shipment included also multiple late edition textbooks donated by Drs. Dufresne, Loubeau, Stern,a gynecologist from LIJ, Okeke, etc…  A complete set up for endo-urology, donated by STRYKER, was shipped in the same container on October 18 from New York to Cap-Haitien, via Miami, with the anticipation that the container would arrive at destination, at least a week before us.

Our last hurdle was that the first day of the mission, November 18, happened to be a national holiday in Haiti. Most of the services at the hospital would not be functioning. Worst of all, the opposition party in Haiti announced that they would organize a major protestation march on that day in Cap-Haitien, since the President was going to be in town for the commemoration of the last Battle for the Independence of Haiti.  However, with the reassurance of the Chief Administrator of the Hospital, Dr. Jean Geto Dube and our local contacts Drs. Jean-Lenic Joseph and Guerline Roney, we took the leap of faith, hoping for the best.

Thus, by November 14, members of the team started converging from the West and the East Coast, the North and the South of the United States toward Port-au-Prince. The First Joint Haitian American Urology conference, also sponsored by the AMHE was held in Petionville on November 15 and seven of the participants remained for the Mission in Cap-Haitien.  On the 16th, the bulk of the group landed at Toussaint Louverture International Airport, spent the night at the beautiful Karibe Hotel and the following morning, we were all on the bus to Cap-Haitien.   The majority of the group had felt some reservations about flying the small planes, albeit for a very short ride. In addition, the bus allowed us to ferry much more luggage than the plane. Finally, it was an opportunity to see more of the country.  The trip was fairly comfortable; the roads were much improved and it took us approximately five hours to reach our destination.  The toughest task was to fit everyone in the nice but small hotel, Auberge du Picolet.  Sacrifices had to be made and we ended up with four people in two rooms and three in another room, while the other team members were lucky to have single or double-bedded rooms.  Unfortunately, by the time we finished registering at the hotel, it was too late to carry out our plans to visit the Citadel or spend any time on the nearby beaches. We rested, although we were full of apprehension concerning the very first day of the mission. Will it be wasted or productive?

Thus, on November 18, 2013, we presented to the newly refurbished administrative suite of the Justinien University Hospital to meet the chief Administrator Dr. Jean Geto Dube and the leadership of the hospital as well as the chief residents of the different services. A reporter of the local television station was also in attendance and recorded this inaugural phase of our mission. The reception was warm and we all looked forward to a week of intense labor, replete with opportunities to exchange information, to the benefit of the population.  Our only disappointment was that the shipment of material did not reach the hospital until the day before our arrival. Thus, it was unlikely that we would be able to have all the material available on this trip.

After a quick tour of the hospital, we were immediately introduced to our respective services, which was all of them, except for Pediatrics, since unfortunately we had no representatives in that specialty. We learned that the screening program for breast and cervical cancers would be held in the Family Medicine outpatient pavilion.  As soon as we entered the hallway, we were delighted to meet throngs of women, who had heard the announcement on the local TV and radio stations.  It was definitely one of the happiest moments of the trip for me. All the women had a breasts examined as well as a pelvic examination. This was complemented with a Pap smear and whenever appropriate a sonogram of the breasts, with sonographically guided core needle biopsies by our radiology team if needed. Six cases of breast cancer and six cases of obvious cervical cancer were detected, notwithstanding the eventual cases that will be detected when all the Pap smears are read.  Our gynecologist, Dr. Deans aided by the four nurses, worked side by side with Dr. Cyril Leconte and Dr. Jenna, respectively Chief of Obstetrics and Gynecology and of Family Medicine at the JUH.  Dr. Deans made bedside rounds with the residents in the service, gave several lectures, discussed case presentations and assisted them in the operating room. In addition, she donated to the operating room brand new sets of surgical tools for gynecological procedures.

The curriculum for the Internal and Family Medicine Services benefitted from the inclusion in the team of Dr. Arthur Luka, a fellow in Infectious Diseases in the North Shore LIJ Health System.  The interns and residents on these services enjoyed the presence of Dr. Luka, who expressed himself well in French. Thus, he was able to conduct bedside rounds and lectures on such topics as “The Use of Antibiotics,” Community-Acquired Pneumonia and Meningitis.  Meanwhile our stalwart Drs. Dufresne and Thelusmond continued their teaching in electrocardiography and echocardiography and saw several cardiac patients in consultation.  Once again, they trained and certified 25 more young physicians in Basic and advanced cardiac Life Support.

The Urology program had the largest contingent so far of specialists.  Dr. Ziegelbaum, back for his second tour, was joined by Dr. Raymond Paul Blanc, Dr. Lars Ellison and two residents for the North Shore LIJ program, Drs. Nikhil Weingangar and Simpa Salami.  They were joined also by Dr. Samuel Broaddus, whose Konbit Sante Project based in Portland, ME, has been supporting the JUH for more than a decade.  With all the supply collected, they were able to create an endoscopy room in the OR Suite.   Once the set up completed, they were able to performed three Trans Urethral Resections of the Prostate, one transurethral resection of a bladder tumor, several cystoscopies, in addition to such open procedures as an open supra-pubic prostatectomy and a correction of cystocele with a mid-urethral sling.  The group took part in the outpatient urology clinic.  They also conducted a Journal club, reviewing such key articles as “AUA Guidelines for the Active Surveillance and the Early detection of Prostate cancer” and “Radical vs Partial Nephrectomy: Functional and Oncologic Outcome.” with the local residents.  Finally, they provided multiple lectures on various topics including “ Hematuria Work up” and “Prostate Cancer: Screening, Diagnosis and Treatment.”

In the area of Oto-Laryngology, Dr. Leveque worked with Dr. Clausel Midy, the local ENT specialist in the outpatient clinic and lectured the residents on diseases of the sinuses. He donated to the service a large collection of medications provided by the Direct Relief Organization, including various antibiotics.

As for Dr. Maxime Coles, after attending the Urology Conference in Petionville, he worked with the Orthopedic residents at the State University of Haiti Hospital in Port-au-Prince, then joined us in Cap-Haitien on November 19, 2013.  He participated in the Orthopedic outpatient clinic and bedside rounds with the residents and interns in orthopedics and lectured them on “Basic Sciences in orthopedics”, “Treatment of Hip Fractures”, “Non-Union in Orthopedics: Assessment and Treatment.”  Finally, as an ATLS instructor, he participated in the didactic and practical sessions of the course on Advanced Trauma Management.

Our Radiology team comprised of Drs. Gail Phillips and Andrew Tyan benefited of a portable sonogram machine that was provided on loan by the North Shore/LIJ Department of Radiology.  Assisted of Brigit Downey, they worked tirelessly, all week long, screening women with breast masses or suspected pelvic neoplasms.  They also provided us with radiologic evaluation of all abdominal or soft tissue masses and thus provided invaluable information throughout the week.  Dr. Tyan lectured the residents and interns in the Internal Medicine on Basic Sonography and Basic cross-sectional imaging. There was no interaction with the staff radiologist who was receiving additional formation in France.

As mentioned earlier, the program in surgery was reinforced by the presence of Dr. Nelson Rosen, our pediatric surgeon with sub-specialty both in Trauma surgery and in Ano-rectal malformations.  Indeed, along with Dr. Amy Kraus, he presented a well-attended and well-appreciated symposium on Ano-Rectal Malformations – embryology, classification and Management, supported with a set of DVDs graciously provided by Dr. Alberto Pena that were donated at the end of the symposium to the surgical library. The symposium culminated by the performance by Dr. Rosen of an 8-hour PSARP procedure for the successful correction of a cloaca in a six-month-old girl. This was the second highlight of the mission, since the baby recovered well and Dr. Rosen left some specific printed instructions for the post-operative management. Dany Westerband, the ATLS course director, aided by the other two ATLS instructors, once again provided instruction on the Advanced Management of Trauma, complete with practical demonstration of endo-tracheal intubation, crico-thyroidotomy, tube thoracotomy,   pericardial tap and paracentesis on manikins.  Textbooks were provided by courtesy of the American college of Surgeons Commission on Trauma. At the end of the course, nineteen participants were certified. Additional academic activities in the Surgical Service included bedside rounds, participation in the outpatient clinic, lectures on Pre-operative and Post-Operative care and a Journal Club.  The Journal Club that we have been introducing as a major teaching tool at the JUH, was presented by Dr. Kraus.  The two articles discussed focused on the impact of ATLS courses on the outcome of major trauma cases and on the value of screening programs in the reduction of mortality from Breasts and Cervical cancers in  Underprivileged countries.  We performed only eight general surgery operations, i-e two modified radical mastectomies, two pediatric hernias with undescended testicles, a laparotomy for a stab wound, a laparotomy for an unresectable retroperitoneal tumor, and the repair of the ano-rectal malformation.

The third highlight of the mission was supposed to be the initiation of the tele-pathology program.  The web-based platform was built and ready to go.  Its creator, Louis J. Auguste, II traveled from England to join the group and teach the physicians at the hospital how to scan and upload the slides.  This trip would have provided an opportunity to test both ends of the program, in Haiti and at the University of London hospitals.  Our pathologist was supposed to teach them how to do the fine needle aspiration biopsies and prepare the cytology slides. Unfortunately, the program failed to reach its goals with the untimely defection of our pathologist.  Nevertheless, Mr. Auguste gave its demonstration and most of the residents felt that with some practice they could master the technique.  The potential benefits of such program are so immense that it deserved to be revisited and we are already working to secure the participation of a pathologist at the time of our next mission.

Our team of anesthesiologists worked well with the local staff of one anesthesiologist, an anesthesiology resident, several nurse- anesthetists and student nurse-anesthetists.  Some of them were able to attend and complete the ATLS course, but the teaching during the cases was very appreciated.  A lot of material was collected and intended for use by the anesthesiology service, but as stated above, the shipment arrived too late and was delivered to the Operating Room suite after our departure.

Our nurses were most valuable.  They worked very hard and spent long hours with the Gynecology team screening hundreds of women and performing pap smears. The PSARP procedure would not have been possible without the assistance of Nurse Surprise who had extensive experience with such procedures. One of their biggest contributions though was the reorganization of the storage room in the operating room Suite. Indeed, the room was full of donated supplies; some of them had never even been opened. Some of the instruments that we were asked to bring, were in some of these still sealed boxes. They sorted them out and reorganized the shelves, so that at least the items could be found when needed in the operating Rooms.

Overall, it was a very fruitful and productive week for
-    the local population who benefited of a free screening for breast and ovarian cancers
-    the patients of the hospital who benefited of the previously unavailable equipment, namely the endo-urology equipment and of previously unavailable expertise, such as the repair of the cloacae in the six-month old baby
-    the resident and attending staff who benefited of the exchanges with the visiting team, the lectures, the journal clubs, the advanced training in cardiac and trauma care, the teaching materials, i-e the DVDs and the Textbooks, etc…
For this, the hospital leadership, including the chief administrator, the medical director, the director of formation, and the chief residents of the different services, in the presence of the Regional Representative of the Minister of Health and of the Population had an award ceremony for us. Several speeches recognized our contributions over the past four years and our contribution of this mission.  The AMHE received two magnificent plaques expressing the gratitude of the institution and every member of the team received a personnel certificate of appreciation, which was a gesture well appreciated by everyone.

Our last task was the debriefing with Dr. Dube who is always attentive to our constructive criticism as a way to improve the performance of the hospital.  First, we congratulated the administration for the work done since our last visit. In particular, all the buildings had been repainted.  Broken doors in the Operating rooms were replaced, but since it did not rain , we could not tell whether the roof had been repaired.  The new administrative offices were more spacious and definitely more functional.  The hospital appeared less congested and it seemed that an effort was being made to limit access to people not directly involved in the care of the patients.  We saw more employees with identification badges, but there were also plenty of employees without name badges.  We were informed that some of the new residents had received late assignments and that the badges were not ready.  However, there are such things as temporary ID badges that can be prepared in minutes.  It is very important to control the flow of visitors in the Hospital, in order to increase the safety of the patients and of the personnel and to facilitate the work of the physicians and the nurses as well as the care of the patients.

Second, for a hospital of that size, when all the surgical services are active, two operating rooms are far from being sufficient, particularly, since the OR schedule is interrupted constantly by unexpected cesarean sections.  We could not perform some of the cases that had been scheduled by the residents even before our arrival.  Furthermore, none of the breast cancers detected during the screening program were operated on during our stay. One possible solution is to open the operating room attached to the Maternity Ward. This alone could greatly alleviate the pressure on the Main OR Suite.

Another issue related to the Operating Room has to do with the fees demanded for the procedures. Certainly, the Hospital must generate income to maintain an inventory of supplies and replace medications and supplies used for example during emergencies. However, some patients are really indigent. One of the patients that I saw during the screening program was aware of a breast mass for over a year, but could not afford to see a physician.  When she heard that the AMHE team was in town, she came for treatment.  I presented the case to Dr. Dube who exonerated her from all expenses.  Thus, she had  a hospital chart created, a chest X-Ray and blood work, free of charge.  However, when she presented to the Operating Room for surgery, she was told that she had to pay, even though she cried and protested that she did not have any money.  I do not know if she ever had the operation.  We thought that she could have been granted a pass, given the amount of supplies, worth thousands of dollars that we gave to the operating room.  We feel now that perhaps instead of spending so much money on shipping, we should keep some of the money and pay for the indigent patients to have access to the operating room.

Stock management is definitely a problem at the Institution. One single person is not capable of handling such a large depot. On our part, we have to recognize that we could and should have sorted out the items by specialty at the time of shipping  and we will keep that in mind next year.  However, to have supplies and equipment and not even know that you have them is a waste, because the items are not being used and may eventually need to be discarded.  Furthermore, it leads to an overload of the depot and further diminishes the ability to manage the stock.  Same situation was observed in the Operating room where brand new items, instruments  and suture materials in such great demand were still in sealed boxes.  We understand that some of the nurses are placed in charge of a service without being formally appointed and without receiving a salary upgrade.  Therefore, they do not feel the responsibility of supervising the stock of medications or supplies.  The administration may want to look into this issue further.

At every single visit, we discuss with the residents the need to examine the scientific basis and the reason behind the way they care for the patients. For example, a patient coming to the hospital for a mastectomy receives intravenous solutions and antibiotics every day for at least one week. The family or the patient herself must buy the intravenous catheter,  the bottle of intravenous solution, the tubing as well as the oral antibiotics.  Multiple studies have shown that the only important dose of antibiotics in the prevention of post-operative infection in a clean case is the one given within the hour before surgery.  All the antibiotics given afterwards are useless.  In addition, there is no need to continue the administration of intravenous solution once the patient is able to take food orally.  Thus, the patients in Haiti, already strapped for cash in most of the cases, could be spared 30, 40, 50 US dollars, money that could go toward paying for the operating room fees or simply towards buying food.

During the week spent at JUH, we had a situation where we needed to use the ultrasound machine, which we had brought from the US, but it was locked in the Family Medicine Pavilion and no one had the keys to the building.  In other instances, certain materials needed in the operating room could not be found because they were locked for the night.  These situations call for the hiring of an administrator on duty or a nursing supervisor with access to all the buildings.

We were very impressed by the new laboratory facility built with the support of the Brazilian and Cuban Governments. However, we were also concerned that there was no possibility to perform any bacteriological culture.  Children are dying of meningitis daily and we are giving them all kinds of cocktails of antibiotics because we cannot isolate the offending organism and treat it appropriately.  What would it take to implement such program?  Has the request been made to the government to provide this facility to the only Major Hospital of the North of the Country?  Would the Miller School of Medicine be interested in supporting it? If not, we could interest other organizations to sponsor it or fund it on a temporary or long-term basis.

Finally, it is unquestionable that the administration has been doing its best to deal with difficult issues: personnel issues, government issues, and yes, money issues!  It is so important for the hospital to increase its revenues.  Every day  paying patients are taking the planes to go to Port-au-Prince, Santiago, DR, or the United States.  These patients could be interested in staying locally  and pay for their care, perhaps a bit more and this in turn could be used to finance the care for the truly indigent patients who cannot afford the operating room fees or the physicians’ fees.  Thus, we raise once more the question: Why cannot the Private Pavilion be reopened and accommodate the paying patients? It also raises the question of safety at the hospital.  Important questions, but problems exist to be solved and we believe that the administration in place has the will and the capacity to solve them.

Every member of the team is grateful for the hospitality extended to them by everyone at the Justinien University Hospital. The delicious lunches, the collaboration, the camaraderie was so much appreciated. Every one has pledged to return next year. We will do our best to include a Pediatrician in the group.  Tele-pathology was a near miss, but we will make it happen.  Already, preparations are under way.

We thank all our supporters of the AMHE, the North Shore/LIJ Health System, STRYKER and KARL STORZ Companies, Direct Relief Organization and all the generous individuals who have supported this effort to improve the present and the future of health care in Haiti.

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