AMHE Medical Mission to Justinien University Hospital
February 26 through March 2, 2012
The AMHE has been involved in medical missions to Haiti since its creation and this cooperation between our organization and the Haitian Ministry of Health resulted in a signed agreement in 1990, which was reaffirmed in 2007 and again in 2011. The concept behind these medical missions is contrary to the approach of most of the foreign medical interventions in Haiti, which for the most part tend to replace or compete with the government provided health services, during the length of their unpredictable stays.
The philosophy behind the interventions of the AMHE has been
- to cooperate with the local resources,
- support the national system with learning material, medications and modern equipment as well as rebuilding the infra-structure when possible,
- empower the Haitian professional to practice better medicine, so that the level of care for the Haitian patient can be elevated and this impact may last beyond our physical stay in the country.
On February 25, 2012, the first contingent of four physicians and nurses took a flight down to Port-au-Prince, Haiti, with the ultimate destination to Cap-Haitien for a weeklong medical mission. This mission was the fourth undertaken under the egis of the AMHE in this Northern Haitian city, since November 2009. Over the ensuing three days, seven additional members joined the group, which constituted so far the largest team to visit Justinien University Hospital. It included:
George Angus, MD, MPH Trauma Surgeon/Critical Care Specialist East Meadows, NY
Louis J Auguste, MD Surgical Oncologist/General Surgeon New Hyde Park, NY
Christian Bijoux, MPH Epidemiologist and Public Health Specialist Boston/New York
Maxime Coles, MD Orthopedic Surgeon Coffeyville, Kansas
Marie Dejoie-Robinson, MD Internal Medicine Brooklyn, NY
Yvan Ducheine, MD General, Laparoscopic and Bariatric Surgeon New Jersey
Isabelle Jean-Pierre, MD Anesthesiology Miami, FL
Gladys Laroche, RN PACU Nurse/ Nurse Educator Elmont, NY
Hubert Leveque, MD ENT Specialist Baltimore, MD
Anne Lihau-N’Kanza, MD Trauma Surgeon/Critical Care Specialist New Jersey
Florence Monplaisir, MD, MPH Internal Medicine Philadelphia, PA
Based on observations made during previous missions, it had become clear that aside from infectious diseases, chronic illnesses, particularly diabetes mellitus, were taking a major toll on the Haitian population, resulting in premature deaths, loss of productive years due to the extensive list of complications and morbidities associated with the inadequate treatment of this illness. The previous missions had also allowed us to see that traumas and acts of violent aggression affected also a large segment of the population and consumed an inordinate amount of resources at the hospital. Therefore, the goals of this mission were set early on, focusing on educating both the medical staff and the patient population about Diabetes mellitus, as well as offering a better approach to trauma care, since unfortunately at this point, our organization is not able to work on the prevention and the reduction of violence in the country, a by-product of poverty, political instability and lack of a strong central authority. Finally, we also had previously appreciated that the scope of the specialties and the number of specialists available often caused inordinate delays in the care and limited the range of services offered at the Justinien Hospital. Thus, the inclusion of an ENT specialist and an Orthopedist constituted significant additions to our medical team. In preparation to this mission, we had contacted and solicited the help of the New York Chapter of the American Diabetic Association. The local chair Hildegarde Payne, RN and Maryse hyppolite, RN, Nurse Educator at Queens Hospital Center provided us with 20 Free Style Glucometer kits, 50 packs of tooth paste and dental care kits and 200 packs of educational materials, including an Audio CD (4 etap pou kontwole dyabet ou pou res vi’w) and a corresponding pamphlet both in Haitian Creole. The local chapter of the ADA provided also instruction sheets for foot care and other preventive measures for the diabetic patient. Dr. Paul Nacier provided informative brochures on the Haitian diet and ways to make it a healthy one. He also provided four cases of diabetic, anti-hypertensive, cholesterol lowering drugs, broncho-dilators etc… Finally, medications were purchased from the Blessings International Center, specifically Cipro, Metronidazole, Metformin, Lisinopril, Pepto-Bismol, Imodium, Silvadene Cream, as well as Regular and NPH Insulin, with the contributions of Dr. Jean-Robert Desrouleaux ($500.00), Frantz Moise($500.00), Vincent Cordice ($300.00), Paul Nacier ($250.00), Marie Dejoie-Robinson ($200.00) and Robert Gluck ($100.00).
On the eve of the mission, after the inescapable visit to the majestic Citadelle and the awe inspiring ruins of the Sans-Souci Palace, the team was treated to a delicious welcome dinner, courtesy of Dr. Guerline Roney and Jean-Lenic Joseph. On February 27, 2012, we were warmly greeted on behalf of Dr. Jean Coq, Medical Director of Justinien University Hospital, by Dr. Yverl Zephyr, director of formation, who also gave us a tour of the institution. Without any further delay, all our members were injected into their respective services and conducted teaching rounds with the residents, participated in outpatient clinics and in the activities of the Operating Suite.
As expected, the highlight of the mission was a daylong symposium on Diabetes Mellitus on Wednesday February 29, 2012 in the Auditorium of the Family Medicine Pavilion of the Hospital. This symposium was geared to the resident staff of the Departments of Internal medicine, Family Medicine, Surgery, Pediatrics, Anesthesiology and Obstetrics and Gynecology, as well as the nursing staff of the hospital. Physicians of the Health Centers of the surrounding communities were also invited. After the opening remarks by Dr. Yverl Zephyr and Dr. Louis J Auguste, nine lectures were delivered by Drs. Florence Monplaisir, Marie Dejoie-Robinson, Yvan Ducheine, Isabelle Jean-Pierre, Anne Lihau-N’Kanza, Guerline Roney, Director of the Ophthalmology Service at Justinien, as well as Ms. Laroche, RN and Mr. Bijoux, MPH. The presentations, which were of the utmost quality, are listed in the appended program. They were delivered in French, English and Haitian Creole. A complementary mid-day collation was offered by the Ophthalmology Service. There were nearly 70 individuals in attendance, who availed themselves of the abundant educational material displayed at the conference. The level of interest was quite high as attested by the number of questions raised by the audience and the prolonged exchanges that followed the presentations. The residents obtained copies of all the Power Point presentations. Dr. Ducheine’s presentation on metabolic surgery generated also some interest, as the surgical option seemed to be a one-time solution for the morbidly obese patient with Type II Diabetes who is unable to purchase costly medications. There were many requests for additional similar sessions.
Just as successful was the meeting with the diabetic patients and their relatives on Friday March 2, 2012. After the initial introduction by Dr. Auguste, Dr. Monplaisir, Dr. Dejoie-Robinson and Ms. Laroche spoke briefly of the nature of the disease, its lifelong health impact and the management options for Type I and Type II diabetes. The conference room of the Department of Medicine was filled to capacity with over 35 patients and family members. All lectures were given in Haitian Creole. The participants were very attentive to the lectures and asked many pertinent questions. Some of them appeared either dehydrated, emaciated or obviously fatigued, suggesting a less than optimal state of control of their illness. Every participant received a packet of printed and recorded material. Ten glucometers were distributed to some of the patients, while the other 10 were given to the different patient units. A pack of Metformin was given to each Type II Diabetic and monetary assistance was provided to each of the 14 Type I diabetics toward the purchase of their Insulin supply. The excess of medications were given to the Medical residents in charge of the Diabetic clinic for free distribution to the patients in need. Overall, the participants in this seminar were very grateful. There is a need for continuous support of this diabetic clinic in the form of medications and/or cash as well as additional glucometers and supplies of testing strips for the glucometers, since the hospital seems quite strapped for resources. This seminar geared toward the patients deserves a reprise at a larger scale, perhaps with the participation of the local media.
Our third teaching objective was to deliver to the Surgery, Orthopedics, Emergency Medicine, Anesthesiology residents and interns a trauma course patterned after the ATLS Course of the American College of Surgeons. The curriculum of the course is also appended at the end of this document. A final exam was scheduled and a certification of completion was to be awarded. This course was also supposed to be the forerunner of a program of initiation to trauma management that we would like to reproduce in all the teaching hospitals of Haiti, leading perhaps to the recognition of the program by the American College of Surgeons. Due to the unavailability of a larger venue for an extended period, the course had to be staggered over five days and its completion required a strict adherence to the schedule. Unfortunately, the difficulties encountered with the Operating Room did not allow us to complete all the planned lectures. Seven of the 12 lectures were given and were well received by the residents who absorbed a large amount of information. The lecturers were Drs. Angus, Coles, Jean-Pierre and Lihau-N’Kanza. This experience should be repeated and carried to completion next year.
Additional teaching activities took place in the Orthopedic Service where Dr. Maxime Coles met and collaborated well with the Dr. Pierre-Louis, chief of Orthopedics at Justinien University Hospital. He gave formal lectures, participated in the daily outpatient clinics and rounded on the hospitalized patients with the residents and the interns of the service. In addition, Dr. Coles performed four major surgical procedures with the residents and was able to discuss different surgical approaches with Dr. Pierre-Louis.
Similarly, Dr. Leveque worked countless hours in the outpatient clinic of Oto-Rhino-Laryngology along with the Chief of Service, Dr. Clausel Midy who gave him some insight into the local habits of the population and the unusual kinds of pathology seen in his clinic. He had numerous didactic sessions with the ENT residents and donated multiple audio-visual materials as well as several ENT textbooks. He had brought with him a flexible laryngoscope, which was otherwise not available at the Hospital. That allowed him to diagnose a laryngeal carcinoma, a nasal turbinate neoplasm, a case of dysphonia and a retained foreign body of the esophagus. In fact, he saved that patient who had inadvertently swallowed part of her denture and who was being prepped for a cervical esophagostomy, by demonstrating that the foreign body had passed distally.
The general surgeons of the group with the surgical residents took care of most of the emergency cases received during that week. We performed a laparotomy for an abdominal stab wound with evisceration, a repair of an incarcerated hernia in a 22-day old baby, the closure of an abdominal wound dehiscence in a 12 day old baby who had undergone a colostomy creation for an imperforated anus, a modified radical mastectomy for a locally advanced breast carcinoma and the drainage of a large breast abscess. Several other cases could not be done, due to the slow pace of the operating room, including two elective inguinal hernias and another mastectomy. Our surgeons participated in the bedside teachings rounds with the surgical residents, conducted by the Chief of Surgery, Dr. Barella.
Our anesthesiologist, Dr. Isabelle Jean-Pierre worked well with the Director of the Operating Suite, Dr. Leconte and performed most of the cases listed above, in addition to providing key lectures during the diabetic symposium and the trauma course. She also provided instruction to the first year resident and the student nurse anesthetists.
Our internists conducted bedside teaching rounds with the residents and had a chance to evaluate their level of knowledge and their approach to the care of the patients on the service. Formal case presentations in the afternoon were planned but could not be carried out due to many unpredictable circumstances.
On the last day of the visit, large supplies of OR equipments, including adult and pediatric electric grounding pads, suture materials, chest tubes, non-sterile gloves, Penrose drains, stethoscopes, medications and glucometers were distributed to the operating suite manager, to the resident staff and the different surgical and medical services. A brand new Harrison’s Medical Textbook (latest edition – courtesy of Dr. Ronald Sanon) and two additional medical reference books were donated to the residents’ library.
The surgical residents were invited to our farewell dinner at LAKAY restaurant/night club and this was the occasion for a sincere expression of gratitude from us toward them for their cooperation and their willingness to learn and reconsider their ways and approaches to the care of our Haitian brothers and sisters in a fairly sclerotic environment that is not often open to change. The residents in turn expressed their heartfelt thanks to the entire visiting team for taking the time from their busy activities abroad to provide the much needed teaching and for giving them strength in the everyday fights that pit them against inertia, lack of compassion, lack of good will, lack of resources to even carry out the minimum.
Overall this fourth Medical mission of the AMHE to Justinien University Hospital was considered a pleasant experience, a relative success and a stimulating challenge both by the first time participants and the veteran members of the team.
First, the reception by Dr. Yverl Zephyr, director of Formation, Dr. Guerline Roney, chief of the Ophthalmology Service and Dr. Jean-Lenic Joseph, Internal Medicine Attending, was enthusiastic and much appreciated. Their efforts started well before our arrival and contributed to make this mission a successful one. They deserve as much credit as we do and we want to express our sincere thanks to them, without forgetting the indefatigable driver Marcellin who was always available to make sure we made it to our destinations in time. We wish also to thank Dr. Jean Coq, Dr. Marc Dube, Dr. Rodolphe Barella, Dr. Clausel Midy, Dr. Pierre-Louis, both Drs. Lecontes and Dr. Jena who welcomed us into their respective departments. The cooperation with these outstanding individuals will be indispensable for the continuation of this program of support to the Residents in training at Justinien University Hospital.
However, conditions at the Hospital are far from perfect and many changes will be needed to improve the quality of care in this institution, considered to be a referral center for most of the Northern Provinces of Haiti. Every member of the team had an opportunity to submit their criticisms and recommendations, which were never malicious, but always made in good faith. Most of these ideas were shared with Dr. Dube, the new chief administrator of the Hospital, on the eve of our departure. At the conclusion of our meeting, he asked us to spell out the different points that were raised The final part of this report will summarize the essence of this discussion.
1- The physical condition of the hospital
a. The hospital is overcrowded. Indeed, since the inauguration of the hospital in 1890, the perimeter of the facility has not expanded, although the population has increased tenfold. The surgical and pediatric pavilions are clearly too small and a second floor could be added on these buildings after proper engineering and architectural evaluation.
b. The sanitary conditions are deplorable. The smell of urine is overwhelming in many areas, particularly near the outpatient clinic. There are not enough bathrooms in the hospital for the public and the few that we found do not have flushable toilets. There is no running water in most of the bathrooms; therefore, one must wonder where the members of the staff wash their hands in the course of the day.
c. Animals, such as dogs, cats, poultry, should not be allowed to roam the campus of the hospital, let alone the patients’ wards.
d. The care of the patient is also hindered by the flow of zealots crowding the patients’ wards at the least opportune moments. These activities could be limited to specific moments of the day, preferably in the afternoon, after most of the acute care has been rendered.
e. Most of the pavilions could use a coat of white paint.
f. The roof of the Operating Rooms Suite is reported to be leaking. This requires immediate attention, since a hospital of that size cannot function with one single operating room. An estimate of the cost of repair of the roof should be obtained and a fundraiser could be organized to secure the necessary funds.
g. Too many vehicles are allowed on the campus rendering the traffic difficult and perhaps even dangerous. There used to be a gatekeeper at the entrance to screen the vehicles that wanted to enter the premises. In addition, consideration should be given to acquire additional space near the hospital to create a parking area.
2- The Power grid
a. The Power circuit is clearly defective. In the course of a surgical procedure, the electric devices have to be reset every five to 10 minutes, because of power surges. This obviously represents a threat to most of the modern electric and electronic devices. It has been reported that brand new Incubators and radiography machines have been damaged by these power spikes. In ophthalmology, every single piece of equipment is connected to a surge protector. The same should be done in all the services, until the electric circuitry of the hospital is improved.
b. The AMHE has previously contracted with Mr. Desrouleaux, electrical engineer based in Port-au-Prince, for the construction of two operating rooms at General Hospital (HUEH). He is certainly an asset that could be very useful in the solution of this problem.
3- Organizational problems
a. These problems had been brought up for discussion during the first and the second medical mission to Cap-Haitien and still have not been resolved.
i. Oxygen supply in the Pediatric Unit. The Hospital should have oxygen readily available for cases of respiratory distress. Otherwise, patients will die while waiting for the parents to go downtown to purchase a tank of oxygen. Sacred Heart Hospital in Milot has offered free Oxygen to Justinien, if only they would come and get.
ii. It is important to separate infected cases from clean ones in surgery.
iii. In addition, there should be an Isolation Ward or room for TB cases and other highly contagious diseases.
b. The delays in payment of the employees’ salaries is a particularly thorny one and brings into question the ability of the leadership to demand strict adherence to the rules of the hospital, such as response to emergency calls, punctuality etc…
4- Additional revenues for the Hospital: It has become imperative for the hospital to generate additional revenues. Governmental funds have become scarce and irregular. This has led to a situation where not even the minimum of supplies, such as emergency oxygen, IV fluids, dressing materials or baseline blood tests is available to the indigent population, unless a special authorization is obtained from the administrators. This results in a certain degree of economic disparity (No Pay = No Care). We saw a young patient with a third degree burn probably with Pseudomonas infection (since the dressing was green), whose dressing had not been changed in two days, because the parents could not purchase gauze pads and bandages.
a. The administration of the hospital should prioritize the most pressing projects, obtain a cost estimate, then seek a potential sponsor for the project and deliver results in time. This will go a long way to encourage donation from individuals and other philoanthropic institutions. The AMHE is willing to take on some of these projects, to the extent of the association’s ability and means.
b. Fund Raisers can be organized within citizens of the community, since rich or poor, they have to use the facility, if only for stabilization, prior to being transferred to Port-au-Prince, Dominican Republic or Florida. Therefore, they all have a stake in the matter. Galas, Walk-a-thon, Tele-thon and radio-thon could bring revenue out of the community. However, the appearance of the hospital needs to be upgraded in order to attract the paying clientele.
c. A community Board should be created to get the business leaders and other influential members of the city a voice in the running of the hospital. Along with these rights would come some obligations to support different projects of the administration and/or any projects of improvement, such as the construction of a new facility or the refurbishing of an existing one, which could be named after an eventual benefactor.
d. The option of reopening the Private Room Suite should be explored, as a way to generate income for the care of the indigent population.
5- Academic Matters
a. The small library created in the residents’ quarters with the help of the AMHE-NY Chapter is well kept and the residents are maintaining a vigilant watch over their precious property. The NY Chapter of the AMHE will continue to support this project.
b. Overall, the residents were quite knowledgeable and were quite eager to learn. The members of the Mission exhorted them to integrate the knowledge gleaned from these reference texts into their practice. Several times during our stay, statements were made that have been established over the years as dogma, some of them absolutely contrary to the practices of modern medicine. The residents were advised to have journal clubs, to discuss significant articles that have been published in their respective specialties. Future missions could integrate one or two journal clubs in their curricula.
c. In addition, the residents were encouraged to take advantage of the expertise of Mr. Bijoux in epidemiology and bio-statistics, in order to develop case series and possible clinical research that will further the local practice of medicine.
d. To that effect, Mr. Bijoux during our stay in Cap-Haitien attempted to obtain some statistical data on the community and found that the records kept at the hospital were woefully incomplete and inadequate for any significant study. These charts would not even allow to tract a given patient lost to follow up.
6- Ethics Issues: It has become clear to us that all the technical and physical improvements would amount to naught unless there is a renewed interest in moral values, a new appreciation of human dignity, a sense of responsibility and a return to our Hippocratic Oath.
a. We wish we could have had more exchanges with the attending staff in surgery, regarding issues such as peri-operative use of antibiotics, drain management, protocol for oral intake resumption after intestinal anastomoses, where there is a sharp contrast between the standard of practice in the US and the one at Justinien. For a physician practicing in the US, it is inconceivable that a team of physicians and/or nurses would leave the hospital at the end of their shifts, without signing out to the next shift. This can lead to extremely dangerous delay in the care of emergency cases. The physical presence of an attending is highly desirable when the residents are dealing with high risk emergencies, such as babies of 12 and 22 days.
b. Patients lay on bloody sheets for more than 12 hours, because a wound debridement had been performed at bedside without properly protecting the bed cover. Patients’ bodies are exposed in the open ward without any possibility of privacy. Health matters are discussed within earshot of neighboring visitors.
c. All hospital workers must learn to see in the patients their brothers and sisters, even though they have not been paid in several months. The golden rule remains: Do unto others as you would like it to be done to Yourself”, since every single citizen of Cap-Haitien is a potential patient at this Hospital.
Meanwhile, every single member of our team has expressed the firm intention to return to Justinien University Hospital and the AMHE will remain focused on the residents at that teaching institution, the next generation of Haitian Physicians. We can improve Haitian Medicine, one physician at a time.
Louis J Auguste, MD L. George Angus, MD, MPH Christian Bijoux, MPH
Maxime Coles, MD Marie-Chantale Déjoie-Robinson, MD Yvan Ducheine, MD
Isabelle Jean-Pierre, MD Gladys Laroche, RN Hubert Lévesque, MD
Anne Lihau-N’Kanza, MD Florence Momplaisir, MD, MPH