Tuesday, August 2, 2016

Orthopedic Trauma Surgery in Haiti

William Slikker
Orthopedic Fellow at BWH
PGY-6


Resources in Haiti are limited and this includes the supply of surgical instrumentation. During our trip we encountered many obstacles but the most difficult to overcome was the lack of appropriate surgical instrumentation and devices that we would typically use in the U.S. For instance, there was no intra-operative fluoroscopy, which we would have normally used for a majority of the procedures we completed on the trip. It took careful planning and a dose of ingenuity to overcome the lack of instrumentation. Adapting to a foreign operating room was difficult, but the local orthopedic surgeons had much to teach us in regards to tackling surgical cases using their set of instrumentation. With the help of the Haitian orthopedic surgeons, we were able to accomplish our goal of providing safe and impactful clinical care. But by collaborating with the Haitian surgeons in this way, we also built a partnership which we hope will continue long into the future.

            This trip served to open my eyes to the complexity of international outreach and the nuances of effectively collaborating with local surgeons and staff. It taught me many things about how to successfully provide clinical care in an international setting. It also demonstrated how the short term efforts of providing direct clinical care are not as important as building bridges for education and communication in a long term grassroots effort to bolster the local medical system in which we are only temporary visitors. Although we accomplished many successful surgeries, our efforts at partnering with the local orthopedic attendings and residents will hopefully build a connection that is even more impactful in the long term.

Academic Emergency Medicine in Rural Haiti: Epilogue

Nahzinine Shakeri, MD

Resident in Emergency Medicine, Brigham and Women’s Hospital and Massachusetts General Hospital
PGY-4

      As I look back on the four weeks I spent as a visiting professor of Emergency Medicine at Hôpital Universitaire de Mirebalais (HUM) in Mirebalais, Haiti, I realize how much I gained from the experience.
As an emergency physician, I was challenged. Over the course of the month, I cared for more critically ill children than I had seen in all of residency, helped manage a mass casualty event when a tap-tap crashed, encountered patients with unfamiliar and tremendously advanced disease processes, and made indescribably difficult decisions. I learned to approach even familiar clinical situations in a new way: diagnosing bacterial meningitis clinically and starting antibiotic treatment without the confirmatory cerebrospinal fluid testing I was used to obtaining, for example, or even using a urine dipstick to check cerebrospinal fluid at the bedside for signs of infection, an evidence-based trick I learned from the brilliant and resourceful HUM residents. 
As a leader, I grew tremendously. I had spent the last year in Boston supervising junior residents at MGH and the Brigham, but always with an attending at my side. This was different. Backup was always available by phone if I needed it, but in most cases I was the most senior emergency physician in the department, acting independently and making clinical decisions on my own. While very much out of my comfort zone initially, I grew to be more comfortable in my role. I learned that I love being an attending, and I was more prepared to make this transition than I had imagined.
As a medical educator, I was inspired. During my short time at HUM, I watched the residents grow, watched them apply new skills I had taught them such as gallbladder ultrasound and chest tube placement. On one residency conference day, I collaborated with another visiting professor to create a pseudo-high fidelity simulation experience with the resources we had available to us and watched the residents approach it with excitement and focus, eager to excel and practice their skills. It was a poignant and profound realization for me that the HUM emergency medicine residents, the soon-to-be first residency trained emergency physicians in their country, are the future of emergency medicine in Haiti. They are the future bedside teachers and residency program directors and curriculum designers who will be teaching Haiti’s next generation of emergency physicians how to ultrasound gallbladders and place chest tubes and run simulations. Education, it seemed to me, was a truly sustainable intervention which would have lasting and exponentially-reaching effects, here in Haiti and everywhere.
As a citizen of the earth, I was stirred by the degree of disparity I encountered, my resolve strengthened to use my career to help alleviate suffering in underserved areas at home and abroad.
I look forward to returning to Mirebalais.

“and with that, my last shift is over and i'm off. goodbye Mirebalais. this morning i'm thinking about the amazing emergency medicine residents at HUM, the soon-to-be first emergency physicians in their country, the future of EM in haiti. and i'm thinking about the patients i cared for, a part of their tragedy and grief becoming my own. and all the amazing, dedicated, inspirational people i met here.
goodbye.. for now.”
-journal entry, 4/30

Orthopedic Trauma Surgery in Haiti

William Slikker
Orthopedic Fellow at BWH
PGY-6


My international outreach experience in Marabelias, Haiti was quite eye opening. After 8 hours of air and land travel to our hospital site, we immediately went to work seeing patients in the clinic and assisting in urgent operations that were taking place in the OR.  Similar to the U.S., it was not uncommon to encounter several severe femur and tibial fractures from motor vehicle accidents on a daily basis that needed urgent treatment. However, we did encounter more unusual injuries as well, including a machete injury cutting off half of the elbow, enormous masses of the extremities with no previous treatment, and chronic shoulder and hip dislocations which would have otherwise been corrected acutely in the U.S.


During our time in Haiti, our team accomplished more than 25 major orthopedic surgeries and evaluated upwards of 40 patients. However, we realized that although we were effective in completing surgeries, there was no way that a short term trip would have long lasting effects. Therefore, our efforts during the trip were focused on education of the local orthopedic residents and collaboration with the Haitian attending orthopedic surgeons. By fostering friendship and partnership during the trip, we hope to establish a line of communication, which will continue via phone, email, and video after our departure. In addition, we provided both clinical orthopedic books and live surgical videos to begin a library collection for the local residents. 
We are currently beta testing a live, streaming surgical video device, which would provide free, real-time interaction and consultation from Boston to the hospital in Marabelias.

Academic Emergency Medicine in Rural Haiti: Prologue

Nahzinine Shakeri, MD
Resident in Emergency Medicine, Brigham and Women’s Hospital and Massachusetts General Hospital
PGY-4

From my vantage point in the back seat of the old Land Rover, bouncing and jolting this way and that down the uneven dirt roads of Port au Prince on the way to Mirebalais, Haiti, things looked bleak. I’d just arrived from Boston, and it didn’t take long to recognize poverty more grim than I’d ever seen it, road traffic conditions primed for trauma, and a paucity of basic fundamentals necessary for the population to stave off disease – clean water, food, sanitation, durable housing.

 Haiti is the poorest country in the Americas and, despite the relatively high burden of disease facing its people, has severely limited healthcare infrastructure and limited access to medical care for most.
I’d traveled to Haiti to learn more about how these seemingly insurmountable problems were being addressed and to see if, in the span of four weeks, I could apply my skills as an emergency physician and aspiring medical educator to contribute in some tiny way.

Outside the window, the terrain became much more rural, more mountainous. Embedded among the rolling green hills and mountains of Haiti’s Central Plateau and the community of Mirebalais was a beautiful white and iron structure - Hôpital Universitaire de Mirebalais (HUM). HUM is a 300-bed tertiary, public teaching hospital which opened its doors in 2013 and is funded by Partners in Health, grants and the Haitian government. The hospital is the first of its kind in Haiti, providing cutting edge care to the community without the traditional fee-for-service payment model. Residency training programs in a number of medical specialties at HUM draw medical school graduates from all over the country, including Haiti’s first emergency medicine residency which was founded in 2014 and which will graduate the country’s very first class of residency-trained emergency physicians in 2017.

Over the next four weeks, I would be living in Mirebalais and working as a visiting professor of emergency medicine at HUM. This would provide me with the opportunity to teach the emergency medicine residents both at the bedside and in the classroom, to care for patients, to learn about what it takes to build, develop and sustain an emergency medicine residency in this setting, and more than I understood at the time, to think about medical education in a new way.

Rollercoaster Rides in Program Development and Implementation in Chiapas, Mexico

Rose Molina, MD

Global Women’s Health Fellow, The Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital

I returned to Chiapas, Mexico in June 2016 to continue my Global Women’s Health Fellowship research project. Working closely alongside the maternal health team at Compañeros En Salud (CES), I have advanced our project around adapting and implementing the WHO Safe Childbirth Checklist (SCC) for a new cadre of obstetric nurses in a basic community hospital. During this most recent trip, our maternal health team focused on curriculum development, grant writing, and adapting and piloting the SCC in our context in Chiapas. Additionally, we have been working with a group of students in creating the checklist into a mobile platform in anticipation of the obstetric nurses’ arrival in August 2016.

This visit has highlighted the ups and downs and turns of embarking on a maternal health project in close collaboration with the Ministry of Health in a new type of health facility (secondary level hospital as opposed to primary care clinics, which is where CES currently works). In order to achieve sustained engagement with the public sector, political setbacks are par for the course. However, it is important to remain optimistic in resolving problems in order to move work forward together. Only when the government is involved can a project be truly adopted and sustained as part of a larger health agenda that can be scaled up to a regional or state level.
Andrea Reyes (CES Maternal Health Coordinator) and Carolina Menchu (Professional Midwife) caring for a pregnant woman in Chiapas, Mexico


I am grateful for the opportunity to have continuous involvement with this project over the course of my two-year Global Women’s Health Fellowship. It has been a wonderful opportunity to see the nuts and bolts of program development and implementation in a new clinical area and with a new collaboration with the Mexican Ministry of Health. Furthermore, I have grown with the maternal health team and have learned valuable lessons in communication and relationship-building, which are the foundation of any meaningful long-term engagement. Lastly, I am excited to bring on a new research volunteer to lead our on-the-ground research efforts in measuring the impact of our project. It has been a roller-coaster ride of all emotions—fear, thrill, uncertainty, and excitement—but a foundational experience in building my career in global health implementation science.