SB Team Haiti would not have embarked on the journey without Dr. Fried's vision and purpose and for that, I know the entire team is thankful.
Below, Dr. Fried shares his final reflections of the trip with some photos of the team
My first thought is that the team we brought to Haiti was
awesome. Everyone did a tremendous job in whatever they did, and everyone
worked well together as a team. More on that later. In reflecting on the core
purpose of the trip, to teach the fundamentals of critical care to Haitian
physicians and nurses, I think this was very successful. The 25 Haitian health care workers that took
the course, were interested, engaged, and showed a real thirst for this knowledge.
In fact, they were more engaged than any class I have taught in the past 12
years. More than half the students passed the final exam, which was not only difficult,
but given in English. Most of the students had the disadvantage of not having
been able to review the written syllabus in advance, as well as having to take
the test in a foreign language. So this was actually an amazing pass rate,
which far exceeded my expectations. I think this was largely due to the
fantastic teaching skills of Jason, Lisa, Diane, Kacie and Connor. The
translations of the materials that Zadok arranged through Equal Health and the
translator services arranged by Toni, as well as the insight and help that she
provided, were all crucial elements to our success.
Dr. Fried with Dr. Toni Eyssallenne, ICU Medical Director from University Hospital of Mirebalais
Dr. Zadok Sacks of Equal Health
The secondary goal, was to teach their nurses some critical
care at the bedside. The results of this were more mixed. Our expectations here
were probably too high. It was apparent that the nurses staffing the ICU suffered
from a lack of adequate training, but also their own expectations of the job when
they signed on, were likely wrong. These were mostly med-surg nurses, without
the background or sense of urgency needed to care for critically ill patients. While
it seemed that they were disinterested at times, they likely lacked the basic
education they needed to care for complex critically ill patients, and I think
were fearful as a result. They lack trained leadership, mentors and role
models, in addition to a lack of basic nursing and critical care education.
Because of this, they are likely overwhelmed by what seem to be simple, basic
tasks. With an ICU mortality rate of 40%, they also suffer from a lack of
successes, which can be demoralizing. Critical care is a brand new concept in
Haiti: it did not exist before the earthquake in 2010. It was brought to Haiti
out of necessity by foreign physicians providing disaster relief. This is only the second ICU in the country,
and there are no intensivists or critical care role models. There is no formal
training in critical care for nurses or physicians anywhere in Haiti. They also
lack basic resources. One tetanus patient exhausted the hospital supply of
paralytics and much of its supply of sedatives after only 3 days. This is a
problem we cannot solve in a week. Additionally, it will take them many years
to develop the needed expertise and leadership. It will require a cultural
change, and change is slow in Haiti, as it is elsewhere. It will be slower
still without the needed basic foundational knowledge and skills. Yet we did
have some successes. Patti, Diane and Maggie, taught them some basic nursing
skills. Important skills that seem simple but are often overlooked or minimized
even in our own advanced practice, with our focus on technology. Skills like:
proper oral care and head elevation in intubated patients to decrease aspiration
pneumonia, appropriate central line care to decrease catheter associated blood
stream infections, proper dressing and wound care, turning to prevent pressure
ulcers, and proper use of restraints. Kaina and Mario taught them how to secure
an endotracheal tube properly, and how to fit BIPAP masks. They taught them how
to clean and maintain their ventilators which are malfunctioning due to this
lack of basic care. They taught them about ventilator alarms and
troubleshooting those alarms, instead of just turning them off repeatedly in
fear. Exploring their biomedical department, they found many new ventilators,
either forgotten about or overlooked, and put them into service.
 |
| Diane Barkas, Clinical Nurse Specialist |
Dr. Lisa Ferrigno
Before the trip, Maggie, a veteran of medical missions, and who
did an incredible job coordinating all of the logistics in advance and on the
ground, told me I would learn more from them, then they from me. I was
skeptical, and perhaps, having never been on a trip like this, didn’t really
understand what she meant. Certainly I would not learn much about critical care
from them. But I did learn how intelligent and resourceful they can be, when
they have so little. Like how to measure a bladder pressure when you do not
have the simple equipment that we take for granted. I learned about the amazing
spirit of these people, who are welcoming and appreciative. The hospital
reminded me much of the care we provided in the 1970’s and 1980’s at LA County-USC
where I trained. This was before a lot of the technological innovations of the
last 40 years, when ICU care and the field of intensive care was in its
infancy. A time when we did not have percutaneous coronary interventions, and
intracerebral artery embolectomy and stenting, and the myriad of new drugs and
antibiotics. In some ways it was like going back in a time machine, trying to
diagnose and treat with limited lab tests and excruciatingly slow imaging, depending
only on our own physical exam skills and limited knowledge. When we had to wait
24 hours for emergency CT scans and had to do gram stains and urinalysis
ourselves. And in their resource constrained environment, we watched them
struggle with the ethical triage of patients. Some too sick to benefit from
intensive care, and would likely die anyway, some not sick enough and who would
hopefully survive without it. Looking for that sweet spot, for those who they
might save with the little resources they have. In some ways it was likely
easier for the older members of the group to relate to all this, having trained
in a similar environment long ago, and watching all the modern advances of
medicine develop over the years. The younger members of the group, Connor and
Kacie, trained in modern technology and consequently dependent on it, seemed to
find this all fascinating and exciting. I think they were somewhat astounded,
that medicine could actually be practiced like this, without microbiology
cultures and drug levels and a plethora of panels of blood tests. But I will
let them share their own thoughts on this.
Dr. Kacie Brumley, Dr. Connor Johnson, visiting MD Sean Kivlehan, Dr. Jeffrey Fried and,
Dr. Jason Prystowsky
Dr. Connor Johnson
Dr. Jason Prystowsky
Jason, an expert veteran of global health care delivery, says
that “our solutions are not their solutions”.
I was also a bit puzzled by this at first. But he is right. This is not
a mathematical problem. These are complex problems which are overlayed with
cultural differences, scarcity of resources , lack of education, failed
political leadership, and a sordid history of woe, that goes back hundreds of
years. They need to develop their own solutions, rather than having well
meaning NGOs and missionaries and the like, thrust their ideas and “solutions” on
them. I personally think it all starts with education. Only with education can
they develop the knowledge to create their own solutions, which will be
sustainable and evolve. They desperately need universal free education as a
society, if they will ever develop this capability. Currently primary education
is $45 per student per year, a huge amount in a country where the per capita
income is only $2 per day. Junior High school is $200/year, beyond reach of
most. Only the wealthiest can pay for high school, let alone a university
education.
Maggie Cote, CCRN
Patti Wicklund, CCRN
So did we have an impact? How much impact could we actually
have in a week? As Jason says, these are the future leaders of critical care in
Haiti. I think we did have an impact. I think we brought them knowledge they
did not have, and taught them things no one there has the knowledge or
experience to teach them. Will it lower their mortality rate from 40%? Even if
it lowers it to only 39%, I think we can consider it a success. I think we have
given this core group of future leaders some of the basic foundations needed for
learning critical care. We identified some brilliant leaders in this group,
ones that I think really can carry the torch forward. Hopefully, they will become instructors in the
future, and share this knowledge with their peers, and their own students. But
a lasting impact will only come when many more are trained, beyond this simple
course, and when they can secure the resources they need to practice 21st
century medicine. This will be a slow process, an evolution, not a revolution.
After all, it took us 40 or 50 years to get where we are in the “our world” it
won’t happen in a week, a month, or a year, in theirs.
Respiratory Care Practitioners
Kaina Gomard and Mario Guillen
Finally, I want to thank every member of this awesome team:
Nurses: Diane Barkas, Maggie Cote, Patti Wicklund. Respiratory Therapists:
Kaina Gomard, Mario Guillen. Physicians: Kacie Brumley, Lisa Ferrigno, Connor
Johnson, Jason Prystowsky. Thank you also to Zadok Sacks and Michelle Morse,
who inspired me to embark upon this journey, and to our host and new friend,
Toni Eyssallene. You are all incredibly dedicated professionals, talented
teachers, warm, loving and compassionate individuals, who donated your time,
energy and expertise, to this enterprise. I absolutely could not have done it
without each and every one of you, and I thank you from the bottom of my heart.
Jeff
It's a wrap (not a lettuce wrap)!
(Dr. Fried is such a good sport!)
Final Reflections from Kacie Brumley, MD
Being home now and reflecting
on Haiti I can't deny that I already wish to go back. I had an amazing
time with all of you and with all of the people we were so lucky to have
met and had the opportunity to teach. I remain humbled that I was given
the opportunity to come with you all on this journey. I am truly
impressed with the resilience of the Haitian people, and I'm
disappointed in myself that I have spent much of my time taking things
for granted. I can honestly say that I have not dressed or presented
myself as nicely as the Haitian people I met and saw each day in quite
some time, and I have more than the means to. I certainly haven't
smiled as much as they smiled while on their way to work on the back of a
moto, or carrying their groceries atop their heads, or when sitting and
enjoying the company of others. They are a truly amazing people who
obviously care for and love each other very much. The sense of community
and camaraderie I felt amongst the Haitian people touched me deeply,
and I will carry it with me.
I wish that I had the opportunity to train
in an environment in which CT and MRI scans (and every other high-tech
scan for that manner) weren't as inappropriately used to give you some
kind of answer before you've had an opportunity to even meet your
patient. I recall watching a second-year Haitian ER resident examining
his patient, and I realized immediately that my physical exam skills do
not even compare to his. Our week at Mirebalais hospital has inspired me
to work harder, to improve my clinical and physical exam skills, to
trust in my instincts, and to not rely as much on those things we've
been trained to rely so heavily upon. It has also helped me realize the
value of community and camaraderie.I
am very appreciative of my time in Haiti and with you all! This has
indeed changed my life in many positive ways. I got up at 5:30 am and
did an hour of yoga with Monster this morning! If someone had told me
weeks ago that I'd be doing that I would have laughed. I can't wait for
our next adventure. Much love, Kacie
Kacie with the Resident Physicians from the Emergency Room
Final reflections from Kaina Gomard
This blog reflects the shared work of every team member who made the trip to Haiti a successful, memorable experience as captured in these photos. It was a magical week because once we arrived in Haiti, each member fell into a meaningful role and it was apparent that everyone wanted to make a lasting contribution separately and collectively as a team. There were moments of joy and happiness, amazement and discovery, sadness and frustration. The team experienced devastation when the patient with tetanus died after two days of working to paralyze and stabilize him. In a world where tetanus vaccines are common, this was a preventable death and it hurt and frustrated the team to know the patient couldn't be saved. Caring for the 7 year old post-op also made an impact on the team. It was difficult to leave that sweet little guy because we would leave not knowing what was to become of him. Even in the days following our return to Santa Barbara, we wondered what happened to him. I think we all had a feeling of what would happen and I hope we were wrong.
SB Team Haiti at the entrance gates of the hospital L to R: Dr. Connor Johnson, Patti Wicklund, Kaina Gomard, Maggie Cote, Mario Guillen, Diane Barkas, Dr. Lisa Ferrigno, Dr. Kacie Brumley, Dr. Jason Prystowsky, Dr. Jeffrey Fried
It was hard not to compare all that we have to the little they have but it was amazing to see what they do with little to nothing. With their shortage of human resources, it was a wonder to see the throngs of patients each morning that lined up and were actually seen by days end. Upwards of 700 patients are seen each day in the hospital's outpatient clinics and 300 more are seen at their clinic down the street. Could we ever manage that? Not with all of our over abundance of tests and interventions. While unheard of in the US, they recycle disposable ventilator circuits because new circuits are costly and hard to come by. And to ask for just 15 gourde ($30 USD) from each patient for a lifetime of care is amazing when health care in the US is so costly and prohibitive even with insurance. On Friday afternoon, the ER physician walked into the ICU to ask for morphine because they were out of morphine until Monday. The ICU could only spare one ampule; a stark contrast to our abundant resources of medications. Little to no resources means the physicians make hard choices to triage even the most critical cases and perhaps that is as much a skill as any in emergency and critical care. On Monday back in our hospital, there was a code blue during morning rounds. The patient was on a ventilator and dialysis at the time. 20 clinicians swooped in on an elderly, end-stage renal patient attempting to save his life. Enough said. Which is best, to do the minimum because of what little you have or to do everything irrespective of need?
The culture of care there is difficult to describe and put a finger on; it's a complex combination of many system deficiencies. We didn't observe the same sense of urgency that we see in our care for an unstable patient. Death is common there and I suppose there is a more casual sense of duty to just face and accept it when it occurs so frequently. These are deficiencies that we cannot judge. Heck, there is no infrastructure in the country, much less this hospital
but against all odds, they are putting up a valiant, courageous battle to care for so many! There's a lot to say for the way they manage in spite of all of their deficiencies. That's more than we can say in our country where we experience so much expense, waste and over-abundance and so much of every man for himself and dog-eat-dog competition. It's a hard pill to swallow when you've witnessed humanity in its most basic form surviving from day to day.
Kaina at the airway skills station
Mario, doing his magic at the vent station
Mario and Kaina caring for the patient with tetanus.
Thanks Mario, for being a super-hero to the patients in the ER, literally.
For Mario and me, as Respiratory Care Practitioners, it was amazing to discover their modern, nearly new ICU ventilators and transport laptop ventilators. GE Engstrom Carestation vents are really good ventilators they can use to ventilate neonates to adults and they had more than enough for their small ICU. The LTV vent in the ER is the same ventilator we use for our pediatric transports but they can use them in the ER as an ICU vent as well (and they do!). It was gratifying and exciting that we found a way to calibrate the ventilators that they were unable to use and were just sitting in their Bio-Med department collecting dust and dirt. We were able to calibrate them and set one up in each bay of the ICU. We also readied the remaining Carestation vents and put them back into storage in their Bio-Med department. It was a hot, dusty room that was full of all sorts of equipment, used and brand new. We actually found 9 brand new LTV ventilators in there and after calibration and cleaning, we got the ER up to speed with 3 more LTVs. We don't know how long they had been operating with just one but they were. Mario helped them to realize that they could put a patient on noninvasive mode on the Carestations. They use NIV often. They now have a Carestation and several LTVs ready to go. The problem is that circuits are expensive and hard to come by, especially LTV circuits and I'm sure that is a challenge they will face for awhile. They also don't have any NIV masks but rather, they use a rescue mask with a rubber head strap, a rather archaic method that we used back in the early 90s (maybe not that archaic being just 20 years ago). They need NIV masks and ventilator circuits badly. They also lack heated moisture exchangers (HMEs) to humidify both invasive and noninvasive ventilated airways.
It was a life-changing week of eye-opening experiences, a bit of discomfort and even devastation but I would do it again in a heart beat. It was so fulfilling and in fact, it filled a void in me that I didn't even know existed. On day two I told a team member that it felt almost addictive; the feeling of doing good that was so appreciated, needed and, wanted. I can see why so many repeatedly go on aid trips as Maggie and Jason have. It fills you with an almost tangible feeling of goodness and hope. Thank you SB Team Haiti, Zadok and Toni and, all of the Haitians clinicians we met and spent time with. It was an experience I will never forget and will hopefully experience again.
Until we meet again, orevwa (Au revoir),
Kaina
It was a life-changing week of eye-opening experiences, a bit of discomfort and even devastation but I would do it again in a heart beat. It was so fulfilling and in fact, it filled a void in me that I didn't even know existed. On day two I told a team member that it felt almost addictive; the feeling of doing good that was so appreciated, needed and, wanted. I can see why so many repeatedly go on aid trips as Maggie and Jason have. It fills you with an almost tangible feeling of goodness and hope. Thank you SB Team Haiti, Zadok and Toni and, all of the Haitians clinicians we met and spent time with. It was an experience I will never forget and will hopefully experience again.
Until we meet again, orevwa (Au revoir),
Kaina
From Dr. Zadok Sacks, Ventura Physician from Equal Health
Equal Health is a nonprofit organization dedicated to supporting quality medical and nursing education in Haiti
I'm touched by your reflections,
which do a great job of capturing the reasons that I love this work -
and Haiti - so much. You should also know that you really made a
difference during your week there; such is the power of teaching! (Toni
has been sending
me texts about how her docs are now "kicking ventilator ass," haha!)
Changes happen slowly in global
health - especially in Haiti! - but I see them happening all the time,
and if the type of spark that all of you saw in Mirebalais can just be
nourished in the right way, I believe that Haiti has a brighter future
to look forward
to. Thank you for being part of that.
With appreciation,
Zadok
Zadok
Copa America
