Haiti Medical Mission 2013 Notes
St. Paul's Episcopal Church of Edenton
Our team of 9 participants went to Haiti January 26-February 2, 2013.
Our Participants were:
Dan Bohl MD FACS (me)
Bart Resta MD (pediatrician)
Brigid Bohl, RN MSN CNS
Honor Montgomery, PharmD (pharmacist)
Henry Smith, EMT (managed drugs and many other things)
Angela Toppin, EMT
Harriet Dehart, EMT
Mark Dehart (managed logistics)
Joan Maxwell (spiritual leader)
St. Paul’s (http://stpauls-edenton.org/) donated over $20,000.
Each Participant gave $500 to cover lodging, etc.
Participants bought their own airline tickets.
Many non-prescription drugs were donated by individuals and by Walgreens.
1) Lespwa Timoun Clinic in Croix des Bouquets (below). Monday and Friday we worked in this clinic within the city. We coordinated with the existing staff. This functioned well for our physician providers, but there was little space and opportunity for our other participants. We saw about 145 patients on Monday and about 50 patients on Friday.
2) Thomazeau. This location was about 45 minutes from the city to the Northeast, and it was accessible only by a dirt road. We saw patients in a concrete open church with an adjacent school. There was no running water or electricity. There was a water pump and pit latrine. We saw about 150 patients.
3) Gorman. This location was an open wood and woven reed building with corrugated metal roof and a school nearby located about 50 minutes east of Croix des Bouquets. The access road was dirt with deep ruts, and no nearby population center was seen. There were agricultural fields and animals but no power equipment. There was an improved toilet with the school, but there was no running water in the clinic area and no electricity. We saw over 200 patients at this location.
4) Crochu. This location is about 75 minutes North of Croix des Bouquets and at about 2000 feet elevation. The road up the mountain can’t be traveled by most 4WD vehicles but can be driven with some risk in special vehicles. The concrete church and school are under construction, and the road access was recently completed. The population is diffuse along dirt trails. There is no water or electricity. Water is carried to the village from a spring located about 20 minute walk down the mountain. We saw 184 patients in this location.
Medical problems encountered:
1) Nutritional deficiency and starvation.
2) Parasite infestation.
3) Fungal dermatitis.
6) Visual problems.
7) Dental problems.
10) Hearing and ear problems.
13) Superficial infections.
14) Surgical disorders.
17) Developmental and cognitive delay in children
18) Otitis media
22) Burns and skin infections
Vitamins, ibuprofen, Albendazole, Zantac or Pepcid, Tums, PeptoBismol, Cipro, Bactrim (tabs and liquid), Amoxacillin ( liquid mostly), Keflex, Metronidazole, Monistat cream, fungal cream, Azithromycin, Tetracycline eye drops, Anti-hypertensive medications, Metronidazole vaginal cream, Albuterol, Iron supplements, topical antibiotic ointments, antihistamines, powdered baby formula.
It continues to be difficult to get medications through customs. Future missions may try to register medications with customs. Fr. Valdema is no longer doing this for us.
Transportation within Haiti is limited. Fr. Valdema has limited capability, and rentals have been unreliable. Few vehicles are capable of going up the mountain to Crochu. Mission teams can accommodate no more than 10 participants with currently available and reliable transportation.
Acquisition of medications by the clinic in Lespwa Timoun has not been reliable. Even with specific request, specific feedback, and adequate funding, the clinic may not acquire the requested medications. Future medical missions are advised to bring their own critical medications and to maintain control of these medications.
Translators are in short supply. While we had excellent translators, Fr. Valdema provided fewer than we requested. This shortage limited our efficiency and decreased the numbers that we could evaluate.
Pharmacy management was difficult. The clinic prefers to use their own staff to dispense medications, and it was difficult integrating our participants into this process. The staff stated that they did not have medications that were later located in their stock. This is because of difficult communication and because the names of medications differ. The staff often provided fewer medications than the physicians requested.
Patient education was deficient because the mobile clinic has no resources that they can send to locations. We suggested that they could use their staff to educate patients about treatments and allow our participants to dispense the medications. I’m not sure how they will respond to this suggestion.
Patients in peripheral locations may be seen only every several months, and different traveling mission doctors see them. There are no available records, so each visit starts from nothing. Medications for chronic diseases such as hypertension are given for only 1 month even though no more medications may be available for several months. A record system and continuity would be useful.
Patients have little or no access to surgery or specialized care. We saw patients who I expect to die from correctable problems due to this deficiency.
Lodging at Villa Mamika:
Villa Mamika is located about 5-10 minutes from St. Simeon’s Parish. It is safe and secure. The cost was $65 per person per night (about $70 after taxes). Breakfast and dinner were included. Food tasted good and nobody developed problems from the food. The owners are friendly, and they speak good English. Air conditioning was on only at night and was adequate. Showers were cool and pressure was low, but this was adequate. Reservations can be made with a toll free phone and good information is on their web site at www.villamamika.com.
The new arrival area is completed, but the “helpers” continue to be aggressive. It is difficult to get out of the baggage area without paying for this “help”. It is advisable not to leave the secure airport area without safe transport. Custom agents continue to be a problem, but they are poorly organized. They tried to confiscate some of our donated medications, but we were able to keep our medications by using our Certificate from MAP and by convincing that there would be consequences from Fr. Valdema. Small payments to individuals were needed.
Suggestions for future missions:
1) Accept no more than 10 participants.
2) Our system of assigning major areas of responsibility was effective. The pharmacy coordinator (Henry) managed our donated medicines and oversaw our medicine counting sessions. The logistics coordinator (Mark) worked with Fr. Valdema to assure secure transport. The spiritual leader (Joan) arranged and coordinated our devotions. As general coordinator, I focused only on the overall project.
3) We selected the air itinerary about 5 months before the project. Participants were required to make their own reservations. This allowed us to get better pricing than would have been available had we registered as a large group.
4) Our professional pilot participant, Mark Dehart, made these suggestions: I reviewed the suggestions so far and as logistics coordinator I have only a couple thoughts. When booking ticketsI would be on the lookout for business class fares that may be as little as $50-$60 above coach so that the amountof free checked bags would be of help if there were a lot of meds donated. Also I would look into traveling out ofRDU as opposed to ORF so that there would be some available flights on mainline 737 or MD-80 aircraft so as not tohave a problem getting the checked luggage on the flight. It didn't bother us this time, but the agents I spoke with atORF said that about 1/3rd of the time they need to limit the amount of passengers that can be carried out of ORF toMIA because of the length of the flight and the amount of fuel they need to carry.
5) The health and safety of the team is critical to a successful project. All participants should be fully educated and compulsively compliant in matters regarding health and safety. I have a separate document that addresses health and safety issues.
6) Arrive at and depart from Haiti as a group. Stay together.
7) Assure that you will be picked up at the airport. Do not leave the airport without your contact.
8) Maintain contact numbers for Fr. Valdema and have a functioning cell phone to call him if needed.
9) Mark luggage containing donated supplies with Pere Valdema’s name. Maintain a list of all donated medications and supplies. Medications should be in their original containers. Attempt to get official approval to bring these medications for donation.
10) Villa Mamika is an excellent hotel for most purposes.
11) Try to take 2 physicians. A third physician may be possible, but this will stretch available resources. A helper assigned to each physician would be useful. Because many female exams are needed, a female helper is preferred for a male physician. In addition to assisting with exams, the helper can escort patients from intake before the evaluation and to the pharmacy area following the evaluation.
12) Translators are critical to success. At least one translator per physician and one more in the intake area are needed.
13) It would be useful for someone to inventory the available medications in Lespwa Timoun Clinic at the beginning of the project. We left patients untreated because we were told that the needed medications were not available, yet these medications were later found on the shelves in the clinic. Communication about medications is unreliable.
14) Consider adding vision checks and donated inexpensive eyeglasses. This can be assigned to a participant with no medical experience.
15) A dental component including fluoride treatments and dental education is easy to add if we have enough non-physician participants.
16) Peripheral locations lacked areas for private examinations. Rope, 2 shower curtains, clothes pins, and duct tape allowed us to construct an adequate examination area.
17) Brightly colored custom t-shirts helped us stay together as we traveled, and they added to the team spirit.
18) Group devotions in the morning and evening provided an opportunity to discuss meaningful experiences.
Dr. Bart Resta added the following suggestions:
1) I only gradually developed a good concept of what was happening in the pharmacy as the week developed. In future missions, would recommend that we work out potential issues with the pharmacy at the beginning of the trip, and have at least one of our mission participants monitoring how the pharmacy is functioning.
2) We were absolutely deficient in educating our patients. This was because of the limited time available for each patient, the language barrier, the lack of medical knowledge on the part of our patients, and the lack of knowledge of the patients' living circumstances and available resources on the part of our mission team (or at least me). The idea of encouraging the Haitian team members to develop an educational program is a great one, and it seemed to be well-received by Carmel.
3) The need for dental and vision services is great. Providing that care would be an excellent way to extend the mission, even if we are short on medical practitioners. Teaching simple dental hygiene to patients, including children and the parents of babies and toddlers, might go a long way to preventing dental caries and the pain and poor nutrition that it causes. Developing a vision program using some simple tools and donated glasses could improve sight for hundreds of people.
5) We need to keep tabs on the status of Fr. Valdema's resources. He may eventually have access to more translators and vehicles. If that is the case, it would allow us to enlarge our team. However, I thought that we did great with the numbers that we have. If we have more trained providers who want to go to Haiti, we might do better by increasing the frequency of the missions rather than by increasing the size of the teams.
6) I would recommend that future medical providers brush up on the list of medical problems that might be encountered in the months preceding the trip. It would also be useful in that time to learn a bit of Haitian Creole for the sake of politeness to those who provide for us as well as to help our patients feel a little more comfortable.
Honor Montgomory, our Pharmacist, added the following suggestions:
1) Just recalling some of the other things we talked about and one of them was printing labels that had pictures of the sun and the moon for those patients that probably can't read. This can be important because there's so much activity on clinic days that instructions get forgotten and are useless if you can't read.
2) Team size was great, but there's got to be a way that everyone who comes gets to participate somehow. There are malaria tests available as finger prick tests that can be done in the field, and it would be a great way to use some of the EMS resources. And also conserve other resources as far as malaria treatments.
3) A lot of the children we saw were actually quite healthy, but mom was telling us they had fevers every night with chills but they presented with no fever. Better thermometers would be good, maybe the digital ear ones if possible. I didn't really follow the armpit idea....
4) My other concern is dosing. I'm thinking the pharmacy didn't pass out cups or oral syringes (just a wild guess here since I saw approximately zero), so maybe we should be looking for those devices for future missions. 50lbs of that would help tons of people. Also, if the team takes their own critical medications, it's advisable to take their own liquid bottles in 2, 3, 4 oz sizes. We took purified water with us to clinics in Niger for mixing liquid antibiotics, not sure if you've done/seen that before.
5) I don't think you need to take as many antacids as we did. The tums are great, but a lot of dyspepsia is a result of their eating habits and menus. We can assume they're calcium deficient anyway and load them up with Tums, you can get by with OTC Prilosec, Zantac, or Pepcid. To accommodate different clinics (eye, educational, etc), I'd advise only taking one PPI or h2-antagonist and a lot of tums. My guess is it's not being taken properly anyway or with water since it's scarce or in the morning, etc. And famotidine is available there already, so for continuity of care, we could consider that. And tums. Always Tums.
6) Staying healthy was a definite bonus for me and Dad this trip, I would continue to advise people to take Cipro once or twice daily while there and the snacks and protein bars were definitely appreciated at times!
7) Oh, and if we're gonna do the whole miami thing again, let's make a day of it and go to the beach or something!!!
Trauma, particularly auto accident, is the greatest cause of serious medical problem or death.
Mugging and theft risks are greatest in the cities.
Infectious diseases are common but largely avoidable.
Environmental hazards such as dehydration and sunburn are avoidable with good planning.
Traveler’s diarrhea is the most common acquired disorder, but it is rarely life threatening.
Insect bites are unpleasant and may also cause life threatening disease.
Immunizations are advised
Tetanus should be up to date (probably within 10 years)
TB screening with tuberculin can be done before the trip to detect conversions.
Malaria prophylaxis is appropriate in Haiti
Malarone daily is best but expensive.
Doxycyclone 100 mg daily is cheap and effective but has side effects.
Mefloquine 250 mg weekly is medium price and has side effects.
Food and water
Drink only water about which you are certain (ice also).
Carry adequate safe water with you. Maintain good hydration.
Eat only food about which you are certain. Avoid all street food.
Take safe snacks in case available food is questionable.
Insect bite and worm prevention
Long pants, socks, closed shoes.
Permethrin impregnated clothing.
DEET on exposed skin.
No clothes on ground.
Bed net at night.
Protective barrier between ground or mattress and bedding.
Spray DEET or Permethrin around bedding.
No bathing in streams and lakes.
Albendazole de-worming following mission.
De-lousing following mission
Dengue fever acquired from day-flying mosquito; incubation 3-14-days; viral and not treatable; occasionally fatal.
Malaria acquired from evening and night flying mosquito; incubation usually 1-4 weeks but may be much longer; preventable and treatable but fatalities are common.
Cholera epidemic is presently ongoing in Haiti; transmitted by contaminated food and water; incubation 2-3 days but may be shorter; diarrhea up to 1 quart per hour may cause death from dehydration; antibiotics help partially; treatment with oral re-hydration fluid (1 quart water+2tbsp sugar+ ½ tsp salt) is usually successful in preventing death.
Amebiasis is acquired from contaminated food and water; incubation is 1-4 weeks; up to 20% of population may be asymptomatic carriers in third world countries; may cause diarrhea; liver abscess, or even death.
Worms come in many types and are extremely common (most locals may carry some); acquired from food or from burrowing through skin of feet or elsewhere; some from insect vectors; various clinical manifestations.
Travelers’ diarrhea is extremely common; bacterial, viral, protozoan; may improve over 2-3 days but very unpleasant; dehydration risk; usually treat acutely with Cipro, anti-diarrheal agent, and Pepto-Bismol. Cipro pre-treatment is somewhat effective but not generally advised.
Giardiasis is common diarrheal disease acquired from contaminated water; caused by protozoan found in 20-30% of locals; incubation 1-3 weeks; treated with Metronidazole.
Travel and Evacuation insurance
Injury is the most common cause of emergency evacuation.
Cost of emergency evacuation can be as much as $100,000 in some areas and circumstances.
Without insurance, cash in advance may be required.
United States insurance may not pay for medical care delivered in Haiti.
Health care in Haiti will be limited and not always safe.
Individuals with significant health problems are advised not to go on this mission.
I would like information about any significant health problems, allergies, etc. for all participants.
You should take a more than adequate supply of any prescription medications that you use along with documentation of the prescription.
You are advised to take a supply of OTC meds including analgesics, anti-diarrheal agents, etc.
I will have a limited supply of prescription medications that may be needed by participants.
Sunscreen (at least SPF 30) and DEET (at least 25%) are essential.
Spare eyeglasses and sunglasses are wise.
St. Paul’s Haiti Medical Mission
Budget: From participants $500 for ground transport, room, and board paid to St. Paul’s.
Participants buy own airline tickets.
Participants pay for immunizations and personal expenses.
St. Paul’s pays minimum $15,000 for drugs, supplies, and Haitian staff.
Other contributions of drugs, etc. are welcome.
10 months: Meeting with Fr. Tom. (no later than April, 2012)
Agreement to proceed and authorization for me to lead mission.
Commitment from St. Paul’s for $15,000 needed to move forward.
(to cover cost of medications, supplies, and Haitian staff as required by Fr. Val)
9 months: Discussion with core participants (Brig, Bart, Henry, Fr. Tom).
8 months: Establish dates with Fr. Val (late January or early February).
7 months: Solicitation of participants (if more needed) and complete team roster.
6 months: Meeting with Participants and assignment of responsibilities.
Participants must pay $500 to St. Paul’s.
Participants should have passports or have application in progress.
Participants should have immunization plan.
5 months: I will notify Participants of airline itinerary (specific flights planned).
Participants will be responsible to purchase own airline tickets.
(Participants must be on same flight, at least in and out of Haiti)
I will work with Fr. Val to secure lodging reservations.
3 months: Second meeting with Participants.
All Participants must have a passport.
Essential immunizations should be complete or at least planned.
All airline tickets must be purchased by now.
Lodging arrangements must be complete.
Request Mission pack from MAP (for Bart also- ? St. Paul’s to sponsor)
Drug request list for Fr. Val (St. Paul’s expense).
2 months: Solicitation of Church for medical supplies, etc.
Develop transportation plans to and from airport.