Relief trip offers valuable lessons in outreach preparation
I led a group of 13 volunteers to Miragoane, Haiti for a weeklong medical mission trip in August. IMANA (www.imana.org) has organized the twice a year trip since 2010. Mufti Shaheed Mohammed and his family hosted us on his farm in an area called Chalon-2.
Like much of Haiti, the port town of Miragoane is impoverished with a population estimated to be 70,000. Shipping/trade, agriculture and fishing are the main industries for jobs in the town. Our team was a mix of five physicians: one emergency medicine, two family medicine, one cardiologist and one retired gynecologist. We had four medical students, two college students and two high school students.
IMANA couldn’t make its spring trip, so we were told our clinic would be busier than usual. Each morning there were about 100 patients lined up outside the clinic before sunrise. Many patients walked several kilometers to see us. All told, we saw about 875 patients in five days. Our patients were registered by a local translator, had triage and vital signs done by a medical student (with my supervision) and then were seen by one of the providers. We used all paper charting. Our high school and college students ran a pre-stocked pharmacy. A local emergency room with limited resources was 25 minutes away by ground transport.
Lessons Learned:
Safety First!
Prior to our departure, earlier in July, the Haitian government raised gasoline prices and deadly riots ensued leading to President Jack Guy Lafontant’s resignation. The resignation led to stabilization of a tense situation, but it was a very unpredictable two to three weeks leading up to our trip. As team leader, working with IMANA leadership, we had to constantly assess if it was safe to even go on this journey. While we often deal with weather issues and at times, violence in the workplace here in the States, it’s easy to lose sight of how important being secure at a macro level (i.e., stable government and safe modes of transportation) is for allowing us to treat patients.
Perhaps the most crucial piece of safety is understanding the relationship the clinic/organization you are going with has among the local populace. Often times, town elders can be the determining factor in allowing medical groups to come work. Physically, many organizations go to underserved communities where there is no police force or true security measures.
The farm where we stayed was started and run by Mufti and his family after they left Trinidad and Tobago in 2010. As a religious minority, he opened up his farm to offer free medical care to the local population to show he was there to help those less fortunate. Mufti described some situations where some were initially hostile to his presence. He noted there were some robberies and intrusions onto his land, but that having the clinic forged stronger community ties. I cannot emphasize how crucial having a consistent relationship with the community is for projects like this—both for security and for providing good, stable long-term healthcare. Try to learn as much about this relationship before even committing to going on the trip.
Know your Team
It is always a good idea to know your team strengths and weaknesses. Find out what skills folks have—both on your team and the locals helping out. In particular, translators are incredible assets. They are able to help with patient care and are fantastic with crowd control too. Since they live in the community, they know available resources and anticipate issues the visiting team cannot.
Taking the time to show interpreters and others, like family members, how to do medical care is worth your time. Jesus and I made specific time to show Mufti’s son, Usama, how to improvise and make a splint (Picture 2), give intramuscular injections and take basic vital signs. In such a rural setting, I am confident that teaching a motivated, good-hearted person a basic medical skill like how to check a blood pressure will pay some dividends and help someone in the community in a time of need.
Many students have done relief work before or had jobs such as a medical scribe, pharmacy technician or military service that come in quite handy. Flexibility is key — let students rotate functions in the clinic so they don’t just get one skill set or feel typecast to do one role.
I learned that several of the other volunteers had not been on any humanitarian/mission trips. The learning curve for them was steep as were the living conditions. It occurred to me after the trip that in spite of the two phone meetings and prep we did, perhaps some would prefer an online prep course, too. The Red Cross offers Health Emergencies in Large Populations (HELP) (https://www.icrc.org/en/document/helpcourse). For those in the military, we had extensive annual and pre-deployment training. I also attended the Military Tropical Medicine course in 2008 (an incredible course with amazing lectures, laboratory time and field experience). While not specific to medical work, the Department of Homeland Security via FEMA offers online prep courses for disaster work (https://training.fema.gov/).
When possible, do a debriefing at lunch or the end of each day. It helps to stay ahead of concerns and check-in on individual and team morale. One thing I love about IMANA trips is the built-in travel, set-up and cleanup time. The clinics start on a Monday, but they reserve the prior Sunday and following Saturday as travel days. While it is not possible on every international trip, trying to organize some activity after clinic is great for teambuilding. Our team members chose to go for short hikes with Mufti. On our last night there we took a short ride to a local beach for a few hours to unwind. When possible, have a team dinner before everyone scatters back home. We had a dinner at the airport hotel restaurant and it was a nice way to share stories, pictures and a meal together after a rigorous week.
Create A Preventive Medicine Project
I have always found education projects are the most rewarding and useful on these trips—both to involve your students and to leave a legacy behind to those in the town.
I tried desperately to get some type of vaccine program up and running, but after consulting with colleagues at WHO, I learned all vaccines have to be refrigerated. I had the idea of bringing 100 doses of oral VaxChora (to my knowledge, the only single dose, FDA-approved oral cholera vaccine) for the children, which has 90% efficacy at 10 days and 80% at 90 days against Vibro cholera. Vibrio, and the accompanying rice-water diarrhea with severe dehydration, can be devastating in a tropical climate particularly after hurricane season (which started two months before our arrival). Unfortunately, VaxChora is very expensive ($270 per 100mL dose) and despite being in a frozen packet solute you need to mix with water, it needs to be refrigerated. I think it would also have been quite challenging to convince locals to take a vaccine from a doctor they have never met or seen (especially one with such short-lived immunity).
Unable to orchestrate vaccine administration, my close friend and colleague Dr. Elizabeth Tran and I came up with a dental hygiene education project. With Caitlin Brumfiel, a second year medical student, she worked on an easy to follow “how to brush your teeth” cartoon-based handout. Jesus Martinez, a fourth year medical student, helped translate the handout into basic Creole. At the start of each day in the clinic, team members gathered all the children waiting to be seen and performed a small song and skit using the handout and visual aids on how to brush their teeth properly. I ordered 200 dental kits that came in a small zippered pouch and contained one toothbrush with a tube of fluoride toothpaste. Half the kits were Spider-Man and Avengers for the boys and the other half were Hello Kitty and Frozen for the girls. It was a nice way to open our clinic each day by seeing smiling, happy children!
The focus on prevention medicine is crucial. If I could pack just five items to give they would be: multivitamins, oral rehydration salts, dental kits, acetaminophen and de-worming medications. Of course, that is a very simplistic view, but the mindset is that when you don’t have access to clean drinking water and food, you have to find a way to help treat the most common medical issues that arise repeatedly in a community.
I was aware HIV was highly prevalent in this community, but it was challenging to implement a diagnostic or treatment program without accurate, rapid point-of-care testing, medications or close follow-up. I also learned throughout the week many patients had cataracts and other ocular disorders that likely would be lessened with simple things like a hat or sunglasses. I was very satisfied with the dental hygiene project we chose because it was feasible, cost effective and sustainable.
Innovation and Improvisation
I decided to bring a portable ultrasound, but this time I rented a Phillips Lumify S4-1 phased array transducer. Given my prior experiences with portable ultrasound, I focused on using the device for Obstetrics, cardiac evaluations and FAST exams.
Since I knew beforehand our population at this clinic had a high prevalence of uncontrolled hypertension, I found the Kardia Mobile device (https://store.alivecor.com/products/kardiamobile) that uses two fingerpads to record a lead I EKG. The device was invaluable both as a teaching tool for the students and also as a simple, easy-to-use visual clue to patients that they were not in atrial fibrillation. The app associated with the device has an icon on the top left for “signal strength” and once it reads “good signal,” it takes 30 seconds to generate the EKG. I found the device produced a nice quality tracing consistently when it was placed near the top of my Samsung tablet (it is compatible with Android and iOS) and when patients pressed down fairly hard on the fingerpads. Overall, it was a small, affordable ($99, one-time cost) and useful adjunct device to have handy.
It’s good to have at least two apps you trust and bring them ready to use on these trips. For me, the two I always make sure I have are:
- Sanford Guide (https://www.sanfordguide.com/products/digital-subscriptions/sanford-guide-to-antimicrobial-therapy-mobile/): this is an annual subscription ($30 per year) with great updates and easy to use tables for antibiotic selection.
- SonoSupport (http://www.sonosupport.com/): has fantastic tutorials and is great for teaching ultrasound ($10, one-time cost)
Doctors without Borders offers the Medical Guidelines app (in English, French and Spanish; free of cost). Many of the team members downloaded it before we left the States.
Innovation doesn’t just extend to products. Sometimes the best ideas come from using what you have available and making it fit into what you need. Before I get to work in any new location, I like to take a walking survey and see what is physically in the room. I make a mental inventory in case something unexpected happens (as it always does!). In a clinic like we had here, there are often leftover items from prior trips that you may find useful at a moment’s notice. As a team leader, it is also good to organize items by category (Orthopedics, Procedures, etc.) so you know where items are that other team members might request for patient care.
One particular example stands out—a young woman walked several kilometers to see us and was clearly in status asthmaticus. We only had salbutamol inhalers and the portable nebulizer machine was non-functioning. I rolled up a small piece of cardboard to make into a spacer and hit her with six puffs of the inhaler, gave her liquid Prednisolone and then asked Mufti to help us transport her to the local ER. While we were woefully underprepared for any true airway emergencies, working as a team, we did the best we could to stabilize her by using what we had available.
It is hard to convince such patients to get seen at an ER for x-rays or other testing. First, it can be very hard to take time off from labor/agricultural jobs. Second, the facilities are often far away and not easily accessible. Universally, I have been told the cost is astronomical. In this case, the patient and her mother noted this happened twice before and so they understood the gravity of the situation and allowed us to transport her.
Work at Having Follow-up
It’s hard in any setting to treat patients and not want some type of follow-up—particularly on trauma, infectious disease and pediatric cases. For these short clinics with high daily volumes, it is crucial to keep a list of patients that need follow-up before the team departs. For IMANA, we have follow-ups return on a Friday morning. On this trip, we did some significant wound care and had a teenager with suspected typhoid fever. All of those follow-ups came back to see us and were improving with our interventions—this was great for the patients and team morale! I like to think the students also learned a valuable lesson on following through with patient care—even in a challenging setting.
There were many cases where we simply could not offer the patient or family what we knew they needed. Rather than feeling helpless, I think gathering a few cases where the team could make an impact (once we had access to more robust medical and surgical resources back home) is something each team leader has to establish on a trip-by-trip basis. Over the years, I seek out surgical eye cases since those could be corrected and help restore vision, particularly in children. On this trip, we identified one child with strabismus and another with what appeared both clinically and on ocular ultrasound to be a congenital cataract. Working with the IMANA chairman, Dr. Mehr and an eye doctor in Fond-des-Blancs (who I found by a simple Google search!), we are trying to get those two children seen and treated. If that surgical referral process works, we also kept a list of elderly patients with cataracts that we hope can be helped.
Summary
International medical trips serve many purposes both for the groups that run them and the individuals that participate and come together as a team. While the overall goal is always to help those in need, the fine balance it takes to achieve group and individual goals is quite a challenge. I don’t think there is any one perfect way to prepare, work or measure performance. Perhaps the most important advice I can impart is simply to know your limits. This applies not just to the level of patient care you are providing, but also to your individual (and team) strengths and weaknesses.
Hopefully, some of the tips we have provided will be of value for those going on medical trips. The work is challenging, but immensely rewarding. We are very fortunate to be in a field that allows us to treat all age groups and to be there when help is needed the most. Finally, if and when you do travel on a medical trip, please share your lessons learned with us!