HUEH – OGSH | RHINOLOGY MODULE (OCTOBER 25 – NOVEMBER 1, 2015)
During the last week of October, Eric Holbrook, MD, led the second faculty trip to the ENT Department at Hôpital de l’Université d’Etat d’Haiti (HUEH) in Port-Au-Prince, focusing on rhinology and skills transfer related to endoscopic sinus surgery. During the previous academic module in June 2015, Dr. Ramon Franco (Laryngology) introduced residents to performing flexible laryngoscope exams in the clinic setting. With support from David Gudis, MD (Columbia University), Dr. Holbrook built on this skillset, teaching HUEH’s nine ENT residents how to conduct nasal endoscopy exams in clinic, improving diagnostic capability and laying the groundwork for building the necessary skillset for endoscopic sinus surgery. Both diagnostic techniques, flexible and rigid endoscopy, when conducted using a camera and monitor, enhance the teaching experience as well, allowing residents and faculty to follow the examination concurrently and record the findings for later reference.
Under Dr. Holbrook’s guidance, graduating resident Dr. Farah Louis performed the first endoscopic sinus procedure in Haiti. The advantages of the endoscopic approach for surgery, which is becoming more common in low-resource settings, include less-invasiveness and improved long-term patient outcomes. For health systems in which patients must travel long distances for surgery, are less inclined to return for follow-up, and face barriers to care in terms of affording an extended inpatient stay, endoscopic surgical interventions offer an alternative to traditional open approaches. Key to taking advantage of these benefits, however, is proper equipment and extensive training.
As with all OGSH faculty-led modules, HUEH residents participated in oral exams and OSATS (objective skills assessment test) based upon the academic subject area. The oral exams, based upon the clinical practice ability instrument used in the Harvard ENT Residency Program, focused on presentations of sinus conditions while the OSATS described the proper method for conducting a rigid nasendoscopy examination in the clinic. In addition to working with residents in clinic and lecturing on sinus radiology, Dr. David Gudis administered the oral exams, which offered the opportunity to better identify knowledge gaps and areas of strength. This information will be used to inform future faculty visits, including a focus on radiology interpretation.
This trip coincided with several major events for the HUEH ENT Department and allowed a valuable exchange among some of the current program stakeholders. A team from LOA (Lien ORL Ayti), including founder Dr. Pierre Bailly, presented a didactic series on oral cancer during the week, continuing their long-standing, foundational role in supporting ENT education at HUEH. Dr. Pierre Bailly, in collaboration with the University of Strasbourg, founded LOA after being brought in by HUEH’s leadership in 1996 to help the transition from combined ENT and Ophthalmology programs to modern ENT Service and accompanying residency program. Dr. Patrick Marc Jean-Gilles was one of the first graduates of the separated ENT residency, following his graduation with three years of continued training in France. Upon his return in 2001, he was appointed the Head of Service and continued to work with Dr. Bailly to build the ENT training program, supplemented with regular didactics from LOA faculty via onsite visits and emailed testing materials. This partnership has allowed the residency to grow to its current size, nine residents (three per year), and makes provisions for continuing education opportunities in France.
In addition to LOA, Haiti-based representatives from CBM, a German nonprofit dedicated to improving quality of life for people with disabilities, Marie Joseph and Betsy Sherwood, were on hand for the inauguration of the ENT Department’s “Clinic-in-a-can” project. This project brought in two customized containers that contain clinic space and an operating room for minor procedures, to enhance surgical capacity. Currently, access to the operating theatre is limited by human resource shortages, supply of oxygen and anesthesia, power issues, and competition with other surgical specialties. Dr. Jean-Gilles, in his address to an audience of hospital administrators and personnel, compared the annual number of ENT surgical procedures – fewer than 450 – to the number of ENT outpatients seen by the clinic at HUEH – 18,000. This disparity is not uncommon for national referral hospitals in low-income countries, where the surgical disease burden greatly outstrips the capacity of the surgical infrastructure. Another inhibitor for the system is the patients’ costs for surgery. Even at public hospitals like HUEH where the service is nominally free, patients must pay for the “kit” necessary for the procedure, including drapes, medication, and disposables as well as diagnostics like CT scans and pathology tests. A few public hospitals (e.g., University Hospital at Mirebalais – funded primarily by Partners in Health) and NGO-supported facilities (e.g, St. Boniface Hospital in Fond des Blancs) offer surgery for no or a nominal fee ($1). These hospitals see even greater demand, and related difficulties in meeting them.
At the end of the week, the HUEH ENT Department hosted their annual “Scientific Day”, which coincided with resident graduation. Graduating residents Drs. Myriam Leandre-Joseph, Farah Louis, and Guimy Francois defended their thesis projects to a panel of ENT surgeons, including HUEH affiliate faculty and Dr. Pierre Bailly. Among the points stressed to the presenters were the importance of better recordkeeping, the need for improved and formalized protocols, and developing strategies for patient follow-up and outcomes. In addition to the senior residents, guest lecturers from LOA and the OGSH spoke on topics selected by the HUEH residents, including CSF leaks and management soft-tissue injuries to the lip and ears, the latter being a common injury resulting from interpersonal violence. The Haiti ENT Conference slated for 2016 will be an even larger affair, aimed at bringing together local and international collaborators for research dissemination and a look at the future of ENT in Haiti.
Our thanks to Dr. Patrick Marc Jean-Gilles (ENT Head of Service and Residency Director) and Dr. Pierre Bailly (LOA) for welcoming our team and congratulations to graduating residents Dr. Myriam Leandre-Joseph, Dr. Farah Louis, and Guimy Francois.