Inside University Hospital’s 24-hour Emergency Department

Of all the lifesaving technology in University Hospital’s emergency room—the portable X-ray machine, the digital medical records, the wall-mounted oxygen—the most important may be a process that dates to 1792 on the battlefields of Napoleon’s army.

“Here we have a triage system so we can care for the sickest patients first,” said Dr. Mirrielle Bien-Aime, a Haitian doctor training to be certified in emergency medicine at the hospital. “At other places I’ve worked in Haiti, we didn’t. We saw all the patients at the same time.”

A working triage system allows experienced clinicians to sort patients according to acuity, rather than just their complaint, and it saves lives. It’s just one of the ways University Hospital is raising the standard of care in emergency medicine.

Emergency medicine demands a swift response to a huge array of injuries and illnesses—clinicians must be prepared for anything at any time.

PIH and our Haitian sister organization, Zanmi Lasante, are working to make University Hospital’s 15-bed emergency department a fertile training ground for doctors and nurses, who will take their learning to hospitals around Haiti, pass on their skills, and inspire a higher standard of care wherever they land. In March of this year, PIH/ZL launched a new emergency medicine certification for Haitian physicians, the first in the country, in collaboration with the Haitian Ministry of Health.

Emergency medicine is by no means new to Haiti. Most hospitals have an area they call “Ijans” after the French “urgence.” But caring for the sickest—or the most injured—requires much more than just a dedicated space open 24 hours a day.

Emergency medicine demands a swift response to a huge array of injuries and illnesses—clinicians must be prepared for anything at any time.

“Emergency physicians, at the end of the day, are the best generalists with a broad knowledge across all the areas of medicine,” said Dr. Regan Marsh, co-director of the emergency department at University Hospital and attending physician at Brigham and Women’s Hospital. She is training Haitian physicians in her specialty.

The curriculum for the certificate program reads like a list of terrible things that could happen to you, masked in dry clinical terms: Blunt trauma (falls or car crashes); penetrating trauma (gunshots or stabbings); cardiac arrest (heart attack), dyspnea (shortness of breath); environmental emergencies (lightning; electric shock, and near drowning); mass casualty events (war or natural disasters).

And in Haiti, poverty puts people at greater risk of needing emergency medicine. Because people don’t always have regular access to primary care, chronic conditions can become acute—for example, high blood pressure that goes untreated can lead to stroke. Traffic crashes can be even more life-threatening than in wealthy countries, because roads and vehicles are less safe—including overloaded, poorly maintained buses, and motorcycles, a cheap way of getting to remote places unreachable by road. And many people still depend on subsistence agriculture for food, causing injuries in farming accidents and falls from fruit trees.

A visit to University Hospital’s emergency department proves this notion. Inside the swinging double doors, the space is clean but hot and crowded at 8 p.m. The doctors are beginning their rounds, reviewing treatment plans for each patient and the hand-off from the day shift to the night shift, which allows for continuous quality care.

A 24-year-old woman who had a baby four months ago is in septic shock from an untreated infection. A man with psychosis is agitated by the critically ill patients around him. A 15-year-old boy suffers from intermittent fever, cough, and diarrhea. They test him for HIV and tuberculosis, and order a chest X-ray. Another young man is missing part of a finger.

To be ready for whatever comes in the door, University Hospital’s emergency department depends on highly trained staff—and enough of them to staff the department 24 hours a day, seven days a week.

To give high-quality emergency care, we work as a team with people across the hospital, and across the entire health system of central Haiti.

In the United States, highly trained emergency doctors and nurses care for patients. For physicians, this means at least three years of hands-on specialty training beyond medical school. PIH/ZL’s certificate program offers a formal teaching program for emergency medicine, which will be expanded through a three-year residency to begin later this year. This will be Haiti’s first emergency medicine residency. The residency will begin the process of training highly skilled emergency medicine physicians and leaders in their field who can help develop the specialty across the country and raise the standard of care. Meanwhile, Zanmi Lasante nurses are training to be specialists in critical care.

These clinicians can’t use their skills to save lives without high-tech medical equipment to make diagnoses and provide therapy. They also rely on other services in the hospital to treat patients. Many trauma patients will require surgery. People with infections need inpatient care with internal medicine doctors and specialized nurses. The emergency department even helps diagnose severe mental illness, and relies on the mental health team to provide psychotherapy and medication.

University Hospital provides the system the emergency department needs to save patients’ lives.

"To give high-quality emergency care, we work as a team with people across the hospital, and across the entire health system of central Haiti,” Marsh said. “Collaboration across the hospital is essential—the lab, the blood bank, and other specialists like pediatricians and surgeons and critical care nurses."

Dr. Mirrielle Bien-Aime, 30, is training in Partners In Health’s emergency medicine certificate program, the first in Haiti. Photo: Rebecca E. Rollins/Partners In Health

Dr. Bien-Aime is one of the physicians training in the new certificate program. She had worked for the Haitian Ministry of Health in southern Haiti before starting at University Hospital about a year ago.

“Mirrielle is going to be an amazing emergency physician,” Marsh said. “She is smart, thoughtful, compassionate, and able to care for many critical patients at the same time—keeping her eye to the whole system. I could not be happier that she’s on our team and will be leading the specialty of emergency medicine in Haiti.”

“Before I worked here, I didn’t know anything about emergency medicine,” Bien-Aime said. “Since May, I’ve learned a lot. In Haiti, we don’t have emergency medicine specialists. I want to help train ER doctors.”

Bien-Aime said one of her most moving experiences at University Hospital was helping a 2-year-old boy receive surgery. He was born with a congenital defect of the colon, and needed a two-part surgery to correct it. He underwent the first part at another hospital in Haiti, which created a hole in his abdomen and connected his colon to a bag for excrement. But his family couldn’t pay the $1,500 that hospital asked for the second part of the surgery, which would allow him to go to the bathroom normally. The colostomy brought stigma to him and his family, and eventually began to cause health problems.

“University hospital is very, very important for us in Haiti,” Bien-Aime said. “We provide free, high-quality care—that’s why we receive so many patients from all over Haiti in Mirebalais.”