Haiti: Radiology Improves Hospital Care

Dieuseul Saint-Ange left his native Haiti in 2006. His destination: the United States. His goal: obtain skills that would help him serve people back home.

Nearly a decade later, he has been integral to the success of the radiology department at University Hospital in Mirebalais, in Haiti’s Central Plateau. Saint-Ange is the administrator for a computerized picture archiving and communication system—called PACS—that electronically stores medical images such as X-rays, CT scans, and ultrasounds and allows clinicians or radiologists to view them anywhere they have access to a computer. Although this technology is common in U.S. hospitals (as many as 91 percent use it, according to one survey), it is far more difficult to implement in resource-poor settings.

“[PACS] allows doctors and nurses to view radiology images very quickly wherever they are in the hospital,” Saint-Ange said. “They can make diagnoses based on what they are able to see in the images, and when a case is difficult for them to understand, they can ask for interpretation from a radiologist.”

University Hospital’s radiology department has been operational since the hospital opened in March 2013. Built by Haiti’s Ministry of Health and Partners In Health’s Haitian sister organization, Zanmi Lasante, the hospital houses the only CT scanner in a public facility in the country. Haitians who need a CT scan would otherwise have to pay about $300 U.S. in a private facility. This is out of reach for most people in Haiti, where the World Bank puts per capita income at about $800 a year.

The hospital also has X-ray machines, ultrasound machines, and dental X-ray capabilities, among other radiology equipment.

Clinicians use the hospital’s electronic medical records system to order a variety of scans. Once the scans are in PACS, they’ve entered Saint-Ange’s realm.

Saint-Ange began studying management and information systems in 2006 at Liberty University in Virginia. When he returned to Haiti six years later, PIH/ZL hired him as operations coordinator and then as PACS administrator. He attended PACS training at McKesson in Canada and has held the position for nearly two years. The PACS at Mirebalais has an unusual configuration; it’s synchronized with a PACS system in Boston.

No radiologists are available in Haiti to staff University Hospital, so U.S.-based volunteer radiologists read studies instead. They access the Boston-based PACS from their home or office via a secured online portal. The volunteers interpret the studies and create reports, which are transmitted to University Hospital and are saved in patients’ electronic medical records for easy access.

In 2014, volunteers interpreted more than 4,000 CT scans, double what they read in 2013, Radiology Coordinator Alexis Bowder said.

“We greatly rely on [radiologists who live abroad] to help us with the increasing amount of reads that we’re having every day,” Saint-Ange said. “We’re available to communicate with them via email or calls.”

These open lines of communication can result in odd working hours or long days. Saint-Ange has received queries while in church or on holidays. Once, he had gone home to Hinche to work on his farm when he learned that system glitches were resulting in lost X-rays 35 miles away in Mirebalais.

“I left everyone at work in the farm. I caught a tap-tap and headed to the hospital,” he said. “When I got there, I was able to find the images they thought were lost, pushed them to PACS, and, at the end of the day, I caught another tap-tap to head back home in Hinche. Everything happened in my farm behind my back that day.”

Radiology Technician Johnson Severe prepares a patient sent by the Emergency Department for a head CT scan at University Hospital in Mirebalais, Haiti. (Photo: Rebecca E. Rollins/Partners In Health)

Volunteers lend expertise

University Hospital initially built its volunteer network through the efforts of radiologist Dr. Jeffrey Mendel, PIH’s senior health and policy adviser for radiology. About 40 radiologists at sites across the country—including the Mayo Clinic, Massachusetts General Hospital, and the University of California, San Francisco—sign up for two shifts per month.

PIH/ZL hopes to expand these ranks. Mendel would like to have 100 volunteers on board by the end of 2015. Bowder is part of these recruitment efforts; she asks surgeons and physicians who visit PIH/ZL to see whether their home hospitals’ radiologists want to help.

PIH/ZL asks volunteers to interpret a minimum of four to six scans per shift, Bowder said. She also asks volunteers to be available to read urgent scans that must be interpreted within a day or two. Timely and accurate reading of scans can be crucial for patients.

“Rapid turn-around for readings is both important for patients with acute illness … and a challenge for a volunteer network,” Mendel said. “Often I am reading urgent studies late in the evening. However, for many patients with an acute illness or injury, a CT scan may be critical. It allows physicians to make treatment decisions and to assess the extent of injury that may not be apparent on physical examination.”

This rapid interpretation is particularly important for patients with conditions such as trauma, acute abdominal pain, a change in mental status, or chest pain, Mendel said. A CT scan for a patient who had been having seizures and arrived in a coma in December required urgent reading, for instance.

Mendel would like to have 100 volunteers on board by the end of 2015.

A 2013 case provides another vivid example. When 17-year-old Roseline Bernard fell from an avocado tree, X-rays and CT scans helped identify broken bones, internal injuries, and a traumatic brain injury. Without the radiology department, surgery, emergency care, and rehabilitation, Roseline’s diagnosis and treatment would have been far more difficult. Read more about her recovery here.

In addition to reading scans, volunteer radiologists have shared their expertise with medical residents and other clinicians in Haiti, Bowder said. University Hospital staff members have participated in teleradiology conferences with the volunteers.

“They’ll pick five scans a month where they weren’t sure how to interpret it or needed more imaging,” she said. “The residents will present it to the radiologist in the States, the radiologist will go over it with them … and they can ask questions and have discussions.”

The main challenge for the radiology department is a backlog of images. As of late December, 170 non-urgent scans awaited interpretation, Bowder said. She and others are seeking more volunteers to help bring that number down.

Radiologists or fourth-year radiology residents who want to volunteer can apply here.