Tuesday, August 13, 2013

The death of a judge in Haiti: Review and Lessons

Host: Herve Gilbert Guest: Dr. Carl Gilbert
Click below to hear the audio of the interview
 Or watch the interview in slideshow below 
The translation of the interview was conducted by the staff of HCC. 

Dear listeners RHC
This is Herve Gilbert of Haiti Connection Network. Welcome to our special edition today, dedicated to a hot topic of the news in Haiti and in the diaspora.
Since the untimely death of Judge Jean Serge Joseph in Haiti occurred under suspicious circumstances, there is an outcry in Haiti or a "hodgepodge" that forced even the parliament, institution dealing almost exclusively with legislation to participate in the investigation of the death ...
Therefore, three commissions of inquiry have since been set up in Haiti on this case and then the transfer of the remains of the Canadian-Haitian citizen judge, to Quebec Canada for autopsy before burial ...
According to the latest news we received this week about the results of the autopsy made in Canada, it appears that Judge Jean Serge Joseph succumbed to intracerebral or intraparenchymal hemorrhage. So we called on a doctor to help us see more clearly in this case.
We have with us on the telephone Dr. Carl Gilbert, surgeon practicing in the United States for years, journalist and writer well versed in Haitian affairs. He will help us clarify certain aspects of this story.
Good evening Dr. Gilbert!
HG: First, Dr. Gilbert, you are a practicing physician here in the United States for years, Before getting into the core of the subject, I'd like you to tell us a bit about your professional experience and what is your specialty as a physician.
DCG: as you said before, before getting  deep on the subject, I would like to express my condolences to the family of Judge Jean Serge Joseph ... struck by this sudden death... and thank you for invitating me.
Dr Carl Gilbert 08-12-13
Indeed, I am a practicing general surgeon ... I have been practicing for many years in the United states. I am a specialist in surgery ... as defined and certified by the American Board of Surgery ... I have a remarkable private clientele in the city of Little Rock, Arkansas. As you stated earlier, I am also a writer ... and a trained journalist and I've also worked with you closely on other Haiti Connection Network programs of which I am the general manager.
HG: So, as a specialist in general surgery, your scope of care on the human body is very diverse. You care ... or you have a deep enough knowledge of ..... pathologies or diseases of the skin and soft tissues, certain diseases of the head and neck, endocrine glands, thorax, all What other abdominal organs ... (esophagus, stomach, intestines, liver, gallbladder and biliary tract, pancreas and spleen), help me ... What else .... and arteries and veins etc. .... is not it?
Dr. Gilbert and Dr. Midi during surgery (left to right) 
DCG: Absolutely ... General surgery deals with these diseases ... but on a more or less regular basis according to the interest of the surgeon or his sub-specialty and advanced training, I'd say ...

HG: And then, Dr. Gilbert, what is your interest??
DCG: Well, my interest is the abdominal cancer surgery or not, some tumor of the soft tissue, cancer or not, the wounds of the skin .... I mean, certain vascular procedures , and then I practice a laparoscopic surgery  which is actually closed intervention techniques approaches with cameras compared to open surgery techniques ...
H.G: Thank you Dr. Gilbert! Now let's begin to the subject of our conversation of the day:
You are well aware that the news of the death of Judge Jean Serge Joseph that continues to make headlines  from Haiti since July 14, 2013?
D.C.G: Absolutely, I've heard ... 

HG: It is a death for which rumors have alleged the possibility of poisoning by members of the current government in Haiti .... And sources close to the family of the judge according to the notes I'm looking at here had even told the press that the autopsy conducted in Canada had confirmed the theory of poisoning. But ... Canadian coroner's office would later corroborate physicians Mevs hospital, that the judge had died of a cerebral intraparenchymal hemorrhage.
Will you clarify this term for the listeners? How to define this medical jargon?
DCG: This is a bleeding that occurs within the brain substance.

HG: At a press conference after the death of the judge, the doctors from the hospital Mevs said that when Judge Joseph arrived, he was already in a critical condition and beyond cure. These doctors  knew the cause of death was a  stroke before an autopsy have been performed. Is this possible?

DCG:Yes, it's possible ?
Dr. Gilbert, we will now play an audio clip of the first declaration of a Physician at the Bernard Mevs Hospital in Port-au-Prince a few hours after Judge Joseph was pronounced dead. This recording is a little distorted but I hope you will be able to hear it. Be patient with us. 

H.G Stay tuned! listeners of Radio Haiti Connection! We have with us on the line, Dr. Gilbert who is discussing with us the tragic death of Judge Jean Serge Joseph. We just listened to  sound bites of a press conference given by doctors at Mevs Hospital.
Catscan - Med
Let me do  a rundown of that press conference which the sound of the audio was a little altered. In my opinion, the physician who was giving the press conference was a little hesitant in his statements. There was some uncertainty when he said he wanted to wait for the autopsy results to decide, he made mention of stroke, of cva... What is your impression?

I wonder if there was a real clinical evaluation of the patient's arrival. Why he did not mention the results of the cat scan if they had one ... So ... ambiguity or speculation ... What do you think Dr. Gilbert?
DCG: First, I must tell you that we are not here to criticize anyone, as not having been on the scene, it is difficult to say exactly what was done or not for  the patient.
H.G: I want to interject here, Dr. Gilbert... according to the audio of the conference, the patient arrived at 3 am, he wasn't seen by a doctor until 7 am, 4 hours later. And he died up until 8:00 pm... That gives us a lapsed time of 18 hours since his admission to the hospital.
And then there was talk of massive cerebral hemorrhage. ... We must then ask ourselves what has been done to stop the bleeding .... Dr. Gilbert you have the floor again ...
DCG: Haiti is not the United States where  an ambulance ride from a private  house to a hospital can takes an average of 10, 11, 12 minutes. In a secluded area, there is a medical helicopter that can transfer a patient to a hospital in 30 minutes ...

However, with that said, we must adopt a scientific approach to the problem:
Someone gets sick and his family and doctors believe he has a cerebro-vascular accident. Immediately, the patient must, in addition to solutions, receive upon arrival to the hospital, a brain scan or a MRI which is the acronym for magnetic resonance imaging to detect, as well as the scanner an intracerebral hemorrhage at an early stage.
HG: Listeners of Radio Haiti Connection, you're listening to our special edition on our discussion regarding the tragic death of the Judge. 
Dr. Gilbert, Can you explain what can cause a "massive stroke"?
DCG: Like any bleeding that occurs in the human body or animal body, brain hemorrhage is caused by a ruptured blood vessel, artery or vein in the brain.
This rupture can happen because of different causes:Of these cases, we have:
Hypertension badly or poorly treated
vascular malformations that can be called in medical jargon cavernoms, arteriovenous malformations, aneurysms.
As another cause of intracerebral hemorrhage we have cerebral venous thrombosis or thrombophlebitis that produces blood clots and block the cerebral veins.
if a patient has a brain tumor, it may be complicated by intraparenchymal or intracerebral bleeding.
HG: But the autopsy could detect a tumor to the judge, is that it?
D.C.G: Yes indeed, it is usually the function of the autopsy to tell us exactly what caused the bleeding.
In most cases, intracerebral hemorrhage are prone to happen in persons taking anticoagulants or anti platelet meds.

I must mention here: there is quite an elevated number of people or patients now under treatment of anticaoagulants. These drugs are  products that are prescribed by doctors to thin the  blood ... and to  prevent the formation of blood clots, which in medicine we call embolism in patients.

If a patient is receiving anticoagulant he may suffer from bleeding as a side effect. This bleeding can be in the intestines, kidneys, brain or any other organ of the human body.

HG: Dr. Gilbert ,apart from anticoagulants are there any other products that can cause hémorrhage in the brain?
DCG-There are aspirin, ibuprofen and all drugs in the same family as aspirin, the vitamie E. And there are many other known or unknown subtances that are in the environment, including plants in our pharmacies and hospitals, etc.. which can cause bleeding.
In the United States we are told that the incidence of intracerebral hemorrhage is 16, 17 or 18% .... Fortunately there are test to determine if the rate of anticoagulant medication is too elevated or not ...We will therefore be able to adjust the dose.
So in summary: A quick brain scan is essential to guide treatment. And as I said earlier, the magnetic resonance imaging is another test that must be done quickly.
Some centers will also do a angiogram if the doctor thinks the patient may be suffering of a  vacsulaire mallformation such as aneurysm...
H.G: Dr. Gilbert! Suppose someone is experiencing anger or  psychological pressure, the stress of this anger or anxiety ... can it also cause "massive stroke."?
DCG: I can say without fear of contradiction that in some cases the stress may cause rupture of blood vessels.
Stress, Hervé is an important factor in the cause of an illness or disease. I'm no psychologist but I recalls well my studies in medical school.

When the body is faced with a stressful situation, it pumps adrenalin, this biochemical substance which then causes a chain reaction in the nervous system or brain. The heart begins to beat faster, the size of the blood vessels of the body changes, it is as if the body is preparing to face scary or emotional event.
In fact, the body put up protective biochemical elements to fight the stress. But these same products can be harmful to brain cells and also blood vessels. In summary, to answer the question, stress especially acute stress can cause an outbreak of hypertension, at home we said "tansyon an monte" - and this pressure rise  can cause ruptures of blood vessels in the organs, including the brain.
HG: Dr. Gilbert can you please tell us about the treatment of intracerebral hemorrhage or intraparenchymatous bleeding  as the autopsy revealed... we listen:
DCG: The treatment starts with emergency care and general measures of resuscitation.
I'll will classify treatment into three categories: medical treatment, surgical treatment and endovascular procedures.

1) Medical treatment with general resuscitative measures is supportive treatment. If the patient suffers from high blood pressure the number should be kept low enough to prevent the worsening of the bleeding.
All anticoagulant therapies should be stopped or antagonized by the administration of antidotes. The patient is connected to a respirator if not breathing properly. Recourse to assisted ventilation is frequent or almost constant if the bleeding is of infratentorial location, hypertension in the brain must be corrected by implantation of brain catheters that will allow the brain to breathe so to speak.

Specific treatments for stopping the bleeding or prevent the reoccurrence of bleeding is evaluated with promising results when performed within three hours after the onset of clinical signs. It involves the intravenous injection of recombinant factor VII.
2) The surgical treatment may be considered in case of a progressive worsening of the clinical picture, especially in young patients. The ventricular drainage or flooding may be done  in some cases, but mortality remains high ...
HG: You say that the surgery can be done in case of worsening of the clinical stage ... and in the case of the judge?

DCG: Yes, early surgical evacuation of the hemorrhage is suggested in some cases, but many times we are not sure of the benefits ...
Image during a stereotactic surgery
A less aggressive option, consisting of a stereotactic surgery consisting of the injection of a fibrinolytic drug in the hematoma, allowing  the breakdown of the clots so their suction and drainage can be done, this procedure is being tested with promising results.

In the case of the judge I cannot comment as I previously stated, because I was not on the scene... The neurosurgical treatment of aneurysms, arteriovenous malformations or cavernomas depends on their location by angiography ( they must be accessible to surgery). Finally, cerebellar hematoma can be evaluated in an emergency when causing compression and life-threatening conditions.
3) Endovascular
It consists of a cerebral endovascular embolization of aneurysms, arteriovenous malformations or dural fistulas. It is most often proposed as first-line treatment of ruptured intracranial aneurysms. It is then used coils (small clusters) platinum to seal the aneurysm sac. Embolization of arteriovenous malformation nest by hyper selective micro-catheters  can be made in most cases using special adhesives.

HG: Finally, I have this question for you: What can we learn from this tragic event and how to remedy this in a country like Haiti.
DCG- It's a great question. I think the lessons to learn are from a medical and legal standpoint.
From a medical point of view, emergency care must be improved and delays in the delivery of care should be shortened, transportation of patients from one point to another within the country should be improved. When I was writing my health topics in the columns of a local newspaper in Haiti, I had even called for a rapid transport of people by medical helicopter (med-evac) from primary health centers to centers secondary tertiaries.
HG: This is an excellent recommendation Dr. Gilbert because imagine if someone gets sick in Jeremie, it would take 12 hours of travel to get to a well-equipped hospital and find a doctor who specializes in a critical case. Our Haiti, is it really in the 21st century ... We have a country without anything while health is the first priority. Every hospital needs to have a personal trauma 24/24. What do you think?    
 D.C.G: Well said Hervé ...
To complete my answer to your question, there are other lessons from this event from a legal standpoint, in my opinion. Let me state that if the circumstances are suspicious about the death of a person, the embalming of the body should not be done before a  autopsy by a qualified forensic pathologist has taken place in a brief delay. Otherwise doubts will persist about the actual cause of death in a country where there is a deficiency of advanced and modern labs and where traditional beliefs and rumors prevail easily over facts! 
HG: Thank you for this interview Dr. Gilbert ; it was informative indeed.
That's it! Dear listeners of Radio Haiti Connection! This concludes our interview with Dr. Gilbert who has been very enlightening . This is  Herve Gilbert from the studios of Radio Haiti  in Florida Thank you for your loyal listening.
Thank you again Dr. Gilbert and thank you all for listening.
DCG:  Please!!! Talk to you soon!

by : Herve Gilbert herve.gilbert@gmail.com

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