Monday, July 31, 2006
In April we examined a seven month old Haitian girl in the clinic in Port-au-Prince. She only weighed nine pounds and had been having fevers and labored breathing. She was brought to the city by her mother from her home about an hour north of here. Her name is Ferna.
Ferna’s exam revealed a loud murmur over her chest. A murmur is “audible turbulence” from flow of blood through the heart. Some murmurs are considered innocent and others signify real disease. Ferna’s murmur definitely reflected real disease. She also had a fever and crackles in her upper portions of her right lung which most likely meant she had some type pneumonia.
I told Ferna’s mom that she needed to be admitted to the hospital across the street from the clinic. Her mother was very happy to receive the news that her daughter would receive care. However, there was no room in the pediatric section of the hospital, so she and Ferna slept in the hospital courtyard that night and Ferna was admitted the next day.
Her chest x-ray revealed a large heart due to congenital heart disease and her lung fields were filled with an infiltrate that appeared to be tuberculosis.
Several months have passed since Ferna was admitted and she remains in the hospital which is the best place for her in Haiti because she is fed nutritious food prepared in the hospital, gets her medication each day, and her mother gets to visit her. She has been placed on the national Haitian tuberculosis regimen for which is three drugs for two months followed by two drugs for the following six months. Her fevers have abated and she looks some better.
However, her congenital heart disease persists and her echocardiogram performed here in the capital shows a hole in the wall between the lower chambers of her heart which allows too much blood to circulate through her lungs with each heart beat. Therefore, she is taking diuretics to keep her lungs dry.
So now what? Do we successfully treat her tuberculosis and discharge her to her city north of here so she can die from her congenital heart disease that can only be repaired with surgery? If that is the case, why are we treating her tuberculosis so aggressively so she can die from another treatable disease?
Paul Farmer and his colleagues have proven that treatment of multidrug resistant tuberculosis and even HIV is possible to successfully do in resource poor settings, such as Haiti. Treating these hard-to-treat diseases actually improves the general level of care given to poor populations. Who would have predicted this? Would performing heart surgery in Haiti some day increase the overall level of medical care? Extrapolating from Farmer’s research would say that it would.
So if developing world patients receive treatment for HIV and very hard-to-treat tuberculosis, why does Ferna not deserve surgical treatment for the tiny hole in her heart that is wreaking havoc on her circulation and will cause her death? What exactly is the down side to saving Ferna’s life?
I propose that Ferna be operated quickly in the United States. I also propose that no baby in the world should die from a hole in their heart in 2006 due to negligence from the world that has everything. The technology is available and a good repair of a mechanically deficient heart can lead to many good years for the child. With the obscene amount of money spent in the developed world for cosmetics, dog food, cigarettes, and military expenditures, developed countries have no excuse not to operate these children from around the world and set up programs to teach developing world physicians the science of delicate pediatric heart surgery.
I also believe that skilled physicians in the United States that want to perform pro bono surgeries in their medical centers on babies like Ferna should be allowed to do so. Doctors need to do what is right and patching holes in babies that are slowly suffocating is the right thing to do. If Catholic hospital administrators disagree because of medical center costs, they need to figure a way to lower costs.
However, if only one doctor approaches hospital administration regarding operating a child from abroad, he or she can easily be rejected and marginalized. Physicians need to show a united front with the entire pediatric department demanding to treat international cases each year. If administrators disagree, they should be removed from their positions as the Ethical and Religious Directives for Catholic Health Care Services imply (Directive 5). Catholic bishops around the United States need to support these physicians and children like Ferna and not try and just appease the big Catholic Medical Industry in their diocese. The Catholic medical centers need to be challenged to do the right thing and act for the reasons for which they were founded---taking care of the poor who need their care.
The Haitian physicians and medical system are doing their best with Ferna. Her mother now hopes and prays for heart surgery for her baby daughter in the United States. In Haiti, the technology eventually needs to come here for complicated heart surgery that requires bypass. Haitian physicians need to be trained, and Haitian babies need to be operated here in Haiti by Haitian physicians. But in the mean time Ferna is not going to wait for all of us to make this happen.
The clock is ticking. Any advice on what I should tell Ferna’s mother?
Tuesday, July 25, 2006
July 21, 2006
We are working at a clinic in Port-au-Prince right across the street from the hospital where we admit the sickest kids. We walk to this clinic in the morning and pass three Haitian police. The officers, one with an automatic rifle, stop the oncoming traffic to check the registration of the vehicles and verify the driver’s license. Several weeks ago a Haitian lady was attempting to stop a carjacking just outside our clinic in the middle of the day and was shot to death in the street by the thieves.
In the recent couple of weeks, the kidnappings have increased in the capital and all the Haitians tell us the “streets are bad”. Many memos on the internet talk of the renewed chaos and violence in Port-au-Prince. Dozens of kidnappings apparently occurred this month. Deposed President Aristide’s birthday was the other day, so he was blamed again for the violence, even though he now lives in South Africa. We were warned by an American friend, who was a kidnapped last fall, not to walk the streets in this part of PAP, and he offered us a vehicle he sent down for our use. But we feel safer on foot and taking public transportation.
Today was a potpourri of pathology in the Haitian pediatric clinic. All pathology is bad especially if you are the one that has it, live in Haiti, and almost no one cares.
One of our first patients today was a baby girl named Tamaika who weighed about ten pounds and was nine months old. She had been having vomiting and diarrhea for one week and had a temperature of 105 F. Her mother stressed the fact that she has no job or money and could not take the baby to the doctor before today.
The baby was obviously very dehydrated and severely malnourished. Her eyes were sunk and her skin tented when pinched. Her arms and legs were sticks—almost completely devoid of muscle. But, as a true Haitian would, she would swing her arms at me and fought when I attempted to examine her.
A baby like this can be septic along with the dehydration. We brought down Rocephin and gave the baby a big dose immediately and admitted the baby to the hospital for IV antibiotics, fluids, and work up.
A five year old girl, Cynthia, came with chief complaints of two weeks of shortness of breath, fever, lack of appetite, and crying with abdominal pain at night. Her attentive father and mother offered the history at the same time. The girl looked well developed but would scream out in an irritable fashion and then almost fall asleep the next second. Of note were the bounding carotid pulsations on the left side of her neck and the hyperdynamic pulse at her right elbow. This meant that her blood was so thin it was causing her vessels to expand and collapse quicker than normal thicker blood would do. Her conjunctiva where white and her tongue and mucous membranes were very pale. Her liver and spleen were very big and intimately involved in her anemia. Her heart rate was only about 100, so she had compensated for her anemia. In my opinion Cynthia had been this way for awhile. Sickle cell is most likely with some iron deficiency contributing to her severe anemia.
We admitted her also. Her blood was very thin and looked like pink Kool-Aid.
Her hemoglobin returned very low at 2.5 and her white count was very elevated at 59,000. Her father will need to go to the Haitian Red Cross and donate blood and obtain blood for her transfusion.
A beautiful five year old angel was one of our last patients and was brought in by her grandma who appeared to be about 60. According to grandma, the child’s mother had died one and one-half years ago when “she had abdominal pain and became thin” in a city 12 hours from Port-au-Prince. Grandma is now doing another family’s laundry in Port-au-Prince to support the little girl. The girl’s check up was pretty good except for anemia and pneumonia.
At the end of her exam the little girl kissed my wife Maria when she got a piece of gum. As grandma and the little girl left the room Maria wondered what would become of the little girl when Grandma is gone.