Tuesday, February 21, 2012

Deconstruction of a Haitian Heart


Teledjol is a Haitian word which means gossip or rumor mill. It is the way news is spread in Haiti. Facebook is here too but teledjol is still king.

When Haitian Hearts comes to Haiti it doesn’t take long before we are seeing patients with heart problems.

The other day a polite 16 year old girl showed up with a “heart problem”. I will call her Beth.

Beth came with her mother who does laundry at a hotel in Port-au-Prince. Mother makes 5 dollars per day and she commutes a long ways via public transportation.

Beth lives in downtown Port-au-Prince with her mother and siblings in a place called Carrefour Feuilles.

Beth told me that in October, 2011 she became short of breath and started coughing up blood. She was hospitalized in LaPlaine for ten days and got better. Her doctor told her she had a heart problem and started her on a strong diuretic (furosemide).

However, Beth told me that she is still short of breath with exertion. She takes her furosemide daily, but she does not know the dose and only had a couple of pills left in a crumpled tiny baggy.

At the appointment with me Beth did bring her chest x-ray and an echocardiogram. Both had been done last fall when she was sick.

I like to talk with patients and examine them before I look at their test results. I want to make my diagnosis with just the history and physical and quantitate a pre-test probability of disease BEFORE I look at test results. Test results can lead physicians astray because tests frequently "lie" and test results need to be combined with the patients exam to arrive at a proper diagnosis.

Beth appeared calm and not short of breath. Her oxygen level (pulse oximeter) was 98%. Her skin was warm and dry.

However, Beth’s blood pressure was bothersome. It was 132/50 in her right arm. That sounds good, but there is too much of a gap between the top (systolic) and bottom (diastolic) number. And in Haiti that frequently means that her aortic valve is not competent. In other words, her aortic valve may be leaking which allows blood to flow in the reverse fashion when the heart is resting between beats. This allows too much blood to flood her main pumping chamber (left ventricle) with blood which can hurt the chamber over time because of volume overload.

Her neck did not reveal any distended neck veins. This was good because it means that the venous return of blood was entering the heart unobstructed-- not blocked from a totally failing heart.

Beth’s heart exam revealed a heart that was slightly enlarged. And sure enough, listening along the left border of her sternum revealed a high-pitched decrescendo murmur during diastole..which meant that her aortic valve is leaking.

Inching the stethoscope out to the apex of her heart below her left breast revealed another murmur. It was loud, medium pitched, and radiated to her left armpit. This told me that her mitral valve was also leaking.

In Haiti these findings mean that Beth most likely had at least two bad heart valves from rheumatic fever that she unknowingly acquired as a child.  (Rheumatic fever is caused by strep throat that is never treated with penicillin. The body’s immune system attacks the strep bacteria and can attack the heart valves at the same time.)

So I peeked at her chest x-ray. It showed a slightly enlarged heart (not too bad) and a big left atrium (not too good). This meant that her mitral valve was indeed leaky and maybe tight (stenotic) too. The good news about her chest x-ray was that her lung fields are clear...no fluid in the lungs.

Her echocardiogram, which cost her mother $80 US here in Port-au-Prince,  showed both her aortic valve and mitral valves to be diseased and leaky, but the function of her heart muscle is good. The left ventricle is beating well because the heart muscle has not been damaged to the point where it is stretched so much that it can't contract efficiently.

So what now?

Beth needs heart surgery. And she needs it sooner rather than later. She does not have the cardiac cachexia brought about by a severely weak heart...yet. She can still withstand the organized assault of heart surgery.

Haiti is in shambles. Her heart surgery cannot be safely done here.

So I told Beth and her mother to start working on obtaining her Haitian passport and Haitian Hearts would start looking for a medical center to accept her.

I also started her on other medications to help her heart beat stronger, diurese more fluid, penicillin to prevent further rheumatic fever, and an aspirin to keep her blood thin so she does not form a blood clot in her distended left atrium and have a stroke.

And all of this was caused because she lacked basic health care. No treatment for a sore throat when she was a kid.

John A. Carroll, MD

1 comment:

Anonymous said...

I stumbled upon your blog after looking for pictures of Haiti, and I just wanted to say that I'm glad there are people in this world like you.

I admire your passion and what you're doing to raise awareness. You make me grateful for good people like you.