Maxime

Dear Doctors,

Maxime Petion is a 21 year old that was operated at OSF in 2002. He had a #27 CE pericardial valve put in his mitral position.

He has done well in Haiti until this year. He had a CVA on Oct. 5 which hit his speech center in his left cortex. He is much improved from a neuro standpoint. He talks and walks on his own. His strength is good in his right arm and leg 4/5. His speech is very good. Some motor aphasia but no receptive aphasia.

His exam today: 110/94 right arm. Bifid pulse at right brachial. Respiratory rate is 40 at rest. Able to lie flat without problem. Dyspnea on exertion but climbs steps well. Heart rate is regular about 80. Not in atrial fib. Neck--no JVD. Lungs diminished tones at right base. Chest xray in morning. Heart: 3/6 holosystolic murmur left sternal border about 6th ICS. PMI at 6th ICS midclavicular line. I think I hear a right sided S3. Could not hear a diastolic murmur.
Abdomen: liver not enlarged or tender. No ascites. No jaundice or icterus.

Echo today: Severe calcificed mitral stenosis with 31 mm gradient across mitral valve. Some MR. Moderate AI. Right ventricle and right atrium enlarged. Significant TR with RV pressure measured at 77 mm hg with PAP estimated at 87. Big left atrium. Normal size LV. LV has EF of 44%.

I have him on the usual stuff to try and keep him alive. Seems like mainly RV failure with high pulmonary pressures secondary to MS. No thrombus noted after stroke. I have him on ASA. No coumadin to give him now. He is alert and totally coherent. Good appetitie. My wife and I have him in our room with us.

I e mailed Sister Judith Ann and others several weeks ago about Maxime with no answer as usual. (Dr. McShane sent me an email a couple of months ago indicating he was blocking my e mails. So much for open and honest communication at OSF.)

Need your help. What should I do? Please ask Kramer and Steffen and Doug Marshall to come to their senses and accept these kids back that should not be denied care. (I know the Sisters have little say so.)

Thanks. His picture and quick video attached.

John

Mwen Swaf

In Haitian creole "Mwen swaf" means "I am thirsty".

The men that pull and push these huge loads are called mules. They usually have no shoes and walk with the traffic, exhaust, and mayhem in the street. The material they transport is frequently car parts and heavy metal. I have no idea how they do this.

Jesus was thirsty when he hung on the cross. The Haitians are thirsty for justice.

Haitian Vaccinations

The national vaccine immunization program in the United States, directed principally at children, is one of the most successful examples of effective preventitive care. One of the most dramatic examples of the benefits of apporopriate immunization is the marked derease in cases of invasive Haemophilus influenzae type b infection since the introduction of this vaccine in 1987. Incredibly, the number of cases of children younger than five years of age in the United States declined by >99% by 2000.

Haitian children have access to standard vaccinations including diphtheria, tetanus, pertussis, measels, mumps, and rubella. They can also recieve oral polio vaccine and BCG vaccine (to prevent tuberculosis). However, very few Haitian children have access to "second generation" vaccines like Haemopilus influenzae described above. This bacteria can be particularly bad causing infections at multiple sites including meningitis and sepsis.

Other vaccines that only Haitian children with means have access to include hepatitis A and B, pneumococcus, influenza, meningococcus, and varicella-zoster(chicken pox).

All of these vaccines are considered "standard of care" for U.S. children that live only 90 minutes away from their Haitian neighbors.

The Wooden Bell

A couple of days ago, after clinic was over, I was eating with the sisters that run the clinic, malnutrition center, and school just outside of Port-au-Prince. Our talk concerned Haiti and its serious unending problems. The sister at the head of the table is from Spain and had been asked to leave Cite Soleil several months ago after gunfire between the United Nations and slum gangs blew big holes in the sister's convent wall as they were forced to lie on the floor to avoid the bullets.

In clinic, the babies with malnutrition and neglect have no real chance. Another difficult problem is babies that show up without a mother. This occurs frequently. The sister from Spain said, "When the Haitian mother dies, you may as well bury their baby at the same time." Unfortunately, this is not far from the truth. Aunts, grandmas,fathers,and neighbors usually are not good substitutes for the absent mother.

Today, the lady at the top of this post showed up where we are staying. Her name is Heureuse. Heureuse lives with Michael, her one year old boy, and her three year old daughter in a notorious slum on the edge of Port-au-Prince called Carrefour.

Heureuse had heart surgery at OSF in Peoria about 4 years ago and Haitian Hearts brings her medicine each trip that keeps her alive. We examine her and a recent echocardiogram here in Haiti shows that Heureuse needs to return for more valve surgery. OSF in Peoria will not accept Heureuse even though the doctors that took care of her several years ago would be glad to have her back and take care of Heureuse at no charge.

When Heureuse dies here, she will leave her two young children. She and her babies live with Michel's father. (The father of her daughter is dead.) Neither child is doing great now from a nutrition standpoint and when Heureuse is gone, both of her children will be at high risk for disease and death.

In todays (10/17/06) Peoria Journal Star there is a 20 page supplement that is entitled "Building a Medical Powerhouse". The articles report the 562 million dollars being spent in Peoria by the two major hospitals and the University of Illinois School of Medicine. They are all located approximately 4 blocks from each other. The local health-care community is lauded for taking the Peoria economy to "new heights" with the jobs and employment that the medical expansion creates.

OSF is building a new 8 story Children's Hospital as part of its 234 million dollar addition. Paul Kramer, Director of Children's Hospital, is quoted as saying that he wants a "world class" facility. However, it will never be "world class" when OSF and Mr. Kramer and other secular leaders dismiss the suffering of Heureuse and refuse to allow her to return to OSF for surgery. Mr. Kramer has his blinders on even though he knows the majority of the "world" live in the same "class" as Heureuse and her children. How can OSF be "world class" when they ignore the cry of the "global community" and focus on Peoria's economy.

New technology and research and jobs for any community are good. However, one obscenity lies in the difference in Peoria's half-billion dollar medical projects and Haiti's extreme poverty. The other obscenity is OSF's negligence of former patients that do not have technology, jobs, and research in their slum.

A Haitian proverb says, "No one hears the cry of the poor or the sound of a wooden bell". The good news for OSF is that Heureuse is "out of sight and out of mind". Her death will not be reported in Peoria and her children's struggles will never be known.

Peoria and its medical community are the losers when they deny health care to those who need it most. If OSF and its leaders really thought big, they would think of Heureuse and her children.

Dear Senator...

Dear Senator Raoul,

We hope that the benefit for GCH was very successful. My brother-in-laws and sister-in-law really enjoyed themselves on Saturday night and were very happy to meet you.

I have to give you a very grim medical report from Haiti. After 25 years of working in Haiti, I have never seen conditions so bad. The people here suffer so much from things that they shouldn’t even have like tuberculosis, malaria, and malnutrition.

Every day I have to force myself to walk to clinic and be part of this desperation. I can barely get in the front door of the pediatric clinic when I arrive because of the crowd that starts accumulating at 5 AM.

During the last year, we have brought a drug called ceftriaxone each trip to Haiti. It is a high powered antibiotic that can be given as a shot and will last for 12-24 hours before the baby needs a second shot. When I see a very sick infant, I give the shot quickly in the clinic. If there is no room at GCH or the baby does not meet the requirements for admission, I have the baby come back in the morning and admit it to GCH if there is a bed, or I take it to another hospital in PAP, and repeat the dose of ceftriaxone. If the baby survives this fiasco of medical care and the baby looks better, I convert the baby over to less expensive antibiotics that can be taken orally.

When I arrived at GCH clinic this morning, there had to be about 250 people crammed into the clinic (includes parents). My first patient was a 3 day old with a temperature of 102 F. I gave it a shot of ceftriaxone and sent the baby home with advice to mother to bring back tomorrow. The baby should have been admitted, but I couldn’t. Three day old babies with fevers are considered pediatric emergencies.

My next patient was a 16 day old baby boy who weighs four and one half pounds. His temperature was 102.5. His mother was very young and she had never given him breast milk, powdered milk, or anything other than water. His picture is attached and he is emblematic of Haiti. I baptized him with stagnant dirty water in a plastic bowl in my office. There was no running water in the clinic today.

I gave this pathetic baby a shot of ceftriaxone immediately and called a missionary who drove to the clinic, picked him up, and took him to another clinic/hospital where we admitted him. Sending him to the General Hospital is not a good option usually. (For one thing, his young mother had no idea where the General Hospital was in PAP!!)

The rest of my clinic day did not go much better. The acuity of disease here is horrible.

Over the years my wife and I have brought thousands of dollars of ceftriaxone specifically for patients at GCH. Since we are about out of this medication at this point, Maria’s parents purchased 300 more dollars worth of ceftriaxone in Peoria last week that I called in to our local pharmacy in Peoria, and sent to us by DHL. We followed the package’s progress via the internet. It arrived in PAP on Friday, but we received no call from DHL until this morning (Monday).

DHL is about one mile from here and they said that we owed them 5,473 gourdes for Haiti customs tax. This comes out to about $144 US. The entire package sent from Peoria has the ceftriaxone for many, many sick babies, and some germ-x soap, and some protein bars which totals about $350 US.

The Haitian government is asking us, to pay almost half of the cost of the package in customs taxes. The delivery by DHL was also very expensive and paid for generously by Maria’s parents. The ceftriaxone was also paid for by Haitian Hearts (Maria’s parents again).

DHL came this morning to deliver the package, but I refused to accept it or pay for it (the customs tax). This is absolutely outrageous. I explained that it contains medication for sick and dying babies, but no one seems to care. I am on my last couple of vials of ceftriaxone that we had from a previous trip and from this trip.

I don’t want to quit working at GCH but I strongly feel like terminating my work there until this problem can be addressed. It is just so difficult to have the medication ordered, purchased, and close by, but not available for the kids that need it most. This of course is not GCH fault or responsibility. Haitian Hearts pays for chest x-rays and medication everyday at GCH for patients who I see in the clinic, and know they have no money to pay for the x-rays and medications at GCH or anwhere else. We also admit them to other hospitals, and Haitian Hearts pays for these admissions also. I don’t want to quit working---I love what I do and who I work with, but if I have no ceftriaxone to take to the clinic, I will be baptizing the first 10 patients I see each morning. This work can feel very futile on a good day. It is just SO difficult as a physician to have my hands tied and not be able to do what is right for people that have no say so in their future.

Senator Raoul, will you get me a meeting with anyone you can think of that has influence at the level of national customs in Haiti. I would be glad to speak with President Preval or the Haitian Senate leader. A very powerful person needs to spend one day in the GCH clinic to see the problems at ground level. Someone needs to step up to the plate in the new Haitian administration. I need this medication now and Haitian Hearts will not pay for it again. We already paid for it in Peoria and sent it down here as fast as we could. The DHL truck drove away with it this morning….a very sad thing to see, especially if you are a sick Haitian baby.

Thank you very much for all you do.

Sincerely,

John

You may forward this e mail to anyone you think can resolve this problem.

Starving in Haiti

This mother, who was covered with sweat, brought her 3 year old in her right arm and 2 year old in her left arm to the clinic yesterday from a small village north of us. It cost 75 cents for each girl for the doctor visit and medication.

The 3 year old weighs 13 lbs. and the her 2 year old sister weighs 16 lbs. Both have fever, cough, and diarrhea. Both have no access to daily nutritious food, clean water, or medical care. Both are starving.

Peoria's major two hospitals are beginning 534 million dollar hospital expansions. The two hospitals are one block away from each other in a city of 113,000.

Tuberculosis and Cavities

The major site of infection of tuberculosis is the lungs. Tuberculosis causes the lymph nodes in the lung to enlarge, can appear like pneumonia, can cause extensive scarring, and even cause part of the lung to cave in and form cavities.

Cavitary lung disease from any cause is considered quite dangerours because of the destruction of lung tissue and also due to the fact that the cavities contain pus and bacteria.

When I listened to the lung of this little girl, I could hear hollow sounds over the cavity which are called amhoric, like the sounds made by blowing across the mouths of jars used in antiquity (amphora). When my stethescope moved slightly away from the cavity, the hollow sound disappeared. This is different than tubular breath tones heard in areas of consolidation like pneumonia without a cavity.

This girl would be considered infectious for tuberculosis because the cavity can contain more tuberculosis germs and she can spread them with a cough or just talking to someone. As a rule, children are not considered transmitters of tuberculosis. Identifying a pediatric tuberculosis case in the community means that there is an unidentified adult(s) that is/are spreading the disease.

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Alternative Medicine in Haiti

Alternative Medicine in Haiti

I saw this young lady in the clinic today. She is 23 years old and lives a few miles from the clinic but it takes her at least 30 minutes to get there down the dirt road leading to the clinic with huge holes, mud, and water.

She was very weak when she arrived and had to be pulled into the clinic. She was also very short of breath. Her blood pressure was 104/0. Her blood was drawn at our lab next door which revealed a hemoglobin of 3. She should have a hemoglobin of 14. She has very little blood cells circulating to carry oxygen to her cells. Her organs are starving for oxygen.

There are many causes of anemia in Haiti with iron deficiency at the top of the list. I don’t know if she has sickle cell anemia. She could have both.

She has no money to go to a public hospital and has no family member to take care of her in the hospital. So hospitalization in Haiti is not an option. She desperately needs a blood transfusion and we need to find the reason for her severe anemia. So I gave her a shot of intramuscular iron and some iron supplements to take orally. We also gave her a high protein drink and some corn curls as she sat in a chair with a smile on her face and devoured them.

I told her to come back to the clinic tomorrow for more injectable iron which is sometimes dangerous to give because of allergic reactions. But that is the best alternative for her now to quickly restore her iron. Haiti has given her no more “alternatives” than this. She smiled and said she would come back, but I realize now it is a national holiday. I had forgotten. I think she had too. Hopefully, she will return in two days.

I practice “alternative medicine” in Haiti and am very embarrassed.

Haitian Fathers

Haitian fathers care about their children. They work as hard as they can to provide for their family. There is much work in Haiti but few jobs. And the jobs that do exist don't pay hardly anything. But Haitian men do work and can probably outwork anyone anywhere. I have seen them do incredible physical labor, such as clearing very heavy rocks from a huge field overlooking the Caribbean Sea, that I did not think was possible...and they did it with their bare hands.

This two year old girl, Chevalier, has a congenital heart defect known as a ventricular septal defect. It is a very common congenital heart problem which allows too much blood to flow back to the lungs through a little hole in the heart that shouldn't be there. After a few years, the heart can become enlarged and weak because it is receiving excessive blood. Also, the lungs can develop high blood pressure and refuse to receive blood from the heart which leads to death.

Chevalier has nothing irreversible right now. Her heart and lungs work well but she needs cardiac surgery now to close the hole in her heart. She will do well if she is operated before permanent damage is done.

Her father cares about her. She loves her father. He is depending on Haitian Hearts to find a hosptial in the United States to operate Chevalier.

Haitian fathers care. They work hard. They deserve much more.

Haiti, Heal Thyself

The baby boy pictured above is 16 days old. His name is Kenley. His aunt carried him into clinic two mornings ago and his seventeen year old mom followed behind.

Kenley was born at home, like most Haitian babies. His mother had a fever during pregnancy, but the delivery went well. He was not premature. The aunt, who carried a cell phone, and mother stated that a few days after birth he developed a fever. Amazingly, he has never been offered breast milk or powdered milk. The only liquid Kenley has ever had in his 16 days on earth was boiled water.

His exam revealed an emaciated, shriveled little baby with the wrinkled face of an old man in severe distress. His temperature was 102.5 F. He seemed to be pretty stiff and did not want to be moved much. His fontanelles were sunk and his skin tented when pinched indicating dehydration. He was not jaundiced and his umbillical area looked free from infection.

Kenley was obviously very sick. Infants with fevers are considered medical emergencies. Two hospitals rejected Kenley but we were able to admit him to a "doc-in-the-box" for an IV and antibiotics. His chances for survival are minimal but maybe better than before. I don't now.

Where was Kenley failed? Many places. He was born at home with the help of a midwife. His young, uneducated mother had an infection of some type during her pregnancy which put Kenley at risk for infection. His mother had no prenatal care. Kenley had not been given nutrition of any sort according to his aunt and mother. He had fever for many days and his visit to me was his first encounter with a doctor.
Two hospitals refused to admit him the other morning. His hospitalization now is not in a neonatal intensive care unit. He is being cared for by nonspecialists in a primitive setting. We have no idea what his blood work is or where is infection is originating. He may not even be receving the proper antibiotics.

Haiti's infant mortality rate is very high---one of the highest in the world. Kenley's horrible case can attest to this.

Haiti has been given the bad end of the deal by the international community for hundreds of years. Hundreds of millions of dollars have flowed into Haiti over decades. The money hasn't reached or helped most Haitians.

Haiti needs benevolent leaders. The corruption in Haiti is fierce, almost as bad as the United States. Money needs to trickle down to the Kenley's that are in need. Haiti needs to point the finger at themselves too. It just doesn't need to be this bad here.

Haiti is embarrassing.

Haitian Dwindles

Many children get the "dwindles" in Haiti. They lose weight, have fevers, quit eating the little they were eating, and can’t learn in school.

Such was the case with Angeline who I examined in the clinic yesterday. Angeline is 7 years old and weighs 29 pounds.

Her exam was normal other than appearing quite chachectic as you can see. So I will work her up for tuberculosis. I treated suspected worms living in her gastrointestinal tract empirically and gave her iron and vitamin supplements.

What Angeline really needs is a government that cares about her and thousands of other Haitian kids with the dwindles, and does something about it. Downstream efforts like mine are ok, but Haiti needs upstream efforts that prevent medical problems from occurring in the first place.