medical adventures in haiti

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Medical Adventures in Haiti

Francis Kim, MD, Dan Shaked, MD, Aimee Grace, MD, & Dan Imler, MD

November 24, 2009

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Trip Overview

November 7-14, 2009 Port-au-Prince, Haiti 2 sites

Grace Children’s Hospital HUEH (General Hospital)

Approx. $600 round-trip $300 reimbursement-Stanford

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Haiti

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Haiti DemographicsHaiti U.S.A. World

Population (millions)

9.0 302.2 6,705

Births/1,000 pop’n

29 14 21

Deaths 11 8 9

Infant mortality

57 6.5 52

Fertility 4.0 2.5 2.7

% under age 15 39 20 28

% over age 65 4 12 16

Life expectancy

58 78 68

% urban 36 79 49

% with HIV 2.2 0.6 0.9

Children <5 underweight

22 1 23

GNI PPP per capita

$1,490 $44,260 $9,940

Pop’n density/sq km

323 31 49

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A Brief History of Haiti

•Columbus landed on Hispanola in 1492•In the 17th century, the western portion was occupied by the French who introduced African slave labor to grow sugar and coffee throughout the 18th century.•In 1804, Haiti was declared independent from France and became the second republic in the Western hemisphere.•Slavery was outlawed but the U.S. would not recognize the new republic.•In 1806, first of MANY Coup d’etats…complicated shifts of power on the island until new constitution in 1874 which resulted in a “Hatian Renaissance”•1915: U.S. occupies Haiti after several years of instability because Haiti owed money to American banks.•U.S. dissolved the National Assembly, replaced the Haitian Constitution, and essentially reinstituted slavery.•U.S. officially pulled out in 1934 but left behind a ruling class to protect its interests and controlled external finances until 1947.

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A Brief History of Haiti•Several dictatorships followed until the election of Dr. Francois Duvalier (“Papa Doc”) in 1957…he soon established another dictatorship.•In 1961, Kennedy froze aid to Haiti because Papa Doc was believed to be pocketing aid money.•In 1971, Papa Doc died and his 19-year-old son “Baby Doc” took control and led Haiti further into ruin while enriching himself.•In the 1980s, AIDS broke out in Haiti, resulting in further stigmatism. •In 1986, due to widespread unrest, Baby Doc was exiled and several provisional governments ruled until 1990.•In 1990, a charismatic Catholic Priest, Jean-Bertrand Aristide was elected in a landslide vote which was believed to be one of the few truly free elections in Haitian history.•Less than a year later he was overthrown by a military coup, only to be returned to power by a US-led invasion in 1994.•He was succeeded by his ally Preval in 1996 but then started a new party and was re-elected in 2000. •In 2004, he was once again overthrown and taken out of the country on a US plane. A UN force was introduced to keep the peace.

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Haiti Trip Goals

Medical education exchanges Presentations between Haitian and American residents and attendings Clinical experiences in hospital/clinic settings Physical diagnosis skills

Cultural exchanges Have fun!

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Team Participants

Stanford Dan Imler (attending), Dan S., Francis, & Aimee (residents)

Texas Radiologist, ER doc, Pediatrician, Radiology Technician

CHOP PICU Fellow 4th year medical student (s/p Peace Corps in Haiti) 1st year medical student HIV educator

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Cultural Experiences

Churches Water purification projects Wings of Hope orphanage Voodoo temple Visit to a rural village Haitian food

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Grace Children’s Hospital

Private Funded largely internationally

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HUEH (General Hospital)

Public Resource-poor Some sub-specialty care

available

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Haitian Resident Presentations

Neonate with pneumothorax, s/p needle thoracostomy

10 yo girl with tuberculosis 5 yo boy with rickets

Calcium/vitamin D metabolism

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American Presentations

Francis: Neonatal Resuscitation Program (NRP)

Dan Shaked: Hyperbilirubinemia, Bilitool

Aimee: Sickle cell anemia (l’anemie falciforme)

Dan Imler: Stanford-Haiti collaboration

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American Presentations (2)

Kangaroo Care Ultrasound 101 PALS Training HEADSS Assessment Early intervention in shock in Haiti

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Clinical experiences

Pediatric E.R. & wards HIV/AIDS clinic Pediatric clinic Ophthalmology Labor & Delivery Adult E.R. Surgery

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Pediatric Emergency Room & Wards

Heavy resident involvement Very late-stage illnesses

Sepsis Sickle cell anemia Jaundice Vomiting & diarrhea

Often chaotic-appearing Families had to buy their own prescribed

medications/fluids/etc. Often not enough fluids or supplies

24 gauge needles Normal saline

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HIV/AIDS Clinic

Very well-run iSante

Electronic medical record

Access to ARVs Mostly funded by PEPFAR (Bush administration) Support groups Decreasing stigma

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Pediatric Clinic

Malnourishment TB Gastroenteritis Urinary tract infections Lymphadenitis Long waiting times

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Case Presentations

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~3 mo old male

Born to HIV-infected mother Inability to take po, lethargy

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Severe Protein Energy Malnutrition

Root of many other diseases, including HIV, TB, gastroenteritis

Primarily a problem in developing countries 13 million children worldwide with malnutrition Leading cause of death in kids <5 yo Types

Marasmus Kwashiorkor Mixed marasmus-kwashiorkor

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Marasmus

Most common form Wasting of muscle mass and depletion of body fat

stores Due to inadequate intake of all nutrients

Especially dietary energy sources

PE: Diminished weight & height for age Thin, dry skin Loose skin folds Thin, sparse hair Emaciated, weak

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Kwashiorkor

Marked muscle atrophy with normal or increased body fat

“Disease that the older one gets when the second one is born”

Due to inadequate protein intake Fair to good energy intake

PE: Normal or nearly normal weight Anasarca “Moon face” Pitting edema Distended abdomen Hyperkeratosis & peeling skin

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Other examples from Haiti

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WHO Guidelines: Tx of Malnutrition

Initial phase Tx hypoglycemia early and frequent feedings Tx hypothermia warming Tx dehydration ReSoMal (more K, less Na than ORS) Tx infections Cotrimoxazole, Amp & Gent, and/or chloramphenicol

Rehabilitation phase Emotional stimulation & sensory development

Follow-up phase Monitor physical, emotional, mental development

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Community-Based Therapeutic Care

Decentralized & early intervention Recovery rates ~80% AND “coverage” rates 72%!

Preferred approach for emergency relief programs

Use of simple protocols and supplies Ready to Use Therapeutic Food (RUTF)

High nutritional quality Inexpensive Easily transportable Minimal spoilage Can be produced locally Mixture of peanuts, sugar, oil, & powdered milk

Supplemented with vitamin & mineral mixture

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Medika Mamba Program in Haiti

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Case: Congenital Malformation

• 17 year old female, believed to have a term pregnancy, moved to OR for C-section due to failure to progress.

• No prenatal care. No imaging or labs available.

• Difficult operative course. Vertical C-section. Surgical wound must be extended to remove the head of the fetus.

• Thick meconium is present in amniotic fluid and umbilical cord is darkly stained.

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Case: Congenital Malformation

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Case: Severe Hydrocephalus

• Neonate is warmed, dried, and stimulated but makes no respiratory effort.

• Heart rate is initially in the 80s and PPV is initiated.

• Ventilation proves difficult and HR gradually drops below 60.

• Chest compressions initiated.

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Case: Severe Hydrocephalus

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Case: Severe Hydrocephalus

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Case: Severe Hydrocephalus

• Patient’s HR briefly rises above 100 and compressions are stopped-PPV continues…

• During CPR supplemental oxygen is set up to be delivered by nasal cannula and intubation equipment is obtained.

• The patient never makes any respiratory effort and intubation is attempted.

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Case: Severe Hydrocephalus

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Case: Severe Hydrocephalus

• Despite several attempts, intubation is unsuccessful.

• Compressions are resumed as HR drops…and drops.

• After 40 minutes…CPR efforts are stopped.

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Etiologies of Congenital Hydrocephalus

• Neural Tube defects- myelomeningocele, anencephaly, encephalocele

• Infection- TORCH

• Syndromic- trisomy 13, 18, 9, 19, triploidy

• X-linked Hydrocephalus with Stenosis of the Aqueduct of Sylvius

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~ 1 yo Haitian female with eye problem…

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Vitamin A Deficiency (VAD)

•Most common cause of blindness in developing countries•WHO estimates 13.8 million children have some visual loss due to VAD•Public health problem in more than 50% of countries•250,000-500,000 malnourished children go blind each year from VAD•Approximately half of which will die within a year of going blind

•Prevalence of night blindness due to VAD is also high among pregnanet women in many developing countries

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Complete blindness with VAD

• Night blindness is an early manifestation• Loss of goblet cells in the conjunctiva

• Responsible for secretion of mucus• Results in xerophthalmia- eyes fail to produce tears and dead epithelial and

microbial cells accumulate on the conjunctiva and form debris• Leads to infection and scarring

• United Nations Special Session on Children in 2002 set the elimination of VAD by 2010

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Treatment

• Oral and injectable forms• Oral capsules cost approx $0.02 and children only require 2-3 doses/year

• Vitamin A supplementation also reduces other morbidity including severe diarrhea, measles, and other infections

• Vitamin Angels (non-profit, non-governmental organization)• Goal: “to eradicate childhood blindness due to Vitamin A deficiency on the

planet by the year 2020. Operation 20/20 was launched in 2007 and will cover 18 countries. The program gives children two high dose vitamin A and anti-parasitic supplements (twice a year for four years), which provides children with enough of the nutrient during their most vulnerable years in order to prevent them from going blind and suffering from other life-threatening diseases caused by Vitamin A Deficiency”

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Your Future as a Global Health Physician

1. Every pediatric physician has something to offer2. Global Health does not mean International Health3. Global Health does not mean traveling4. Global Health in 10 years may be very different than

what it is now5. But you are not trained nessesarily for resource poor

health6. But the AAP & ACGME say you must be7. So what are YOU going to do?

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[1] Live and Practice Primary Care

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[2] Travel Occasionally to Different Countries to practice primary care

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[3] Practice in the US, but have an ongoing commitment to a single resource poor community

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My Challenge: Commit to a Community

1. What are my strengths?2. What resources do I have?3. What do I do when I do it for

free?4. Who do I like being around?

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2008

2009

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What “Room of Sorrows” are you

going to change?

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Merci!

Francis Kim: fkim821@gmail.com Dan Shaked: drshaked@gmail.com Aimee Grace: agrace@stanfordalumni.org Dan Imler: imlerdl@gmail.com