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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: [email protected] Dan Shaked: [email protected] Aimee Grace: [email protected] Dan Imler: [email protected]