Medical Adventures in Haiti<br />Francis Kim, MD, Dan Shaked, MD, <br />Aimee Grace, MD, & Dan Imler, MD<br />November 24,...
Trip Overview<br /><ul><li>November 7-14, 2009
Port-au-Prince, Haiti
2 sites
Grace Children’s Hospital
HUEH (General Hospital)
Approx. $600 round-trip
$300 reimbursement-Stanford </li></li></ul><li>Haiti<br />
Haiti Demographics<br />
A Brief History of Haiti<br /><ul><li>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 c...
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 resulte...
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 finance...
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 him...
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 on...
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 pe...
Presentations between Haitian and American residents and attendings
Clinical experiences in hospital/clinic settings
Physical diagnosis skills
Cultural exchanges
Have fun!</li></li></ul><li>Team Participants<br /><ul><li>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</li></li></ul><li>Cultural Experiences<br /><ul><li>Churches
Water purification projects
Wings of Hope orphanage
Voodoo temple
Visit to a rural village
Haitian food</li></li></ul><li>Grace Children’s Hospital<br /><ul><li>Private
Funded largely internationally</li></li></ul><li>HUEH (General Hospital)<br /><ul><li>Public
Resource-poor
Some sub-specialty care</li></ul>	available<br />
Haitian Resident Presentations<br /><ul><li>Neonate with pneumothorax, s/p needle thoracostomy
10 yo girl with tuberculosis
5 yo boy with rickets
Calcium/vitamin D metabolism</li></li></ul><li>American Presentations<br /><ul><li>Francis:
Neonatal Resuscitation Program (NRP)
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  • Distended belly: Lack of protein synthesis blocks the synthesis and export of lipoproteins, with retention of the lipid components
  • Medical Adventures in Haiti

    1. 1. Medical Adventures in Haiti<br />Francis Kim, MD, Dan Shaked, MD, <br />Aimee Grace, MD, & Dan Imler, MD<br />November 24, 2009<br />
    2. 2. Trip Overview<br /><ul><li>November 7-14, 2009
    3. 3. Port-au-Prince, Haiti
    4. 4. 2 sites
    5. 5. Grace Children’s Hospital
    6. 6. HUEH (General Hospital)
    7. 7. Approx. $600 round-trip
    8. 8. $300 reimbursement-Stanford </li></li></ul><li>Haiti<br />
    9. 9. Haiti Demographics<br />
    10. 10. A Brief History of Haiti<br /><ul><li>Columbus landed on Hispanola in 1492
    11. 11. 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.
    12. 12. In 1804, Haiti was declared independent from France and became the second republic in the Western hemisphere.
    13. 13. Slavery was outlawed but the U.S. would not recognize the new republic.
    14. 14. 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”
    15. 15. 1915: U.S. occupies Haiti after several years of instability because Haiti owed money to American banks.
    16. 16. U.S. dissolved the National Assembly, replaced the Haitian Constitution, and essentially reinstituted slavery.
    17. 17. U.S. officially pulled out in 1934 but left behind a ruling class to protect its interests and controlled external finances until 1947.</li></li></ul><li>A Brief History of Haiti<br /><ul><li>Several dictatorships followed until the election of Dr. Francois Duvalier (“Papa Doc”) in 1957…he soon established another dictatorship.
    18. 18. In 1961, Kennedy froze aid to Haiti because Papa Doc was believed to be pocketing aid money.
    19. 19. In 1971, Papa Doc died and his 19-year-old son “Baby Doc” took control and led Haiti further into ruin while enriching himself.
    20. 20. In the 1980s, AIDS broke out in Haiti, resulting in further stigmatism.
    21. 21. In 1986, due to widespread unrest, Baby Doc was exiled and several provisional governments ruled until 1990.
    22. 22. 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.
    23. 23. 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.
    24. 24. He was succeeded by his ally Preval in 1996 but then started a new party and was re-elected in 2000.
    25. 25. 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.</li></li></ul><li>Haiti Trip Goals<br /><ul><li>Medical education exchanges
    26. 26. Presentations between Haitian and American residents and attendings
    27. 27. Clinical experiences in hospital/clinic settings
    28. 28. Physical diagnosis skills
    29. 29. Cultural exchanges
    30. 30. Have fun!</li></li></ul><li>Team Participants<br /><ul><li>Stanford
    31. 31. Dan Imler (attending), Dan S., Francis, & Aimee (residents)
    32. 32. Texas
    33. 33. Radiologist, ER doc, Pediatrician, Radiology Technician
    34. 34. CHOP PICU Fellow
    35. 35. 4th year medical student (s/p Peace Corps in Haiti)
    36. 36. 1st year medical student
    37. 37. HIV educator</li></li></ul><li>Cultural Experiences<br /><ul><li>Churches
    38. 38. Water purification projects
    39. 39. Wings of Hope orphanage
    40. 40. Voodoo temple
    41. 41. Visit to a rural village
    42. 42. Haitian food</li></li></ul><li>Grace Children’s Hospital<br /><ul><li>Private
    43. 43. Funded largely internationally</li></li></ul><li>HUEH (General Hospital)<br /><ul><li>Public
    44. 44. Resource-poor
    45. 45. Some sub-specialty care</li></ul> available<br />
    46. 46. Haitian Resident Presentations<br /><ul><li>Neonate with pneumothorax, s/p needle thoracostomy
    47. 47. 10 yo girl with tuberculosis
    48. 48. 5 yo boy with rickets
    49. 49. Calcium/vitamin D metabolism</li></li></ul><li>American Presentations<br /><ul><li>Francis:
    50. 50. Neonatal Resuscitation Program (NRP)
    51. 51. Dan Shaked:
    52. 52. Hyperbilirubinemia, Bilitool
    53. 53. Aimee:
    54. 54. Sickle cell anemia (l’anemiefalciforme)
    55. 55. Dan Imler:
    56. 56. Stanford-Haiti collaboration</li></li></ul><li>American Presentations (2)<br /><ul><li>Kangaroo Care
    57. 57. Ultrasound 101
    58. 58. PALS Training
    59. 59. HEADSS Assessment
    60. 60. Early intervention in shock in Haiti</li></li></ul><li>Clinical experiences<br /><ul><li>Pediatric E.R. & wards
    61. 61. HIV/AIDS clinic
    62. 62. Pediatric clinic
    63. 63. Ophthalmology
    64. 64. Labor & Delivery
    65. 65. Adult E.R.
    66. 66. Surgery</li></li></ul><li>Pediatric Emergency Room & Wards<br /><ul><li>Heavy resident involvement
    67. 67. Very late-stage illnesses
    68. 68. Sepsis
    69. 69. Sickle cell anemia
    70. 70. Jaundice
    71. 71. Vomiting & diarrhea
    72. 72. Often chaotic-appearing
    73. 73. Families had to buy their own prescribed medications/fluids/etc.
    74. 74. Often not enough fluids or supplies
    75. 75. 24 gauge needles
    76. 76. Normal saline</li></li></ul><li>HIV/AIDS Clinic<br /><ul><li>Very well-run
    77. 77. iSante
    78. 78. Electronic medical record
    79. 79. Access to ARVs
    80. 80. Mostly funded by PEPFAR (Bush administration)
    81. 81. Support groups
    82. 82. Decreasing stigma</li></li></ul><li>Pediatric Clinic<br /><ul><li>Malnourishment
    83. 83. TB
    84. 84. Gastroenteritis
    85. 85. Urinary tract infections
    86. 86. Lymphadenitis
    87. 87. Long waiting times</li></li></ul><li>Case Presentations<br />
    88. 88. ~3 mo old male<br /><ul><li>Born to HIV-infected mother
    89. 89. Inability to take po, lethargy</li></li></ul><li>Severe Protein Energy Malnutrition<br /><ul><li>Root of many other diseases, including HIV, TB, gastroenteritis
    90. 90. Primarily a problem in developing countries
    91. 91. 13 million children worldwide with malnutrition
    92. 92. Leading cause of death in kids <5 yo
    93. 93. Types
    94. 94. Marasmus
    95. 95. Kwashiorkor
    96. 96. Mixed marasmus-kwashiorkor</li></li></ul><li>Marasmus<br /><ul><li>Most common form
    97. 97. Wasting of muscle mass and depletion of body fat stores
    98. 98. Due to inadequate intake of all nutrients
    99. 99. Especially dietary energy sources
    100. 100. PE:
    101. 101. Diminished weight & height for age
    102. 102. Thin, dry skin
    103. 103. Loose skin folds
    104. 104. Thin, sparse hair
    105. 105. Emaciated, weak</li></li></ul><li>Kwashiorkor<br /><ul><li>Marked muscle atrophy with normal or increased body fat
    106. 106. “Disease that the older one gets when the second one is born”
    107. 107. Due to inadequate protein intake
    108. 108. Fair to good energy intake
    109. 109. PE:
    110. 110. Normal or nearly normal weight
    111. 111. Anasarca
    112. 112. “Moon face”
    113. 113. Pitting edema
    114. 114. Distended abdomen
    115. 115. Hyperkeratosis & peeling skin</li></li></ul><li>Other examples from Haiti<br />
    116. 116. WHO Guidelines: Tx of Malnutrition<br /><ul><li>Initial phase
    117. 117. Tx hypoglycemia  early and frequent feedings
    118. 118. Tx hypothermia  warming
    119. 119. Tx dehydration ReSoMal (more K, less Na than ORS)
    120. 120. Tx infections Cotrimoxazole, Amp & Gent, and/or chloramphenicol
    121. 121. Rehabilitation phase
    122. 122. Emotional stimulation & sensory development
    123. 123. Follow-up phase
    124. 124. Monitor physical, emotional, mental development</li></li></ul><li>Community-Based Therapeutic Care<br /><ul><li>Decentralized & early intervention
    125. 125. Recovery rates ~80% AND “coverage” rates 72%!
    126. 126. Preferred approach for emergency relief programs
    127. 127. Use of simple protocols and supplies
    128. 128. Ready to Use Therapeutic Food (RUTF)
    129. 129. High nutritional quality
    130. 130. Inexpensive
    131. 131. Easily transportable
    132. 132. Minimal spoilage
    133. 133. Can be produced locally
    134. 134. Mixture of peanuts, sugar, oil, & powdered milk
    135. 135. Supplemented with vitamin & mineral mixture</li></li></ul><li>Medika Mamba Program in Haiti<br />
    136. 136. Case: Congenital Malformation<br /><ul><li>17 year old female, believed to have a term pregnancy, moved to OR for C-section due to failure to progress.
    137. 137. No prenatal care. No imaging or labs available.
    138. 138. Difficult operative course. Vertical C-section. Surgical wound must be extended to remove the head of the fetus.
    139. 139. Thick meconium is present in amniotic fluid and umbilical cord is darkly stained.</li></li></ul><li>Case: Congenital Malformation<br />
    140. 140. Case: Severe Hydrocephalus<br /><ul><li>Neonate is warmed, dried, and stimulated but makes no respiratory effort.
    141. 141. Heart rate is initially in the 80s and PPV is initiated.
    142. 142. Ventilation proves difficult and HR gradually drops below 60.
    143. 143. Chest compressions initiated.</li></li></ul><li>Case: Severe Hydrocephalus<br />
    144. 144. Case: Severe Hydrocephalus<br />
    145. 145. Case: Severe Hydrocephalus<br /><ul><li>Patient’s HR briefly rises above 100 and compressions are stopped-PPV continues…
    146. 146. During CPR supplemental oxygen is set up to be delivered by nasal cannula and intubation equipment is obtained.
    147. 147. The patient never makes any respiratory effort and intubation is attempted.</li></li></ul><li>Case: Severe Hydrocephalus<br />
    148. 148. Case: Severe Hydrocephalus<br /><ul><li>Despite several attempts, intubation is unsuccessful.
    149. 149. Compressions are resumed as HR drops…and drops.
    150. 150. After 40 minutes…CPR efforts are stopped.</li></li></ul><li>Etiologies of Congenital Hydrocephalus<br /><ul><li>Neural Tube defects- myelomeningocele, anencephaly, encephalocele
    151. 151. Infection- TORCH
    152. 152. Syndromic- trisomy 13, 18, 9, 19, triploidy
    153. 153. X-linked Hydrocephalus with Stenosis of the Aqueduct of Sylvius</li></li></ul><li>~ 1 yo Haitian female with eye problem…<br />
    154. 154.
    155. 155. Vitamin A Deficiency (VAD)<br /><ul><li>Most common cause of blindness in developing countries
    156. 156. WHO estimates 13.8 million children have some visual loss due to VAD
    157. 157. Public health problem in more than 50% of countries
    158. 158. 250,000-500,000 malnourished children go blind each year from VAD
    159. 159. Approximately half of which will die within a year of going blind
    160. 160. Prevalence of night blindness due to VAD is also high among pregnanet women in many developing countries</li></li></ul><li>Complete blindness with VAD<br /><ul><li>Night blindness is an early manifestation
    161. 161. Loss of goblet cells in the conjunctiva
    162. 162. Responsible for secretion of mucus
    163. 163. Results in xerophthalmia- eyes fail to produce tears and dead epithelial and microbial cells accumulate on the conjunctiva and form debris
    164. 164. Leads to infection and scarring
    165. 165. United Nations Special Session on Children in 2002 set the elimination of VAD by 2010</li></li></ul><li>Treatment<br /><ul><li>Oral and injectable forms
    166. 166. Oral capsules cost approx $0.02 and children only require 2-3 doses/year
    167. 167. Vitamin A supplementation also reduces other morbidity including severe diarrhea, measles, and other infections
    168. 168. Vitamin Angels (non-profit, non-governmental organization)
    169. 169. 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”</li></li></ul><li>
    170. 170. Your Future as a Global Health Physician<br />Every pediatric physician has something to offer<br />Global Health does not mean International Health<br />Global Health does not mean traveling<br />Global Health in 10 years may be very different than what it is now<br />But you are not trained nessesarily for resource poor health<br />But the AAP & ACGME say you must be<br />So what are YOU going to do?<br />
    171. 171. [1] Live and Practice Primary Care<br />
    172. 172. [2] Travel Occasionally to Different Countries to practice primary care<br />
    173. 173. [3] Practice in the US, but have an ongoing commitment to a single resource poor community<br />
    174. 174. My Challenge: Commit to a Community<br />What are my strengths?<br />What resources do I have?<br />What do I do when I do it for free?<br />Who do I like being around?<br />
    175. 175. 2009<br />2008<br />
    176. 176. What “Room of Sorrows” are you going to change?<br />
    177. 177. Merci!<br /><ul><li>Francis Kim: fkim821@gmail.com
    178. 178. Dan Shaked: drshaked@gmail.com
    179. 179. Aimee Grace: agrace@stanfordalumni.org
    180. 180. Dan Imler: imlerdl@gmail.com</li>
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