1. Medical Adventures in Haiti Francis Kim, MD, Dan Shaked, MD, Aimee Grace, MD, & Dan Imler, MD November 24, 2009

3. Port-au-Prince, Haiti

4. 2 sites

5. Grace Children’s Hospital

6. HUEH (General Hospital)

7. Approx. $600 round-trip

9. Haiti Demographics

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. In 1804, Haiti was declared independent from France and became the second republic in the Western hemisphere.

13. Slavery was outlawed but the U.S. would not recognize the new republic.

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. 1915: U.S. occupies Haiti after several years of instability because Haiti owed money to American banks.

16. U.S. dissolved the National Assembly, replaced the Haitian Constitution, and essentially reinstituted slavery.

18. In 1961, Kennedy froze aid to Haiti because Papa Doc was believed to be pocketing aid money.

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. In the 1980s, AIDS broke out in Haiti, resulting in further stigmatism.

21. In 1986, due to widespread unrest, Baby Doc was exiled and several provisional governments ruled until 1990.

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. 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. He was succeeded by his ally Preval in 1996 but then started a new party and was re-elected in 2000.

26. Presentations between Haitian and American residents and attendings

27. Clinical experiences in hospital/clinic settings

28. Physical diagnosis skills

29. Cultural exchanges

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

32. Texas

33. Radiologist, ER doc, Pediatrician, Radiology Technician

34. CHOP PICU Fellow

35. 4th year medical student (s/p Peace Corps in Haiti)

36. 1st year medical student

38. Water purification projects

39. Wings of Hope orphanage

40. Voodoo temple

41. Visit to a rural village

44. Resource-poor

45. Some sub-specialty care available

47. 10 yo girl with tuberculosis

48. 5 yo boy with rickets

50. Neonatal Resuscitation Program (NRP)

51. Dan Shaked:

52. Hyperbilirubinemia, Bilitool

53. Aimee:

54. Sickle cell anemia (l’anemiefalciforme)

55. Dan Imler:

57. Ultrasound 101

58. PALS Training

59. HEADSS Assessment

61. HIV/AIDS clinic

62. Pediatric clinic

63. Ophthalmology

64. Labor & Delivery

65. Adult E.R.

67. Very late-stage illnesses

68. Sepsis

69. Sickle cell anemia

70. Jaundice

71. Vomiting & diarrhea

72. Often chaotic-appearing

73. Families had to buy their own prescribed medications/fluids/etc.

74. Often not enough fluids or supplies

75. 24 gauge needles

77. iSante

78. Electronic medical record

79. Access to ARVs

80. Mostly funded by PEPFAR (Bush administration)

81. Support groups

83. TB

84. Gastroenteritis

85. Urinary tract infections

86. Lymphadenitis

90. Primarily a problem in developing countries

91. 13 million children worldwide with malnutrition

92. Leading cause of death in kids <5 yo

93. Types

94. Marasmus

95. Kwashiorkor

97. Wasting of muscle mass and depletion of body fat stores

98. Due to inadequate intake of all nutrients

99. Especially dietary energy sources

100. PE:

101. Diminished weight & height for age

102. Thin, dry skin

103. Loose skin folds

104. Thin, sparse hair

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

107. Due to inadequate protein intake

108. Fair to good energy intake

109. PE:

110. Normal or nearly normal weight

111. Anasarca

112. “Moon face”

113. Pitting edema

114. Distended abdomen

117. Tx hypoglycemia  early and frequent feedings

118. Tx hypothermia  warming

119. Tx dehydration ReSoMal (more K, less Na than ORS)

120. Tx infections Cotrimoxazole, Amp & Gent, and/or chloramphenicol

121. Rehabilitation phase

122. Emotional stimulation & sensory development

123. Follow-up phase

125. Recovery rates ~80% AND “coverage” rates 72%!

126. Preferred approach for emergency relief programs

127. Use of simple protocols and supplies

128. Ready to Use Therapeutic Food (RUTF)

129. High nutritional quality

130. Inexpensive

131. Easily transportable

132. Minimal spoilage

133. Can be produced locally

134. Mixture of peanuts, sugar, oil, & powdered milk

137. No prenatal care. No imaging or labs available.

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

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

142. Ventilation proves difficult and HR gradually drops below 60.

144. Case: Severe Hydrocephalus

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

149. Compressions are resumed as HR drops…and drops.

151. Infection- TORCH

152. Syndromic- trisomy 13, 18, 9, 19, triploidy

156. WHO estimates 13.8 million children have some visual loss due to VAD

157. Public health problem in more than 50% of countries

158. 250,000-500,000 malnourished children go blind each year from VAD

159. Approximately half of which will die within a year of going blind

161. Loss of goblet cells in the conjunctiva

162. Responsible for secretion of mucus

163. Results in xerophthalmia- eyes fail to produce tears and dead epithelial and microbial cells accumulate on the conjunctiva and form debris

164. Leads to infection and scarring

166. Oral capsules cost approx $0.02 and children only require 2-3 doses/year

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

168. Vitamin Angels (non-profit, non-governmental organization)

170. Your Future as a Global Health Physician Every pediatric physician has something to offer Global Health does not mean International Health Global Health does not mean traveling Global Health in 10 years may be very different than what it is now But you are not trained nessesarily for resource poor health But the AAP & ACGME say you must be So what are YOU going to do?

171. [1] Live and Practice Primary Care

172. [2] Travel Occasionally to Different Countries to practice primary care

173. [3] Practice in the US, but have an ongoing commitment to a single resource poor community

174. My Challenge: Commit to a Community What are my strengths? What resources do I have? What do I do when I do it for free? Who do I like being around?

175. 2009 2008

176. What “Room of Sorrows” are you going to change?

178. Dan Shaked: drshaked@gmail.com

179. Aimee Grace: agrace@stanfordalumni.org

180. Dan Imler: imlerdl@gmail.com