No safety net

Today a mother complimented me on how well I speak Creole. I have been working translator-free this week, which feels a bit nerve-wracking – like working without a safety net, but it has gone better than I expected. I have only needed to ask for help with two things – both of them fairly serious discussions. In the one case I think I probably did a better job anyway, and in that same case I was the one to get important details from the family about what was actually wrong with my patient. He came in this afternoon. It is a sad case but an interesting one. He is a boy who had heart surgery 3 years ago in Guatemala. After the surgery they put him on blood thinners, which the family has dutifully given him at 3pm each day – they proudly told me they never missed a dose. Today he fell, hit his head, and became unable to move one side of his body. The pupil opposite the paralyzed side is quite dilated. His presentation is classic for a stroke – something I’ve been lucky enough not to see in a child until now.

The tough part is that we are in Haiti, at a hospital that doesn’t have a CT scanner to see which type of stroke he has had. As a cardiac patient whose lesion we don’t know for sure, if he has a right-to-left shunt he could have thrown a clot to his brain, causing an ischemic stroke. But as a patient on warfarin (a blood thinner), he could have had a hemorrhagic stroke. I think the hemorrhagic stroke is more likely, making his massive stroke a side effect of his family’s diligence in giving him his medication. I am working on getting a hospital to accept him, and have word that we can likely transfer him by tomorrow morning, but that slogan “Time lost is brain lost” keeps running through my head. Until we know which type it is, we can’t even treat him medically – guessing the wrong one would have very bad side effects, since the causes are opposite – in one you bleed too much and in the other you have a clot that you want to go away.

Could his stroke have been prevented? Ideally patients on warfarin get frequent laboratory monitoring, especially in younger kids as they are growing. I am almost certain he didn’t get that, and for most kids once they have recovered from cardiac surgery they don’t need to stay on blood thinners. Something got missed – a consequence of having surgery in another country. You don’t get the same follow up, and the local doctors are left managing something they might not be at all familiar with. That safety net of continuity disappears, and even with good local doctors, things get missed.

I did get to have a rock-star moment with my resident – when we started discussing the patient and I mentioned the possibility of a stroke, he had this great “ah-ha” moment and high-fived me, saying “You really think as a pediatrician!” – he hadn’t considered that a child could have a stroke. He is a family medicine resident, so he’s seen plenty of adults with similar problems, and could name treatments, management, etc. but it hadn’t entered his mind until we started talking about it.

For tonight I will pray that the other hospital’s director is able to find space for my patient, hope that my own hospital’s director can find a functional ambulance, and wait until morning to see whether my patient has stayed stable enough to make the trip to Port-au-Prince. Kids tend to have better outcomes than adults, so he’s got that working in his favor, but just by virtue of his location this kid has a lot working against him. You might say that his particular net seems to have a few extra holes. We will see what tomorrow brings.

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  1. Uncle Dick

     /  January 11, 2013

    It didn’t take long for you to get back in action in Haiti that child is fortunate that you were there to diagnose his problem. Keep us informed we love you Sara take care,
    uncle Dick

  2. Mom

     /  January 12, 2013

    Listen to your Godfather, Sara. We hope & pray that the boy is okay this morning.
    So proud of you!
    Love, Mom

    • Thanks Mom! Unfortunately, as I shared with you privately, the boy did not have the outcome we hoped for. However, discussion of his case prompted the cardiac surgery coordination team to renew its efforts to find patients who have been lost to follow up. They found 24 of 50 “lost patients” when they were here this past weekend.
      Apparently my particular patient hadn’t been seen by one of our doctors in the three years since his surgery. As I suspected, it was a local doctor who was managing his medication. So even though we couldn’t help him, I am comforted to know that we’ve found 24 other kids who may benefit from getting re-involved in our system.


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