Emily A Hartford, MDPediatric Resident R3Global Pathway

Health Education And Relief Through Teaching

LIBERIA::HEARTT

Emily A Hartford, MDR3 Pediatrics, Global Pathway

Outline

Background: LiberiaAdmission data: JuneTypical pediatric caseHEARTTCurrent projectsOpportunities for involvement

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Context::Liberia

1847-1980: Americo-Liberians (Congo people) and Country people

1980-1990: Military dictator

1990-2003: Civil War

2003-2005: Interim government

2005: Democratically elected President Ellen Johnson-Sirleaf, Africa’s “Iron Lady”

Context

Population: 3,685,076 (July 2010 est.)

Religions: Christian 40%, Muslim 20%, indigenous beliefs 40%

Development Indicators:-85% unemployed-80% poverty-76.4/1000 infant mortality-56.5 yr life expectancy

Extreme “brain drain” and instability1980-2003

Now: Intense rebuilding

http://www.youtube.com/watch?v=D_bD-Zu030Q&feature=player_embedded

http://www.youtube.com/watch?v=qqdAI2l0gtM&feature=player_embedded

Pediatric Resourcesover time…

60 practicing doctors in Liberia (population = 3.6 million)

ONE PediatricianMOH hospitals trying to keep up with

demand

Pre-war: premier hospitals for W. Africa,Accredited medical school

1990-2003: MSF opens hospitals in many of Liberia’s 15 counties

2003-2005: MSF begins handing over hospitals to MOH

June 2010: final MSF hospital closes

Pediatric Access to Care

2010

40-50 Pediatric+NICU+ED beds

Dr. Emmanuel Okoh2-3 Interns rotating

2-3 Physician Assistants10 medical students

Visiting HEARTT physicians3 other hospitals

(90-130 beds)

Setting: JFK Hospital

Monrovia, LiberiaBuilt in 1968600 beds Opened in 1971US funds until 1978Now main referral center and only

academic institutionFull service hospital: Inpatient wards, ED,

Maternal-infant care, Surgical services, Outpatient Center

TROUBLES PLAGUE LIBERIAN HOSPITALBy KENNETH B. NOBLE, Special to The New York Times

MONROVIA, Liberia— The John F. Kennedy Memorial Hospital, once the finest in West Africa, recently announced on the radio that its morgue could no longer accept ''dead-on-arrival bodies'' until relatives claimed the ones that were already decomposing. The hospital said the morgue's refrigerator was broken. Hardly anyone here was surprised. Twenty years ago the 600-bed hospital, built and equipped with American money, was a technological marvel. Today, even by the relatively modest standards of medical care in sub-Saharan Africa, the Kennedy hospital is regarded by most Liberians as a destination of last resort.

''Things have become so bad there we wonder if we can still call it a hospital,'' said the Rev. Walter Richards, a Baptist minister and former Government Cabinet member. He said one of his church members who had been hospitalized told him she would rather die than continue suffering there.

February 11, 1990

Ward Admission Diagnoses: June 2010

Malaria

Pneumonia

Sepsis

Manutrition

Anemia

Gastroenteritis

Measles

Cellulitis/Abscess

HIV

Cancer

Tetanus

TB

0 10 20 30 40 50 60 70

Case fatalityDiagnosis Deaths by

diagnosesCase

Fatality Rate

Malnutrition(Severe 21, Moderate 8)

     7  (all severe)

24.1%  (36% for severe)

Pneumonia                       

     4 11.4%

Sepsis(2 with suspected meningitis)                         

     3 10.0%

Anemia                           

     3 16.7%

Gastroenteritis                 

     2 18.2%

Measles                             

     0 0

Cellulitis/Abscess    

     1  (had tetanus)

16.7%

HIV                                    

     0 0

TB                                     

     0 0

Cancer (all eye)           

     0 0

Tetanus                            

     1 50%

NICU Census: June 2010

Neonatal Sepsis

Prematurity

Seizures/HIE

Congenital Malaria

GI bleed

Birth defects

0 1 2 3 4 5 6 7 8 9

JFK NICU

Case fatality

Cases by Diagnosis

Deaths by diagnoses

Case Fatality

RateNeonatal Sepsis      1 11.1%

Seizures/HIE      1 20%

Prematurity      4 66.7%

Birth defects    ?

ED Case :

Chief complaint: “hot skin and jerking”10 mo PH carried to ER with 2-3 days of

hot skin, especially at night, not eating, vomited 2-3 times, no diarrhea, also coughing and breathing fast.

History:PMH: vaccines UTD, no issues at birth, exclusive

breastfeeding until 6 mo, healthy weight for height

FH: only sibling died with similar symptoms 2 yrs ago

SH: Single mom age 22, grandparents/uncle died in the war, dad’s whereabouts unknown, no bed nets

Physical Exam

Vitals: 8 kgT 40 HR 155 RR 52 Sat 94%

RAGen: minimally responsive,

agitated with a weak cry, withdraws from painful stimulus, low tone, no sz activity

HEENT: conjunctiva paleLungs: crackles bilateral

bases, tachypnea/severe retractions

Abd: spleen palpable 2 cmExt: cap refill 2 sec, warm

ext

Differential and Studies: SCH

MalariaPneumoniaGastroenteritisMeningitisSepsis

What studies?CBC, Bld cx, CRP,

lytes, glu, BUN, Creat, LFTs, gas

CXRUA, urine cxHead CTLP

Malaria smear (takes 1-2 hours)

Hb (2 hrs to 1 day)CBC (1-2 days)Lytes, BUN, creatinine (machine broken)Glucose (out of strips for glucometer)Cultures (not available)Urine (no bags, only 8 french catheter

available)CXR (1 day)LP (no supplies, no ability to culture)

Resources at JFK:labs and studies

Resources at JFK: management

Antibiotics available: Ampicillin, Gentamicin, Chloramphenicol, Amoxicillin, Cloxacillin, Penicillin, ?Ceftriaxone, Ciprofloxacin, Erythromycin, Cotrimoxazole

Malaria protocol: Quinine, Artemether available

IV access: expert RNsFluids: NS or D10

For our patient: management

HB and Malaria smear

Antibiotics: Ampicillin, Gentamicin

Malaria protocol: Quinine

IV access: expert RNs

Fluids: NS or D10

HEARTT:: health education and relief through teaching

Founded by Liberian-American ED physicianGoals:

Support improvement of medical systemEducate new and existing providersEncourage and promote sustainable practicesContinue long-term relationship and

communicationEmphasis in Pediatrics and Emergency Medicine

Associated with Mt Sinai and U Mass (UW?)

Visiting Physician RoleClinical support on a rotating basis:

ED, NICU, wards, chronic care clinicTeaching: interns, medical students, RNs, PA

studentsProtocolsCPITropical disease

Current HEARTT projects

Neonatal Resuscitation Pediatric HIV clinicChronic Illness ProjectChemotherapy RegimensMedical school curriculumPediatrics GME – Liberia’s first

residency!

“Mama Africa”Bed nets campaign

Liberian Wisdom

“Monkey works, baboon draws”

the person who does the work should get the credit

“Your child cannot poo-poo on your lap and you cut your

legs off, you just have to clean them”

don’t walk away from your responsibilities

“You can’t be sitting on someone’s head and say

their hair stink”be thankful for what you

have

Interesting cases…

What next?

Email me and Dr. Ellie Graham for more info eahart@uw.edu, ellieg@uw.edu

HEARTT websitewww.heartt.net

Read more about Liberia!House at Sugar Beach by Helene CooperThis Child Will be Great by Ellen Sirleaf-

Johnson

Many thanks!

Ellie GrahamGeorgietta OliveiraEmmanuel OkohSuzinne Pak-GornsteinManeesh BatraThe ChiefsWilfred JordanPatrician McQuilkinRyan Hartford and my familyGracious and inspirational people of Liberia