Miracles We Have Seen

by Harley Rotbart

  At the time of surgery, Jim had a six centimeter (approximately 2.5 inches) size aneurysm. Aneurysms can grow rapidly. Studies have shown that aneurysms of six centimeters in males have an 8 to 10 percent chance of rupturing each year. The death rate from a ruptured aneurysm is greater than 50 percent. However, if we can fix the aneurysm before it ruptures, as we were able to do with Jim, the death rate is reduced dramatically to only 1 to 5 percent.

  Even more remarkably, studies have been done testing skilled physicians’ abilities to detect aneurysms in patients who are known to have aneurysms present. Even in the best of hands, physical examination can only detect an aneurysm 50 percent of the time. That’s because physical findings of aneurysms and many other conditions can often be subtle, transitory, or absent entirely. The physical examination is as often the “art of medicine” as it is the “science of medicine.” Ryan Jones was by no means a skilled examiner—he was still a medical student, early in his training. But he was a medical student with astute observation skills and the confidence to pursue what he believed he discovered, no matter how unlikely it may have been. He may well have saved Jim’s life.

  It was Jim’s good fate to have fallen into this medical student’s hands on that particular day. We are blessed to be in this profession.

  Date of event: 2012

  Three Teens and a Miraculous Machine

  Mary Catherine Finn Ring, RN, MSN, PNP-C

  Bruce Ring, MD

  After the devastating 2010 earthquake in Haiti, medical teams from around the world mobilized to provide urgent aid. In the years since, recovery has been glacially slow and medical teams have continued on missions to the battered country. We have been privileged to be among those who have made repeated visits. Our work has been focused in a rural mountain village one hour from Port-au-Prince where a tiny clinic stands, overwhelmed by the needs of the impoverished residents. The village had no running water until 2012. Medical supplies are limited to what we can fly in from the States, which we gather by soliciting donations of medicines and equipment prior to each trip. Typically, each mission is staffed by two medical personnel and several non-medical folks, sometimes including teenagers volunteering through their school.

  There is no computer access in this village, and in fact, electricity is only intermittent, as is true almost everywhere in Haiti. As only the most basic lab tests can be performed, such as a simple blood count and a few others, care is delivered mostly based on the practitioners’ diagnostic skills.

  An electrocardiograph (EKG) machine for testing heart function was desperately needed in that clinic.

  Teen #1—The Robotics Techie

  On this particular trip, the team was excited to have procured a donated EKG machine to bring along with them for the clinic. The excitement was short-lived, however, when they arrived with the EKG machine in the clinic only to discover the machine was broken. One of the volunteers on that trip was a student named Daniel who was a member of the robotics club at his high school. Daniel suggested he and his fellow club members might be able to repair the machine, so arrangements were made to bring it back to the States with the team. Sure enough, these tech-savvy high schoolers, who had never before worked with an EKG machine or other medical equipment, got it up and running again in time for the next trip to Haiti.

  Teen #2—The Basketball Star

  On the next trip, the two medical team members were a cardiologist (heart specialist) and an internist (general internal medicine doctor). They brought the usual potpourri of donated supplies, along with the now refur-

  bished EKG machine, courtesy of Daniel and the robotics club. Although Daniel was not on this trip, the cardiologist’s sixteen-year-old son Trevor was one of the volunteers. Tall, handsome, and athletic, Trevor was a star on his school’s basketball team. The cardiologist’s participation on the trip, as well as his son’s, was something of a fluke. At home, the cardiologist had gone to watch one of Trevor’s basketball games, but there was a mix-up in the schedule and Dad went to the wrong game. At that game, he ran into the aforementioned internist who had been on these Haiti trips in the past. The internist told the cardiologist about the missions, sparking the cardiologist’s interest and prompting him to make the next trip and bring his son. The internist’s teenage son would also be going on the trip.

  Shortly after arrival, the physicians on the team were anxious to test the EKG machine to see if it still worked after the arduous trip to the remote clinic. It wasn’t as easy as they’d hoped, though, because although they had a machine now, they realized they didn’t have the lead wires necessary to attach the machine to a patient. They were about to give up on having a functioning EKG machine that trip, but thanks to the industrious and determined efforts of a nurse also on the volunteer team from the U.S., they were able to find the lead wires they needed.

  The two teenage boys, Trevor and the son of the internist, were standing next to each other in the clinic when their physician fathers wanted to try out the machine for the first time. Neither boy was much interested in being the first “guinea pig” volunteer, but the cardiologist insisted it be his son so as not to impose on his colleague’s son. They clipped the standard twelve lead wires to electrodes placed on Trevor’s chest and turned on the machine. Indeed, it worked. But as soon as the strip of paper with the test results came out of the machine, a collective gasp filled the room—what they saw on the EKG test on this seemingly healthy young man was devastating. This strapping, athletic teen had a potentially lethal heart defect.

  This was the very beginning of the trip, but his dad, the cardiologist, knew he had to get Trevor to a major medical facility. They carefully observed him until the first opportunity to return to the States, when he was admitted to a premier medical center. He was evaluated by the heart surgeon there, who told the family the boy needed urgent open-heart surgery to correct a life-threatening heart defect, probably present since birth but not detected until the serendipitous testing in this remote Haitian village with a patched-up EKG machine. The surgery was successful, and Trevor went on to become a nationally recognized high-school basketball player.

  Teen #3—The Malnourished Orphan

  A few weeks after Trevor’s lifesaving experience at the clinic, a fourteen-year-old girl named Betiane was brought to the same clinic by her aunt to see the current medical team, of which I was a part. As a pediatric specialist, I was the designated caregiver for most of the kids we saw during my volunteer trips to this clinic in Haiti. This young girl, in tattered clothes and appearing frightened, sat in my exam chair. She was extraordinarily thin and clearly malnourished.

  Even more urgently, Betiane had such severe difficulty breathing she could not complete a sentence without gasping for air. I listened to her chest with my stethoscope and heard the loudest heart murmur I can ever remember hearing. A heart murmur is the sound blood makes when flowing through abnormal compartments or valves in the heart. I then knew she had heart disease, but did not know what type. Our EKG machine, the same machine that had been repaired by Daniel, our robotics club volunteer, and the same machine that saved the life of Trevor, our star basketball volunteer, con-

  firmed our suspicions of severe heart disease as the cause of Betiane’s breathing distress. At this point, we suspected she had rheumatic heart disease, a dread complication of a childhood strep infection (usually strep throat). Rheu-

  matic heart disease is rarely seen in the United States any longer because of timely use of antibiotics for strep infections, but in the developing world and impoverished communities, rheumatic heart disease remains a significant and life-threatening problem. Betiane needed surgery if she had any hope of surviving—and surgery was an impossibility in this setting.

  As if that wasn’t enough, Betiane’s aunt announced that because of her own dire poverty, she could no longer care for the child. We learned that the girl’s mother had died, after which her aunt took over her care. T
he child’s father was never involved. The aunt had tried her best but was now giving up for the sake of the girl who needed more than the aunt could possibly provide. Betiane’s profound malnutrition was testimony to the aunt’s des-

  perate situation. As the aunt walked away from her niece forever, I left the examining room in tears for what this child was going through, trying to pull myself together for what we next needed to do. Betiane would surely die of malnutrition if the profound breathing distress from her heart disease didn’t kill her first.

  Struggling for breath, Betiane walked with us a mile to a nearby orphan-age where we begged them to take the girl into their already overcrowded and overwhelmed facility. The orphanage had no medicines, but agreed to provide the girl with food and shelter to the best of their ability. I left feeling overwhelmed with sadness, fearing I would never see her again. With all our good intentions, there was nothing more we could do for this poor child.

  Postscript

  But the story didn’t end there for our teens. Through his dad (the cardiologist who was now part of the medical teams serving the Haiti clinic), Trevor heard of Betiane’s grave situation. Having himself been saved by the clinic and its valiant, patched-up little EKG machine, he was tormented to think that it was only because of his good fortune, living in the United States and being able to afford the best medical care in the world, that he would survive and Betiane would not. So when it came time for his hospital discharge following open-heart surgery, Trevor’s surgeon came in to say good-bye and asked if there was anything else the boy needed before going home. Yes there was, he said. Trevor told the surgeon about Betiane and asked if he would be willing to operate on her if a way could be found to bring her to the States and to this premier medical facility. Would the surgeon give Betiane the gift of life as he had for the cardiologist’s son? The surgeon didn’t hesitate a moment—of course he would!

  Turns out getting the surgeon to agree was the easy part. Betiane had no papers, no documentation of who she was or where she was from, and no way to leave the country. The bureaucratic hornet’s nest that was then unleashed rivaled any medical challenges we had faced in Haiti. Between the governments of Haiti and the United States, and even turf wars within the medical community in the U.S., one hurdle after another seemed to doom Betiane to never leaving Haiti for the lifesaving surgery awaiting her in the U.S.

  Meanwhile, in the orphanage, Betiane’s nutrition improved somewhat and, as a result, she was in a little less breathing distress. On a subsequent visit to the same rural village in Haiti, an immigration attorney and a schoolteacher were now part of the volunteer group. They, along with the nurse practitioner clinic medical director, went to plead Betiane’s case at the U.S. Embassy in Port-au-Prince. Faced with more stonewalling, a call was finally placed to a newly elected U.S. senator from the state where the surgery would be done. With the senator’s help, and the tireless determination of these volunteer individuals over many months, Betiane was flown to the U.S. where she, too, had open-heart surgery by the same doctor who had cared for Trevor. The surgeon replaced a heart valve ravaged by her rheumatic heart disease and the procedure was a success. The heart failure that had caused her severe breathing problems was cured.

  Following discharge from the hospital, Betiane continued her recovery for the next three months in the home of another one of our medical colleagues from the Haiti missions. She returned to the orphanage, where we visited her on each of our subsequent trips to Haiti. Betiane, now seventeen years old, is healthy, well-nourished and, to our eyes, has become the “Queen Bee” of her orphanage. She is very grateful for the life she has been given.

  So, to sum up, a donated but broken EKG machine was repaired by a teenage volunteer on a medical mission to Haiti. That machine returned to Haiti and diagnosed severe congenital heart disease on another teen volunteer who was only there because his dad had gone to the wrong basketball game. This teen had no symptoms of a heart problem, but he may well have very soon thereafter become one of those tragic cases we read about—a young athlete who collapses on the playing field or basketball court and cannot be resuscitated. Instead, that young athlete survived thanks to major surgery and not only continued to excel in his sports career, but also paved the way for lifesaving surgery for another teen who otherwise had no chance of survival.

  Three teens, who never met each other, saved each other’s lives with the help of a miraculous little machine in a remote Haitian clinic. Today, the machine continues in use daily and is still the only EKG machine we’ve ever had there.

  Date of event: January 2013

  An Impossible Delivery

  Amanda Yeaton-Massey, MD

  Kay Daniels, MD

  When Karen walked into the emergency room she knew something was wrong. Since New Year’s Eve she had felt an uncomfortable growth and had experienced some light vaginal bleeding, a rare occurrence as she had not had a period in five years. Her first thought was that this was another episode of vaginal bleeding from her uterine fibroids to add to her long list of previous emergency room visits for the same problem. Uterine fibroids are benign tumors of the uterus that can cause heavy and prolonged menstrual bleeding, with sometimes serious consequences. With this episode, as with some of her previous ones, her bleeding had gotten so heavy she could no longer manage it at home. A tall, fit woman of forty, Karen had undergone numerous treatments for her condition, including surgical removal and a procedure known as uterine artery embolization intended to cut off the blood supply to the fibroids. She was unsure what to attribute this bleeding episode to as she had only rare spotting in the years following the procedure.

  Karen and her husband had been told that the lifesaving procedures to decrease the bleeding from her fibroids had likely rendered her infertile. While they had wanted children, they had made the decision to save Karen’s life and had shifted the way they envisioned their family. Waiting patiently on her gurney for an ultrasound, she tried to quiet the nagging sense that something was different this time. She lay on her back in the dimly lit room with her exposed belly covered in the blob of blue gel used for the ultrasound test. A quiet fell over the room when the tech placed the probe over her abdomen to reveal not fibroids but a fetus. It moved. Its heart beat. It was a female and, as it turned out, had been growing inside Karen for almost seven months. As the ultrasound continued, the apparent cause of her bleeding was revealed: a placenta previa, an abnormally located placenta covering the opening to her cervix. She and her husband now took in the wonderful news that they would be parents and the terrifying news that the location of her placenta posed a threat to both Karen’s life and that of their growing child.

  Karen was quickly transferred to a hospital equipped with a neonatal intensive care unit that could care for her baby and a high-risk obstetric team that could care for her. The ultrasound was repeated once she was admitted to the second hospital and confirmed her seven-month pregnancy and the abnormal location of the placenta. This ultrasound, however, also demonstrated an area of the placenta that appeared to be invading into the wall of the uterus, a very dangerous condition known as placenta accreta. While a placenta previa typically requires delivery by caesarean section near the completion of the pregnancy (as long as bleeding can be controlled prior to that), a placenta accreta typically requires immediate delivery by caesarean section followed by a hysterectomy (complete removal of the uterus). Thankfully, Karen’s bleeding stopped and she had a few days to absorb some of this life-changing information.

  I was in my second year as a resident on the high-risk obstetrics service and had the pleasure of seeing Karen and her husband daily on rounds. I watched as they gracefully came to terms with the news of her pregnancy along with the potentially life-threatening complications. Karen was a vivacious woman who would have much preferred being on a hiking trail than in a hospital and she yearned to return to her home and friends. She walked the halls every day to get out of her room and
develop some semblance of normalcy. I would visit with Karen and her husband on these walks and listen to stories of their community banding together to get their home ready for their baby. They shared with me that their little girl would be named after Karen’s late mother-in-law. The baby was becoming more real by the day and the team could tell these two would be incredible parents. We hoped, though, that we would all have a chance to wait a few weeks to meet their little girl, who needed more time to grow and develop inside her mother.

  After two relatively quiet weeks in the hospital where she was carefully being monitored, Karen developed sudden, excruciating abdominal pain and contractions. She was rushed to the ultrasound suite for evaluation where, to the shock of everyone in the room, her fetus was noted to be freely floating outside of her uterus, in her abdomen, which was full of what was likely amniotic fluid. Her uterus had ruptured, expelling the baby, and now her baby was at imminent risk of separation from its uterine lifeline; the fetus and umbilical cord would likely tear away from the uterus at any moment. Without immediate delivery the infant could die from lack of oxygen, and Karen could die from massive bleeding.

  Minutes after receiving this catastrophic news, the team was wheeling Karen from the ultrasound suite to the operating room. My heart pounded as I held her hand and tried to reassure her and her husband that we would do everything we could to save Karen and their infant. With anesthesia at the head, her nurse on the left and me on the right we were an unlikely sight as we raced the unwieldy gurney and IV pole down the hall. As our convoy entered the doors to the operating suite we were pointed down the hall to the room being prepared for her. There was a palpable sense of urgency as word of Karen’s extraordinary circumstances preceded her.