A Clinical Perspective: My Visit to Haiti

Dr. Brendan Campbell, surgeon at Connecticut Children’s Medical Center, speaks to his clinical colleagues about his most recent trip to Haiti and the challenges and opportunities that present themselves.

campbell-in-haiti

The poverty, pathology and ethical dilemmas you collide with in Haiti force you to think creatively about clinical problems because the options for establishing a diagnosis, providing treatment and dealing with complications are limited.  Surgical volunteerism at Hopital Sacre Coeur in Milot makes you think differently about what providing high quality surgical care means and puts your troubles back home in clearer perspective.

One of the hardest things to appreciate before you try and perform a surgical procedure in Haiti are the challenges of putting the infrastructure in place that allow it to happen.  The CRUDEM organization which runs Hopital Sacre Coeur does a remarkable job making sure that these basic requirements are met (i.e., electricity, running water, security, and hospital staff), so that the medical and surgical teams that visit for one week at a time can focus on providing clinical care and teaching.  For us this means sorting out which pediatric surgical cases exceed the capabilities of the local surgeons, and how we can best help the surgeons there while providing pragmatic education.  The Lancet Commission on Surgery proposed a group of 3 bellwether procedures (i.e., Caesarian section, laparotomy, and treatment of open fractures) to identify hospital systems operating at a significant level of complexity that would allow them to do most other surgical procedures.  Hopital Sacre Coeur meets this standard, but it’s not clear how accurately this standard can be extrapolated to pediatric surgical cases.  The emerging field of “global pediatric surgery” in low and middle income countries is largely uncharted territory about which we still have a lot to learn.

The unique thing about trying to provide safe and responsible pediatric surgical care in Haiti is that you have to get comfortable feeling really uncomfortable.  If you are easily frustrated, prone to temper tantrums in stressful situations and are unable to adapt to changing circumstances – Haiti’s austere clinical environment isn’t for you.  Cancellation of scheduled cases for spurious reasons (without speaking with us), poor quality basic surgical instruments and scrub techs unfamiliar with pediatric surgical customs and priorities are a few of the challenges we encountered this past week.

In Northern Haiti, we have identified an opportunity to help the local surgeons manage patients with anorectal malformations. While we don’t yet have a “mega-team” (i.e., fully staffed/equipped anesthesia and OR team) geared toward a single congenital anomaly (e.g., cleft palate surgery, cardiac surgery) that some groups have developed, we’re making some progress in that direction.  Simple things that we take for granted back home can be a real impediment to getting these fairly complex reconstructive cases done efficiently and safely in Haiti.  A few examples include not having equipment to optimally position the patient (we’re used to doing these operations on babies, many Haitian patients are older/larger), poor quality surgical instruments that won’t handle small needles and substandard lighting in the operating room.

Virtually all the kids we see who were born with anorectal malformations, survived beyond the neonatal period because Haitian general surgeons gave them colostomies when they were newborns (i.e., relieving the intestinal obstruction and allowing them to feed and grow).  This is lifesaving for the patient and allows the definitive procedure to be delayed indefinitely.  The challenge for the surgeon is that with the more complicated anomalies there is no option for a pressure-augmented distal colostogram and no equipment to perform vaginoscopy/cystoscopy for the purpose of surgical planning…

So, at the end of our third short-term surgical trip to Hopital Sacre Coeur I think we’re getting a little better. We understand that these trips should not occur in isolation.  Having an unflappable pediatric anesthesiologist (Rich Kuntz) makes the anesthesia part safe.  We have a spreadsheet to track our anorectal malformation cases, monitor our results objectively and to try and plan our case list ahead of time.  Our team led by Dr. Rob Freishtat (Children’s National) included nurses, a pediatrician, a pediatric ER doc, physician’s assistant, a respiratory therapist and two child life specialists and they all did an amazing job and were a lot of fun to spend time with.  Next year we hope to bring a scrub tech from Connecticut Children’s and Drs. Hight and Kuntz both want to return.

Visiting the same hospital and building relationships with the local surgeons and staff is mutually beneficial.  To quote another surgeon, “It is much better to pick one country and serve it well, than to hopscotch all over Africa, going everywhere and truly getting nowhere.” (World J Surg 2010;34:466-470). We still have a lot to learn about providing pediatric surgical care in Haiti, but hopefully we’re getting somewhere, and making the lives of a handful of Haitian children a little better along the way.

Life Experiences Shape Surgeon’s Desire to Care for Children

This article was first published in the Hartford Business Journal. Dr. Christine Finck, Surgeon-in-Chief at Connecticut Children’s Medical Center and associate professor and principal investigator at UConn Health, was recently named as one of nine Health Care Heroes in Greater Hartford. The title recognizes individuals working in health care who “share a common passion for the services they provide and life-changing impacts they have on the lives of others,” and “[make] a difference in the community every day.” Finck and her fellow award-winners were honored in December at the Connecticut Convention Center in downtown Hartford.

30ccmc160108As a pediatric surgeon, Dr. Christine Finck sees her share of babies born with esophageal atresia, a defect where the tube between the mouth and stomach fails to connect. Finck treats up to a dozen infants born with these long gaps in their esophagus each year.

Typically, treatment involves closing the gap with a piece of the stomach or intestines – which brings the possibility of rejection – or stretching the esophagus by pulling the two ends together. That procedure requires a long hospital stay, Finck said, and can possibly be painful for the babies.

“Here’s this poor kid in the ICU who’s getting their esophagus stretched,” said Finck, who is surgeon-in-chief at Connecticut Children’s Medical Center. “It’s kind of a morbid type of procedure. I just felt that there should be a better way.”

As an associate professor in the Department of Pediatrics at UConn Health, Finck and a team of researchers are working hard to find that way, using tissue engineering to develop new methods for treating the condition, which affects one in 4,500 babies.

Finck has partnered with Biostage, a biotech company that has developed a polyurethane tube known as a scaffold that can be seeded with a baby’s own cells. The scaffold is then implanted as a placeholder to bridge the gap in the esophagus. Over time, the esophagus begins to grow around the scaffold, Finck explained.

“After about three weeks, we take out the scaffold and let the rest of the esophagus regenerate,” said Finck. The scaffold is then replaced with a stent to keep the esophagus open. When removed, “a fully regenerated esophagus is left behind,” she said.

Cells for the procedure can be taken from biopsies of the esophagus, from stem cells in amniotic fluid, or from bone marrow. Her team is currently examining which cells produce the best outcome. The procedure can also be used for adults with esophageal cancer or kids whose esophagus is burned after ingesting lye or other caustic substances.

Finck said clinical results in animal models have been successful. “We can do gaps of about 10 centimeters now, which is novel,” said Finck, whose research also focuses on lung disease in premature infants. She expects the procedure will be available for patients in about five years.

A native of Long Island, Finck earned her bachelor’s in biology from Boston University in 1990 and her medical degree from the State University of New York Health Science Center in Syracuse in 1994. She did her fellowship in pediatric surgery at Arkansas Children’s Hospital, and spent five years at St. Christopher’s Hospital for Children in Philadelphia before joining Children’s, where she has high praise for her team.

“Having a team that works and shares your vision is the best,” she said. “That’s when you get things accomplished.”

Growing up, Finck always wanted to be a doctor and loved taking care of children, a trait she inherited from her schoolteacher mom. She said she fell in love with pediatric surgery “the minute I did it,” and enjoys building relationships with patients’ families.

Reflecting on her career, Finck said two unexpected life events profoundly influenced her. “My first husband passed away from a brain tumor when I was in fellowship,” she said. “That gave me a true vision of being on the other side – of being at the mercy of hospital care.”

Years later, while working in Philadelphia and remarried to her current husband, she adopted her daughter Isabelle, one of her tiny patients.

Isabelle, now 11 and healthy, was born with her intestines outside her body, a condition that required multiple surgeries. Her mother, a teenager with no family support, had confided in Finck that she wasn’t able to care for the infant.

“It just came out of my mouth: ‘I’ll take her,’” Finck recalled. “I remember she turned all red and said, ‘That would be wonderful because you know her best.’”

Finck, who also has two biological children, 8 and 5, said her experience parenting an infant with a complex medical condition continues to drive her research, and helps her empathize with her patients’ families.

“She’s one of the most compassionate and dedicated people I’ve ever met,” said Shefali Thaker, a postdoctoral fellow working as a research associate in Finck’s lab. “She will push and strive to see that all of the children she interacts with are comfortable, and that their families are comfortable. She goes above and beyond every single time.”

Post doc and research associate Todd Jensen called Finck a wonderful mentor to new physicians beginning their research. “She’s supportive and helps them find their niche,” he said.