Tuesday, June 1, 2010

Breathing Easier in Ecuador

MassGeneral Hospital for Children Specialists Collaborate with Colleagues in South America

In the most extreme case during their medical mission to Ecuador, the MassGeneral Hospital for Children specialists treated a 6-year-old boy who suffered such severe airway trauma that he was unable to speak. Instead, he produced pained squeaking sounds with each labored breath. Because he expelled all of his energy just to breathe, he was malnourished and small for his age.

Airway surgeon Christopher Hartnick evaluates a child's airway through a procedure known as a rigid bronchoscopy.

Airway surgeon Christopher Hartnick, MD, MS Epi; pulmonologist and chief of Pediatric Critical Care Medicine Natan Noviski, MD; and critical care physician Phoebe Yager, MD, hadn’t planned to operate on any patients at the Hospital de los Valles in Ecuador this spring, but they performed an emergency tracheotomy to save the boy’s life. The specialists inserted a tube in the boy’s airway, allowing him to breathe with help from a ventilator.

The boy had suffered airway trauma after going in for surgery on his eye, Hartnick says. During that surgery, the boy was given anesthesia and a tube was placed in his airway to assist with his breathing; in the process the boy’s trachea— the passageway from the voice box to the lungs— was damaged.

Similar but less severe cases were a common sight to the MGHfC clinicians on their recent trip to Ecuador, where critical care and collaboration among doctors are also emerging concepts.

Value of Collaboration

Had the 6-year-old been a patient at MGHfC, he would have benefited from the collaboration of medical specialists working together to provide care. Patients who undergo complex surgeries like airway reconstruction with Hartnick, who is based at Massachusetts Eye and Ear Infirmary, are then taken around the corner to the Pediatric Intensive Care Unit (PICU) at MGHfC to receive additional care from Noviski, Yager and their colleagues.  

Noviski says he returned from Ecuador with “the feeling that we are very lucky to be able to provide that care to kids here.”

Though the idea of collaborative care is nascent in Ecuador, the MGHfC team has high hopes for teaching Ecuadorian physicians to replicate what they do, from the coordination of care to procedures including tracheotomies.

“How incredibly well-trained the clinicians and subspecialists there are really solidified my belief that it’s something they could do,” Yager says.

Addressing a Need

As part of MGHfC’s first mission of this kind, the team evaluated 45 children with complex medical issues as the first step in what they hope will become a global mission.

MGHfC specialists Christopher Hartnick (second from left), Natan Noviski (second from right), and Phoebe Yager (right), collaborated with colleagues in Ecuador.

The trip emerged as a result of Dr. Noviski’s longstanding ties with physicians in Ecuador. On previous trips Noviski organized a national conference on artificial ventilation in children and gave a hands-on workshop on flexible bronchoscopy with the assistance of Brian Cummings, MD, an MGHfC pediatric intensivist. Noviski has helped edit a textbook in Spanish on Pediatric Critical Care Medicine and has been instrumental in solidifying the Ecuadorian Society of Pediatric Critical Care Medicine.

After one of their workshops about airway problems, Noviski and Cummings were met in the parking lot by families with children suffering from respiratory issues.

In the United States, most children who require tracheotomies are those who were born prematurely and whose airways did not fully develop. In countries like Ecuador, however, the surgery is often the result of infection or trauma, as was the case of the 6-year-old patient.

“By talking with these families and examining these children, Dr. Ernesto Quinones (an Ecuadorian pediatric intensivist/pulmonologist) and I came up with the idea that we could help them by bringing doctors to Ecuador and by teaching the doctors there to be able to do this,” Noviski says.

With funding from the Hospital de los Valles Foundation, Noviski, Hartnick and Yager traveled to the hospital to evaluate 40 children with trachea problems and five additional patients in 48 hours.   

“Everyone was amazed at what we did in two days,” Noviski says.

Families traveled by car, bus and/or by foot to reach the MGHfC and Ecuadorian doctors, who evaluated children to identify issues that would require medical and surgical intervention, to take histories, and to provide initial medical management.

Next Steps

This summer the MGHfC team plans to welcome physicians from Ecuador to the Pediatric Intensive Care Unit in Boston. In the fall, the MGHfC team will return to Ecuador to operate on children there.

“It is a place where we can sort of plant roots and make the system work,” Hartnick says.

Noviski adds, “The first mission in Ecuador is just one small step in a bigger mission of going globally.”

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