In 2006 I made the first of several trips to Honduras to volunteer in hospitals there. My intitial trip was associated with the Foundation for International Education in Neurolical Surgery (FIENS). Subsequent trips were in support of the wonderful work that Central American Medical Outreach (CAMO) is doing in Honduras. My most recent trip was in November 2010, but before I get to that trip... Here is Part 1 of an story that motivates my continued interest in helping those that need it most.
Part I. November, 2009: CAMO, Hospital Occidente, Santa Rosa de Copan, Honduras.
The neonatal ward was bright, hot, and crowded. Young mothers with tired eyes hovered by their infants while doctors and nurses moved methodically between them. Outside large windows, vultures hopped and jostled along the gutter, eyeing the potential banquet within.
Enrique [not his real name] lay listless in a crib by the far wall. Two months old, his head was grotesquely swollen and still, the scalp stretched taught and shiny. His tiny arms and legs splayed froglike and oddly wrinkled, like a balloon person my father made me when I was a child after the torso and limbs mostly deflated. His eyes were open, but heartbreakingly blank white, with thin rims of iris peeking above the lower lids.
“Hydrocephalus” literally means “water head,” and occurs when clear cerebrospinal fluid continuously produced in the fluid chambers or ventricles of the brain is unable to drain and be reabsorbed. The fluid builds up, causing the ventricles to enlarge, increasing pressure inside the head and compressing the brain from within. In infants, whose skull bones have not yet fully formed and fused together, hydrocephalus produces head enlargement. Because the eyes, along with the nerves that control things like swallowing and breathing, are direct extensions of the brain, blindness, malnutrition, and pneumonia soon follow, often resulting in a slow and agonizing death.
I had treated children with hydrocephalus many times before, both in Honduras and in the United States, but Enrique’s hydrocephalus was far advanced. The eye abnormality, called Perinaud’s phenomenon or “sun downing” is a sign of severe, rapidly building pressure deep in the brain. This was my fourth visit to Central America as a volunteer neurosurgeon, yet I had not seen a case like this in years, and realized most of my medical students back in the United States never would.
“He has been waiting for you,” Dr. Roberto Alvarez, my Honduran neurosurgical colleague, said as I photographed the child.
“And they for him,” I said as I also photographed the big bald birds outside.
“I think they will continue to wait,” Roberto replied.
“I hope so,” I said, thinking that the vultures, which I had never seen so close and eager before, perhaps knew something we didn’t. Did they know this child was too far gone for us to help? Enrique’s mother studied me intently, looked out at the dark vultures, and curved protectively over her son. I kept my thoughts to myself.
As devastating and horrible a condition as hydrocephalus can be, the best treatments are relatively simple: either remove the cause of the hydrocephalus, as when removing a brain tumor that obstructs normal drainage pathways, or drain the cerebrospinal fluid to a place where it can be reabsorbed, as in placing a shunt. Shunts are implantable devices that basically consist of a valve between two thin flexible catheters, one to drain the brain ventricles and another to divert the fluid beneath the skin and into the peritoneal cavity (the space around the stomach and intestines in the abdomen). Available in the developed world since the 1960s, shunting for hydrocephalus is one of the great neurosurgical triumphs of the 20th century. The procedure typically takes less than an hour, and is so safe and effective that severe hydrocephalus such as Enrique’s has become a rarity in the United States.
In the developing world, such cases are unfortunately very common, with thousands of children in western Honduras alone suffering permanent brain damage or slow death each year as a consequence. However elegant or simple, successfully treating a child with hydrocephalus requires at least three things: a neurosurgeon, a shunt, and sustained follow-up. This triad is in short supply in the developing world, and the conventional “band aid brigades” and surgical mission trips do not fulfill it. Dr. Alvarez, through CAMO and the neurosurgery program established at Hospital Occidente in January 2009 does. The CAMO neurosurgery program successfully treats dozens of children with hydrocephalus each month, giving many the possibility of a normal life. Although CAMO had run out of shunts weeks ago, I brought with me a freshly donated supply from Integra Neurosciences. I knew it was not me so much as the shunts that Enrique had been waiting for.
Enrique’s was a difficult case: On the CT scan, the expansion of the ventricles was so great that only a thin rim of brain remained pressed against the skull: like coconut inside the shell. In addition, the ventricles were abnormally formed and compartmentalized. The placement of the ventricular catheter would need to be extremely precise for it to drain properly and do any good. The valve pressure would need to be carefully selected to avoid under - or over- draining the ventricles. Enrique’s tiny shriveled body would also make placement of the peritoneal catheter problematic. Dr. Alvarez and I agreed on a plan and scheduled the case for the following day.
The next morning we learned that we would be unable to perform the surgery because Enrique had developed pneumonia. His pediatrician felt that with the pneumonia, the risk of general anesthesia and surgery was just too great. Hopefully, the pneumonia could be cleared with a course of antibiotics and a shunt could be placed the following week.
My heart sank. This news was beyond bad. The pneumonia certainly resulted from airway and breathing problems caused by brain and nerve malfunction in turn caused by the hydrocephalus. The chance of clearing the pneumonia with antibiotics alone was vanishingly small. The chance the hydrocephalus would kill him in the interim was overwhelmingly large. The best way to clear the pneumonia included restoring brain and nerve function by relieving the hydrocephalus. In the United States, Enrique would have received an extra-ventricular drain (EVD), a bedside procedure performed with local anesthetic that involves placing a ventricular catheter and connecting it to a sterile external drainage system. With an EVD, the cerebrospinal fluid is diverted outside the body altogether until a shunt can be placed. Aside from the fact that there were no EVDs at Hospital Occidente, EVDs require intensive care settings and meticulously clean surroundings, with constant qualified nurse supervision. Even if we had one, placing an EVD in this crowded, sparsely staffed, tropical hospital was out of the question.
In the following days, other patients and cases crowded in, and I returned home to the United States. My frustration and sadness over being unable to help the tiny boy with the hydrocephalus and Perinaud’s phenomenon was eased by the knowledge that we were able to help many others. I also comforted myself with the hope that his case would help my students and colleagues understand and remember his disease process, thereby helping future patients with similar problems.
Part II -- When I Found Enrique a Year Later. Next Post.
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