American Doc in American Samoa: Update

Note: This is a follow-up to this article Dr. Halderman wrote about the extraordinary efforts of the United States Air Force to save the life of a 5-year-old on a remote Pacific American outpost.

The island remains beautiful as we enter hurricane season. Last weekend's 2009 American Samoa Tattoo Festival attracted a crowd of dozens to Tisa's Barefoot Bar. I observed traditional Samoan tattooing with curiosity and have more than a little concern about hepatitis. The artistry displayed was incredible, but I've not willingly allowed needles near me since my ears were pierced as a teenager.

The little boy I call "Abe" (not his real name) is alive. But unlike one-hour prime-time medical dramas, this one about my patient isn't neatly wrapped up yet.

Less than 24 hours after Abe was transferred by a U.S. Air Force C-17 jet to Tripler Army Medical Center from the LBJ Tropical Medical Center in American Samoa, his lung function deteriorated. The Pediatric Intensive Care team there transferred him to Kapi'olani Women and Children's Medical Center in Honolulu. He did slightly better for a few days, but started to decline further from a lung function standpoint.

Six days later, he was placed on a form of cardiopulmonary bypass called "ECMO" (Extra Corporeal Membrane Oxygenation). What happens is that the child's blood is taken out through a catheter in one vein. It is filtered through a machine that removes carbon dioxide and adds oxygen and then returns the blood to the patient through a catheter in another vein. 

It's a medical tour de force, kind of like being on heart bypass except that it's lung bypass. It allows failing lungs to heal. Very few medical centers offer it because it's so resource-intensive, including a team of cardiothoracic surgeons, Pediatric Intensivists and legions of top -quality ICU nurses.

ECMO requires blood thinners, and the child has had some bleeding complications. When Abe was in the hospital here on American Samoa, I placed two tubes in his right chest, and another in his left. The team at Kapi'olani placed a third tube on the right, and this started bleeding when combined with the (necessary) blood thinners. It's under control now but remains an ongoing risk.

I remain in close contact with the care team through Pediatrics resident/U.S. Army Captain Dr. Chris Jordan.

Abe remains critically ill but is holding on.  He is neurologically intact, meaning that there is still a little boy in there to be saved. His kidneys work, which is amazing considering how sick he's been. He is still on the ventilator, so he can't yet speak.

Pieces of this strange clinical puzzle have been added, but Abe still baffles all of the experts and specialists who are caring for him.

We know this:
  1. He has H1N1 influenza and this accounts for pulmonary failure. But this does not explain the pus we drained from around his heart, lungs, and abdominal organs.
  2. He has a rare childhood disease that was started by either his initial infection or some unknown cause. It's called Kawasaki Syndrome, and it causes his coronary arteries to dilate (swell abnormally). It is treatable, and he has been given intravenous Immunoglobulins to help.
  3. He had either an atypical type of Dengue Fever or a bacterial or viral infection that we couldn't identify in the laboratory. If we could find it, we could target treatment. But for now, he's being given treatments that cover the possibilities.
  4. Whatever "syndrome" this represents, it does not appear contagious. No hospital staff member or patient has suffered similar symptoms or health consequences.
Abe's case may represent a unique one worldwide.  I'm not happy about that; it's always a bad idea to impress your doctor enough to be a potential subject of research. But we are trying to learn from Abe so we can help other patients. There will likely be others...somewhere.

The outpouring of prayers and concern for this child on a local and national scale has humbled me. I hope I never again underestimate the capacity for compassion in my countrymen. 

I'd like to offer my gratitude on behalf of Abe's family and the teams who cared and continue to care for him at LBJ Tropical Medical Center in Pago Pago, the U.S. Theater Patient Movement Requirement Center (medical transport team led by Major/Dr. Nims), the U.S. Air Force (it was their C-17 jet), Tripler Army Medical Center in Honolulu, and Kapi'olani Women and Children's Medical Center in Honolulu. Kapi'olani, Hawaii's only specialty hospital, has chosen to donate the cost of Abe's care.

Many people have contacted me to ask about Abe. I will offer updates when I can. No one has requested information that would violate the patient's or family's privacy, and I appreciate the respect and decency you have shown.

I cannot identify any of my patients without their permission, and I decided not to request permission from Abe's family. They might have said "yes," but this long journey will be difficult enough for them without adding the stress of the loss of privacy. They are dealing with the critical illness of their child with dignity and strong family unity.

In the month I have been on the island, I have found the Samoans on the whole to be tough as iron but with a dry sense of humor that seems to contribute to their resiliency. They look for opportunities to joke in the aftermath of disaster, and their children are as likely to laugh at themselves as one another.

I've avoided prying into the community's emotional response to the devastating earthquakes and tsunami of September 29, 2009. But one man, a speechwriter for American Samoa's Congressman Eni Faleomavaega, offered me an unsolicited story. 

He is Eti Sa'aga, a well-known poet in the Pacific islands. Eti's description of the event sounded poetic to me as we drove past the Leone village that was largely destroyed by the three waves of the tsunami.

"There was a man, a friend of mine, who saw the wave coming in. He held his 5-year-old son and wrapped his other arm around the closest thing he could grab -- a tree branch. But the wave was strong and he could barely hang on.

"My friend told me that he heard a girl screaming in the water. He saw her being carried by the wave close enough so he could grab her. But he would have had to let go of his son to reach her. He had to choose.

"He chose his son and didn't let go. The little girl disappeared under the waves. Her body was found later when it was over. She was 9. He told me he sees her when he closes his eyes.

"After the first wave receded, the man tried to run up hill with his son to safety. But the water was coming too fast. So when he saw a refrigerator floating in the shallow water before the wave hit, he tossed his son inside and grabbed the refrigerator's handle. He braced himself for the second wave.

"The second tsunami wave, and then the third, carried the refrigerator and my friend out to sea and back. He held on while his son inside the refrigerator was tossed like a Coke can against the shore.

"A week after the tsunami, we were still burying our dead. We had a Sunday umu (barbeque) for the whole village in front of what was left of my friend's house. The little boy was there. I asked him, 'Hey, are you the boy who rode in the refrigerator?'

"He smiled at me and said, 'Yeah, it was a good ride, you know?' We all laughed."

Linda Halderman, MD, FACS
Department of General Surgery
LBJ Tropical Medical Center
Pago Pago, American Samoa
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