Heart Cases at Shyira

This week Dr. Caleb King had to take three pediatric patients to Kigali because of their heart conditions. Apolline is 13. On exam I heard a loud, grade VI systolic murmur radiating to her axilla. I could feel a palpable thrill on her chest. Dr. King took her and two equally impressive cases for an echocardiogram in Kigali and hopes of getting them onto a list of 30 cases that a visiting team of cardiologist surgeons will perform next April. The echocardiogram showed that Apolline had mitral stenosis, mitral regurge, and aortic stenosis. Her heart was enlarged from working so hard to keep up with the demand. She was also in atrial fibrillation most likely because of the extra volume of blood in the atria. She was put on diuretics and an ACE inhibitor to relieve the heart. She was put on digoxin to control the rate and anticoagulants to prevent her atrial fibrillation from throwing a clot into her lungs, brain, or elsewhere in the circulation.

While discharging her I looked over the cardiologist’s notes. He recommended an INR weekly to check her blood’s coagulation since she was on coumadin. I asked Caleb if they did that test here. They do not. But, like a true inventive African doctor, instead of accepting the lack of technology, he headed off to the lab. We discussed what an INR actually measures, then put a drop of his blood onto a slide and timed it to see how long it took to clot. While trying to think how to get a proper control, his wife Louise said, “Why don’t you just use her blood now before treatment as a control?” So thus was born a practical way to check her coumadin levels.

The three children all need cardiac surgery to survive. We hope they make it on the list, survive until the surgeons come, or someone with wealth decides to sponsor their trip to a generous hospital in the states. We assume that the damage to the mitral valve was from an untreated case of Strep throat that has caused rheumatic fever. It seems to me that the hardest part of medicine in Africa is not what you do with your hands, but having your hands tied so frequently…realizing what your facility cannot do.