Wednesday, September 19, 2007

Haitians and Mannequins

Medical schools in the United States purchase expensive mannequins so medical students and resident physicians can examine them.

The mannequin is programmed so that the student or resident can hear different heart sounds and attempt to learn their significance.

One hundred years ago in the United States, rheumatic fever was a disease that destroyed many people’s lives because it destroyed their heart valves. Now rheumatic fever is almost gone due to our standard of living and the availability of antibiotics in our resource rich country.

However in Haiti, rheumatic fever is common place and destroys many young lives. Unfortunately, Haiti is a good “laboratory” to study rheumatic heart disease. Haiti doesn’t have mannequins with funny sounding hearts…it has real people with funny sounding hearts.

Erline, pictured above, is a patient of mine in Haiti. She is 39 years old and has multiple valves destroyed from rheumatic fever. She is in chronic congestive heart failure.

Erline is not a mannequin that can be folded up and put back in the closet after you listen to her abnormal heart. She is a human.

For example, Erline has a very loud systolic murmur over her right upper sternal border. The murmur originates from aortic valve which is calcified, stenotic, and destroyed. Also, her heart is very irregular and after a compensatory pause, her systolic murmur becomes louder. This gives even more evidence that her pathology lies in her aortic valve (and not in her mitral valve because of unequal pressure gradients).

Interestingly for all of us except Erline, she has a diastolic murmur down the left sternal border which means that her aortic valve is leaky and insufficient also. She has the “diastolic blow” of aortic insufficiency which is consistent with her blood pressure of 160/60.

What mannequin in the States could teach us so much?

Problem is, what do we tell Erline? How do we help her? Do we tell her that we give better exams and care to our mannequins than we do to most Haitians?

Erline has a lot more to teach us than just her heart exam. We just are not listening closely enough.

(Erline died at the end of 2007.)

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