Pediatric Electrophysiology Medical Relief Work on the Yucatan Peninsula: A Labor of Love

By all accounts, this year s trip was a success. The only remaining challenge was to complete the drive from Chicago O Hare airport to Iowa City, Iowa, as a winter storm had made a wide swath across the I-80 corridor, leaving snow drifts and long patches of ice on the interstate in its wake. As daunting of a task this seemed, it could not dampen the spirits of our team as we returned home from our 2008 medical relief trip to the Yucatan Peninsula. Background Nearly 30 years ago, a pediatric cardiologist in Des Moines, Iowa had the idea of helping some of the less fortunate children with congenital heart disease on the Yucatan Peninsula. Children who had less complex heart disease were often selected for surgical repair in the United States, while others were medically managed; however, I m sure many of those children who were diagnosed with more complex disease did not survive to the next annual clinic. From that inauspicious start, the program has grown substantially. The program is now coordinated by the Mexican DIF (Department of Integrated Family Development), the last safety net for the uninsured in Mexico. The most notable eligibility criterion for DIF participants is the lack of a man-made floor in their home. The DIF allots approximately 3,000 pesos (around $300) for each qualifying participant. When Steve Mooradian, my friend in Des Moines and a former cardiology fellow who I had attended the University of Michigan with, mentioned this program to me five years ago, the wheels started spinning and I naively offered up the possibility of a traveling EP program. What could be more straightforward: get a small team together, gather some pacing and recording equipment, a few EP catheters, and off we go. For EP procedures that are less dependent on specialized post-procedural care, it seemed more logical and cost-effective to perform the procedures in Mexico. Finding a group to join me was by far the easiest step. It turns out that my plan of traveling to Mexico from Iowa in the dead of winter was not a hard sell. The early momentum was quickly quashed by the chore of gathering up all that was needed to make the trip feasible. A monoplane catheterization lab already existed in Merida where we could do the procedures, but the only EP equipment was a defibrillator. Case Studies This year more than 350 children were seen during two clinics in Campeche and two clinics in Merida, Mexico. Thirty of these children have been chosen to return to Mercy Hospital in Des Moines over the next year for surgical repair. Diagnoses include tetralogy of Fallot, atrial septal defects, ventricular septal defects, Ebstein s anomaly, unobstructed total anomalous pulmonary venous return, and an aortopulmonary window. Electrophysiology procedures performed in Merida included two transvenous pacemakers, two electrophysiology studies, and eight electrophysiology studies followed by radiofrequency ablation procedures. The youngest patient was a 3-year-old boy who had presumed congenital complete heart block (resting heart rate of 30-35 bpm). A single-chamber transvenous system was implanted. Half of the ablations (ages 7-21 years) were performed on patients with Wolff-Parkinson-White (WPW) syndrome; the others had concealed accessory pathways. Four of the accessory pathways were left-sided and were ablated via the transseptal approach. The most notable ablation patient was a young man with WPW syndrome who, despite anti-arrhythmic treatment with propafenone, was having three episodes of SVT per week. Up to seven ablation procedures were performed per day, and all but the transvenous pacemaker in the 3-year-old were performed under moderate sedation (Versed and fentanyl). Medical Checklist For those interested in taking on an adventure similar to ours, here is an abbreviated traveling EP program packing list: Ablation equipment needed: Pacing and recording equipment (a gurney can be used in place of those fancy carts) Standard electrophysiology catheters (you forget how many are needed for each case) Cables for the EP catheters (sticking with one company limits the selection required) Radiofrequency ablation catheters A variety of sheaths (too many is better than not enough) Transseptal needles and sheaths (depending on your approach to left-sided pathways) Radiofrequency generator (don t forget the personality module) Radiofrequency grounding pads R2 pads compatible with the defibrillator in the lab Pacemaker implantation equipment needed: Pacemaker generators (single and dual chamber) Transvenous leads Introducing tear-away sheaths (although a normal sheath and iris scissors will work) Absorbable suture Skin glue Other optional supplies needed: O2 sat monitor Local anesthetic Adenosine Your trusty cath shoes Your favorite lead apron and skirt (the days can be long in heavy, uncomfortable lead) Antacid (depending on how accustomed you are to the mild salsa of Mexico) Once you ve gathered all the needed supplies, you will need to find a way to get it all to the country of interest (in this case, Mexico). To be more precise, just getting the equipment/supplies into the country is not enough. Although customs is technically inside the country, it is not an ideal place to do procedures (although I ve considered this option after the equipment sat there for four weeks waiting to clear)! Ideally, the equipment and supplies should arrive in the catheterization lab sometime before the first procedures are scheduled. The most crucial piece of equipment is the pacing and recording system, and preferably someone should arrive with it who knows how to set it up and troubleshoot problems. When the pacing and recording system is up and running (thanks to a capable technical support person), you can breathe a huge sigh of relief. However, if you realize that an RF generator cable is missing, a box of EP catheters did not arrive, the RF grounding pads are missing, or any other seemingly small detail is missed, the program can grind to an abrupt halt. Our team learned a lot from the first trip in 2004. First and foremost, double- and triple-check the packing list, and ship the supplies as soon as possible. Expect the unexpected and prepare for more cases than are scheduled. There are no set roles in the EP lab: everyone contributes to every task including lab set-up, patient transport, and lab clean-up. On a side note, for those with a weaker stomach stick to the bottled water or be prepared for a bowel purification ceremony! Summary For all the work that goes into planning such a trip, the rewards of medical relief work far outweigh the effort, and are too numerous to count. Without a doubt, the generosity of our industry colleagues has been unexpected and overwhelming. Trips like this would be cost prohibitive, if not impossible, if it were not for the loaning of equipment and donation of supplies. Almost equally as important has been the assistance of company representatives to set up the equipment and the working relationships that quickly transformed into lasting friendships. The assistance of the DIF in organizing and transporting the patients and families (some from as far as six hours away) for the procedures, as well as the cath lab staff who worked longer hours than we did to prepare the lab in the morning and care for the patients afterwards, was unbelievable. However, far and away the most gratifying part of the work is the incredible appreciation expressed by the patients and families. We live in a society where health care is often taken for granted; this is clearly not the case on the Yucatan Peninsula. The payment for our work was a smile of a child before and after the procedure, the tears of the parents, a firm handshake with unwavering eye contact, and a long hug. While my Spanish-speaking skills are lacking, I had no problem whatsoever understanding the parents thankfulness. Acknowledgements I would be remiss if I failed to mention all the people and companies that have contributed to this project over the years. Our gratitude is only exceeded by that of the patients and families who have benefited from their generosity. Our team is very grateful to the cardiologists who assisted us, Drs. Ricardo Alejos and Eddie Favela, and the staff of the catheterization laboratory. I would also like to acknowledge the following companies and their representatives that have been extremely helpful since initiating EP procedures in Mexico four years ago: EP MedSystems, Inc.: EP-WorkMate ^® system: 2006, 2008 Carlos Iglesias (system expert): 2006, 2008 Dave Montgomery: 2008 Bard Electrophysiology: Bard Duo system: 2004 EP catheters: 2004, 2006, 2008 Robert Kincaid (system expert): 2004 Joel Criner (supplies): 2006, 2008 David Levin (supplies): 2008 Medtronic: Pacemaker and leads: 2004, 2006, 2008 Steve Deloe (supplies, long-distance troubleshooting): 2004, 2006, 2008 Brian Faulkner (supplies): 2004, 2006, 2008 Pat Richter (supplies): 2004, 2006, 2008 St. Jude Medical: Sheaths and catheters: 2004, 2006, 2008 Brian Yunker (supplies): 2004, 2006, 2008