Yucatan Pediatric Electrophysiology Program

The room was bright from the fluorescent lights, giving the groups on opposite sides of the room ample opportunity to visually acquaint. Our crew from Iowa must have been quite an interesting sight; we were much taller than the Mexican patients and families, and our late-winter pallor stood out in stark contrast to their bronzed skin. For the majority, this was our first chance to get to know one another, although we had met a few of the families during a clinic in Campeche two days earlier. If they were nervous, it was well hidden behind their friendly smiles and sense of excitement. I hoped that our group's attempt at projecting a calm demeanor was effective in minimizing any fear they might have had, because despite months of planning and coordinating, the first case had yet to be done and there were still many unknowns. The late arrival of the pacing and recording equipment, after sitting more than two weeks in customs, only compounded our anxiety.

Background The idea of performing electrophysiology procedures in Merida, Mexico on the Yucatan Peninsula was initially entertained after one of our pediatric cardiology fellows for the Children's Hospital of Iowa returned from a medical relief trip with a group of pediatric cardiologists from Des Moines, Iowa in February 2004. The Des Moines group had just completed their 24th annual trip to the Yucatan Peninsula. Our fellow, who was fluent in Spanish, had invited a Mexican adult cardiologist, Ricardo Alejos, back to the Children's Hospital of Iowa to gain experience in performing pediatric heart catheterizations. Ricardo entered the catheterization laboratory just as I localized a left lateral accessory pathway in a young patient with Wolff-Parkinson-White syndrome. Ricardo shared in the sense of awe that even the most seasoned electrophysiologists have as the radiofrequency energy normalized the QRS complex. After the case, Ricardo had many questions and mentioned that he was caring for several children with Wolff-Parkinson-White syndrome. He also mentioned during this visit to Iowa that his group of adult cardiologists in Merida had just built a new heart catheterization laboratory, but there was no electrophysiologist in the area. Hence, the proposed idea was born of a group from the Children's Hospital of Iowa going to the Yucatan to assist in the care of his arrhythmia patients.

Preparing for the Task The initial excitement of traveling to Mexico to assist Ricardo was quickly surpassed by the sense of panic in accomplishing such a task. The concept of performing procedures abroad is by no means novel, but our group had never taken on such a task and had no idea where to start. Common sense would have lead us to contact well-organized groups such as Doctors Without Borders for assistance, but since the Des Moines Pediatric Cardiology group had been doing medical relief clinics for 24 years, our group felt like the ground work had been laid, and we merely had to follow their footsteps. It soon became quite apparent that we take many of the behind-the-scene operations of our daily heart catheterization activities for granted, including ordering supplies and medicines; procuring, setting up, and maintaining pacing and recording equipment; arranging lab personnel; and arranging anesthesia services. Behind every electrophysiologist is a talented electrophysiology team, often making any electrophysiologist look good! What started out as a seemingly innocent commitment on our part, ablation procedures on the Yucatan Peninsula turned out to be a tremendous amount of work for the cath lab crew from the Children's Hospital of Iowa. Our electrophysiology nurse, Jean Gingerich, did most of the heavy lifting. The first task was to locate pacing and recording equipment. The NASPE (now HRS) scientific sessions were just around the corner, and turned out to be the perfect opportunity to join forces with our industry colleagues. Bard Electrophysiology graciously agreed to lend us a Duo demonstration unit for recording, and also donated numerous diagnostic and ablation catheters. St. Jude Medical's Daig Division donated catheter sheaths, and through Medtronic's International Device Program, pacemakers and transvenous leads were secured. The only needs remaining were a radiofrequency generator and pacing system. With the assistance of our adult electrophysiology colleagues at the University of Iowa Hospitals and Clinics, a Bloom pacing system (Fischer Imaging) was located in remote storage, dusted off, and given the okay by our biomedical engineering department. We then obtained approval from the Children's Hospital of Iowa to take our EPT radiofrequency generator. Having checked off the list of requisite items to perform the procedures, we took a short breather. It then quickly occurred to us that performing ablation procedures in Merida, Mexico would require that all of the equipment to perform the procedures also be in Merida, Mexico. Our shipping department was invaluable in assisting in the boxing of equipment and making arrangements to get the items through Mexican customs. Bard was equally helpful in shipping the Duo demonstration unit. Arranging the necessary personnel was the final task. Our 2004 electrophysiology team consisted of Annie (translator), Jean (electrophysiology nurse), Robert Kinkade (Bard electrophysiology representative) and myself. Each team member was, in theory, assigned a specific role in the laboratory. In the end, we all became part of the room set-up, patient transport, and room clean-up team. We also received outstanding assistance in Merida by Ricardo and his staff.

The First Cases After the initial exchange of smiles the first morning, the description of the day's activities took place. Annie translated the procedures to the group and went through an Americanized consent process. This was obviously a foreign (no pun intended) concept to the patients and families, and the general consensus gained by their bewildered looks and comments later was that the families trusted us to do the right thing. The first procedure was an ablation to be performed on a young girl with Wolff-Parkinson-White. Her willingness to calmly walk into the lab, the slightly tense smile on her face, and her slow but deliberate climb onto the catheterization table amazed our team, and in a sense paralleled our own entrance into the lab. The lab was clean and the monoplane equipment relatively new. The anesthesiologist carried a small tool box with his medicines and a portable gas scavenger unit in case he decided to give an inhaled agent. There was no pulse oximeter in sight, and airway management was primarily a jaw thrust. The procedure table contained one 10 cc syringe, one needle, a bowl with saline, four gauze pads, and the sheaths we had brought with us. These were only the bare essentials, but clearly sufficient. The thought of countless syringes and needles of all sizes that lay side by side on our table in Iowa crossed my mind, and I paused to ponder the excess. I tended to use more gauze than was provided, probably more out of habit than need, and Jean quickly learned how to ask for more gauze in Spanish. After the second ablation we had our process down. Robert mopped most of the room while I held pressure for hemostasis. Jean and Annie prepped the next patient. We all transferred the patient from the catheter lab table to the gurney, and while two of us rolled the patient to the recovery room, the other two finished clean-up and started set-up. The next patient was then rolled into the lab. It was no surprise that the majority of accessory pathways we ablated in Merida were left-sided, since that is where the majority are, but we had hoped that we would see more right-sided pathways based upon a limited supply of transseptal needles. In the end, supply kept up with demand. Just when we had become most efficient at performing ablation procedures, our attention turned toward pacemakers. The surgical lamp consisted of a 60 watt bulb in a metallic dome lamp. The pacemaker procedure table contained more instruments than that seen on the catheterization table, but far less than I was used to seeing. I again pondered the question I often find myself asking my two young daughters, Is that something you NEED or something you WANT? As was previously noted in the ablation procedures, the number of instruments was sufficient. Both pacemaker procedures went well. The single pair of scissors had to be re-sterilized for the second device. I debated as to whether it was better to have a brighter light bulb for visualization, or less radiant heat bearing down on the back of my head. I stuck with the 60 watt bulb!

Back to Merida, February 2006 A second trip for the Yucatan electrophysiology program took place this past February (2006). The lessons learned during the first trip should have been more helpful for the second, but as usual, this was not the rule. We had continued problems with getting equipment through customs, but in the end everything worked out. Many of the first electrophysiology team returned in February 2006, with the addition of Carlos Iglesias from EP MedSystems, and Dr. Macdonald Dick from the University of Michigan Congenital Heart Center. EP MedSystems also kindly provided the pacing and recording system. Bard, Daig and Medtronic continued to offer their support in the way of donating supplies. Seven electrophysiology and ablation procedures were performed, and one pacemaker was implanted.

Program Details The patients treated through this electrophysiology project have their health needs covered by the Mexican DIF program (roughly translated, Department of Integral Family services). The DIF has an annual budget of 12 million dollars for all of Mexico, and functions as the last safety net for Mexico's uninsured. An accurate estimate of uninsured people in Mexico is difficult to obtain, but the population of Mexico is 106 million, 25 million who live in and around Mexico City. There are an estimated two million uninsured Hispanics in Los Angeles alone. To put this in perspective, the state of Iowa appropriates 27.3 million dollars for indigent care, covering an estimated 147,000 Iowans (Iowa population = 2.97 million). While there are many criteria that qualify a person for DIF assistance, the one that struck our group as the most astonishing was lack of a man-made floor at the place of residence. Despite their relatively low standard of living, the families possessed a tremendously positive outlook on life, were incredibly generous, and extremely grateful for the care they received. The memories of these past two trips have given us a better perspective on our lives and motivated us to become better care providers.

Acknowledgements The electrophysiology team from the Children's Hospital of Iowa, University of Iowa Hospital and Clinics would like to acknowledge the amazing past and present effort of the Des Moines Pediatric Cardiology group of Drs. Basaviah Chandramouli, Thomas Becker, and Steve Mooradian, who have been caring for the children of the Yucatan Peninsula for several decades; Robert Kinkade (Bard) and Carlos Iglesias (EP MedSystems) for their assistance in setting up and running the equipment donated by their respective companies and performing other duties as assigned; and Dr. Ricardo Alejos for the use of his catheterization laboratory and his staff for all the hours of work. We would also like to thank Bard, Daig, EP MedSystems, and Medtronic for their incredibly gracious donations of equipment, supplies, and employee time.