Partners In Health

week 31:  this week i'm gonna... provide health care for those in need

The ultrasound image revealing that the twins were joined at the abdomen.

The ultrasound image revealing that the twins were joined at the abdomen.

Manoucheca Ketan lay on an exam table as her doctor traced an ultrasound wand back and forth. 

“Pwoblem!” he said in Haitian Creole. The doctor said he saw three babies... and two of the babies’ bodies were connected.

Ketan was shocked. How would they afford food, clothing, diapers, and schooling for three children? Where would they find space for everyone? And how would she care for conjoined twins?

As her pregnancy advanced, her worries only increased. Ketan and her doctor in Port-au-Prince planned for the delivery; he proposed taking the triplets by C-section at 6 months. Because the babies would be significantly premature, he said postpartum care would be $1,000 a day for each child. Factoring in the cost of her delivery, he estimated her bill at $100,000.

As Ketan sank into despair, her younger brother suggested she visit Mirebalais, a town in Haiti's Central Plateau. He had heard that patients receive free care at University Hospital (HUM), a state-of-the-art facility that Partners In Health (PIH) had opened there in 2013.

Ketan was in her sixth month when she arrived at HUM in August 2014 to meet with Dr. Christophe Milien, the hospital’s Director of Obstetrics. “The guarantee I can give you,” Milien told Ketan, “is that we're going to look for help for you so that we can keep these babies alive.”

Milien was true to his word, but he had committed to no small task. Conjoined twins are a rare phenomenon, occurring once in every 200,000 live births. Ketan’s pregnancy was even rarer - conjoined twins within a triplet pregnancy occur in less than one in a million deliveries. And their outlook wasn't good - just over a third of conjoined twins survive only one day, and their overall survival rate is between 5 and 25 percent. 

CT scans revealed that Ketan’s twins shared a liver, but no major vasculature - a fact that made their separation more viable. But the HUM team’s challenge was daunting. They had to prolong Ketan’s pregnancy as much as possible, monitor the twins carefully to avoid infections and ensure weight gains, and assemble a team of experts to perform the separation procedure, which would be the first of its kind in Haiti.

Ketan and her conjoined twins

Ketan and her conjoined twins

At 36 weeks gestation, Ketan felt contractions. On November 24, 2014, a crowd of HUM staff gathered outside the operating room. Milien and Chief Nursing Officer Marc Julmisse led a team that had practiced for this C-section with hours of simulation training. Baby girl Tamar was delivered first. Then, the twins, Michelle and Marian. All three screamed their greeting into the world; thankfully, there was no need for a ventilator. Applause erupted. 

For Ketan, the relief of delivering three healthy babies was brief - she now had to worry about the eventual separation of her conjoined twins.


 
 

"We go. We make house calls. We build health systems. We stay."

The mission of Partners In Health (PIH) is to provide a preferential option for the poor in health care. By establishing long-term relationships with sister organizations based in settings of poverty, PIH strives to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.

PIH works in over 10 countries, caring for patients in their homes and communities. They work in close partnership with local government officials and the world’s leading medical and academic institutions to build capacity and strengthen health systems. And they stay, committed to accompanying the people and communities they serve for the long-term.


Ketan cradles the sleeping twins on her lap, while Tamar rests on her grandmother's lap. 

Ketan cradles the sleeping twins on her lap, while Tamar rests on her grandmother's lap. 

Five-month olds Michelle and Marian sucked each other’s hands while their mother fanned them with a piece of paper. When anyone switched their hands to their own mouths, they swiftly reverted back to their preferred position. Clearly sister’s hand tasted better. Tamar lay in a neighboring crib. Bigger and stronger than her sisters, she was learning to sit on her own and was very smiley.

The visiting nurse talked to Ketan about the upcoming separation surgery, which the HUM team had been planning since the conjoined twins were still in the womb. An international team of experts had been assembled with the help of PIH, including Dr. Henri Ford and Dr. James Stein, Chief of Surgery and Associate Chief of Surgery, respectively, at Children’s Hospital Los Angeles.

Meanwhile, Dr. Michelle Morse, Deputy Chief Medical Officer for Haiti, coordinated the complex operation from her base in Mirebalais. Dr. Romain Jean Louis, the hospital's director of pediatrics, checked on the triplets weekly. And Chief Nursing Officer Julmisse meticulously tracked down materials and equipment, brought her team up to speed, and recruited nurses from U.S. hospitals to help fill the ranks. 

The national and international teams came together in Mirebalais on Thursday, May 21, 2015, to run through simulations. Everyone was divided into color-coded teams - red for Marian, yellow for Michelle. Although nerves were on edge until late in the evening, the Thursday simulation finished strong. Friday, everyone decided, would be the day.

Marian's surgical team with red bandanas, and Michelle's team with yellow.

Marian's surgical team with red bandanas, and Michelle's team with yellow.

On the morning of Friday, May 22, Ketan and her husband planted kisses on their daughters’ cheeks before they were whisked away to the operating room. Four hands, arms, legs, and feet wriggled and intertwined as the twins lay on an operating table surrounded by over two dozen doctors and nurses. With great care and coordination, the team prepared them for what would be a seven-hour procedure.

The first incision was made a little after 1 pm, and just over an hour later, Michelle and Marian had been separated. There was a quick cheer before the entire team split into two groups to separately attend to the infants. After a few more hours of surgery, doctors finished by creating a new belly button for each baby.

By early evening, Michelle and Marian laid in separate cribs in HUM’s intensive care unit. Tubes crisscrossed their bodies, but they were stable and sleeping peacefully. Within 48 hours, they were breathing on their own. Within 72 hours, they’d already had their first bottles. And nurses noticed one curious thing: Michelle would calm down whenever they rubbed the side of her face where Marian used to be.

 
(Left to right) Michelle, Marian, and Tamar Bernard rest in the same crib days after the twins' separation.

(Left to right) Michelle, Marian, and Tamar Bernard rest in the same crib days after the twins' separation.

 

The girls’ birth and the conjoined twins’ separation were welcome and unprecedented successes in a country like Haiti, where even basic medical care is a luxury. PIH has proven it doesn’t have to be that way. They have been in Haiti for nearly 30 years, after sprouting from a small rural clinic in Cange and spreading to 12 communities across the Central Plateau and Lower Artibonite - two of the country’s poorest regions.

Ketan proudly holds her healthy 1-year old triplets: (left to right) Michelle, Marian, and Tamar.

Ketan proudly holds her healthy 1-year old triplets: (left to right) Michelle, Marian, and Tamar.

Ketan is also part of PIH’s mission; she recently started teaching mothers how to care for their newborns. She’s an expert, after all - three times over.


Notes for this week:

  • National Twins Weekend is August 6th and 7th
  • Our collective givetwig donation will sponsor the delivery of one healthy baby!
  • For further information regarding Partners In Health, please check out their website.
 

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