3.3 Case Studies

Doctors working on a very small baby.

Case 1 – Working in East Timor

A 2-day-old baby girl is brought to the hospital by her father.

As in most developing countries, 90% of infants in East Timor are born at home.

The concern is that the baby has stopped breastfeeding and the parents have noticed the baby is having strange spasms. […have noticed the baby has been suffering from strange spasms.]

As the doctor, you listen through the interpreter and ask for more information.

Question: What kind of questions would you consider asking the family?

Things you might be asking: Information you obtain after further questioning:
Mother’s health status The mother is doing well and is resting at home
Details around the labour and delivery (especially with respect to cultural practices) The labour and delivery was uneventful
Any trauma or injury There was no trauma or injury to the baby
More information on the baby’s condition (fever, lethargy) The baby has no fever, appears well and healthy, and is not lethargic
Information about the spasms (aggravating or precipitating factors) Spasms appear to get worse with sudden movement or noise
Medications or toxic exposures No medications or herbal products were given

On examination you find:

  • Vital signs (heart rate, blood pressure, temperature and respiratory rate) are normal, including the oxygen in her blood (oxygen saturation)
  • The heart and lung exam are normal
  • BUT, each time you place the stethoscope on the baby she goes into spasms

Question 1: What is wrong with this baby?
Question 2: What is the nature of these spasms?

Upon further questioning, you find:

  • The baby was born in a remote village far from their home as they were forced to flee during the violence
  • The umbilical cord was cut with the only sharp implement they had, a rusty razor the father had used for over a year [sharp implement they had: a rusty razor the father had used for over a year]

Question 1: What is the diagnosis?
Question 2: How do you manage this baby’s disease in this resource-limited setting?

Tetanus

  • In the USA (pop. 300 million) there are 40 cases per year of tetanus
  • Worldwide, there are over a million cases a year with accounting for approximately 300,000 deaths
  • In 2002, neonatal tetanus accounted for 180,000 deaths (approx. 5-7% of all neonatal deaths worldwide)

Basic Management of Neonatal Tetanus

  • Antibiotics
  • Tetanus immunoglobulin (antiserum)
  • Diazepam drip for spasms; and treat hyperpyrexia (fever) with acetaminophen
  • Intravenous rehydration (maintain fluid, electrolyte, acid-base balance)
  • Intubation and ventilatory support
  • Vaccination before discharge

Eddleston M, Pierini S. (1999) Oxford Handbook of Tropical Medicine, Oxford University Press

Case 1 – Working in East Timor (Revisited)

Outcome

  • In this case, the baby received antibiotics, diazepam drip (a muscle relaxant to stop spasms), tetanus immunoglobulin injected into the spinal column (to treat the tetanus), intravenous fluids to keep her hydrated
  • Although we wanted to intubate her and put her on a respirator, that resource was unavailable and this baby died

Lessons Learned

  • As sad as this individual case is, the bigger shame is this that this was a preventable death
  • Our response to preventable unjust deaths must include compassion and seeking to understand the complexities behind preventable deaths

Prevention

  • We could reach out to the midwives and other health workers in the community to learn about local practices concerning sanitation and hygiene
  • A key prevention measure is immunization
  • In this particular case, tetanus immunization would not have prevented the infection as the first tetanus vaccine is usually given at 2 months

A group of adults in East Timor attending a lecture outside a small school building.

Case 2 – Comorbidity and Older Refugee Healthcasestudy3

Mr. F, an 80 year-old male, presents to the emergency room with his wife after feeling unwell. Mr. F and his wife are Iraqi refugees who came to Canada 10 years ago after fleeing sectarian violence. Since arriving in Canada, Mr. F has seen multiple healthcare specialists and is currently being treated for several conditions including congestive heart failure, diabetes, depression, anxiety and COPD. He is prescribed multiple medications. When you are assessing Mr. F you realize that he is not taking his medications properly and that he may be experiencing adverse drug effects.

Question 1: What factors could be contributing to Mr. F’s overall negative health outcomes?

  • Older immigrants may face similar challenges of chronic disease and ageing as the general population, while also experiencing additional immigrant-specific risk factors. As a medical expert, you must be aware of the potential exposures that are unique to Mr. F and his immigration journey. This means consideration of the health risks (A) In his country of birth, (B) During his migration journey, and (C) After resettling in Canada.
  • Other immigrant-specific factors contributing to Mr. F’s overall negative health could include:
    1. Previous discontinuity in his healthcare – resulting in lack of screening, preventative care, and sub-optimal management of  chronic health conditions
    2. Language barriers and lower health literacy – due to limited educational experiences and naturally declining cognitive function with age. Communication barriers greatly increase the likelihood of medication related errors or misunderstandings in treatment plans
    3. Increased exposures to infectious diseases, malnutrition and/or trauma during his migration journey

Question 2: What approaches should be considered when treating Mr. F?

Medical experts must be aware of the long-term effects of traumatic exposures on the health of ageing immigrant and refugee populations. The life course approach “aims to identify the underlying biological, behavioural and psychosocial processes that operate across the lifespan.”1  Applying the life course approach will allow medical experts to better contextualize medical concerns in older immigrant populations and apply a holistic treatment plan to address each patient’s individual psychological and physiological needs.

Given Mr. F’s multi-morbidity and significant medication burden leading to poor treatment compliance, it would also be beneficial to use medical reconciliation. Medical reconciliation involves the systematic history taking, verification and documentation of a patient’s current and past medications. Through medical reconciliation Mr. F’s medications can be assessed to determine if there are any opportunities for deprescribing. To perform medical reconciliation correctly, healthcare providers must obtain a comprehensive and accurate medical history of the patient and effectively communicate the information to other members of the healthcare team. If a sub-optimal history is acquired or recorded at any point, it runs the risk of exacerbating or solidifying pre-existing errors and discrepancies throughout the therapeutic chain. It is necessary to ensure Mr. F fully understands the instructions associated with his medication regimen. As mentioned in the communication module, the teach back method is an effective strategy to confirm Mr. F’s understanding on his medication schedule and improve adherence.

1. Ben-Shlomo, Y., Mamluk, L., & Redwood, S. (2019). A life-course perspective on migrant health. In Migrant Health A Primary Care Perspective (pp. 77-89). New York, New York: Taylor and Francis Group. doi:https://doi.org/10.1201/9781351017190

Note: For additional case studies and information, you can complete the optional Blackbelt section.