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Romania, 2005
Day Two: The Echodoppler's New Home
BUCHAREST, ROMANIA (May 13, 2005) - Romanian pediatric cardiologist Dr. Alin
Nicolescu has waited for this day for a long time. This morning on the seventh floor of the
Hospital Fundeni in the pediatric center, at the end of a long white tile hallway, there's a
newly refurbished room where a dark, heavy cloth has been draped over the single window to
make the room dim. There's only one bed, two chairs, an older metal table, and a sink in
the spartan room. Clamped to one edge of the table is a metal arm that's designed to
suspend a computer monitor up in the air.
But instead of holding a computer monitor, now sitting atop the arm is a humming and glowing new Acuson Cypress echodoppler device donated to the Bucharest clinic by Siemens. The Cypress arrived yesterday from the United States in the hands of Bradley N. Stanton, the chairman of the charity Gift Of Life International, and this morning it will do what it was sent here to do: give Dr. Nicolescu eyes and ears deep inside the small chests and hearts of the Romanian children he treats here for their highly-complicated heart birth defects and other serious, and often fatal, conditions.
Dr. Nicolescu will be very busy today. Even though it is early, in the center of the building where the two hallways intersect - by the elevator and stairs - the seventh floor is crowded with outpatients and their parents who are waiting to be seen. Nicolescu spent most of last evening setting up the Cypress unit at home and programming into the computer the "profiles" and calibrations, testing the Cypress on both of his young daughters, Malina, 6, and Mara, 3, as well as on his wife, Madalina (who is also a physician). He wanted to make sure the unit was ready to go for this morning's tests and that there would be no delays.
"I will try to see the babies first, because they're easily agitated," Nicolescu explained. "Making them wait longer will only make them more agitated, and I need for them to be still and to be calm to do a good echodoppler exam." There are a few older and larger children waiting too, and they will wait for a bit while most of the babies go first. Two transducers (sensor heads) used for ultrasound imaging came with the donated Cypress: a smaller one for infants and a larger one for bigger children. Both are metal pen-like units that are held against the skin on the chest, above and around the heart from the outside, and the duo will get heavy use today.
Nicolescu started with a young boy who had been referred to the clinic in Bucharest in hope of a more accurate diagnosis. The youth pulled off his shirt and got on the bed and within moments the screen of the Cypress displayed a vivid two-dimensional image of his beating heart, clearly showing a heart valve opening and closing with each contraction. As Nicolescu guided the sensor across the boy's skin with gentle turns and points, different images of the heart came into view from various depths.
As he measured the "structure" of the heart's chambers and the flow of the pulsing blood, Nicolescu was able to store the information in the child's medical record by clicking "Save" on pieces of data that he wanted to keep. When he finished making images and calculating some measurements, the doctor explained to the boy's mother that her son "is fine, it's an 'incidental' murmur and is not a problem." The new echodoppler, which only yesterday was riding inside carry-on luggage in a Lufthansa overhead bin with clothing folded around it for padding, had already started its new life in Romania, and examination No. 1 was finished in just minutes. Not all of the exams today would go as quickly or have such a happy outcome, but this one was "a good start."
Before noon, Nicolescu has worked his way through a stack of patients - several young boys, a girl who had been sent for surgery three times before but who has not yet had the procedure, and then a four-month-old baby girl whose skin color is a deep blue to even the most casual viewer. She was crying heavily, "too agitated" to hold still long enough for a clear exam. Hers is a serious case; she's been sent from her home 100km from Bucharest to get a second opinion after local doctors delivered a grim forecast. So the child and her parents traveled to see Nicolescu as do hundreds of Romanian parents each year, sent to Bucharest from the rural villages and towns to Romania's leading center for pediatric cardiology with the hope for some better news and more cheerful outcome.
Always unruffled with his young patients, Nicolescu tried his usual bag of tricks to let the child calm down: nursing from her mother's breast, playing with a small rattle toy, bouncing up and down on her mother's lap, and being swayed in her arms while walking. But nothing worked, so he called for a nurse to give the child a mild sedative and then put the baby and her family into an empty, quiet hospital room to wait. Until she could be still he could not examine her, so he moved on to the next patient, a young boy, while waiting for her to become drowsy.
"The Fundeni Clinic is one of the largest and most important hospitals in Romania," Nicolescu said. "The medical departments include abdominal surgery, urology, nephrology, cardiology, pneumology, hematology, gastroenterology, neurology, and pediatrics. At Fundeni we do renal transplants, liver transplants, and bone marrow transplants."
The pediatric department is part of the Fundeni Clinic with 150 pediatric beds where more than 4,000 children per year are treated, mostly in the areas of four medical specialties: hemato-oncology (around 35 percent of the children, those with leukemia, lymphomas, and other tumors); nephrology (30 percent of the children, those with renal failure, dialysis, and transplants); cardiology (20 percent of the children, those with cardiac malformations); and gastroenterology (children with liver failure and transplants). "Because of this, the pediatric department at Fundeni is one of the most important pediatric centers in Romania, receiving children who come from all over the country," Nicolescu said.
"Without the basic necessary medical equipment, like the new echodoppler, it is impossible to treat the children properly," he said. Getting an echodoppler for the pediatric department has been Nicolescu's priority for at least three years now, as the technology can be used to instantly visualize and diagnose his young patients. "Too many children would not be helped if we had to wait for the eventual state budget to be available.
"Last year, sponsors made it possible to remodel one room into a children's playing room. The total budget, including personnel costs, came from our donating sponsors. The results are wonderful. The room is where the patients for a little while can forget their sickness, they can play games, do paintings, have ergotherapy, art therapy, music therapy, and there are support groups for children and parents and a play therapist and a social worker. The feedback has been wonderful and this encourages us to continue."
The simple availability of one machine to do cardiac ultrasound will change the way Nicolescu is able to treat almost all of his patients. "Our actual focus all along has been a cardiac ultrasound machine. The majority of the pediatric patients need cardiac exams. Without this equipment, we have had to transport the children with their parents to other places, through snow and rain and extreme temperatures. This is, of course, not helping their health situation," Nicolescu explained.
"Worse is that some children cannot be transported, and children that are in an emergency situation cannot be helped." Nicolescu for three years has tried to raise funds for the machine through the White-Yellow Cross foundation, but not nearly enough money was raised to even come close to buying an echodoppler, and the money was not in the state budget for a machine for the pediatric department. If the machine were to come, it would have to come from a sponsor or donor. "If people could visit us and see the children, they would better understand our needs," he said.
Down the hall, the four-month-old baby girl who is blue is now calm from sedation and ready for the echodoppler exam. Her family gently carries her from the patient room down the long white tile hall to the darkened temporary room Nicolescu has prepared for the new Acuson Cypress. Now that she is still he is able to quickly examine her and to visualize the structures of her heart.
Holding the pediatric-sized sensor to her tiny chest, Nicolescu sees immediately that she has a very serious condition. There is an extremely large hole in the upper wall of her heart, the septum that separates the top two atrial chambers of the vessel, and the freshly oxygenated blood coming back to the heart from the lungs is mixing there with old blood that's coming back to the heart from the body. So instead of oxygen-rich blood being pumped to the body from her heart, the blood that's being circulated is diluted by the oxygen-depleted blood that has already been circulated. She is blue now because her body is not getting the oxygen that it needs to survive. Nicolescu can see this clearly on the new color echodoppler screen, as well as seeing additional possible defects to one of the major blood vessels of the heart. She is no longer an outpatient; he hospitalizes her immediately and has her admitted to one of his pediatric rooms across the hall from his office. "It's a very difficult case," he explains, "and she is so small and needs an immediate surgery but I must do more tests first."
On the Acuson's first day in service at Fundeni, Nicolescu has used it on 14 children in less than eight hours. The parents have been able to stay with their children the entire time, and they have not had to travel outside the clinic to other locations for tests as they have had to do in the past. Nicolescu is clearly pleased. The echodoppler has been a necessary goal for such a long time, and now it is finally here and it is changing the way he can see his patients and view their hearts.
"Without saying a word, you can see in his face and in his every movement as he uses the machine just how excited Dr. Nicolescu is about having this ultrasound," Stanton said. "Now his ability to discuss with the family the seriousness of the child's condition, and the treatment that's needed, is wonderful -- whereas before, without the echodoppler, it may have been guesswork. But now with this echodoppler, now he knows. The ability to see the blood flow, and to hear the blood flow, that's just amazing. Also, with the parents there and watching, now they're in a better position to ask more meaningful questions about the condition of their child and Nicolescu is able to actually show them what's happening on the screen."
As the day ends and Nicolescu heads home to dinner with his family he looks tired. But he also looks very
happy. Today was a day that he's waited for and thought about countless times over the last few years, and thanks
to the donors at Siemens the Acuson Cypress has fundamentally changed his ability to quickly and accurately examine and
treat his young Romanian patients at Fundeni. This is an evening to celebrate with his family and his own children, and
so he does. -- Donald Winslow
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