From: Peter Manning
Sent: Tuesday, May 04, 2004 8:30 AM
To: Todd Wilson
Subject: Re: Message from Nestor

Todd,

My address and fax number are below. If our board is able to approve her care, do you see major impediments to being able to get her here or find her accommodations here?

For management, presuming she is exhibiting CHF symptoms, our mainstays would be diuretics and digoxin or captopril. I would start with Lasix 1mg/kg bid or TID. Could add Spironolactone 1mg/kg bid for K-sparing effect, particularly if you use TID lasix. It may be wise to start with just BID Lasix and see what effect you get. If Captopril is available, I would use this as the next drug to add, usually start at 1-2 mg/kg/d split TID. If digoxin is more readily available, the dose is 5mcg/kg BID.

Best of luck.

Peter B. Manning, MD
Director, Division of Cardiothoracic Surgery
Cincinnati Children's Hospital Medical Center

Subject: Update from Iraq
Date: Wednesday, May 5, 2004 6:58 AM
From: Todd Wilson
To: Peter Manning

Dr. Manning,

Thanks for your reply. To update you, Fatima is at present stable. Her father worries about her increasing fatigue and poor appetite. Although thin, she does not appear anorexic, at least relatively speaking in comparison to others of this culture. There are no overt signs of CHF. She has no edema, her lungs are clear, no JVD or hepatomegaly. She is extremely tachycardic (160) which I know is compensatory. As I have little experience with Peds Cardiology, should I await these signs prior to initiating treatment? As well, I will not only have to obtain meds (which is possible), but will also have to coordinate with local Iraqi physician for baseline and follow-on labs, as I am in an Aid Station and not a modern facility. As her appetite is poor, she may very well already be electrolyte depleted.

I contacted Dr. Michael Brumage, 1st ID Division Surgeon, regarding procession. I am awaiting reply, but he forwarded message to Dr. Miriam Othman from Ministry of Health here in Iraq. He says there is an NGO (Non-Governmental Organization) that specifically deals with congenital heart defect repairs. This may take some time, but in response to your question regarding impediments, I am awaiting answer.

I will keep you informed, and let you know when to proceed. The NGO will arrange transfer and accommodations. She will likely have to be transported to Amman, Jordan for flight to US. Although this can happen and organizations are in place, I think we are writing policy and SOP as we go.

I assure you, if futile, I will inform you as to not waste your time. However, there is some measure of unpredictability here.

These children are innocent and impressionable. The oppression that their families have lived through is unknown to them. Our hospitality, and concern for them may make a lasting impression that will revive and unite as is unlikely otherwise. They are the future of Iraq. Lord knows I don't want to come back.

Sincerely,

L. Todd Wilson PA-C
2LT, SP
1-150th AR, 30th eSB, 1st Infantry Division
Battalion PA

From: Peter Manning
Sent: Thursday, June 10, 2004 11:51 AM
To: Todd Wilson
Subject: Re: Wassup from Iraq

Todd,

Great news! I've just been informed that our administration has given the OK to treat Fatima here. The next step is to nail down some dates for her care. We will need to pick on OR date, then an outpatient visit at least a few days prior to get an echo and an exam by one of our cardiologists and myself to be sure there aren't any surprises or other issues to plan for.

To set up dates, please work with Celeste Naber in our office.

Once the dates are set, I guess the ball is back in your court for getting her paperwork arranged and getting her physically here.

Let us know if we can help in any other ways.

Sincerely,

Pete

From: Peter Manning
Sent: Friday, June 18, 2004 12:23 AM
To: Todd Wilson
Cc: Cc: Celeste Naber
Subject: Getting closer

Celeste,

To keep you informed, we are finalizing the last steps. Let me tell you, operating and living out of a very small base, well "Fort", without often leaving due to risk of life is not easy. In America we are used to making phone calls at leisure, unlimited internet access, transportation to and from where we please, communicating with folks that actually understand what the hell it is we're trying to say, but unfortunately that aint happenin here. All that just to reiterate, the task required in making this thing happen. I am at the mercy of my computer and email.

Currently the family is finalizing travel documents and passports. Should be able to transport them to Baghdad soon and then to Amman where they will likely spend a week waiting on Visas. Once I have clear visibility of this, I will inform you so that the hospital and Dr. Manning can procure OR time, preop appointment, media relations, etc.

Please contact me if there is any additional information that you need. It's safe to say I'm not goin anywhere.

Thank you sincerely

Todd Wilson
L. Todd Wilson, PA-C
2LT, SP
1-150th AR BN, 30th eSB, 1st Infantry Division
OIF II
Battalion PA

From: Celeste Naber
Sent: Thursday, July 01, 2004 9:31 AM
To: ltwilson@firstphysician.com
Subject: Re: Latest on Fatima Saad (VSD)

Todd:

I was hoping that I could get additional information regarding Fatima. In order to get appointments made, I need to have her birthdate, and parent names. If there is an address, I would like to have that as well. This is really a wonderful thing that you are doing. Projected surgery date is August 2, 2004. I will be making an appointment with Dr. Robert Beekman for Fatima's cardiology appointment and an echocardiogram on the same day. I will schedule Fatima to see Dr. Manning in pre-op on July 30, 2004. She will have ample time to rest and perhaps enjoy some of the local sites while relaxing and awaiting her surgery date. Do you know if she will have an interpreter with her or should I request one? If so, I need to have the name of the language that they speak so I can procure one. Many thanks and hope that you are rewarded in some special fashion for your caring.

From: Todd Wilson
Sent: Monday, July 05, 2004 3:36 AM
To: Celeste Naber
Subject: RE: Latest on Fatima Saad (VSD)

Celeste

Iraqis are not at all concerned about birthdays. In fact, they are not even sure of their own. Documents I have gathered will provide that info---will get to you soon. Her escort is a middle-aged, female cousin, as her mother was unable due to care of young child. For the father to have been considered as an escort, many months of waiting for background checks would have delayed her care. Her escort's name is (deleted at family's request) She is a teacher in Baghdad and speaks decent English. You may still want to have an interpreter. The language is Arabic. She is extremely devout Sunni Muslim, and would feel most comfortable with Arabic folks. Many Iraqis despite their identity as Sunni or Shia, coexist without much tension especially in capital city Baghdad. If you recall the history of Iraq, Sunni's and Shia's, although both Muslim, are not the closest of friends.

The girl's full name is Fatima Saad Abdul-Aziz.

From: Todd Wilson
Sent: Monday, July 05, 2004 1:10 PM
To: Celeste Naber
Subject: RE: Latest on Fatima Saad (VSD)

Celeste

I just confirmed today that Fatima has Passports. They should God Willing, (In sha Allah), be on a flight Saturday July 10. The appointments that you made should work fine. I see that you are in contact with Mr. Kleinloh. Things seem to be working out. Sure has been Heck on this end over the months. It's all been worth it though. Let me know if you need anything else.

God Bless America.

Todd

From: Todd Wilson
Sent: Saturday, July 10, 2004 9:07 AM
To: Peter Manning

Subject: And they're off!

Folks

I saw Fatima bright and early this morning. They are now on their way to Baghdad for a 1300 flight to Amman. As we can all imagine, her emotion covered the spectrum of joy, fear, and sadness. It is particularly difficult for the father as he is extremely close to her. He expressed to me that his heart would be sad and that he would sit on her bed and think of her till she returns. I comforted him by letting him know that she would be well cared for and looked after by the folks at CCHMC and the city of Cincinnati. He could barely express his gratitude for we American soldiers and the hope that his daughter will now have through our diligent efforts and God's grace.

Pre-op appointments are scheduled for the end of the month followed by surgery on August 2. I expect, barring any complications, that she will return to Iraq in early September.

Let me reiterate the positive impact that this small deed of kindness has had on the local community here in Iraq. One thing is for sure, Iraqi's definitely talk and spread the word--------whether it be good or bad. Futhermore, as Fatima's escort is an influential educator in Baghdad, we can hope that same message permeates her "circle" as well.

My sincere thanks again to all who have been involved both in deed and in prayer. My our efforts help to transform the good people of Iraq and give them hope of a better future.

Sincerely

Todd Wilson
L. Todd Wilson, PA-C
2LT, SP
1-150th AR, 30th eSB, 1st Infantry Division
Battalion PA

On 7/28/04 5:06 PM, Peter Manning wrote:

Dear Jonathan,

Thank you for the update. She has now completed nearly 2 weeks of antibiotics. It's a bit odd that her blood cultures never grew anything (I assume I{sbquo}m interpreting the info correctly) but there is still ample evidence that we are dealing with endocarditis. If she is clinically well (it sounds like she is), she should complete 6-8 weeks of IV antibiotics before considering surgery. Assuming this adequately treats the endocarditis, her surgery could be any time after that (immediately or months later). The lab test I would like to see normalize, that would best indicate that her endocarditis is being well treated is her CRP, or C-reactive protein, which was quite elevated on the results I was sent. If it is possible that she will be able to continue her antibiotics in Baghdad and be monitored reasonably it probably makes the most sense to let her go back there. In a stable child we would typically complete the IV antibiotics on an outpatient basis. If there are real concerns that she cannot receive adequate treatment at home, I am open to considering bringing her here as long as we have hosts for them for a few months. We could potentially complete her antibiotics as an outpatient, and if all goes well do her surgery a week or two later. If we want to consider this option, I will need to bounce it off of our administration again, as the change in plan will add some cost and some uncertainty.

I'm not in a good position to make the decision about where she should go next, because I don't know what is available at home for her. Let me know. I will start the process of running things by our administration just in case.

Peter Manning

From: Jonathan Miles
To: Peter Manning
Sent: Thursday, July 29, 2004 5:22 PM
Subject: Iraqi cardiologist to travel with Fatima?

Dear Peter,

I am concerned about the quality and consistency of care and lab work that Fatima would receive in Iraq, as well as the administrative difficulties of getting her in and out of the country. It would also seem ideal to have her under the supervision of one medical team rather than several. But we will have to hear back from our host families in Cincinnati, and you from your administration, to know when it is possible to send her on to the US. In any case our tentative flight bookings are only for an August 11 flight, which will already be four weeks into the IV treatment.

Our staff in Amman describe Fatima as very weak and not traveling well, and ask if she could have the continuing IV and central line cath care done at home in Cincinnati. This raises the possibility of sending an Iraqi cardiologist with Fatima. (Name withheld upon request) is the leading pediatric cardiologist in Iraq, and she is prepared to come to the US August 11 for several weeks of further training in echocardiography. (US doctors who have seen her echoes say she is technically proficient but the echos are incomplete). We had first thought of sending her with another child who is going to Tampa for surgery; but if CCHMC is open to working with her perhaps we should send her with Fatima, with an option for travel later on to Tampa.

Thanks for your consideration of these issues. God bless,

Jonathan