Monday, July 3, 2017

Interventional Cardiology Training in Tanzania: Challenges and Rewards

Mazen Albaghdadi, MD MSc
Graduate Assistant, Interventional Cardiology
Fellow, Vascular Medicine and Intervention
Massachusetts General Hospital
PGY9

Interventional Cardiology Training in Tanzania: Challenges and Rewards

Cath Lab Team

The cath lab team at the JKCI was very excited to schedule the many complex cases during my visit that they have been collecting over the past months. Each day, thus far, we have been working until around 8 or 9pm to perform elective complex cases that have been scheduled for this training visit as well as incorporating urgent and semi-urgent (ie, acute coronary syndrome, pre-cardiac surgery cases, etc.) into the schedule.  

The logistics of operating a cath lab are very challenging and require coordination between referring providers and interventional physicians to determine procedural appropriateness and timing, cath lab nurses and administrators to coordinate peri-procedural admission/in-hospital/discharge logistics between home and medical floors, cath lab managers to determine insurance coverage/financial issues, etc. The planning and follow up for a procedure can be more complex than the procedure itself. Cath lab operations are, I would posit, an art and a science, and a craft that has by no means been absolutely mastered to a Zen-like level of autonomous functioning by the 3+ different cath labs I have experienced back home in the States. It goes without saying that the ambitious effort to develop de novo catheterization services in Tanzania by the JKCI and Madaktari (the NGO that I am volunteering with here: https://www.madaktari.org) is not immune to these challenges.

Accordingly it has been difficult to maintain a consistent 8AM start time in the cath lab here at the JKCI but progress is being made. I have recommended a few suggestions including having the general cardiology fellow take responsibility for the cath lab schedule the day prior and then having the entire cath lab team “run the list” the morning of the procedures to determine appropriateness, triage of case order, etc. We have attempted to implement these recommendations and the lab has been very receptive.

After several long days in the cath lab and rounding on patients before and after procedures, a few cases standout. A 36yo male patient with a recent inferior MI who had a residual (sub)total occlusion of the LAD that we were able to recanalize successfully with the use of over 50mm of drug-eluting stents.
Before revasularization


After stent placement
Our chief cath lab technologist and supply manager went to great lengths to ensure we had the appropriate equipment including literally running back and forth between the cath lab and the central supply to obtain the necessary stents (another logistical issue that needs resolution). A 20 yo male patient with a ventricular septal defect (VSD) who needed to undergo right heart catheterization but team hadn’t performed this procedure for over a year and were concerned about placing a 7F sheath into the relatively small statured man; he was ultimately found to have significant left to right ventricular shunting (almost 5:1) and warrants closure (percutaneous vs surgical tbd). Another 40yof with end stage rheumatic heart disease (RHD) in cardiogenic shock with cardiac cirrhosis, renal failure, and pulmonary hypertension. She did not have any cardiac cath procedures but I encountered her in the ICU after rounding on some of our post-percutaneous coronary intervention patients. She had marked abdominal ascites and was in severe respiratory distress, and I recommended a paracentesis. She had previously had multiple paracenteses over the past few weeks, which were performed using an angiocath needle (usually used for IV placement) but it was clear that her ascites was becoming refractory in the setting of inoperable RHD and decompensated heart failure. However placement of a traditional peritoneal drain (generally only performed for refractory ascites for palliative purposes) was not possible as there are no formal paracentesis kits in the hospital. A visiting Chinese ICU physician recommended placing a central line into the peritoneal space which he did successfully and allowed for gradual/safer removal of her ascites without repeat abdominal puncture over the course of the following several days with improvement in her shortness of breath.

Working with my Tanzanian and international colleagues and caring for the incredibly gracious patients with a surprising degree of advanced atherosclerotic and non-atherosclerotic CVD has been eye-opening and amazingly rewarding. I hope the benefit has been mutual and look forward to my return visit.

Developing Cardiovascular Care in Tanzania


Mazen Albaghdadi, MD MSc
Graduate Assistant, Interventional Cardiology
Fellow, Vascular Medicine and Intervention
Massachusetts General Hospital
PGY9

Developing Cardiovascular Care in Tanzania

I was delighted to return to the Jakaya Kikwete Cardiovascular Institute (JKCI) at the Muhumbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. It’s been a year since I last visited and I was eager to see the progress that has been made in the cardiac cath lab where I spent most of my efforts training local cardiologists in the techniques of interventional cardiology.  After arriving, I reviewed with my local colleagues 2 cases of ST-segment elevation myocardial infarction (STEMI) that had been treated the day before my arrival at the JKCI. I was impressed by their ability to technically and logistically manage the care of these complex and severely ill patients. Equally impressive, was the evolution of a referral network that transferred in these patients to the JKCI from surrounding clinics and hospital. This network has steadily been evolving since my last visit, and requires the concerted efforts of administrators, clinicians, and most importantly the trust of patients and the community.

Division of Cardiology Weekly Meeting

Based on our discussion of the STEMI cases, I was asked to share a case. I had the opportunity to present a case at the Division of Cardiology weekly meeting. It was excellent experience, but unique in that I was flanked by pharmaceutical industry banners….a new experience in my short and non-illustrious academic career!

Thursday, June 29, 2017

Leaving

Pediatric Hospital Care in Uganda
Scott Nabity, MD, MPH
Resident in Medicine-Pediatrics at MGH
PGY 4

Leaving
February 3, 2017

When the time comes to head back to the U.S., I feel both positivity and regret.
The positive excitement largely represents the longing I feel for the return to comforts of home, familiarity, friends, and family. It also comes from reflection on the contribution, regardless how small, my interactions may have had on the work of frontline Ugandan clinicians. Regret, conversely, seeps from a place where not giving enough and missed opportunities reside. While the clinical need appears endless, we are not interminable beings, and sustainability requires some attention to self. Choosing impact rich activities helps, too.

Teaching session for staff at a district health center
During my last trip to MUST, I was given the opportunity to break away from the main hospital and see the workings of one district health clinic. In exchange, I was asked to given an educational lecture, a simple but brilliant arrangement. I talked about pharyngitis, something the clinic staff had asked to learn about. They simplified a complex health system for me and walked me through some clinical decision pathways where only clinical impression is at play. While I’d also spent an afternoon of clinical work in the hypertension clinic, I surmise the lasting effect of a few hours of educational swappery far outlasts the impact of a few blood pressure measurements and med changes. I hope I added something to the armory of the bright Ugandan clinicians I interfaced with then. They had clearly taught me more about how to navigate an environment where resources are limited.

The MGH-MUST Global Health Collaborative is an established, multifaceted, long-term investment in research and education. Over the course of three years, the collaborative provided me freedom to better identify sustainably oriented opportunities in such settings, even when strictly short-term in contact and scope. Because we often arrive focused on hard outcomes – abstracts written, research studies funded, gadgets produced, procedures performed – the simplicity of exchanging information as the desired outcome can fall aside. Hard outcomes are important, but so are the soft ones. I’m fortunate to have had the privilege to learn about choosing wisely.