Wednesday, March 15, 2017

Cardiac Surgery in Africa: the Rwanda Experience

Jeff McLaren
Resident in Anesthesiology at Brigham and Women’s Hospital

Posting #1: 2/24-3/4

Friday 2/24: First thing you notice about Rwanda is the smiles.  “The land of a thousand hills and a million smiles” is what our driver tells us as he picks us up from the airport in Kigali. When we arrive it is dark and we can only see the lights of the city scattered across the landscape but it is clear he wasn’t joking when he said a thousand hills.

Sunday 2/26: Today was the patient selection meeting. A group of 50+ people including cardiologist from both the US and Rwanda, Surgeons, Anesthesiologists, nurses and care coordinators sat in a room and reviewed ~40 patients for 16 surgery slots. The goal of this meeting is to select the best candidates; sick enough to need surgery now, but not too sick to be too high risk.  This decision was not one taken lightly by any in the room and I left feeling guilt that we had to choose who would be sent away. Danny, one of my anesthesia attendings did remind us that choosing was better than no choice, which is what most patients suffering from rheumatic heart disease are faced with.  We finished the day by setting up our ORs. An entire cardiac OR and ICU packed up and shipped to King Faisal Hospital in Kigali. Overall the operation is impressive and despite the location, the hospital is reasonably well equipped to supply us with the things we couldn’t bring. My co-resident Matt and I went to preop our patients before leaving. I still am astounded by the trust that the patients and their families have shown in all of us. As our translators explains the plan for the following day they ask questions appropriate to what will happen but you can’t help but feel like they don’t fully grasp what tomorrow will be like for them.

Monday 2/27:
First cases are completed. Our first two cases are straightforward without issue and the first case had already been extubated prior to leaving the hospital for the night. Matt and I met one of the two residents we will be working with over the next 10 days. Gerald, originally from Uganda is a 2nd year anesthesia resident and has been assigned to work with us over the week with his co-resident Cervant. Today Gerald mostly just watched and helped as we talked him through what was going to happen during the procedures. They have no experience in cardiac surgery except in what they have read. There is no actual cardiac surgery in Rwanda, as the only cardiac surgery done is from medical missions that visit,. Formerly there were 3 a year but now we are down to 1. There is only one cardiac anesthesiologist out of the 20 anesthesia attendings in the ENTIRE country. Mind you there are 11 million people in Rwanda. King Faisal is a private hospital owned by a Spanish company, but it is the best hospital in the country and the Ministry of Health has worked out some arrangement with them to give us OR time and space for an ICU. The hospital is like a tropical hotel in that the interior is all open to air and as I was transferring my patient to the ICU after the first case I couldn’t help but look out over the rolling hills in the distance and smile. Today was great, everyone did well and we are all excited to work. Tomorrow the patients are more sick, and will be much more challenging.

Tuesday 2/28:
My patient today was an 18 year old girl weighing 66 pounds. She looks younger than the 11 year old we operated on yesterday. She had horrible mitral stenosis and aortic regurgitation that has stunted her growth. She now has two new mechanical valves and will likely never be able to have children due to the dangerous clot risks encountered during pregnancy with mechanical valves. This is something many women here face apparently after their surgery. The inability to bear children is a scarlet letter to most women here and our group has told stories of husbands leaving because of this. She is one of the sickest patients I have ever cared for but she did very well and will be extubated soon. Today was our first real day teaching the residents. Despite being in their second year it is very clear that the learning curve during our 10 days will be steep. It was our intention to use the 10 days to have a cardiac anesthesia tutorial but based on what we have seen, Matt and I will likely focus more on more basic patient care knowledge and use cardiac anesthesia to focus on communication skills. Their knowledge base is good but their clinical experience overall is lower than those in the US at a similar stage. This is likely due to the lack of health care available. Our attendings mentioned to us that the knowledge we pass on to these trainees is likely to help hundreds to thousands as they will use this knowledge to care for many other Rwandans. Tomorrow we have some of the sickest patients we will operate on all week.

Wednesday 3/1:
Technically it is 3/2… I just got back from a washout of our first case. A very sick 15 year old girl with systolic PA pressures and bad mitral stenosis. She too looks like an 8 year old and she was diuresed aggressively over the last two days just to get her to surgery. She was already showing signs of liver dysfunction and her INR was on the rise. The case was initially complicated by a rocky return to bypass after attempting to just repair her tricuspid valve, which turned out to be futile. She instead needed a full replacement. When we dropped off at the ICU her chest tube had put out 1000ml of blood, which given her weight was just under half her blood volume. The blood bank is Rwanda is across town so as we waited for the cab to return with the blood products she was in need of, we started by autotransfusing the blood coming from her chest tube(after filtering). I have worked in one of the nations top hospitals and despite our location and lack of resources I can honestly say that better care couldn’t have been given in the US. The team here is incredible and the focus is only one thing, caring for the patient. There are no administrative hurdles to jump, only the limitations of a developing country. Eventually the decision was made to go back and look for bleeding sources. We didn’t find much… but when we got back to the ICU the bleeding had decreased. Hopefully she will be doing ok by the AM.

Saturday 3/4:
Been a couple days since writing but today was my birthday, and my first Rwandan birthday. Someone found an amazing French bakery and I had an amazing chocolate moose cake with everyone. Definitely one of my more memorable birthdays. My friend from Tuesday night is still intubated but is stable. Our concern now is will she be extubated before we leave next Wednesday. Officially our ICU team leaves next Thursday so if its not by then she will be transitioned to the King Faisal team, something that has been done before but none of us want that to happen.  We have had nothing but success over the remainder of the week and our patients continue to do well.  You can’t help but think the reason these patients are doing so well despite their illness is their young age. Our oldest patient is 37, youngest is 11. Thought their bodies have been ravaged by disease they recover so quickly. Well kinda…

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