Tuesday, May 2, 2017

Cardiothoracic Surgery in Nigeria

Asishana Avo Osho, MD, MPH
Resident in General and Cardiothoracic Surgery at Massachusetts General Hospital

Cardiothoracic Surgery in Nigeria: Entry 2 

The clinical experience in Nigeria so far has been excellent. I have had the opportunity to participate in surgical care in multiple settings encompassing practices in both the Private and the Public sectors. My primary clinical site (Tristate Cardiovascular) partners with a private university, but currently has no surgical residents. This has meant that I have been directly assisting the primary surgeon in complex cardiac surgical cases. Our cases have included valve replacements (in both the aortic and mitral positions), reconstruction of a severely dilated aortic root and complex congenital cardiac procedures for patients with tetralogy of Fallot, primary ventricular septal defects and complex ventricular abnormalities.
 ICU staff at Tristate
From a systems standpoint, the private setting benefits from relative freedom to obtain whatever supplies are needed including ICU equipment, medications and operating room supplies. There have been some limitations based on what is attainable within Nigeria (and how quickly things are available), but for the most part these are not prohibitive. I anticipated some restriction in our ability to perform cases based on personnel availability, but was surprised to find just how tight things are. Cardiac surgeons are hard to come by (speaking honestly, my site preceptor is the only indigenous surgeon regularly performing on-pump cardiac cases in Nigeria), as are anesthesiologists, but it turns out that perfusionists – specialists who run the cardiopulmonary bypass machine – have been the limiting providers during my time in Nigeria. From conversations with the rest of the team, there seem to be only two independently practicing perfusionists in Nigeria (The population of the country is anywhere from 180 to 200 million). The scarcity was particularly evident when our go-to perfusionist travelled for a week to assist with cardiac cases elsewhere. We performed no major cardiac procedures that week and ultimately lost a patient who could not undergo surgery as expediently as he needed to.
Perfusionist equipment in the Tristate Operating room
During our “quiet” week (when our perfusionist travelled), I had the opportunity to visit with the cardiothoracic surgery team at a Public hospital in Lagos. So many differences were immediately evident, from the uniformity of scrubs – everyone wore green scrubs that were deliberately chosen to be reminiscent of the green in the Nigerian flag –, to the army of residents and medical students who made the operating theater quite a bit livelier than I had gotten accustomed to at my primary site. The company was very welcome as I had the opportunity to discuss training paradigms and patient care with residents and students. On the other hand, however, this meant that I had a lot more competition for direct, hands on operating experience. At this hospital, limitations in ICU capacity and equipment availability meant that the cardiothoracic surgery department was essentially a general thoracic surgery service with much of the case volume involving non-cardiac procedures. From my discussions with the residents, it appears that on-pump cardiac cases at this center happen on average once a year, typically when cardiac surgery teams are flown in from India, the UK or the US to perform two to three cases a day, for a week. The cases I did get to see with the team included ligation of a patent ductus arteriosus, open thoracotomy for lung resections and an Eloesser flap (This last procedure was a real treat for me to be a part of as such semi-permanent open chest drainage is rarely necessary in the US as we initiate management of chest infections much earlier, before pathology progresses so far as to need such procedures).
[Image 2c]
Completed Eloesser Flap Procedure
 There were multiple systems issues in this setting, some of which I have hinted at in discussing limitations in ICU capacity. The senior surgeon was particularly passionate about limitations imposed on him by institutional and federal bureaucracy: Every new device requires a meeting with some committee or the other; every complex patient requires a stack of paperwork. I was impressed by the barren-ness of the operating room walls, very different from the cabinet-laden walls in most other operating rooms that I have been in (The residents carry with them a basket that contains the sutures that typically fill OR cabinets).

Operating room at the Public Hospital
In all, both experiences have been quite enlightening. Nigeria is gradually building capacity to be able to consistently provide procedural care for complex cardiothoracic pathology. However, limitations in personnel and ICU capacity mean that the country is some ways away from meeting the national need for these procedures. I am eager to see how emerging, minimally invasive and percutaneous techniques can be embraced to leverage weaknesses in the health care system.  

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