Mazen Albaghdadi, MD MSc
Interventional Cardiology Training in Tanzania: Challenges and Rewards
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.
Graduate Assistant, Interventional Cardiology
Fellow, Vascular Medicine and Intervention
Massachusetts General Hospital
PGY9
Interventional Cardiology Training in Tanzania: Challenges and Rewards
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| 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.
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.
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| Before revasularization |
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| After stent placement |
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.
