Bringing Erneste Home

Kayla Quinn, RN, writes:

As the road to Erneste’s home began to narrow, our anticipation grew. Ceeya, George, Suellen and I escorted Erneste to his home near Nyagihunika. As we bounced around in the Range Rover bracing ourselves for each bump, we were quietly taking in the spectacular views. Erneste handed each of us thank you notes that he wrote proudly in English. We all knew that this experience was going to be touching beyond explanation, and we are thankful for being by his side for his return.

Erneste sat in the rear of the Rover with Ceeya by his side. As he was gazing out the window, he would point out to us some of the homes that belonged to his relatives and friends prior to the genocide. Turning a corner as we neared his home, Erneste noticed his brother standing in the road with his friends. He began to chase us down the road with all of his friends in tow. Erneste’s father was eagerly anticipating his arrival as well, standing in the road surrounded by friends and family. In true Rwandan fashion, there were double hugs and many thanks to our group. From the road, we headed uphill along a small footpath. Erneste held his mother’s hand and later exclaimed how thankful he was to be able to walk to his home without becoming breathless.

Erneste and his family welcomed us into his home and had all of us sit in Erneste’s bedroom. We were in tight quarters, sitting face to face with our knees nearly touching. First, we rinsed our hands in a bucket with water, and then Erneste’s cousin presented us with a home cooked meal, including Primus. A small window in his room provided daylight for our luncheon. Following lunch, we headed to the rear of Erneste’s home. His family was so proud to show off their goats and cow. At this point, we were feeling adventurous and each tried some banana beer—eeek!

More exploration of their family farm ensued as we hiked up a hill behind Erneste’s home. Erneste was thrilled to have us there and wanted to show us his school as well—more uphill climbing. Erneste explained to us that he would have to leave for school an hour early in order to get there on time for his classes, while his little brother and sister only needed about five to ten minutes. We were introduced to his best friend once we reached his school. By this time, we were soaked, not just from sweat but also the torrential downpour that snuck up on us. Downhill was never a problem for Erneste. This time, however, he was stopped by a curious soldier who was camping out with a number of other soldiers to protect the district office from robbery.

Once we arrived back to his home, we grabbed a seat outside. Each of his parents made wonderful thank you speeches and presented us with gifts of baskets filled with fruit and nuts. The emotion of Erneste’s return was apparent to all those present. Erneste asked for a picture with his two mothers. Ceeya and his mother were touched by his request.

The time for our departure was nearing. We were escorted by the group downhill to the Rover with an air of sweet sadness. We were certainly happy to bring him home, but he will be missed until April when we return again. Erneste wanted all of us to extend another special thank you to the members of Team Heart who helped make his journey and surgery a success.

Back in Rwanda

Team Heart members Ceeya Patton-Bolman, Suellen Breakey and Kayla Quinn are back in Rwanda this week, working alongside and learning from Australia's Operation Open Heart Team, which is performing life-saving heart surgery on Rwandan children at King Faisal Hospital.

Ceeya writes:Our small team of three arrived in Kigali last week to join Operation Open Heart. It is a wonderful opportunity for us to evaluate our educational goals for next April and synchronize with the Australian team. The supplies we left here are intact, and the unit looks great with Brigham-donated monitors. Many thanks to Kumar and his Kigali-based team of bio-meds.

We are having a wonderful time meeting up with old friends and colleagues, and we were delighted to see two of our patients doing well. A highlight was seeing Erneste reunite with his dad for the first time in six months upon our arrival at the airport. He was VERY happy, as he says! I visited a potential boarding school with him and was pleased with the emphasis on academics and good physical facilities. Both will be good for him.

How excited we were to seee Egidia's brother (above with Erneste)! No trouble trying to identify him. He looks just like Egidia and has that same wonderful personality. He cannot wait to see her in April when she joins us for Team Heart 2009.

Today, Kayla is working in the stepdown unit, and Suellen in the pediatric ICU. I think the Australians are very appreciative of this. Both are happy to pitch in and do what is necessary to help--a quality most valuable in Team Heart members.

Tomorrow we take Erneste home and, although I am sure I will be sad in many ways, I am very, very happy for him. He looks wonderful and is enjoying life. Who would know that he had a double valve in July after being so close to death? He is the answer to the question of why we do what we do. So many people played a large role throughout the Brigham community and Team Heart is so appreciative.

As we return him to his remote village, he has convinced Suellen and I that, since it is eight miles uphill from the nearest road, we must take a moto-bike on a single path dirt track. Of course Kayla is thrilled to do so--she cannot wait. She is also in her 20s! The vote is not in on the method of travel yet...

From Jose Zeballos, MD

Today the last three of our patients are leaving King Faisal Hospital in good health. Vedaste and Samuson will be heading home here in Kigali, while Jean will be taken by Dr. Schulze, cardiologist, to Butare Hospital closer to his home town.

The many obstacles that previously would have made this transition diffilcult have been facilitated with the availability of internet. Technology has allowed us to communicate and pass off patient information with ease and will allow us to provide follow up care as closely as we would back home. Patient history, lab results, discharge summaries, follow up echocardiogram results and medication lists are a few of the items listed.

This was initially proposed by Dr. Rawn, and thanks to John Connell my co-resident, my job was made easier in putting the information together to pass off to our colleagues here in Rwanda. We've even found a nurse who will be trained to oversee each patient's progress in regards to antigoagulation and follow up. It seems appropiate that today is also the first day of follow up for one of our first cases. Jean was seen by Dr. Bukhman today and is in good health. Dr. Bukhman will follow some of our patients and has been extremely helpful in helping organize each patients follow up.

On a personal note, although I did not get to be with the whole group, the experience was just as rewarding and at the same time inspiring. I have to thank Jo Fagan for her help with the patients during my last few days here and Leslie for a well thought out plan for me to be ready for whatever may happen. What once was a thought, maybe a conversation, is now a life-changing experience. Thank you all.

Above, Gene Bukhman provides follow up care to one of our patients.

From Leslie Sabatino, RN, clinical coordinator

Good Morning,I am here this morning after a long night's sleep and shower and I am wondering what to do. I have been in a constant 'frantic' rush for the last 9 months to get things together and packed, make sure everyone is comfortable, and this morning I feel quite lost and confused. I have no where to run to or calls to make today. It is an odd feeling.

Yesterday, I came home to the most beautiful banner that my family had draped across the front of my entry way. It had all of the Team Heart member and patient pictures with blog entries. To see all your faces and the faces of our patients at my home had the most emotional response from me.

WE DID IT!!!! We changed 11 people's lives forever and for the better, and we should all be proud. The ripple effect will be unknown to us but you should all know it is there. These patients will be able to finish school, help their families or return to their work.I will hold a special place in my heart for all of you and for all you did. The long shifts, innovative treatments, and lack of sleep for many is very, very appreciated. What a Team Heart Spirit.These are the true rare moments that make life worthwhile. I miss you all and will see you all very soon.

From Ceeya Patton Bolman, RN, program coordinator

I sit in an empty ICU and reflect on what the past 10 days have been not only for us, the 36 members of Team Heart, but for those patients who do not share a common language and yet entrusted us to provide their care.

It was an eerie feeling to transfer the patients out to the surgical ward, and I had forgotten in the past few years the incredible emotional connection physicians and nurses develop with patients in that critical period. I was dreading moving that last patient out...and returned to find it empty. Leslie--after working all night--showed up at the right moment and moved him over, so I would not be alone!

We leave many friends, both at King Faisal and Partners In Health, and it is hard to say goodbye. We will take a group photo of those we can gather...3 patients have been discharged, happy as can be with huge smiles and hugs all around. One patient remains in the King Faisal ICU for monitoring heart rate, but I think we can walk him outside for the photo. All the others are in the surgical ward in 2 rooms and doing well, supporting each other. I walked in yesterday and they were lined up at the mirror checking out incisions!!!

To cover all bases, we pray and keep our fingers crossed they will continue to improve to go home soon.The local team is feeling more confident and is under the leadership of Dr. Joseph Mucumbitsi, Dr. Mugisa, Jo and Dr. Joseph, and they have Gene and Jose for the following week. I have no doubt they will continue to provide care at the same level and, thanks to Jim Rawn's computer skills and google docs, we all can follow the lab values from wherever we are!!!

We miss our team members. Thanks for all the incredible well wishes...we all teared up at Prem and Chip's emails. We head home in a few hours and will see you all soon!!
Murabeho! (Goodbye in Kinyarwandan)
Ceeya

From Chip Bolman, MD, chief of Cardiac Surgery

I got back yesterday p.m. The trip was an unbelievable experience, probably the most intense and powerful of my life. We operated on 11 Rwandan patients, who came from the four corners of the country. Fortunately, despite extremely challenging conditions and various equipment shortages and breakdowns, they all survived and are doing well.

These are some of the very most forgotten and disadvantaged people that could be found anywhere. One young man was personally driven to the hospital by Paul Farmer from the refugee camp where he lives in the eastern part of Rwanda. All the patients had huge hearts, and very late stage disease, which was it's own challenge. Our visit coincided with the 14th anniversary of the genocide, so alot of stuff like restaurants, the hotel gym and pool, etc. were closed for the entire week.

The Rwandan nurses and doctors and staff were very helpful, to the limit of their training and background. Our team of 35 people all worked very hard, and, believe it or not, we need a few more to do this without overworking certain elements of the team. It was a remarkable time, and I think everyone found it quite transforming and moving. There was so much we did not know, and to have it ultimately go so well is very gratifying for all of us.

The patients were so brave- they had absolutely no frame of reference for this, as no one in Rwanda has previously had heart surgery, and they let us do huge operations on them. On top of that, we did not even speak their language. They were also quite stoic after surgery. All the patients lost family members in the genocide, some lost their entire families. They, as well as our hosts in the hospital and the Ministry of Health of Rwanda, were all exceedingly grateful to the team for giving them some hope. All in all, an experience unlike any other. As my friend and scrub nurse from Minnesota said, it seemed as if we had been preparing for this for our whole careers.

The members of Team Heart performed above and beyond the call of duty, by any measure I can think of, and all in an environment that was consistently outside their comfort zone, in terms of equipment, communication, monitoring, you name it. I know no one really wants or needs any credit or public praise for their participation, nonetheless, I would like to introduce each team member and her/his role in accomplishing the mission.

Vlad Formanek and Luigi Nascimben- Anesthesiologists
Radhika Dinavahi- Anesthesiology Fellow
These three did every case, and provided superb teaching and clinical support, including transesophageal echo with a finicky TEE probe.

Gene Bukhman- Cardiologist
Pat Come- Cardiologist
Gene is 50% at Partners In Health in Rwanda, and he diagnosed and cared for the Rwandan patients. Furthermore, he selected the patients for surgery, and will be providing critical aftercare. Pat provided dedicated, highly-competent and timely cardiology support for all the patients, and helped us make decisions regarding case selection and post-op care.

Brenda Graham- Respiratory Therapist
Felix Gregorian- Respiratory Therapist
These two provided excellent support to our post-op patients, achieving early extubation in virtually all within 2-6 hours, and helping them maintain good pulmonary function.

Mike McAdams- Perfusionist
Amy Patel- Perfusionist
What can I say? They both did all the cases together. They developed successful methods to maintain patient temperature, after the heater-cooler failed. They provided consistent help and good humor, wherever needed.

Katie Morrison- OR Theatre RN
Jonnye Mastel- OR Theatre RN
These two provided great support in the Theatre, setting up, scrubbing, cleaning instruments, unpacking, packing instruments. They were great help for us and the patients, and their dedication was awesome. Jonnye came from Seattle, where she had moved from Minnesota. She was the main cardiac nurse at the U of M when I was in training and later on staff.

Jenn Loayza- Surgical Technician
Jenn was tireless in helping set up and circulate and support the cases in the Theatre.

Nurses- ICU
Susan Gabriel
Susan Hall
Lisa Kelley
Rhonda Martin
Kevin McWha
Leslie Sabatino
These guys were superb. The patients received Brigham-level care, and the Rwandan nurses received a great education.

Nurses- Ward
Marie Caulfield
Pavel Nelyubin
Kayla Quinn
Denise Ricci
Terry Roche
They provided very dedicated care, with not much equipment, and served as an amazing resource for the Rwandan nurses, patients and families.

Suellen Breakey- Nurse Educator
Suellen worked with Egidia Rugwizangoga, our Rwandan nurse at BWH, to develop educational materials in the native Rwandan language, Kinyarwanda, that were a huge hit. It turned out they were the only reading materials in the hospital, and the patients and families, as well as the nurses, read them all the time. She did alot of nursing as part of her education efforts.

Jim Rawn- Cardiac Intensivist
Jim provided very disciplined care, rounded consistently with and taught the Rwandan doctors and nurses, and organized the clinical information electronically, so patient care and followup would be more facile.

Resident Surgeons
John Connell
Jose Zeballos
John worked tirelessly to care for the ICU patients, and to scrub in the Theatre, whenever possible. We finally had to make him leave and go to bed. He stayed in the ICU physically every night we operated. Jose arrived near the end of the trip to provide ICU care.

Barry Shopnick- Surgical PA
Barry was a bulldog. He was in there on every case, beginning to end. Even though Prem and I scrubbed on nearly all the cases so that we could both see all the pathology, Barry was the first assistant almost all the time, this despite not feeling the best at all times.

Jono Devasagayam- Biomed Technician.
Jono was amazing. He came from Australia, having met part of our team in October during their visit to operate on children with CHD. He provided outstanding
technical support, including setting up all the Brigham monitors that were sent over for the ICU, Theatre, and Stepdown. He's also a great guy.

Scott Chassay- service technician
Scott came to service the Sarnes heart-lung machine. He worked with Mike and Amy to keep it functional.

George Shortis- Pharmacist
Also from Australia, George is an entrepreneur who does these trips 6-8 times per year, and does whatever is necessary to help. He also provides great pharmacy support.

Surgeons
Prem Shekar
Yours Truly
We enjoyed working together in case selection, choice of procedure, and scrubbed on most cases together, at least long enough to see the critical anatomy, and to help one another as needed. Thank you, Prem. It was a pleasure and a privilege to work with you, and the patients are definitely the beneficiaries of your expertise.

Diane McCormick- Photographer
Liz Smallcomb- Writer and Video Producer
These two ladies documented the experience and were a true joy to work with. Their enthusiasm, sensitivity and class added greatly to the entire atmosphere.

Trip Coordinators
Jess Lynch
Bill Garside
These two people took care of the countless activities coordinating the non-medical side of things, from checking us into the hotel to arranging transportation, to helping unpack and pack, and many other tasks as well. Jess is my niece, and it was a joy to be with her. Bill manages the NightShift- need I say more?

Last, but certainly not least, the two great ladies who basically made this all possible: Leslie and Ceeya
Rather than try to list their respective contributions to this trip, let me say that the two of them are an incredible team, in their own right. They worked together beautifully for many months, out of the sight of almost everyone, constantly staying on task, making sure nothing was forgotten, fighting the constant procurement battles, the shipping saga, keeping us all focussed on the mission at hand.

Once they arrived in Rwanda, they got everything organized, and provided day-to-day and minute-to-minute encouragement, problem-solving, anything and everything necessary to get the job done, and done right. I have only known Leslie through this process, and I am obviously biased when it come to Ceeya, but I am tremendously proud to have done this with both of you, and know that we truly couldn't have done it without you both. Quite fittingly, at the end of the trip, the two of them ended up being the last two nurses there, working with Jim and Jose and their Rwandan counterparts to ensure a smooth handoff of all the patients. Thank you.

Thank you to all the members of Team Heart for all the great work, and for sharing this unforgettable occasion.
Chip

From Paul Farmer, MD, co-founder of Partners In Health

Paul Farmer surprised Team Heart with a visit to King Faisal Hospital this week. Above, he and Ceeya Patton-Bolman greet Alice, who underwent mitral valve replacement the day before.

“Blog” from the mountains of Northern Rwanda

It was awesome—not a word I use lightly—to stand in the anesthesiologist’s spot (“behind the blood-brain barrier,” they used to say at the Brigham) and to watch Chip Bolman and an ace team from BWH cannulate the aorta of a 26-year-old man about to undergo mitral valve replacement (Prem Shekar has already done a big case that morning, so this was the second one of the day).

I’d had the good fortune to transport Jean-Claude Muhozi from rural southern Rwanda, where he lives in a refugee camp, to King Faisal Hospital, where “Team Heart” is repairing the valves and lives of many young Rwandans this week. It was awesome medically, as it always is when the pericardium is opened; it was awesome personally, as someone who has fought alongside many others to make sure that quality medical care be made available to the poorest; and it was awesome spiritually to see, on the exact anniversary of the 1994 genocide, that the power to heal continues to trump the power to maim, sicken, or kill.

Who knows what Jean-Claude, who lives in a tattered refugee camp with his brothers, has gone through even prior to falling ill with valvular heart disease that has made him cough and gasp for breath for years?

It was of course great to see nurses and doctors and techs and PAs from the Brigham, some of whom I’ve known for almost 20 years, here in Rwanda; indeed, a couple of them had been to our site in Haiti too. The members of this team are not only saving the lives they touch here—for who could imagine that a young man like Jean-Claude would have a chance without a team like this, providing its services free of charge to the patient?—but are also serving as living links between Boston and Rwanda. The members of this team are reminding people here in central Africa and in my native country that to be poor and sick should not mean a death sentence. The members of this team have done nothing less than lift a death sentence from those served, all of them symptomatic and facing grim prospects, at the same time that they have lifted the spirits of the patients, families, staff, and students here in Rwanda.

Two nights previously, we had a small dinner with the senior surgeons of Team Heart, some friends from the Ministry of Health, and members of the Partners In Health team based here in Rwanda. We had a nice meal and some toasts. The most moving one, for me, was from Dr. Innocent Nyaruhirira, who as a young orthopedic surgeon finishing his training in Belgium decided to return to his native Rwanda in 1994 while this continent’s worst mass violence was in full swing. Although his teachers counseled him to remain in Belgium, he returned to care for trauma victims of all sorts (landmines were then a huge problem here). He recently served in the Rwandan cabinet at the level of Minister and has been, since prior to PIH began working here in 2005, one of our best friends here; he’s now the Executive Director of KFH. He raised his glass to the team from the Brigham and reflected on the mass violence that had interrupted his training, noting only that, as a physician, he could think of nothing more important than seeing that efforts like those launched this week continue to flourish.

There: this is my very first blog entry, and I hope I’ve done a decent job. I’m now up at one of our rural sites high in the mountains of northern Rwanda. I’m so grateful to Ceeya Bolman, Leslie Sabatino, our own Gene Bukhman and all the others, including the staff at KFH, who made this miraculous week come to pass. Those of us who are “implementers” in the field understand, I think, some of the complexities around logistics and procurement that you’ve had to address and overcome. We join the patients served, and their families and caregivers, to say Murakoze cyane—thank you so much!
Back to Team Heart Official Blog.

From Chip Bolman, MD, Chief of Cardiac Surgery

We are off and running.

We did our first surgery Saturday, a 25 year-old with an ASD, a congenital defect in the septum between the upper chambers of the heart. He did very well- extubated very early, came out of the ICU on day 1, and was surrounded by his family.

Today, we performed two more surgeries: an aortic valve replacement for post-endocarditis aortic insufficiency, and a mitral commissurotomy for rheumatic mitral stenosis in an adolescent. Both went very well.

The Team has been unbelievable- no surprise- and have all been working extremely hard. Everything here is just harder, at least the first time around, and the amount of energy required to set up and perform these operations, and to care for the patients afterward, is surprising.

During our first operation, we had technical difficulties with the heater-cooler. Fortunately, that patient did fine. Ceeya and John Stephens, the former hospital Executive Director, aided by Mike Gilfeather at home and by Jono, the Australian Biomed. Engineer par excellance, have spent all day trying to locate another heater-cooler. Amazingly, they have succeeded, and one will hopefully be arriving from Mombassa, Kenya, tomorrow, Monday, April 7.

This has so far been a fairly overwhelming experience for all of us. Several have visited the Genocide Memorial and an orphanage. These are profoundly moving experiences. This week is the 14th anniversary of the 1994 genocide, and will be marked by services and periods of reflection. The atmosphere is very subdued and somber.

The fact that we are here trying our best to put lives back together stands in stark contrast to what has gone before, and the people here are quite moved by it. We are just trying to put one foot in front of the other and get through the days and cases the best way we can. It is truly a privilege to be able to be here and to try, in some small measure, to leave things maybe slightly better than we found them. More important, we hope to establish a firm and positive foundation upon which to build in the future.

Back to Team Heart Official Blog.

Heart Failure in Rwanda

Heart failure leaves thousands of young Rwandans literally gasping for breath and slowly suffocating for years on the brink of death with little access to the life-saving surgery they desperately need.

The heart failure patients Team Heart will operate on beginning this weekend were screened and identified by cardiologist Gene Buhkman, MD, of Partners In Health (PIH) and Brigham and Women’s Hospital, who works six months of the year in Rwanda treating patients.

PIH first became involved in Rwanda in 2005, working with the support of the government to improve the country’s rural health systems.

“We found that a huge portion of the patients we saw in the hospitals and clinics had heart failure,” Bukhman said. “The causes of the disease here are very different than in Boston and the rest of the U.S., where most heart failure patients are elderly.”

In Rwanda, the average age of a patient with heart failure is 35. The disease mainly results from cardiomyopathies not caused by heart attacks, and two causes virtually eradicated in the U.S. thanks to available treatments: malignant hypertension, or skyrocketing blood pressure, and rheumatic heart disease, caused by untreated strep throat.

“There is a lot we can do for these patients, even after they have been deprived of health care for so long,” Bukhman said. “We are working to prevent new cases from occurring by making medication available. For patients with advanced rheumatic heart disease, surgery is the best option.”

But few hospitals in sub-Saharan Africa have the capability to perform heart surgery.

Bukhman said that Joseph Mucumbitsi, MD, the only pediatric cardiologist in Rwanda, and the Rwandan Ministry of Health are steadfast in their commitment to get heart failure patients the care they need by sending them outside of the country for surgery when possible and opening King Faisal Hospital’s doors to groups like Team Heart and Operation Open Heart, an Australian cardiac surgical team.

“Cardiac surgery is not affordable for anyone in the country,” Bukhman said. “And there are many barriers to ensuring good outcomes after surgery. One of the great things about Team Heart is that it also is committed to helping remove other obstacles patients face that could prevent them from staying healthy after surgery.”

Back to Team Heart Official Blog.