Monday, April 14, 2008

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.

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.

Wednesday, April 9, 2008

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.

Sunday, April 6, 2008

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.

Saturday, April 5, 2008

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.