Sunday, February 19, 2012

Almost home!

It has been a long journey through many countries but I'm almost home. So far I've been through: Rwanda, Uganda, Brussels, Montreal and Toronto. Currently sitting in Toronto waiting on my delayed plane and praying the snow in Raleigh holds off until I can get home! It was nice to finally get Starbucks in Brussels (whatever time that was!) with Judy Kay before we went our separate ways.
It was a great trip this year full of lots of team work and I can't wait for next year! Also can't wait for my bed and shower tonight!

Friday, February 17, 2012

Signing off to our Rwandan Collegues

Suellen ( ward RN leader) and Dr Joseph Mucumbitsi taking to Theopista

our Rwandan collegues getting report and taking over Team Heart pt

Our hardworking Gita signing off

Ceeya teaching valve types to pt Jean Diodonne

Susan Gabriel and Jean De Dieu ( operated in 2009) visiting

Team Heart founder, Leslie Sabatino packing up

More pictures from Team Heart 2012

Chip and Paige Bolman

our first patient of 2012   Jean De dieu

Ceeya and Chip taking a break after a long day

Susan and Connie ( resource nurses) passing on report in the ICU

our triple valve patient Diodonne ( a strong boy)

Dr Dimitrios hard at work

Dr Maurice ( Rwanda cardiac surgery canidate)

Dr Maurice, Jabaris, Joseph, Gita, and Dimitrios

Pat and Jolie


Erneste, Kevin and Alexis

our important words

jolie and husband walking to the ward

Rich our pt from the class of 2011 with a gift and his caretakers

Pat Come, Diodonne and Connie

pals celestine and Jean de dieu

Team Heart 2012
Team Heart 2012 Patients and Staff say Goodbye

Today we left our patients in the good care of our Rwandan collegues and said good bye.   This is always a sad and difficult process.   It was buffered by a visit from our former patients who look and feel wonderful.   This is one of the first times all if of our patients were together at the end.   This was truely a wonderful mission.    

Tuesday, February 14, 2012

Surgery Complete Team Effort!

Yesterday was a long day with the last two patients rolling out of theater, one returning for exploratory for bleeding, but now doing well. This week has been heroic effort by the theater (nursing, perfusion anesthesia, surgery) and ICU team, working long-long hours, but as a finely tuned machine. It is hard to leave the others also desperate for surgery here......but we are happy the Spokane team will be here in two months.

Morning rounds, pictured here, with Team Heart began in ICU and illustrates the strong sense of working together. Our quiet warrior, Dr. David Morrison has been phenomenal, although, he is not concerned with titles here. He is so quiet is is easy to take him for granted....he does everything needed before it is needed and works well with everyone. To say we could not do this without him is trite--there is no way! He works well with the nurses and listens to their concerns and values the care they provide. If David is ever irritated , you have to work hard to find out. We have come to love and appreciate the calm and thorough way he cares for each patient. He has has a strong team, Jabaris (we miss him) Dimitrios, Maurice (Rwanda) and Gita.

Thank Goodness Bobby Oakes was here doing everything it takes. He stayed over in ICU when needed for long hours and we have to credit our good fortune not only for his skill in theater--but his willingness to do what ever it takes to provide the best care. He should be landing in US about now, waiting to connect to Lincoln. He had the ultimate compliment from the the theater nurses who all three wanted to scrub with him.

Step-down is full and overflowing with 12 of 16 patients moved over and now have a chance now to move forward in their life. Hopefully Sueellen will have a long newsy entry today....I love watching the patients support each other, each clutching the bright red Shumsky Therapeutic pillow, as they walk and begin rehab.

A surprise visit this morning is Emmanuel Nteziryayo. He had an email from Ashley we were here, so he came to visit for his post op echo and he looks fantastic. Emmanuel had a pericardial stripping two years ago, days from certain death. He is in driving school currently, and hopes to become a taxi driver. I hope Taufiek sees this, as he sends his greetings to the team not here on this trip! Just another reinforcement that the patients return to productive members of their community and again give back.

Monday, February 13, 2012

Sunday, February 12, 2012

Last night shift...feels like we JUST started!

It's my last night shift in the ICU and 2nd to last shift at King Faisal Hospital and I FINALLY have a chance to sit and reflect on this amazing here goes:  We land at the airport last Saturday after what feels like a million hour flight and I really have no idea what to expect.  The air smells good...earthy.  We load into a van like a clown car and head to our hotel.  The next day we wake up to a beautiful rolling hill view with people everywhere.  We experience the Union Trade Center (UTC) and exchange money, meet craftspeople at the co-op and meet Jean Paul (former patient and all together amazing person).  Monday we open the ICU with our fearless leader Ms. Consiglia Fail and lets just say we hit the ground running.  I admit the first patient from the OR with the constant help of Connie and Kristen and the more than helpful Bonnie (pharmacist from BWH).  His name is Jean de Dieu and he is a fiesty 14 year old (did I mention my youngest heart patient I've taken care of?)  Day 2...the patients are sick, the resources are not what I am used to and I have to find a different way to approach the care of the critically say that I have relied on creativity is an understatement.  To be completely honest I felt overwhelmed and wanted nothing more than to be home...until day 3.  Something changed and I thought to myself "Now I know why people come back here"'s pure magic and almost impossible to explain.  The people of Rwanda are amazing and our patient's are resilient fighters who bounce back from the most complex of procedures.  Day by day we recover patients and each day they progress until they move to the step down unit (SDU).  The teamwork is unreal from the OR to the ICU to the SDU...we are all there for the same help someone who would not survive without intervention.  The care our patient's get is phenomenal and the Rwandan nurses in the ICU are a dream come true.  They have stepped up and want to learn.  Their leader (also named Connie) has been such an asset and heart swells...such love and camaraderie.  We've melded together as a team...Team Heart 2012.  Tomorrow (or today for some of us) we operate on #15 and #16...our final two patients and I cannot believe how fast this has gone by.  I am blessed to have had the privilege of working with such amazing people and meeting some of the finest people Rwanda has to offer.  May our patients be blessed throughout the rest of their recovery and may we all remember the beautiful lessons we have learned from them.


OR day 7

Wow hard to believe that tomorrow is our last day in the OR! It has been an amazing trip and I've loved working with everyone. We all come from so many different hospitals but are all working seamlessly together.
One of our OR nurses is from Spokane and has been a hilarious addition to the OR! Terra is extremely hard working and even late at night after a hard day has us all cracking up!
Time for the second case of the day to go on cardiopulmonary bypass!

Follow-up to Alexis

We have had the great pleasure this week to help Alexis, a wonderful 16 year old boy who lives in an orphanage with very devoted caregivers, one or more of whom have visited him every day he has been at King Faisel. His mother is alive, but was too poor to raise him. Alexis had been unable to play with his peers, as he had had significant shortness of breath with exertion. He had kept up with his studies, however, despite his disability. On his screening echo, he had what appeared to be isolated severe tricuspid valve regurgitation (leaking of a right-sided heart valve). However, his labs came back with an hematocrit of 79 (nl is about 40-45) and the oxygen saturation in his arterial blood was very low at 77% (nl 98-100%). We had to search further, for a communication between the right and left heart, which would allow blood returning from the body and, therefore depleted of oxygen, to bypass the lungs and get into his left heart and then to his head and body. To evaluate for this communication, we injected agitated saline into an arm vein and we saw the saline contrast enter the right atrium and, then almost immediately, enter the left heart. We had found the communication between both atria (upper chambers of the right and left parts of the heart). To compensate for the low oxygen saturation in his arterial blood, his body had produced almost 2 x the amount of red blood cells to try and oxygenate his body. We then had to make sure that he did not have what we call Eisenmenger physiology where a hole in the heart initially causes excess flow to the lungs, followed by the development of high and irreversible pressure in the lungs. That high pressure would make the shunt reverse direction, sending unoxygenated blood to the body. Our echo, with a small pulmonary artery, equal to the size of the aorta, and only low velocity leakiness of his pulmonic valve (the valve separating the pumping chamber to the lungs and the main vessel to the lungs) did not support irreversible pulmonary hypertension. However, to make sure, our anesthesia team did the first ever right heart catheterization, passing a catheter from a vein in the neck into the right heart and pulmonary artery. We found a normal pulmonary artery systolic pressure of 20 mmHg. We then extensively consulted among our entire team and, via e-mail, cardiopulmonary experts at a combined adult-congenital heart disease program at Children's and the Brigham and the head of cardiac anesthesia at Children's Hospital. Our anesthesia team, led by Drs. Danny Muehlschlegal and Nelson Thaemert, and our perfusion team (they run the heart-lung bypass machine) came up with a surgical game-plan. This involved taking off units of blood and replacing it with fresh frozen plasma to correct his coagulopathy and lower his hematocrit before putting him on the heart lung bypass machine. There was concern that his baseline high hematocrit would cause him to clot in crucial areas of the heart and brain and also that his coagulopathy would cause him to bleed in other areas. On the pre-op night, Alexis developed a supraventricular tachycardia, rate 166/min on 2 occasions, but we were able to restore normal rhythm with medications. He had no chance without surgery. What a brave soul he is. He made friends with all of the other boys we have done and watched them have surgery and begin to recover, while he patiently waited while we determined his operability, tolerating a tranesophageal echo (where he has to swallow a probe a bit smaller than the size of a quarter, to better visualize his communication between the atria), a right heart cath to determine the pulmonary artery pressure (if elevated, he would not be able to be helped), and multiple visits by our entire team to determine if we could do him. I saw occasional tears from the corners of his eyes, as he looked at his fellow operated-on patients and said "I wish that were me. "We were pretty convinced of what was wrong with him, but we lacked the full heart catheterization, CT angiogram and MRI imaging that would have been available to us in the US. We knew there was a small chance that he could have additional pathology which we had not been able to detect. However, we also knew that our team offered him his only chance to grow up—we had been told that he would not be a candidate to go the the Sudan or India for surgery. Fortunately his heart had the pathology we had predicted and, with the excellent skills of our 2 anesthesiologists, our perfusionists and our two very experienced senior surgeons, Dr. Chip Bolman and Dr. Chuck Edwards, he successfully had his huge atrial septal defect closed and his tricuspid valve replaced with a mechanical valve. His blood immediately turned from blue to red. His breathing tube is now out, he is sitting up and enjoying the fact that he is alive and will feel much better. No one in our group had ever cared for this type of problem before. The orphanage has previously been his salvation and the wonderful staff there have promised to bring him back very frequently for INR checks and medical appointments.

We feel lucky to have them be our partners in restoring Alexis to a full life.

Pat Come, MD, cardiologist

Permission granted for disclosure of information from Alexis, 12.Feb.2012

My fifth year back; why rwanda is so special

       This is my fifth year coming to Rwanda with Team Heart.   I did not know until a few days ago that i am one of four team members who have made all of our mission trips.   Ceeya and Chip Bolman, Suellen and I  are the lucky ones who's schedules have allowed us to come each year.  
      This year more than any i feel this " Veteran leadership".  I sat in on the patient selection process, have worked closely with Connie ( our ICU resource nurse) in the ICU and been able to teach Rwandan staff ( and newly graduated nurse Paige) in recovering some of our sickest patients.   It has been exhausting yet exhilarating at the same time.
      Coming back to King Faisal Hospital is almost like returning to summer camp.  I see many old friends whom i share a common bond.   The ease in which we renew our friendship is a testament to strength of our bond from previous years.  I think the most dramatic change is watching someone like former patient Erneste Simpunga, who i met in 2008, help recover from surgery in Boston that year and watch grow into a strong, bright young man.   He recently graduated from high school and would like to be a heart surgeon someday.  He always comes back to encourage our patients and recently i was drawn to both tears and laughter watching him teach and comfort our 16yo orphan patient.   He was giving Alexi and his caretakers some preoperative advice and i was in awe watching him.   He was so confident telling this frighten, young boy he must concentrate on 3 things before surgery to achieve success.

1.  He must have confidence the surgery will go well.
2.  He must pray to God to keep him safe and guide his caretakers
3.  He must do everything the medical staff tells him to do and he will recover strong like him.

I think this is sound advice to every person undergoing surgery!

    I am not sure how to express this except i feel a spiritual presence in Rwanda and with our patients unlike any other time i have felt.   Maybe it is the raw desperation of some of our patients,  maybe it is the beautiful way they recover from surgeries it would take days or weeks at home for my patients to  recover from or maybe it is the touch of hand and the gratitude in their smiles and eyes.   I truly feel like God is guiding our work and it is a special place to be.   I feel fortunate and blessed to be here.  You can fall in love with Rwanda and Africa.   I have.

TEAMWORK! Felicity!

During the past week we have had great nursing support from the King Faisal ICU.Both Connie, nurse manager HDU where we are located, and Judith, nurse manager of ICU have been here for whatever we need--negotiating with customs and bureau of standards inspection, as well helping provide care. We know three of the nurses from the past, always favorites, (Clementine, Idi, and Placide), and now joining, a new addition to the ICU, Felicity. It has been a pleasure to work with all. Felicity has been incredibly helpful during her day shifts. She is a dynamo of action, and always anticipating needs of both the patients and the team. Taking full patient assignments, today she is assigned our triple valve patient who has been in unit for a couple of days, doing well, but needing the expert care she provides. She has wonderful credentials and has a vast knowledge base from previous positions of working throughout cardiac surgery programs. What a pleasure it is to be on the same team!

Saturday, February 11, 2012

Mr. Fix-It and Ms. Personality

A few of us here feel like something should be said about the Healing Heart members from Spokane, WA. Though Jim and Terra make up a small fraction of this year's team, their presence here is imperative. Terra signed on to come with us at the last minute when one of the OR nurses had to back out because of a car accident. She arrived ready, no-nonsense, and raring to go. She's been an integral part of the OR team that's been working through the daylight hours since Monday morning.

Jim Dixon is our biomedical engineer, but I like to call him Mr. Fix-It. Because it seems that no matter what you put in front of him, he is able to finesse it into working order. He has adapters hidden in his pockets, a magical touch with anything electrical, and earlier I saw him fitting a rubber casing snugly to its wires over an open flame that later kept our lunch warm. I'm beginning to think that maybe we should put him into the OR and see what happens. ;)

As our personal "McGuyver", he's done a spectacular job so far, and with a "can do" attitude that gives everyone the confidence so important to these difficult operations and recovery periods. Jim's not content to sit idle. So in a rare moment of down-time, here's Jim custom-fabricating a special adapter so people in Erneste's village can charge their older cell phones with the new solar charger we brought as a gift.

And of course, with the usual shipping issues, we were missing pressure transducer
lines and with a few emails, Sandy and Michelle identified the correct box for Jim to look in, and we have pressure lines! Thank you Healing Hearts!

Each year we are blessed with individuals that seamlessly integrate into the flow of things while bringing their unique talents to the table, greatly improving the outcome. These two are no exception!

OR Day 6!

It's hard to believe that we're already more than halfway done with our cases! As anesthesia residents with Team Heart for the first time, this has been an incredible educational opportunity for us. We are learning a lot about how to take care of complicated patients that we don't generally get a lot of exposure to back home. Also, practicing medicine in an environment that we are less familiar with has pushed us to be creative problem-solvers! Every day is so different and a new challenge arises every morning, but that's what keeps things interesting!
In addition to working closely with Danny & Nelson, we've gotten to know the surgical team, cardiologists, nurses and procurement engineers better these past few days and it's so great to be working with a group of energetic, dedicated and fun-loving people! We feel lucky that we were invited to join such a great crew! Days in the OR can be pretty busy and intense, but its always so refreshing to walk down the hall and see our patients in the ICU and step-down doing so well. We look forward to another few days here in Kigali with Team Heart!
-Trusha & Joyce

Today is Saturday in Kigali. It is like a holiday for us, we have had many visitors, and all tell wonderful stories about their lives. We love seeing Deborah, Richard and Jean Damascene (2011). Yesterday Suzan and Delphine visited. Marilyn has been keeping busy doing follow up studies and we even did an INR or two. They all are so happy to see the Team and miss those of you not here with us. It keeps us busy and focused as while we for our first patient of the day to roll out. Sighs of relief and a smile or two since word coming out things going very well. We are all so amazed and touched by the incredible teamwork. It is that stage of the trip where we are so very, very busy. For Chuck, and Alysia, here today in the unit with us, I think they have enjoyed seeing those who have captivated our hearts....And for those of us who saw how very sick they were last year, it seems nothing short of a miracle.....and now 5 minutes until the next patient rolls through the door!

Why I keep coming back

This picture shows why I keep coming back every year. One of our patients from last year, Richard, came to see us today. He came all the way from the DR Congo where he lives with his sister so he can go to a school at a reasonable price. Before his surgery he wasn't able to go to school and now he looks so good! It was great to see him today!!!


One of the most amazing aspects of watching Team Heart is how, from the moment they hit the ground, the individual members of the group, all from different hospitals, different programs, different parts of the country, immediately transform into an integrated, cooperative, well-oiled machine. I've been watching Julia Jones with awe. On our first day, we all walked into two large, empty rooms of the King Faisal Hospital with huge trunks and pallets lining the walls. Twenty four hours later, I returned and found Julia scrubbed in a fully equiped heart room, accompanied by a heart ICU, and across the hall from a cardiac step-down unit. Magically, Julia and the team transformed the place into a beautiful heart unit. And immediately went to work.

The fourth case of the week was particularly difficult. Julia was scrubbed from about 8 in the morning, until close to midnight. But I got a call around 11:45 p.m. - "Let's go shopping tomorrow - I don't have to scrub until the afternoon! See you at 7:30 a.m. I don't want to waste a whole lot of time in case I'm needed again!" Wow! I had selected a nearby and relatively "tame" market to take Julia to - we had no time to waste, after all. As the cab driver started off, I explained my choice to avoid the "traditional market" to make things easy. Well, Julia's eyes widened and she said "No! Let's turn the cab around and go to the REAL market!" And so we went where few tourists dare to tread. And we had a blast! Hopping out among rows of plantains, bags of rice and beans, crowds of women with pineapples on their heads - Julia was in heaven! We wound our ways through the stalls, bought yards of fabric and negotiated with a seamstress to make and deliver skirts, bags later that day to the hotel. We ogled jewelry, baskets, carvings. Women were amused by the sight of a Muzonga (white girl!) outside the tourists' usual haunts. But Julia's easy going style of adventure suited everyone! How did the morning end? We were laden with wares, had an appointment to see our newest friend that evening, and the phone rang to call Julia back to the OR. I don't know how she does it - and most of all, I don't know how she makes it so much darn fun!

Dayna Matthew

Friday, February 10, 2012

Exciting day in the OR

Our Rwandan Perfusionist Emmanuel is making great strides in the OR and pumped both of the cases today. This picture is Emmanuel with myself and Chris Swanton. He has the needed book knowledge and is working on the application. It isn't an easy thing to do as the 3 of us "seasoned" Perfusionists often find ourselves scratching our heads and racking our brains as these patients are far sicker than any we see in the States. And even have some diagnosis's that we don't see such as tricuspid stenosis. Tomorrows case is one of those cases that has had the entire OR team communicating on what is best for the patent and how to best handle his complicated problems. This particular patient is mentioned in an earlier blog and has undergone many tests by several different specialties to tell us hopefully all we need to be able to help him. This is one of the great things about Team Heart, we are truly a team and have excellent team work to do what is best for our patients!
Goodnight for now!

Team Heart Newbie- A note from Jeanne DeCara

Pat Come,  Jeanne DeCara,   Marilyn Riley

This is my last night in Rwanda before I head back to Chicago. I was new to Team Heart this year. I didn't exactly know what to expect but knew I'd be the company of Team Heart veterans like cardiologist Pat Come and sonographer extraordinaire Marilyn Riley who would show me the ropes. Our first day of screening started with a vehicle breakdown en route to Butare, which was fortuitous in many ways because it gave me time to get to know other members of the team like Gita Mody (surgical resident from BWH) and Saidi Kayiranga (Rwandan sonographer) who were invaluable in the screening effort that day and on those that followed. I was amazed at the severity of heart disease we saw during our screening days, and even more amazed at the grace with which the Rwandans live with their illnesses. Seeing each patient come through surgery by Drs. Bolman and Edwards (who, in addition to being incredibly skilled, are undoubtedly the kindest cardiac surgeons I have ever met)  and now walking around the stepdown unit with smiles on their faces has been a real thrill. It has truly been a privilege to enter into the lives of these patients. Even though the encounters are brief, I'm hopeful that the effects will be long-lasting. Thanks Team Heart for welcoming me to the team. It has been a pleasure. Farewell for now.

The thing about this trip....

There are so many reasons that Team Heart is such a success: the coordinators, the personnel, the country of Rwanda and its people, and best of all, the patients. I think if you asked any return volunteers this year why they do this, most likely their answer would be the patients. An example of this occurred today, Friday, early in the afternoon. There is a patient here who has wiggled his way into all of our hearts. He is from an orphanage in Kigali and was brought to us by his teacher, so we aren't the only ones under his spell. Maybe it's his eyes and the way he watches, the hopeful arch to his brow, his eager friendship with the patients already in stepdown. Surely his bright, beautiful smile, flashed on demand, coupled with his willingness to undergo any test we throw at him both play a part as well. Because this young man is sick, any way you look at it. His right heart is huge. He has an abnormal tricuspid valve that resembles a hose, and a huge foramen ovale, all increasing the workload of his heart. His apical pulse is visible from across the room and without surgical intervention his future will surely be cut short.

In order to determine if he is a viable candidate for surgery he has undergone oodles of tests to give us the information we need. Finally today we inserted a pulmonary artery catheter under ultrasound guidance in the hopes that we could finally discover the pressures in his right heart and pulmonary artery and thus whether we can do surgery or not. This young man has found advocates in every corner of this team, in anesthesia, in surgeons, our cardiologists, and our nurses. As the team worked together to procure this vital information, the discovery of his pulmonary artery pressures being within a normal range elicited surprised gasps from all present. His surgery is scheduled for tomorrow morning.

Though just getting him into surgery is a win, the next steps will not occur without risk. But he is literally in the best hands possible and no matter what happens, we're all pulling for this one.

Thursday, February 9, 2012

Operating room life

We have had several great days in the operating room with everybody pitching in to get the work done. This makes the long days so much more enjoyable. In the first picture, the cardiac surgical and cardiac anesthesia staff are (from left to right - Bobby Oakes, Danny Muehlschlegel, Chuck Edwards, Nelson Thaemert, Chip Bolman, Thomas Matthew). The second picture shows the cardiac anesthesia team (from left to right - Nelson, our patient Celestine, Danny, Joyce Lo, Trusha Govidnji). Last but not least, probably the most important people on the trip are the procurement engineers Andy Willett and David Wilson doing everything from washing instruments, getting food to fixing toilets.

Wednesday, February 8, 2012

Nightshift in the Stepdown :)

Hello from the first night shift in the stepdown unit! We have 2 patients in the stepdown ward, who are both doing well. They are both 2 days post op from single valve replacement surgery. It is amazing to see the difference in the patient's personalities once they arrive in the stepdown ward. The ward is where they started off preoperatively, so to return here is a huge step in their recovery and it is nice to see them smiling and laughing again (most of the time they are laughing at our poorly pronounced Kinyarwandan!). We are anticipating at least two more patients to be transferred from ICU tomorrow and by the weekend the Stepdown ward will be filling up.

Seen here is a picture of Angela, RN and Regine (taken with permission). Keep following...lots of good pictures of our patients and Team Heart members to come. Thanks for all the continued support.

Another surgery completed!

It's 945pm and we're finishing up our second case of the day! Drs. Bolman, Edwards & Oakes did a great job operating on a very difficult case! It's been another long day but it's worth it all to see our patients doing so well and the one from this morning is already extubated and talking!!
The one downside of Rwanda is there are no speedy restaurants so we get creative and send a few people ahead to place our orders while we clean up in the OR. Great teamwork! :-)
Things are exciting from a Perfusion perspective this year as we have a Rwandan Perfusionist working with us. He was trained in India and is eager to continue his education in perfusion and is doing great pumping cases. I'm excited to see the progress he will make as we continue in the OR!

Gorillas in Volcano National Park

Throughout the years, many of us have come to enjoy the beauty of Rwanda. In particular, the mountain gorillas are a special treat. Attached some pictures of a recent excursion, showing how playful, loving and human our close relatives really are.