Thursday, January 31, 2013

First days in Kigali!

So it begins….

Screening begins at CHUK. (University Hospital of Kigali City) with long time referring physician, Dr. Kagame. He has arranged a wonderful clinic full of the patients we are most happy to see –those who need us and have no other chance. The patients are quiet and wait their turn, some up by dawn and then having traveled 4 hours by bus. Waiting 4-6 hours is more the normal routine they expect and are resigned to. Both cardiologists, Dr. Pat Come, Harvard Vanguard, Boston and Jeanne DeCara, University of Chicago, have been through the routine before.  Pat is in her 5th year and Jeanne is returning for her second.  Both sonographers are return visitors. David Adams , Duke, Durham NC for his second visit, And Marilyn Riley, Boston, Beth Israel Deaconess for her 3rd visit.  New to our team is Julie Carragher, NP, MSN, from Braintree MA.  Everyone jumps in an begins.

We immediately see several we can help and diagnosis our surgeons will like. But all too soon we see some who we will not be able to offer a future.  Several, have such hope on their faces.

Rwanda has Universal Health Care, Mutuelle. But to even access  Mutuelle, the entry to the health care system you have to be healthy enough to travel for papers and have cash to pay even the small amount. Even to come see us, they must be able to pay the 10% co-pay. A physician assures us defensively it is a modest amount when I ask how someone so ill is supposed to be able to have the amount to register. Rwanda is quick to say “there is no such thing as free care, someone must pay”.  But for a young 18 year old who developed rheumatic fever in the first place because she did not have money to go to a physician for penicillin at age 10, now she must find several hundred US dollars if cardiac surgery is to be done.  As we leave, she sobs quietly wiping away tears. She has been told she needs cardiac surgery, and three heart valves will be needed-- and she has no money for the return trip…..the equivalent of $6.00.  It makes us all concerned as there are few listening who can change the system to make easier.  We know they say the system works. We just want it to work faster to help this young mom.

That sight follows us home, as we  muster the energy to go  for dinnerl and yes we are all feeling guilty for eating a meal. We discuss the patients we have seen, the wonderful physicians and nurses and how it must feel to them to want to do much, but do not have the equipment.  

We arrive in Kigali with familiar sights. Missing is the familiar smell which made each of us look at each other knowingly and say, we are here. In the past, the pleasant smell of charcoal always welcome us. Now with new initiatives to have safer air quality with distribution of cooking stoves, that is missing.  I am hoping the smell will not be replaced by cigarette smoke, now so popular with those bringing economic growth with construction. Even though our hotel is non smoking, the tourist ignore and smoke pours from the social spaces.

Day 2 finished in a blur.  Anxiously, we are awaiting the shipment arrival of our five pallets, known as skids in the shipping world.  As they leave US air control, we are unable to track as they criss-cross Europe. A near sleepless night for several of us, supplies figure heavy on our mind. The hospital is very low in disposables and although we try to conserve our resources, cardiac surgery requires more than most other surgery and you really cannot reuse or recycle as much as you wish.

While the team is downstairs in a very busy clinic at King Faisal, I have the opportunity to catch up on email for various open-ended arrangements. The to-do list is very long for each of us.  We love that the password works at the hospital and gives  a sense of belonging.  The walkway outside ICU makes a perfect makeshift office as the breeze is gentle, the goats baaing and there is a choir down below practicing for Sunday. It is almost calming as I log on AGAIN to see where skids 1-5 are at the moment. I know there is a holiday in Rwanda on Friday and they MUST clear customs before we can then to begin set up. If we are required to “clear second customs” on Friday, everyone will be disappointed with us for having to work on holiday.

A highlight of the day is catching up with Vianney, the HRH nurse at KFH ER who has a background in cardiac surgical care, Rwandese and now living in Rwanda.  He is accompanied by Emmanuel the Kigali perfusionist now for  2 years . Emmanuel and Vianney speak the same language as we do. They know hard decisions are in the works with patient selection. And they too, share the visions we have for the future. 

Meanwhile Vedaste, the chief procurement person at King Faisal who has been chasing an order for  over 8 months.  He takes it seriously and feels very bad as he sees anxiety climbing. He is working hard to provide solutions.

The patient screening day 2 is going well.  We have two rooms and Dr. Nathan has prepared well for the visit. He has several patients who have been not selected by us or the past teams and have been scheduled for evaluation as he feels they are ready--And they seem to be candidates. There are probably 5 who will require surgery, but can we do all 5? Our list is already near full and we have two more days of screening to go.  Hard choices are ahead as we know not everyone will be able to make it on the list.

As we walk a patient though the system for lab and radiology studies, I watch Noella immediately illustrate the compassion and care which will make her a great physician some day. Although she is serving as our translator, she sees what needs to be done and takes care of it.  Immediately playing the patient advocate, she wins everyone’s heart.

Although there are a few less patients than yesterday, we are again late leaving. We decide the only answer for dinner is pizza at the top of the hill, CafĂ© Havanna, as we walk by. The cardiologists still must upload the H & P and send to the surgeons…..still hours more work ahead.

Arriving to hotel we discover emails from our home-based team. Julie our executive director in Boston, has made contact with all who will carry a second case. She will arrange for the iStat cartridges which will be critical and can only be packed last minute.  And Steve,--wonderful Steven Senat, is still juggling supplies with Vedaste and notices we need the portable hematocrit machine to travel with perfusion.