Thursday, March 2, 2017

Updates from the Step-down Ward

Good evening! 

It's been a beautiful day in Kigali. Our patients were perking up like flowers in the sunlight after yesterday's rainy weather. Three of our six post-op patients have transitioned from the Intensive Care Unit to the Step Down unit with pacing wires and chest tubes being taken out. They are returning not just back to baseline, but doing even better than they were before surgery now that they have their new valves.

So what does all this mean? Intensive Care Unit (ICU) and Step Down? Well, that is one of the things as a medical student and up and coming resident I am learning. Determining how far along a patient is in their recovery and if they are ready for less invasive monitoring is one of the most important aspects of post-operative care. I have had the opportunity to discuss care in the ICU with the intensivists as well as surgical residents and learn about ventilator settings, the type of medications, and monitoring patients are on while in the ICU. And today I had the opportunity to talk to Sue Ellen, the nurse in charge of the Step Down unit to discuss the difference between ICU and Step Down and the different goals for transition out of each.  

The goal of the ICU is  immediate recovery after surgery. This includes recovery from the effects of anesthesia, intensive monitoring for life threatening complications of surgery such as bleeding or stroke, and removal of lines and wires that are placed on them for surgery. Once we have monitored their vital signs, blood pressure, breathing, heart rhythm on an EKG, and made sure there is no bleeding in their chest, monitored by output from a tube that is placed in their chest at the end of surgery, and the patient appears to be doing well, they are transferred to the Step Down Unit.

The goals of the step down unit are to optimize the patient's condition and prepare them to go home. A challenge unique to the work we do in Rwanda is that they do not have the accessibility of visiting nurses and medical care that we have in the United States. Therefore, before patients leave we must make sure they have the education and resources to get the medications and follow-up care that is needed after surgery.

While the patient is in the step down unit, we make sure they are getting up and moving around, doing deep breathing to prevent complications in their lungs, their pain is well-controlled, and that any fluid built up around their heart as a result of their damaged valves is starting to come off. We can tell the fluid is decreasing with chest x-rays, listening to their lungs, and tracking their body weight.

Once the patients start to feel better the goal is to educate them on what they need to know for post-surgical care, about the Warfarin medication they will be on, and making sure they are connected to a local physician who will be able to monitor and manage them. To educate the patients we have local nurses who translate and work with the patients and we have videos in Kinyarwanda - the language of Rwanda.

When a patient does not do well after surgery it is not usually a direct effect of the surgery, it is a result of lack of follow-up care. We must make sure they will have access to the medications we discharge them home on, that they are available in the country and that they are inexpensive enough the patients can afford them.

Educating the patients is essential for them to be able to advocate for themselves once our team has left. For the same reason, it is important to educate the patients' families as well as the local nursing staff - together they can all advocate for the patient to ensure strong follow-up care.  

Our first patient Emmanuel is doing extremely well. Today, one of our nurses in training, Sam, began speaking with Emmanuel about possible barriers to his follow-up care so we can figure out ways around potential obstacles that may arise in terms of patient education, finances, transportation, etc. Sam and Emmanuel are pictured below having this discussion. Emmanuel gave a big smile when Sam asked him  if he would mind me taking his picture for the blog post today. I am so happy to see him smiling and feeling well again. 

I will post more as the week goes on and we see our patients in the step down unit walking around, talking, watching videos, sitting outside and starting to feel even better than they did before their surgery. 

Have a great day everyone! Until the next post…

~Bridget C.

Patient Emmanuel receiving post op teaching

Dr. Bruce Leavitt with one of our patients and his father

Volunteer Judy Sgantas with one of our patients and her family

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