Pallets make it to Kigali in record time!

Day 3, February 3, 2013—Pallets have arrived-O Happy Day!

Wireless in the hotel allows for emails which might arrive after we go to bed given the 7 hours EST difference. At 2:30 when we are awake and do not want to be, an email from Carol Phillips, our American River shipping coordinator alerts us the pallets have been on the ground in Kigali for 48 hours. And the transit was in 5 short days.What a wonderful job. We originally planned for 3 pallets and reserved space, but when the shipment direct to Rwanda never materialized, we cannot run the risk. We pack more supplies and with now 5 pallets, we must go on “space available”.  We plaster the outside with notes of Life saving cardiac surgery for Rwanda and a note to pass as quickly as possible.  It seemed to work.  When I notify Vedaste he is ready!! He has already filed for the permit from the MoH and picked it up.  He tells me the goods will be delivered to the hospital by this afternoon!!! All 131 boxes, and near 3000 pounds. Motrin will be passed out all around in anticipation.

David Adams and Ceeya will join Dr. Emmanuel  Kamanzi and Dr. Joseph Mucumbitisi for the follow up of the 17 patients identified in September 2010 to be potentially positive for RHD.  The screening begins at 9 and the children seem to be happy to be missing school. As they line up, they seem pretty laid back except for one little guy that seems to be rather wishing he was in school.  A highlight was a lovely little lady we identified with an ASD in that September 2010 screening. She had surgery by the Belgian team the following month!

An ASD, opening between the top two chambers, or atria often go un-noticed in an otherwise healthy child. Often the symptoms of an ASD do not appear until adulthood.  So we like to think we saved her a life-time of deteriorating health!

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 5^th 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 3^rd 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, Café 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.

December Planning Trip to Rwanda.

In mid-December BWH Team Heart volunteers Steve Senat and Leslie Sabatino traveled to Kigali with one mission in mind; Determining the barriers to order supplies direct and ship direct. A first time visitor to the country, it was clear Steve immediately loved the countryside and the people he met. He approached the task at hand systematically and immediately understood the challenges the local team faced.  Together he and Leslie identified where they could work together to meet those challenges and look for a positive resolution. It was amazing to see their heads bent close together hour after hour over a computer, as Leslie, A BWH CISU Nurse,  who knows inventory needed inside and out, and Steve, BWH operating room procurement team,  who knows where to find inventory,  excitedly met with outside vendors and hospital staff alike. This is the unseen side of a trip and one of the largest efforts to build a sustainable program. If you do not have supplies consistently managed, you will never have a cardiac surgical program….

Day 2 brought a trip to Butare. A beautiful drive down with Jean Paul, our favorite transportation expert....and a patient from 2008, we made a stop in Gitarama to meet the nurse who forms the backbone of Coumadin delivery and INR testing for about 7 of our post-operative cardiac surgical patients. It is wonderful to finally place the name and face and see the area where  she works.  Her photo is here with the Team Heart visiting group, Libertha does not get nearly the recognition she deserves for this critical need!

Gitarama Visit 12/11/12-Nurse Libertha from Coumadin and testing clinic with BWH Nurse Leslie Sabatino, BWH Operating Room Procurement Team, Steven Senat Team Heart Volunteer and Coordinator, Ceeya Patton Bolman, and BWH resident in Global Surgery and Health Equity Jabaris Swain, MD

Butare visit to CHUB brought the introduction to the visiting team members to Dr. Ganza, recently returning from training in Brussels following a cardiology fellowship.  First hand, we were able to see the challenges Dr. Ganza and his local team face, as they do not even have the basic echo machine for diagnosis available.  However, with little resources Dr. Ganza was able to present an amazing group of patients, all requiring urgent cardiac surgery. Two  beautiful and frightened  young ladies in early 20's were pregnant and with severe mitral stenosis. They will undergo elective C-sections by a competent OB team in the next few weeks before labor can begin.  They then will recover, nurse their infants and wait for our team to arrive to undergo cardiac surgery when babies are just a bare month old.  They were frightened and overwhelmed by the attention and crowds we attract, but we had two successful patients with us who could speak with them to reassure them there was a future ahead and they might live to take care of their children.  One young lady's eyes opened wider as she looked at the healthy individual showing her a well headed chest incision. She seemed to calm in front of us she talked with the volunteer about how she too became ill when pregnant and found her cardiac disease was rheumatic heart disease. Often rheumatic heart disease is silent until pregnancy increases the demands of the workload of the heart. Until then she had no ideal how ill she was!

Following the pre-op evaluation where each patient was presented efficiently with appropriate  lab results reported.   The  attempt to accurately diagnose using an abdominal echo probe for cardiac diagnosis was a challenge. It is apparent how much this wonderful physician can do with so little resources.  We also watched as he worked closely with the local team with  much respect for the work nurse Marie Claire,  who runs CHUB Coumadin and testing center provides for post operative patients.  Ww watched in amazement as they worked with a machine using the most basic of echo machine with a probe not designed for cardiac echo.  We hope to meet this need in January with a generous donation from Philips of a CX-50 machine to share between two wonderful cardiologists. 

The local team hosted tea for several post operative patients and our visiting Team Heart members and it was only after Dr. Ganza began speaking that we realized the patients had been carefully selected to illustrate the profound change in their life following  critical cardiac surgery. Each postoperative patient in the room would have died without surgery… many within 30 days of the time we initially saw them. It was a profound moment to look around the room and see the healthy individuals.  Choking back emotions, those of us visiting,  were moved to be able to se the result of our work. Several, from the more recent surgical visit still struggle to return to the work force, but others from earlier surgery could relate what had worked well for them,  providing both hope and encouragement. The other amazing moment was to realize that each was part of the intricate post operative care system! Voila...it works!

Putting clearly into perspective, this is what we do...every aspect. Supply and demand of inventory, surgical expertise, postoperative follow-up, screening and prevention and economic stimulation to return patients to education or the work force.   It distills down to people--People here on US ground and people there on Rwanda soil.

This holiday season, we appreciate your donations and gifts which continue to make this program possible.  Warm season greetings and Happy New Year to you and yours.

Butare Visit 12/11. Team Heart members with patients from previous surgical development trips with Cardiologist, Dr. Jean M.V. Ganza. Leslie and Steven in back with joyeuse and Jean H. Sammy, Marcelline with Deborah, our local administrator for Team Heart in front !

Update 10.10.2012

v  Approval to work in Rwanda is now required for all NGO's. In response, the application for official INGO status in Rwanda has been prepared and submitted.  A comprehensive 104-page document prepared under the leadership of Team Heart project manager, Noella Bigirimana details the work we do, the partners in country we work with and the source  and amount of our funding. We anxiously await approval, indicating the country values the contributions TH makes to both education and care delivery in cardiac disease and acknowledges TH's careful attention to following  guidelines for providing care. An advantage of the process includes the opportunity to align Team Heart and Rwanda's goals and to determine the best measurement of outcomes. 

 Noella, a pre-med graduate of Cornell University in Ithaca,NY, is a  native of Rwanda and taking a gap year while working with Team Heart. Noella will travel with the surgical team to Rwanda in February and currently is coordinating a meeting of international surgical partners working in Rwanda, scheduled June 2013 in Geneva, among other strategic planning.

v  A successful Team Heart Golf Tournament raised funds for team travel for the 2013 surgical trip to deliver life-saving surgery for young adults and adolescents. Held October 1 on a gorgeous day in Nashua, NH, the tournament was chaired by three-time traveler and step down-ICU nurse, Michelle LaChance. The course at Sky Meadow Country Club is already booked for the third annual tournament in September, 2013, as planning began as soon as we wrapped up play. Thanks to an amazing organizing committee who, incidentally, all work full time at leading hospitals!

v  A comprehensive curriculum has been developed and copyrighted under the leadership of Dr. Patricia C. Come, a 5-year traveler for Team Heart pre-op evaluation team. Submitted for approval to the Senate of the Medical School of the National University of Rwanda, we anticipate and hope applications will be entertained for January admission. The curriculum is a diploma program designed to increase the cardiology knowledge of selected internal medicine physicians working in regional centers to improve post-operative care and increase the identification and early intervention of those with rheumatic heart disease and other heart disease. The selected physicians, after completing the program, will work closely in regional clinics with nurses to provide care. The regional  Rwandan nurse led clinics, forms the backbone of the health care system.  

v        JaBaris Swain, MD, 3-year traveler with Team Heart begins his two-year Cabot Fellowship in Global Health Equity Residency in General Surgery, designed to train academic surgeons in the science and practice of surgical care delivery in austere settings, as well as develop research and policy leaders in this nascent field. Housed in the BWH Center for Surgery and Public Health, the program is one of the few global surgery residencies in the U.S. His work will be designing a proposal to investigate the cost benefit analysis of cardiac surgery in resource poor settings to submit to the Ministry of Health for consideration to work with local caregivers and investigators. Team Heart is proud to support a portion of this fellowship.

In October, under Team Heart sponsorship, JaBaris will travel as an invited guest to the NIH as an observer in global health. In December he will travel to COSECA, (College of Surgeons, East Central and South Africa) in Addis Abba, Ethiopia and will return with the team in February to provide direct care.

Team Heart and Dr. Swain was featured in the recent RHD News Newsletter for the World Heart Federation! Thank you JaBaris for your acknowledgement of Team Heart and the work we do in Rwanda!

v  December travel to Rwanda will include BWH procurement expert Steve Senat and Leslie Sabatino.  Steve and Leslie identified a short list of critical items to order and procure with direct delivery to Kigali working with local team leaders, led by Vedaste Ndayisaba, King Faisal hospital and the newly restructured CAMERWA. Team Heart is the first expatriate cardiac team to take this critical step to sustainability.  This step to transfer expertise for cardiac surgical procurement must happen if surgery is possible independently.

v  Rwanda welcomes back home Dr. Jean Marie Vianney Gapira Ganza from completing his interventional cardiology fellowship, Université Catholique de Louvain Brussels. Originally located in Butare where his family lives he had previously worked in the NUR Medical School UTHB. Team Heart has worked with him since our first year in Rwanda, and he is both loved by his patients and respected by his colleagues. His graduate thesis was regarding rheumatic heart disease, the leading cause of heart disease in Rwanda at this time.  We look forward to working closely with him in the future.

v        Dr. Maurice Musoni has begun his first year of general surgery and cardiac surgery in Johannesburg, South Africa. We have very little information about how his work is going, he is on trauma service now and is working very hard. He traveled with the support of the Ministry of Health.Team Heart is very proud to have arranged the position and to ensure he is able to take advantage of the comprehensive learning experiences.

v  Strategic planning for Team Heart. Do we expand, do we focus, do we build? Do we answer the multiple requests to fill urgent needs in other countries?  If you would like to join a meeting or sit on a committee, or receive minutes contact: teamheartinfo@gmail.com

v  Screening-What happened to the screening program of school-age children from September 2010? Data analysis is in process at this moment. Thanks to Boston cardiologist, Bernard Bulwer, and Studycast, all echocardiograms have been read. Echo findings must be graded for input into computer and Dr. Mucumbitisi is compiling  gradings in Rwanda. Early indications could predict a large number of unknown individuals with RHD in the country who will one day need surgery if not identified and placed on prophylaxis. Even then, some will progress to require cardiac surgical intervention. Thank you to The Medtronic Foundation, the J. Warren Harthorne, MD Fund for Screening, Studycast, and Cathy and Mannie Jackson Gift for funding this project and making it possible.

v  Support Team Heart! Consider a Capital ONE Credit Card! A percentage of your charges will be donated back to Team Heart each month to support these projects. To apply for the card, visit:

https://www.cardlabconnect.com/AffinityPortal/visitorAction.do?affinityName=TeamHeart,Inc.

Father's Day Tribute Card....

This father's day, show your support of Team Heart by purchasing one of our Fathers Day Tribute Cards. All proceeds will go to improving our post-operative patient care in Rwanda. With the new Rwanda requirement of  10% co-pay for all patients, accessing the health care system is a challenge for some. Many of our patients have been ill for years, on the brink of death,  waiting for the chance to have life-saving surgical intervention. Most are young and may never have entered the work force without our help. Though survival rates and post-operative health are improving, our patients still need jobs to pay for medical care. Though Rwanda offers universal coverage, or "mutuelle," the care providers  who are knowledgeable about rheumatic heart disease and post-operative care are located in just a few hospitals throughout the country--and because many people do not have access to public transportation, they do not know about the options available to them.

It's hard to believe that $15 tax deductible donation of the $20 sales price could have much of an effect on our patients. But it could save a life.  

For more information? information@teamheart.org.