Update from Bruce Leavitt, MD February 5, 2013

February 5,

Today is my third full day in beautiful Rwanda.  Here is a little background as to what has transpired since arrival.  After two long flights from North America, I landed in Rwanda on Saturday evening.  I never really saw the light of day on Saturday, and Sunday passed mostly in a  haze of jet lag. Team Heart met in the early afternoon to review all of the cases that had been seen by the awesome pre-visit evaluation team.  We prioritized the patients for the week which was a difficult job.  Monday the fourth of February was our first operative day.  The first case was a 39-year old man who received a new mechanical aortic valve by Drs. Oakes and Bolman.  The second was a 21-year old female who received a mechanical mitral valve for her rheumatic mitral stenosis by Drs. Matthew and Bolman.  Both cases went very well, especially considering that it was the first operative day; the kinks were small and worked out very smoothly.  

I am truly amazed at the teamwork, dedication, knowledge and skill of everyone on Team Heart.  I guess I now know why "Team" is the leading word for our organization.  Today (Tuesday, February 5th) we started with my first cardiac surgery case in Africa.  Our patient was a 19-year old young man with severe mitral insufficiency and tricuspid insufficiency, again from rheumatic disease.  His case was difficult because of the greatly enlarged size of his heart.  He received a mechanical mitral valve and a tricuspid valve repair with a ring.  He did have one of the largest hearts I have ever operated on, especially for such a young man.  After today we will have finished 4 cases with 12 to go.  More to come.

Bruce Leavitt, MD

Mackenzie arrived.....February 4, 2013

This morning began bright and early at King Faisal Hospital in Kigali for many members of team. Today, surgery begins! The patients have been screened, evaluated, and carefully selected.  Though there are still decisions to be made and some factors to consider for individual patients, the team has set the surgery schedule for the week and patients have begun to filter into the hospital. It’s a day of hazy sunshine with a perfect breeze, the kind that feels like the first day of summer back home, and everyone is smiling.   Jetlagged, exhausted, but smiling—there is a palpable current of pride and purpose in the room where Team Heart has taken over.

The hospital itself is surrounded by some incredible views of Rwanda. There is an open air walkway all along the outside of each floor of the hospital; hazy mountains seem hundreds of miles away, and local men and women farm the land, for potato crops we think, just beyond the hospital property. In between, there is a fascinating mix of sights.  Modest homes with corrugated metal roofs, a sweeping golf course, government buildings, a palatial private residence, and a lake are just a handful of things that fill the countryside. 

Inside the ICU where the team has set up shop, there is a stillness and real sense of anticipation as we await the first patient.  The first surgery of the trip has just finished, and at any moment our first patient will be wheeled in for post op care.  The surgeons come in first, and we’re told that the surgery went well.  Everyone seems relieved, but anxious to begin work! A calm before the storm, they know. This will be the first  patient of 16 over the next week or two, and this ICU room will become increasingly more hectic.

The first patient is wheeled through the door, and Team Heart is all smiles.  The room is quite suddenly bustling and one of the talented surgeons says “First one down…It means everything is working. More or less!” We all get a kick out of the “more or less”.

The mobility here is amazing.  The volunteers have set up what is essentially a portable post op unit, and the team tells me that much of what I see in that ICU room has been brought and donated by Team Heart over the years.  Suitcases and backpacks are stuffed under every surface in the room, a pharmacy is set up on two folding tables set in an “L” shape, and about 20 people have converged around the patient to get him connected to all the machines and monitored. 

The patient is stable, and the anesthesiologist reports on what happened in the operating room.  What we’re seeing is part of a program called ‘PAUSE’, and it is intended to ensure that everyone involved with the patient care is on the same page.  It’s meant to encourage open dialogue between team members and ensure that no detail is overlooked; there’s a real sense of unity and a common goal of success as everyone gathers around to discuss this surgery and the plan of care going forward.

One down, 15 to go!  I met 2 more patients on Team heart’s list today—stay tuned!

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 !