A heart operation is not just a work of hands or steel or thread that gathers together tissues to shape a new version of to and fro. We work also with light and sound and air. We work in a sequence of small moments where each takes its place or all come together. Then at some time we leave the heart to take on the biggest share of all the work to come.
There is a point where the surgeon feels the operation is closer to the end than the beginning. In cases where the heart has been left still with a dose of potassium through the arteries there comes a moment where it is asked to wake. It is time to ask the heart if it is ready to do the work.
During part of that process we add breath to the lungs, holding them buoyant to try to bring multitudes of air bubbles back to somewhere we can remove them with a sucker. Then the surgeon asks for the flows through the bypass machine to fall and releases a clamp. The flows go back up and we wait as the heart gets the idea that it’s time to come back its calling.
In many operations we have an extra tool for looking at the heart. An ultrasound, casting particular wavelengths out to the back of the heart, listens for the returning echoes and constructs a picture of dots with all manner of resolutions and characteristics. The machine turns sound, distance and time into the light of a monitor screen where we can see the structure of the heart and what the chambers hold.
After the release, a wash of dancing pearls will tumble around those chambers. These are a few remnant bubbles of air. They are most often a note of a moment that will leave you with a bright speck of something beautiful on the screen. On some occasions this air becomes something else.
One of these pearls, a small bubble, may find its way out of the chamber and down an artery supplying the heart. Stuck within the narrowing vessel it blocks the normal flow of blood, maybe briefly. That can be enough to have the heart struggle and develop a rhythm that would be fatal in the absence of a heart-lung machine. One that needs quick action. Losing all coordination the muscle fibres mark their own time, twitching without any of the effect of a heart that pumps at a nudge from one conducting wave. Blood would not go anywhere.
On bypass this fibrillation is less critical but eventually it becomes harder to interrupt and get that heart back to work. At these times the sounds are a quick back and forth of plans and suggestions, requests made, drugs given and electricity added to the heart’s surface.
Twice on this trip in kids with hearts made into bags by disease, the air we see blocked the flow of blood and left the heart fibrillating. These were in hearts so large the strongest beat is felt low in the ribs and a hum makes its way to the fingers where you rest them. It took drugs, drains, wires, flow and electricity, jolt after jolt of current, to get the reset and time the heart needed.
They feel like long minutes when that first jolt doesn’t set things to right. Or the second. Or the third and fourth.
The operation is where the work might be concentrated but it’s the heart that has to do the rest of the running. The long haul later isn’t the first thing you think of when you contemplate an operation, but it’s the effort that asks much more.
We don’t count the charges. It is enough to know that the time after the air became enough. Those hearts got back to their reset point and took over.
The Big Challenge
The Jakaya Kikwete Cardiac Institute has hosted us well. There must have been a lot of intense labour to set up the three floors. There are wards and clinics, operating theatres that join to the intensive care units and many of the machines and technology that you need to serve a people.
They have people creating a hospital that will serve kids in Tanzania well. They have moved across the country. The paediatric surgeon drives 90 minutes for his commute so he can offer his hands. Before he had the chance to do that he had to go to Israel to start his training in his very small subspecialty. He says that learning Hebrew is not that difficult really.
Their anaesthetist, Onesmo Mhewa, tells me Russian is quite difficult. It is Russia that he travelled to when he decided anaesthesia was his path and he had to find the best way he could to get it done. He now provides the anaesthesia and almost all of the medical drive for the intensive care unit.
These are just two people among many. They have cardiologists who are very clear-eyed about what they need. They have nurses who work every day at doing a bit more and claiming their vital role in that operating theatre or ward or intensive care unit with more confidence.
(They also offer frank life advice over fish heads. That advice provides the highlights you need to sustain a team when it’s late. We promise them we wouldn’t want to be distracted by actually eating the fish heads while we learn from them.)
It must have taken a lot of intense work in the set-up phase to make things happen. The challenge now is the long, quiet effort. Setting up a hospital gives people bold ideas to latch onto. The buildings and walls can be admired. Machines can be used to wow visitors. Optimism can sustain things for a while.
What the clinicians trying to build this service will need is long-term support. That stage is a far more arduous request. This sort of care can chew up a lot of resources. The enthusiasm for providing ongoing funds is always under threat wherever you might work. At the moment for an outsider it looks like there are decisions made every day that are heavily constrained by the constant effort to find the resources for the mundane costs that all add up.
That the team figure out a way to provide care is inspiring. They know that there are some things that separate really good services that don’t cost money. The way you encourage communication and work within a team. Identifying the heroes in each little part of the whole who will make everything in their section work better. This team has a very clear idea of how they can get there. Were their support to be dropped even a little though, the long effort will be that much harder.
I have little doubt that any of the teams from outside that have been coming to help whether from Australia, Saudi Arabia, Italy or Israel will all be very keen to see ongoing support for this group building something special on the edge of the Indian Ocean. It’s one of those aid trips you go on where you can see that you’ll be the smallest part of something that will take off.
A little bit more of the intense effort for now might be necessary but they’ve already made it clear they are ready for the rest of the work. We never even had that moment where we had to ask if they were ready.
I think it’s worth having a look at the Open Heart International post which mentions our colleague Onesmo. He is more than impressive.
If something about these trips makes you want to learn more, you could check out the OHI site. It provides comprehensive stuff on what they do and how people can help out either by volunteering or donating.