We have come to Tanzania from Australia over three flights and a day of time. We have come to work with local health workers in a big block of a hospital on a hill. We sent tubing for a heart-lung machine, surgical equipment and paraphernalia to go with drugged sleep. This equipment is sitting in an office somewhere at the airport awaiting clearance at customs because the person we need to sort it out isn’t available until the end of the weekend. It is Saturday morning.
I can’t quite figure out if the person we need is a person from customs or a person who works at the hospital who has to sign for it but it is pretty clear that there is no one we need to get this stuff sorted who will be anywhere before Monday.
We have 5 and a half days of operating available.
Day 1 needs some improvisation.
This is the second trip for Open Heart International to Mwanza in Tanzania. The hospital is known as the Bugando Hospital Clinic and has a view past the centre of town to Lake Victoria. I am told Mwanza is the second biggest city in Tanzania. It is a maze of paved and dirt roads that reduce taxis to a bouncing crawl.
The road to the hospital is very much through the town and then up the long haul of Bugando hill. The hill starts with schools then shops each side as we draw closer to the hospital. At least half of the shops are selling their best coffins. White or brown shells with purple or white cushioning.
On the way up the hill we pass a new building of brick and tinted glass. The gates show its links with a big kids’ hospital in Texas. One of the biggest. Later I get told it was first set up with a view to doing work dealing with HIV. When we check in at the hospital it feels like the gates wearing the name must be where it stops. The intensive care unit lacks a working analyser to test levels of oxygen in the blood.
We don’t have time to figure out how all these histories and commitments work together. There’s that case to start.
We’ve been asked to help a local team, led by Dr Godwin Sharau, to do about 5 operations. No rushing, lots of support and teaching. A first operation will let everyone take a breath. The operative team who want to be busy and the set-up team who have been screening patients for days.
The first operation needs no aid from the heart-lung circuit. This child has a mix of holes and obstructions that mean blood doesn’t make it so easily to the lungs to pick up oxygen.
If you’ve ever had one of those pegs on your finger that spits out a number close to 100 and been told it’s all about the oxygen that’s getting around, you can imagine you’d be shocked if it said 60. 60 would be high for this one year old. If you look closely you can see the effects of this bluer blood mixing in with the red. Parts of her eight kilograms seem to stretch a little over her ribs.
After her drift through the levels of sleep, the surgeons will take a piece of gortex and link one of her bigger arteries back to the vessel feeding her lungs. The extra blood flow means extra oxygen picked up and a chance for growth and more surgery later.
It is a long operation today. But we’re not here for taking over. They are building and we need to step back. When the clamps come off there’s not too much bleeding and we’re really on our way.
By the afternoon this one has been introduced to the intensive care staff and no longer needs the breathing support of a ventilator. When we finish in 5 days she’ll be home already.
Dinner at the end of 14 hours relies on old haunts. We know the buffet at the hotel, one hotel restaurant on the lake and the crew who were here last year know the hotel from November. It’s up the top of another hill via a dirt road that had the transport car bogged twice last year. Five days of rain upfront means that isn’t an option until later in the week.
At the end of day 2 of operating, we head straight to the water. The only spot free is outside, thatching sheltering us from a storm while we eat curry. Every day we eat curry. Today it is in the form of pizza.
Lightning strobes the lake, showing up a boat bearing the name “African Queen” listing nearby. It is about three storeys high. Maybe they planned a sequel.
The rain filters normal conversation, shouting the only sound to carry to ears. We watch as the manager skis down a sheet of water on flat tiles towards us, a Dutchman on his way to schmooze and seek return business.
The international symbol for OK appears to be acknowledged here as a thumb pointing up. No one uses a circling forefinger and thumb with three other fingers raised. Forefingers and thumbs are for measuring.
We have a patient, PC. PC has a sick heart he thinks is for ignoring.
If you have a minute, stop and feel your breastbone, right from the top. When you trace it down, you’ll feel a slope fall away, dropping to the ground.
Now just where that slope drops, feel where the rib joins in. This is your second rib. Follow it to the left, almost halfway to the armpit. Then let the fingers trip and roll past those bony ridges. To rib number three. Then four. Then five.
Now you might need to take a breath. Or lie down in the quiet. Just below the fifth rib, around the line of the nipple you might just be able to feel the tap of your heart. Take two fingers and feel it beat a quiet greeting.
PC’s heart is trying to crash through his armpit, low down close to the end of the ribcage. It strains because he has a valve in his heart, named for a bishop’s hat but scarred by disease, that leaks blood backwards with every beat. It is his mitral valve that can no longer hold.
His heart is left to sweep in great pools of blood to make sure some jets forward with each beat. But he smiles and says he can walk up the Bugando hill past the coffin houses.
He is 10. He weighs less than my luggage on the way over. When I circle my forefinger and thumb, they join around his arm.
Later in the day, Godwin and Dr David Andrews, a surgeon flown from Perth, repair this valve. The perfusionist takes over circulating blood around the body so the heart can lie, lax and drained. They tighten flailing leaflets to hold against the leaking.
In the moments where we need his heart to start again, the stretched muscle can’t catch the beat. Minutes of writhing twitches spreading across his heart as it fibrillates. We add drugs and circulate blood. We jolt it with electricity over and over.
Finally a reset.
That evening PC is smiling at staff. The next day he wins the bubble blowing competition in the intensive care unit.
Numbers in Boardrooms
We have a meeting with the head of the hospital. Every team member not asleep after a night at work or handling a patient heads to the fourth floor of the hospital. Our colleague Godwin has arranged this meeting. He is the surgical end of trying to enhance heart care in this spot, along with Dr Antke Züchner.
Antke is a paediatric cardiologist, first from Germany but here for five years. She finds the patients. She screens them. She is the final line who makes all of our requests happen. There are days in her work when she pays for her patients to get her care.
We are here because we want to show that these two have our support and admiration. It is a display of slightly dusty and weary solidarity.
The hospital director is a giant with big smiles and bad numbers. He talks of how much they would like to provide this care to the children nearby, how many more times he would like to see our faces. He tells us the entire health budget for the country is equal to 10 US dollars per year, per person. A plan for 15% of the country’s budget is stuck at 5%.
Our team leader tells of how much we would like to support efforts in Mwanza. He stresses that we will always seek to find a way back. No one in the room says out loud that we can never be sure we will come back, no matter how much we might wish it.
The team from Australia is probably the easier bit. A surgical aid trip just commenced remains delicate. We need things in Tanzania to keep lining up to meet the drive of the committed few. Until we land next time we won’t know if we’re really getting back.
There’ll be other days when we provide support that isn’t just about the medical aid. Days when we’ll hold back crews of press while operations go on. Days where Godwin will be asked to perform two very different roles. We say we don’t sign up for those bits, but aid is about support and this is support.
We reach the final day of operating. We are up to case number 9. In a few hours our surgeon David will leave but Godwin has one case to complete. This child, 6 kg, has a vessel that lost its path and forgot to close. In the womb it linked the artery to the lungs to the aorta. In utero this makes sense because those lungs are soaked in fluid, and it’s quicker to ferry as much blood as possible straight out to the body.
Once born, this vessel usually closes. Blood leaves the right side of the heart, gets washed in air and returns to the left heart to be pumped to the body. In young H, that lost vessel is still there, a patent ductus arterious.
This is another one of the few operations not needing the bypass machine. Godwin works down behind the lung to find a vessel. Aided by the soon to depart Dr Andrews they find this 4 millimetre branch and close it with silk ties.
H returns to the intensive care unit with a little oxygen whistling in her nose.
That’s 9 operations of a planned 5.
With all the packing done, we leave. We operated for five and a half days. We helped the local team with nine operations that wouldn’t have happened otherwise. Our intensive care and ward staff worked hard alongside local staff in the postoperative days and nights. Our engineer got the blood gas machine to tell us about those oxygen levels.
But there were challenges to meet, as you’d expect of a fledgling service. Issues with supply of blood products to replace any bleeding. Times we thought we’d lose all blood testing services. Decisions on lots of cases of how to adjust things just that little bit to make sure things were safe.
It’s a compressed way to help start a service but it’s not the only part of the efforts being made. We’re not even the only team helping to support Godwin and Antke. And we really need to keep being part of a long-term process that will take years or decades to settle in. And it will still have ups and downs.
But that planning has already started in Tanzania and back in Sydney somewhere at the end of 36 hours of travel.
And for now there is a drive to the airport. Past the Educational Supermarket. Past bicycles laden with charcoal and scaffolding and crammed minibuses and horns. And Dolly Parton playing on local radio all the way to the airport, explaining that love is like a butterfly. I guess that applies in Mwanza as much as anywhere.
And there will be PC walking faster up that hill.
This is my second chance to be involved in a cardiac surgical aid trip. I had more time to write on last year’s trip to Rwanda. Those posts kick off here.