Bits from a Trip – The Long Haul

This is the third post covering the Open Heart International kids’ heart surgery trip to Tanzania. You can find the first one here and the second one here

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The support for Tanzania is coming from all over, including Australia via Israel.

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.

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The local team taking the lead during this trip.

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.

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Getting big this quickly requires continuous growth in funding.

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.

 

Note:

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.

 

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Bits from a Trip – The Masterclass

On the way to the hospital in Dar es Salaam there’s a sight that slightly jars. This is not to do with the minibus trip which starts at “I left the stove on and what if my house burns down?” pace and usually hits a point where the cars are so stuck you’d imagine they’d wedged themselves in a tar pit.

On the way there is a collection of shops, open for the bustling people in the small city that spreads out from the front gates of the hospital. This is before you get to the “Curare Pharmacy” which seems a bit curiously named if they actually know that curare is the root form of drugs that paralyse your muscles and would kill you if you were left to your own thwarted attempts to breathe.

These are shops, decorated in the preening advertisements of big American soft drink corporations, which are part of a cemetery. The old tombstones hold their air under shading low trees and swooning blades of grass, seeming to slowly crumble in that space. We never have the time to stop for an abstract reminiscence among those graves but we can see where they rub up against the stalls selling Coke and chips to eat first so you need something to wash them down. Like Coke.

The tombstones arrest all thoughts for a moment as the minibus picks up speed closer to the hospital, before clearing the security gates on the way to the Cardiac Institute and our waiting patients.

The other reason the first shop stands out is the name.

“The Rich Also Cry Shop”.

 

French Influences

The major operation we’ve been asked to help with this time around is for a particular condition called Tetralogy of Fallot. This naming dates back to a time when industrious people involved in medicine could claim signature diseases in a way that would stick.

Fallot was a French doctor who managed to put together a sequence of particular findings and have them named after him because he did that first little bit of detective work and put all four findings together. It’s possible he wasn’t the first to make the observation but he was the doctor who attached his name to the constellation.

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Notorious hipster, Fallot

To understand his four findings, maybe a refresher on heart anatomy would help. This is not to do with the poetic sort of heart anatomy that finds space for soaring highs and crushing, broken lows.

At some point while developing the heart develops into chambers. Some of these chambers are receiving areas and are called the atria. This is also not a real estate section. These atria receive blood. From the atria the blood passes through into the ventricles to hurry on to somewhere important.

When the blood returns at first it arrives at the right side of the heart, enters the right atrium, moves on to the right ventricle and from there jets out to the lungs to pass by the air sacs that provide space for the outside world. The layers between blood and air are so thin it’s as if a sheet of blood hangs suspended in the atmosphere, entering dark and spent and being painted bright red by an inrush of oxygen.

The blood, now embarrassed with its riches, returns to the heart but this time on the left side to be received in the left atrium. From there the next stop is the left ventricle, and then it flees onwards to the aorta.

So it’s fair to imagine whichever cartoon version of a heart catches the back of your mind and imagine a crucifix dividing it up into those four chambers.

 

The Four Stars of Fallot’s Constellation

The plumbing of the heart has many described variations. Sometimes the rooms are not walled off quite right and there is an additional doorway between two chambers where the blood shouldn’t be mixing. Any of the valves that act as doors between the chambers can be undersized, narrowed or have less swing in their function as a door. Whole blood vessels can be joined to the wrong ventricle.

In Tetralogy of Fallot there are four distinct findings. The right ventricle, usually a not particularly muscular muscle, has an overabundance of fibres. That’s the first part of the grouping. The area where the right ventricle leads up to the vessels to the lungs shows a degree of obstruction to the flow of blood, either below the valve or at the door or just about anywhere else. This is the second part. This makes the flow off to the lungs that much harder.

To go along with these two, the two ventricles have an opening between them, known as a ventricular septal defect. Part three. For many patients with such a hole in the heart, blood would mostly head back from the left ventricle to the right ventricle, circling back around the lungs.

For these patients though, the obstruction to those lungs means some of the blood feels it is easier to head to the left ventricle. This shunting of blood leaves it short of oxygen and the resultant mixing with the blood that did make it to the lungs that is in the left ventricle ready to head to the body drops the total amount of oxygen heading out to the body.

The last sign? The whole of the aorta, the big highway for blood to the body is shifted a little to the right, sitting a little over that hole in the heart.

 

Looks Blue and Squats

So these kids will sometimes be obvious because they have a hint of blue about them, thanks to that slightly underoxygenated blood. On top of that every now and then the overzealous muscle in the right ventricle can twitch right into spasm and when that happens the blood really struggles to reach the lungs. Less flow to the lungs means more of that oxygen-depleted “blue” blood getting out to the rest of the body and the patient actually turns blue.

At that point you might assume the patient does what comes naturally when you have something happening to your heart and lies down. Well the “doing what comes naturally” is definitely the case but they don’t lie down. They squat.

The reason they squat is pretty simple. When you squat you raise the pressure in the areas where the aorta is heading. That makes the pathway up to the lungs that little bit more interesting to that blood because just shifting across the hole in the heart becomes a little bit harder. Hopefully the blue loses some of its depth.

That “turns blue, squats and goes less blue” thing sounds perilous. It can be. At the same time, the blood flow around the body is generally continuous because at least the blood doesn’t slow down dangerously on the way to the lungs and stop reaching the left side of the heart at the rate you need to keep getting it out to the rest of you. That hole between the ventricles allows that blood to hurry on, even if it’s still a little blue.

 

So many blue kids …

The local team have been seeing lots of these kids turn up. Of the 88 operations they’d done in this spot, about one quarter have been for Tetralogy of Fallot, which is a really high number. You’d expect relatively straight forward holes in the heart to be presenting in overwhelming numbers. They’re not.

The locals have a theory about this. Kids with a relatively simple hole in the heart don’t present with obvious changes in colour or a history of squatting suddenly. They tend to look a bit malnourished, not grow quite as quickly and get lots of chest infections. There are plenty of other explanations for that. If they don’t get seen by the right person, they might just be put in a different category and die.

The right person might be a local doctor or health worker, but sometimes it takes the specially trained to pick these things up. Tanzania has about 45 million people with 4 or 5 million of those in Dar es Salaam. There are three paediatric heart specialists. They are all in Dar.

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The unnervingly anatomically accurate garden sign outside the institute.

So the current theory is that the kids with Tetralogy of Fallot survive to a point where their symptoms are obviously something heart-related, while the kids with a simple hole in the heart like a ventricular septal defect with no other associated heart issues don’t get a diagnosis.

 

That’s the Masterclass

Dr Sharau and team aim to develop their skills on the patients they are seeing now. They set up the plan for this trip – a masterclass in Tetralogy repair. Almost every day they’ve done another repair with a little support and guidance from our visiting team to try and make the repairs as good as possible. This is no small feat.

The surgeon needs to safely hook up the plumbing of the cardiopulmonary bypass system (sometimes popularly called the heart-lung machine) to keep blood circulating around the rest of the body during the operation. The team then needs to take the necessary steps to stop the heart and after opening a path to the outflow of that right ventricle they have to perform a number of steps to remodel that muscle and widen the outflow tract enough to make sure there is no ongoing obstruction.

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Dr Godwin Sharau, hard at that repair.

All while the heart is an entirely different state. After all, the heart won’t be empty, open and still once the operation is finished. If any level along the way isn’t right when you ask the heart to do its work again the obstruction will still remain but the defect between the ventricles will have been closed. That would mean there’s only a hard pathway up to the lungs with no chance for the blood to skip over to the left heart and keep things going.

The kid has a repair, but they have different issues.

For this trip things look to be going pretty well. Godwin and team seem happy with what they’ve achieved. The next challenge is to figure out how to make sure those patients who aren’t even reaching them get picked up with their much simpler holes in the heart. That will require work across a whole system.

Because there are kids out there who are never reaching the front gate of that hospital. They’re stuck somewhere else,maybe near some shops or struggling to get through the day, waiting to be found. It should never come to that.

 

Note: 

The first post from this trip is right here.

There are way more stories from this aid trip hitting the screens over at the Open Heart International blog too. I reckon it’s well worth a look. Of course, while you’re there, you could consider chipping in (*nudge, nudge).

Start Lines/Finish Lines

A trip to another country to work on open hearts starts with packing and checklists. It starts in a storeroom under a shed where they keep boxes and boxes of needles and tubes, blades that open chests and drapes to cover the skin. We check off spreadsheets and try to imagine exactly how many small plastic tubes we could want to place in veins and arteries and how many times we will need a second go.
Three months ago we wrote on lists and checked expiry dates and taped the boxes in two different directions. We stacked them on pallets and trusted that things we’d left before would still be found, somewhere in a storeroom.
 

Glamour starts here.

 
 The Real Start

A trip to open hearts starts earlier, now that I think about it. This trip started at least a year ago. Around the time of the last trip, where the seeds were sown to move the whole thing from Mwanza, curling around the shore of Lake Victoria, to Dar es Salaam where the water belongs to the Indian Ocean.

The local team had a plan that did not include machines that could not be convinced to work and time offered in theatres that would never materialise into actual time and space. So they moved and let anyone who was helping them know that they had turned the light on somewhere else.

The planning started a year back now and only looked like having a name change into an aborted mission twice along the way. Once even after the boxes were packed and on their way. Then Tuesday came and we were here and we found holes in hearts that could be patched and sewn so the blood pumping around the heart would follow better directions.

The Real Finish
Not every aid trip is the same. The Open Heart International trips are mostly not about serving lots of people right now. We volunteer to come and do a particular job which is to put ourselves out of work.

The aim isn’t to turn up and do lots and lots of cases. There’s probably a part of that which is about logistics and funding. It takes a bit of effort to get here from Australia and bring all the gear.

The bigger reason is that it doesn’t matter how often we drop by for a week of operating, we can’t meet the needs of Tanzania. You can set up trips where you aim to do 6 or 7 operations a day and leave 60 fixed kids but it takes a pretty big team and some resources to boot. The sort of resources you have when the guy in charge up Saudi Arabia way sends a team in his private jet with as many widgets and people as you need to do exactly that. That happens next week. That’s not a joke.

Ultimately even those efforts can’t serve Tanzania. A team that was here every day of the year that could look after patients every day, not just when a couple of weeks line up, is the real answer.

 That’s why our week is more about helping the local team working at Jakaya Kikwete Cardiac Institute. We’re not here to take their work. We need to be spending time supporting in areas they want to build their skills the most. This means less operations, but making those operations count for every member of the team here in Dar es Salaam.

 

Everyone here keeps commenting on how cold it is.

 
For this trip they’ve chosen the type of operations they want to focus on and they’re really working on the intensive care side. This isn’t to say they aren’t doing the other work. They do most of everything. So while we packed a surgeon (only recently, not in the boxes) the local surgeon, Dr Godwin Sharau, leads most of the cases with our guy, David Andrews, providing assistance and clever insights (and no, I won’t comment on whether complimenting a surgeon is a contractual arrangement).

Our nursing staff in theatres do their job in conjunction with the local nurses. Our perfusionist, the Red Leopard*, takes up most of the work of driving the wheels of steel (not interesting ones that would drop sick beats, just the ones that replace the work of the heart while the surgeons operate on it) but is also pretty much continuously chatting as he provides teaching for his local colleagues.

The anaesthetists? We just step in for bits when the local guys want us to keep things ticking over. Probably. We’re called upon mostly because the local anaesthetist who does most of this work is spending extra time in the ICU. It’s the ICU they want to focus on.

The goal? About two operations a day. We particularly want those operations to be the sort that mean the kids will end up getting on with school and a full life because all they needed was that pesky heart plumbing re-plumbed.
The bigger goal? Five years. That’s how long we want it to be before we’re out of a volunteer job. Our five year plan is to aspire to being tourists only. 

 

PS I feel like the name Red Leopard could do with an explainer. Our perfusionist, Brad, is a tall member of a tribe defined by their ginger colouring. Upon receiving a compliment from one of the local staff that she thought “his colour was good” he took it, as any proud redhead would, as a sign of admiration of his particular variant of freckled glory. The compliment was directed at his shirt. His very blue shirt.

 It did draw the rest of us to comment on the extreme usefulness of having an arrangement of red freckles perfect for breaking up his outline if he wanted to hide in the wild in these parts. A bit like a leopard with their spots. A bit like a red leopard if you will. We were just trying to be helpful, but he seems to have taken to it.

 

Chui mwekundu in his natural habitat

 
 That said, I think it’s probably better if he relies on his skill with the heart-lung machine than hiding in the long grass to earn his supper. 
For a broader take on this trip you could check out the Open Heart International website at www.ohi.org.au. They have a daily blog running and Brittany is starting to get stories from some of the kids and families.