J. Frank seven days after surgery
Our surgical development trip begins with the first 7 members of the screening team meeting the Rwanda cardiology team for a long hard week of patient evaluations. Each patient has previously been diagnosed by a Rwandan cardiologist and felt to need a referral for surgery. Mutually agreed upon parameters guide the referral process. The candidate must be healthy enough to survive but sick enough for the team to feel they cannot wait until the next team arrives. The Rwandan 5 cardiologist are very good at this by now. They unfortunately have to watch as those who are very sick or develop complications die while often waiting for a team.
It is a powerful experience. Patients feel this is their only chance. They have been told by their referring physician the seriousness of their condition and just how necessary this critical surgery is. They have also been told their biggest risk will be-- to not be selected. You immediately see how weary some patients are just to reach screening. They have been compromised by illness for months, some for years. Many leave home the day before to sleep on the ground outside the screening hospital with a colorful kanga wrapped as a blanket around their thin bodies-- or if lucky, on the floor of a relative in Kigali. They begin lining up near daylight to enter the hospital holding their worn slip of paper that states they have gone through the process of registering for the community based health (universal insurance, which costs about $2.50 a year per/person, yet still is often not affordable) and visited at least 2 other health centers for referrals. Most often they have very little cash, as it is not unusual to be near bankruptcy after a long illness. They are exhausted, but dare to hope. That hope is shaken as they see others waiting, some more ill, some less. They have heard, only 16 will be selected. In the custom, they greet each waiting with nods and quiet spoken greetings of respect.
For months, the US based surgical team has been reviewing lists and requesting donations of supplies. Donations are often made out of loyalty to hospitals or health systems, but there is only so much one company can do. Team Heart founder Chip Bolman states, "We all know this is temporary. You cannot build a sustainable program on donations". The future of these programs depend on a partnership between humanitarian pricing and industry.
In Vermont, the University has been incredibly generous over the past 3 years. They show a great deal of pride in "their team" led by surgeon Bruce Leavitt, and UVM supports them well. This year about 10 of the volunteers will come from Vermont. But Team Heart is stressing their generosity as critical gaps are identified and more items join the list.
Much discussion about valves, sutures, and value of some higher cost technology flies back and forth from Vermont, Massachusetts, Nebraska to Colorado. Safe care is priority with realization that keeping cost down ultimately means that high priced technology will not reach Rwanda as they begin to do surgery more independently in the coming year.
In NH, a perfusionist orders supplies for the heart lung bypass machine. They do not do cardiac surgery yet in Rwanda independently, so they are not going to have anything to "make do" if something is forgotten. Lead perfusionist, Dan counts, checks, counts, and checks. He is mild-mannered and polite and has the presence of competency. The supplying companies respect him so they agreee to donate $26,000 of supplies--again. The donated supplies are definitely top of the line, with valid expiration dates. The program in Rwanda would not be able to purchase them due to cost. But Dan has designed a pack costing 1/3 of the cost of this pack—but no one wishes to manufacture that pack without a larger number to order. He gives the supply list one last long look--he will see them next in Rwanda where he will divide the boxes into 16 separate cases. He delivers them over to Sara, knowing they are in good hands.
Still on the US side, Sara, a petite nurse pushes around 30-50 pound boxes, as if they were lightweight onto a scale and with a tape measure quickly finds the dimensions. She stacks the boxes as a puzzle, hoping to balance weight and size to obtain a perfect 48 inches X 48 inches X 48 inches X 48 inch. She counts, checks expiration dates and notes how many of certain items are there. Sara documents every detail. Where was it made? What is the shipping code? How many in one box and how much did it cost? Not only an expert medical ICU nurse, she has also become an expert in shipping medical supplies internationally. She stacks on pallets and admires her perfect puzzle. She wraps each separate pallet in saran-like wrap ready for the iron bands that wrap to keep from shifting during their 7-day air trek to Rwanda. She has given up a week of her life to do this, and it is done well. Her ER Medicine physician husband and two toddlers have all participated in this endeavor. Young Henry rides in bicycle through storage halls and Amelia naps in a stroller. Sara oversees the loading of the pallets on the truck and only then breathes a sigh of relief. She signs paperwork, as a “known shipper” allowing consent to search, acknowledging she is not a terrorist, and the expectation that the supplies representing a quarter of the near $160,000 donations will reach Kigali in one week—plenty of time for unpacking on February 2.
Meanwhile, In Rwanda at Oshen-King Faisal Hospital, checks are made for laboratory supplies, air conditioning repair to keep surgeons happy, nurses on duty, and blood gas cartridges and the state of oxygen concentration, portable chest film access and generator system checks. They must take care of their patients while preparing to care for ours. Local teams must stop surgery early enough to clear the hospital surgical wards. They have to move crtically-ill patient s recovering from a brain tumor to a makeshift ICU to make room for our patients. This means reduced income for the local hospital. And they do it willingly and with a graciouness that defies expectations. Discussion about systems billing to arrange for the “free” care, medications in stock and the physiotherapist on duty. The proper paper work is completed for the screening appointment required to notify admissions. Judith, an organized ICU nurse oversees all and confirms orders of what is missing. Her check list increases. Public relations is wary of the sheer number the team brings, trying to accommodate everyone and share the hospitality Rwanda is known for and team has experienced for 12 straight years.
The team arrives over two days exhausted and excited. Everyone has brought their skills and expertise to share with 16 very ill young people and colleagues with friendly welcoming faces. One volunteer stated, she has spent her entire career waiting for this moment. To give back and teach others, but this time, in a place where they are the only cardiac team for months who will take on this type of complex cardiac surgery. There is a sense of responsibility from the volunteers who give thanks for what they have in US and for this amazing opportunity to help others in such a beautiful country with warm people.
Selection Sunday shows the fatigue of the screening team who has worked 6 straight days 12-15 hours a day. They have maybe 30-40 patients who could benefit and will not survive another year, or if they do, their hearts could be too damaged for another chance. No one they see will survive this disease without surgery. They have spent hours with the patients, hearing their stories and wanting them to have one of the 16 slots.The surgeons review the physical exam and asks probing questions. Highly skilled sonographers show images that make even a seasoned team catch their breath. With disbelief they again ask the age, and by now the surgeons and anesthesiologists are even looking exhausted as they contemplate the amount of disease, the few slots. Each person in the packed conference room is encouraged to share their perspective. The Rwandan cardiologist team knows the family and the potential or lack of support present. Nurse Julie knows who the family planning will be a challenge to engage for female patients—a topic of immense proportion if the mandatory blood thinners are utilized as required following a mechanical valve replacement in a culture where the possiblity of child bearing means everything to a future of a 17-year old girl. The clinic nurse knows who returns for follow-up and who does not. Ethics collides with reality as everyone must readjust to a normal that is just beginning to sink in.
Everyone files out of the room slowly and much quieter than on entry, a combination of jet lag and anxiety showing on every face. Each team is seasoned professionals, with here and there a new volunteer or one fairly young in their career to balance natural transition of the team for the future. Each person mentally reviews their checklist. Do you have every critical item, and are you prepared? The team is awesome, some of the very best. They are the ones you select to provide care for your mother, your sister. The volunteer based team comes from 5 countries 14 states, 18 hospitals. They have about 12 hours to countdown before it all begins.
Tomorrow, we are one team.