Day 7 – Saturday Goodbyes and Departure
A challenging week is coming to a close. The cases proved to be difficult and complex. And while we would have liked to see more rapid recovery, our patients are indeed recovering. The Ugandan team has enthusiastically stepped up to take full control of each patient’s progress. We packed our trunks, said good-byes, had our annual de-briefing session, and closed with a small farewell party and cake with patients in the regular cardiology ward, families and some former patients. Now for the long journey home.
No individual shout out today. But we all acknowledge the key player and leader of this team, Dr. Mark Turrentine. It is his continuing legacy and vision to provide this cardiac surgery care to places and patients in need, and we belong to the team that he puts together. The reward and benefit definitely goes two ways.
Joey and Melissa had a busy night. Sadat had a drop in blood pressure that required a significant amount of meds to help him recover. By the time we arrived, he was stable and much better. So we took him to the OR to see if we could band his vertical vein and then close his sternum. The suture on the vertical vein to close it had been removed on his first night to help reduce the left atrium pressures. In the end Dr. Mark could only very loosely band this vessel, and then closed the sternum. Sadat tolerated this well and returned to the ICU.
Saidat was intubated yesterday afternoon so that we could more effectively open up her left lung. After this her chest X-ray was much better. So we asked Dr. Joey and Melissa to allow a few more hours of respiratory treatments, and then extubate her (if possible) in the morning before we returned. Unfortunately her pneumothorax (air in the chest cavity) and lung collapse returned very quickly. We decided to call the ENT specialists to see if they could do a test to look for an airway problem, and also to replace her chest tube so we could keep the air out of the chest. This all was done in the OR after Sadat returned. Saidat came back to the ICU intubated but sounding much better. Hopefully she will now make steady forward progress.
Maria was successfully weaned off of her ventilator, and looks very good. Sheila was moved to the step down unit. And Aaron and Thomas continue to progress well.
Despite all of this activity, we did proceed with a last scheduled case – Tracy Kiconco. She is a 6 year old with Down Syndrome and a large VSD. She has some restriction across the VSD, as well as a mild narrowing below her pulmonary valve. She was known to have high blood pressure in her lungs, but a previous cath study showed that she would be safe for surgery. She came from quite far away in SW Uganda, and we really wanted to not have to post-pone her repair. She did very well, and returned to the ICU around 7:30 – 8:00 pm. We are going to follow our typical pulmonary hypertension precautions this first night – which means she will stay on the ventilator.
Our shout out tonight goes out to our daytime Cardiac ICU nurses, Sheila and Rebecca. As always it has been a busy and demanding week that just builds each day. But this year from Wednesday onward has been extra challenging. Often 3 ventilators at a time, alarms, desaturations, low blood pressure, and more. All of this has been handled with grace, excellence, professionalism, and great spirit. And their energy and enthusiasm have continued into our evening dinners and gatherings. They are a true asset to this team.
Day 5: Thursday
After our long day yesterday, we returned to the Hospital this morning – a little surprised that we did not get any calls from the night team about Sadat. He continues to be on a lot of medical support but was generally stable overnight. Maria, Thomas and Aaron were also stable through the night. Saidat however redeveloped her left sided pneumothorax (air inside the chest cavity) and collapsed left lung. Based on the impending need to reintubate Saidat, and a bit of a bed crunch (it even happens here in Uganda), we decided to do just one operation today on a patient with the least risk of needing post-operative ventilator support. That patient was Sheila Kanyelele – a 13 year old with girl with a large VSD, and right ventricle muscle bundle that was obstructing flow to the lung arteries, and a large ASD. She was identified and referred to us by Chain of Hope – another organization that is strongly committed to the ongoing mission here in Uganda. So much so that we were the grateful recipients of their support for a portion of the cost of our trip here. Many thanks! Her operation was largely performed by the Ugandan team (anesthesia, perfusion, scrub nurse, and surgeons). It went very well, and Sheila returned to the ICU already extubated.
Thomas was also doing well and moved out to the Step-Down room next to the ICU. He has a bit of gas and abdominal pain, but is otherwise recovering very well.
While our one surgery case was under way, the ICU was a very busy place. Maria was gently weaned down on her ventilation settings. She tolerated this to a point but we had to stop as she was still to sedated to breath deeply on her own. Saidat was reintubated and received aggressive therapy to help re-expand her left lug and by the mid-afternoon her x-ray was much improved. We hope she can be extubated tonight. Maria was up and down with her blood pressure. She is slowly improving in terms of her lung edema. We echoed twice throughout the day and saw her heart function get a bit better. Late in the afternoon she seemed to be improving quite a bit from a blood pressure and circulation perspective, and may be able to be weaned from some of her cardiac medications tonight. Our hope is that we can take her to the OR tomorrow afternoon to close her sternum.
Our shoutout today is going to 2 members of our OR team. They have been to many (Dr. Scott Walker), if not most (Mike Horner), of Dr. Turrentine’s mission trips both here in Uganda and to Jordan. That in itself speaks to their importance in making cardiac surgery as safe and “like back home” as it is at Riley. They also are the force that seems to take a group of people who are not too familiar with each other at the start of a mission, and help transform us into a team and part of a special family. We can’t imagine a mission trip without them.
Day 4 – Wednesday
Earlier this week Dr. Michael Oketcho and the the Pediatric Cardiology Fellows here mentioned a newborn that was in the Mulago Nursery. They wanted to know our thoughts about a baby who had early and persistent cyanosis and poor feeding. Her oxygen saturation levels were 40%-70%. An echocardiogram demonstrated pulmonary valve atresia, near tricuspid valve atresia and a severely hypoplastic right ventricle. This is a defect that results in no normal blood flow into the lung arteries, and no usable right ventricle. At the time of the echo, she did have a PDA that was fairly large – this temporary vessel was supplying some blood flow to her lungs. Yesterday evening this baby and mother came to our post-operative area for us to see and evaluate. She was small and markedly cyanotic (blue). She was 2.5 kg at birth and probably less than that now at 5 days of age. Her oxygen saturation level was about 55%-60% (very low). I did a very limited echocardiogram with a portable echo machine and showed the above diagnosis and a small PDA – too small to allow adequate pulmonary blood flow. The PDA naturally closes in the first few days after delivery unless you give an IV medicine called prostaglandin. This is not a medicine that is available here, and we did not bring any. We decided to re-arrange our schedule and plan to do an operation in the morning to give her a central shunt. So, Maria Tusingwire was our first case this morning. She did well and her saturations went from 40% or less in the OR before the shunt to 85% afterwards. We all agreed that Maria had very good timing.
For many of our patients today was a good day. We extubated Saidat who had a complication of a pneumothorax (air in the chest cavity) overnight. Thomas is recovering nicely and starting to drink more. Keturah and Aaron moved out to the step-down room. Aaron is not very happy as we are doing chest percussion to help open an area of lung collapse, but Keturah seems back to her usual self. She will likely move to the ward on the Pediatrics service to begin dealing with her airway problem.
Our second case today was a very alert baby named Sadat Mutungi. He is a 5 month old boy with a diagnosis of Total Anomalous Pulmonary Venous Return (TAPVR). Instead of his lung veins draining to the left upper heart chamber as they should, they drained to a vessel that went up toward the neck and then drained back into the heart on the right side. This was a baby who was initially evaluated by our Ugandan colleagues the week before we arrived and they requested we try to fit him into our schedule. The repair went very well even though the left atrium was quite small. The initial post-bypass trans-esophageal echo showed good function and repair. There was evidence that the left atrium was not very compliant so it was a bit harder for blood from the lungs to easily enter it. However, very soon after the sternum and skin were closed, and before leaving the OR, problems developed. Low blood pressure, and ventricular fibrillation, flash pulmonary edema, acidosis, poor heart function, pulmonary hypertension. Over the next 2 to 3 hours his chest was reopened, he received chest compressions, cardioversion shocks, and many resuscitation meds and continuous infusions. Remarkably, and in large part due to the great efforts of the Ugandan team and the Riley team working together, Sadat became stable again, and eventually made it to the ICU. He has a long night ahead of him, and is still very fragile, but we hope and pray that he continues to recover.
Today’s shout out goes to our awesome night duo of Dr. Joey Hobson and NP Melissa Johnson. All of us in the medical field know that nights can be a little scary. Bad things tend to happen then, and there are far fewer people to help in an emergency. Add to that an unfamiliar hospital system, and it is clear you need a calm, resourceful and valiant team to keep our patients well. Dr. Joey and Melissa have lived up to this demand and our Ugandan patients have benefitted. Their hands will be full tonight.
Day 3 – Tuesday 9/22/2015
We arrived to Mulago Hospital today and got report from Dr. Joey Hobson and Melissa. Aaron and Keturah both did well overnight and would be ready for extubation this morning. Our first patient this morning was Thomas Kisyakye. He is an 18 month old boy with a transitional AV Canal Defect – a defect that results in a large hole between the upper chambers and in Thomas’ case a small hole between the lower chambers. Often this defect is seen in patients with Down Syndrome, but Thomas does not have this syndrome. He was in mild heart failure. He did very well but anesthesia felt we should leave him intubated (breathing tube in place and on the ventilator) and plan to extubate him early this evening.
We were able to extubate Keturah even before the night shift left. She struggled a bit at first and Dr. Scott and Dr. Rania “MacGyver’d” a racemic epinephrine nebulizer (seen below) that helped a great deal. Later she was still fussy, but was completely consoled by the toys, blanket, cups and sunglasses that are included in each child’s gift bag – courtesy of the generosity of Sheila, Rebecca, Leesa Hertz (back home) the Riley Child Life Department, and the Riley Children’s Foundation.
Also during the morning, I was asked to staff rounds as a teaching exercise on the pediatric cardiology inpatients that our team is not following – about 6-7 patients. Three of these patients were being treated for endocarditis. One of whom also had a severe cardiomyopathy preceding her infection, and current problems with electrolyte imbalance. Another had severe regurgitation of his aortic valve. There were great clinical exam findings to discuss, and interesting comparisons of diagnostic and treatment differences between our systems. This does make one appreciate the resources at our disposal in Indiana.
Our second surgery patient of the day was another beautiful 4 year old girl named Saidat Namuyingo from Masaka, Uganda. When you see her picture below, I know she will steal your heart. She also had Tetralogy of Fallot. Dr. Michael, with Dr. Mark’s assistance, did a valve sparing repair with excellent results. She returned to our ICU at about the same time Dr. Joey and Melissa were getting report from us about our day.
And the daily cycle continues. Interesting developments late in the day led to a last minute change in tomorrow’s schedule. I will explain it all in tomorrow’s post.
Today’s shout out goes to Brittany Mote and Ashley Woolen. Two of our OR nurses who are indispensable in helping our cardiac surgeons succeed both at home and here in Uganda. Seen below, I am pretty sure Ashley is suggesting the best strategy for Dr. Turrentine before his next operation.
Day 2 – Monday 9/21/2015
Our first patient today was a beautiful 1 year old boy named Aaron Anyijo with a diagnosis of Tetralogy of Fallot. This will be one of the main themes this week – Tetralogy of Fallot and VSDs, plus a couple of other diagnoses for repair. Aaron and his family are from a small village in northwest Uganda near the Sudan border. When we did an echo on Aaron yesterday, there was concern that the coronary artery anatomy was abnormal in a way that could compromise the surgical repair. Today, when Dr. Michael and our Dr. Mark looked closely at the heart, they confirmed our suspicion – the coronary arteries were abnormal. Initially they tried to repair the typical narrowing of the right ventricle outflow tract without putting a patch in this area. But our esophageal echo showed still too much narrowing, so a limited patch was placed to avoid the abnormal coronary, and the narrowing improved greatly. The repair looked great and Aaron is recovering in the ICU. We plan to extubate him in the morning.
During the morning several patients were seen to determine their readiness for this weeks’s surgery, or to consult to see if they could safely be repaired this week. This happy 6 month old boy (pictured below) has a large VSD (hole between the 2 lower heart chambers), but also a membrane partially obstructing flow from the the left pulmonary veins into the left atrium. He was a total charmer and “talked” and “helped” me perform his echo. He was pretty hard to resist.
Our second patient was a quiet 5 year old girl named Keturah Nansamba who has a large VSD, mild pulmonary valve narrowing and a patent ductus arteriosus. She is from the central Kampala area and is know to have a history of repeated hospitalizations for recurrent pnuemonias. Unfortunately we were unable to proceed with her heart surgery. When she arrived in the Theater (operating room) Dr. Scott was unable to intubate her (place the breathing tube for the ventilator) as expected. He had to use the smallest tube we had (one intended for a small newborn or premature newborn). She apparently has a severe airway narrowing below her vocal chords. Due to resource limitations, the otolarygologists were unable to fully evaluate or treat her today. Our team and the Ugandan team felt that the heart surgery was unsafe, particularly afterward when an small airway might seriously jeopardize her recovery. She came back to our ICU to rest for the night and plan for extubation tomorrow. Her airway will have to be addressed before she can be rescheduled.
Our team has humbly requested that I do a “shout out” each day for one of them. I will do my best. While every member of the team is extraordinary and all deserve daily accolades, today’s shout out goes to Rania Abbasi – Pediatric Cardiac Anesthesiologist. Pictured here helping Aaron fall asleep for his operation.
First day in Uganda – Sep 20, 2015
After our usual long day of endurance travel we arrived safely and uneventfully to Kampala, Uganda. Dr. Scott Walker is our travel time keeper and reports that we walked into the hotel in Kampala just shy of 28 hours from when we checked in at the airport. These are our before and after shots. Not too shabby after all those hours. We all discovered a pleasant and appreciated surprise gift basket of fresh fruit in our hotel rooms from the Gift of Life. Thank-you!!!
From left to right: Tim Cordes, Mark Turrentine, Joey Hobson, Ashley Woolen, Rania Abbasi, Melissa Johnson, Brittany Mote, Sheila Rocchio, Rebecca Mahlie, Michael Horner, Scott Walker.
We had a short night of sleep, enjoyed a great breakfast at the Golf Course Hotel, and then headed to Mulago Hospital to prepare for the week ahead. Eleven trunks were brought to the hospital with our equipment, etc. and unpacked and organized. Then we gathered with Dr. Tom and Dr. Michael, and their team to review the potential cases for the week and set our preliminary schedule. We also met and got some additional echo images on our first 3 patients.
Aaron Anyijo and Ketarah Nansamba – Tetralogy of Fallot patients for tomorrow. Aaron (on the left) smiles constantly until you bring the camera to your face.
We gathered for a delicious Indian dinner nearby, and then headed for bed (or blogging) before we start in earnest tomorrow. More to come…..