Teaching and Learning

Today we had another break from the usual pre-surgical cardiac screening and echoing and ventured a bit into Uganda. We woke up and got to the hospital bright and early to start seeing and echoing children with heart disease. We continue to routinely see such extreme, unrepaired heart disease and it can be overwhelming at times.

Anyway, for a break today we went over to the medical school and gave a lecture to the pediatric residents here at Mulago hospital. We're in a room with all of the same kinds of information posted on the walls as our residency programs - various acronyms to remember pediatric diseases are posted on large posterboards on the walls. They are all crowded together waiting for us in a small room, tucked into wooden desks and perched on stools with their pencils and notebooks. I'm a little nervous - I hope that I have something to say that is worth writing down! Anyway, they greet us with smiles and we launch into our lecture on pulmonary hypertension, which went very well. They were very appreciative, and were actually sorry we were leaving! (So are we.)

Later that day we visited one of the patients who had their heart surgery last year while the team was in Uganda in one of the first open heart procedures in all of Uganda. We arrive at his school and surprise him. The children love the visit, and it is incredible to see them in their element, in school at their desks with their uniforms on.

Transition

Today was the last day there were OR (or as they say here, "theatre") cases. There was a PDA ligation, and it was done entirely by the Ugandan team. This isn't new, as they have been doing these cases on their own for a little while now. Still, it was a fitting cap to what has been going on. Each successive time I've ventured into the OR, there has been a progression. I've seen our the UNC scrub nurse and perfusionist farther from their positions and their Ugandan counterparts running the show more. I've seen Mike Mill, the UNC surgeon, on the assistant side of the table, and Tom Mwambo, the surgeon from the Uganda Heart Institute, leading the case. I've seen Gene Fried, the anesthesiologist from Wolfson Children's Hospital, away from the head of the table in lieu of the Ugandan anesthesiology team. This whole trip has been amazing, and although there has been many moments that have been personally, emotionally, or intellectually significant, this transition is probably the greatest thing to see.

More pictures to come tomorrow, as well as input from the rest of our team members. Honestly, we've just been putting in that much time, but we'd all like to get some of our thoughts down.

Lowell

Back from the wild

Today (Monday) was a whirlwind day. We were in Murchison Falls National Park this morning, and after an early day game drive, we flew back to Entebbe and then drove to Kampala. After a quick stop at the guest house, we headed back to Mulago to get to work. The first surgical case was already underway. One of the local surgeons actually took the lead on the case, as Dr. Mike Mill of UNC, this trip’s surgeon, assisted. We had 12 patients waiting for us to be screened – that’s half a day’s load. We certainly appreciated the break that yesterday’s trip provided, but it’s hard not to feel at least a little guilty about taking such an incredible trip with so much work to be done.

Today’s patients had some very unusual findings, and as you can probably imagine, that is usually not good for them. One patient was an add-on with truncus arteriosus, admitted with respiratory distress and failure to thrive. Another was an adolescent with an enormous PDA and what is likely severe pulmonary hypertension. A third had severe pulmonary stenosis and what seemed like almost no pulmonary blood flow. Sometimes the things we see here can be depressing because we could do so much more back home, but can’t do anything but wait while here. Other times – as was the case a few times today - it’s depressing because we can’t do much at home, either, and that means we have even less here.

Tomorrow should be one of the busier screening days, and of course, we have a lot of kids in-house to check on. Now that we’re in our second week, though, our departure date is creeping up on us and we want to get as much done as possible.

More to come later…

Side Trip

Saturday's case went very smoothly, and the patient was extubated in the operating room. No major events from the day, so most of us had some downtime. After a run through Muyenga (hills, at altitude!), we hit the town with Peter Lwabi and his wife.

More on that later, but for now, it's off to Murchison Falls for a little trip. We'll be back tomorrow morning with more updates about the work in Mulago.

Lowell

More Pics

Edwin after his VSD repair.

Kato after his ASD repair.

Jonah, post-septostomy! He's showing off his pink(ish) mucous membranes.

Saturday Update

Friday night was a great one for the kids, as it was quiet in the ICU and everybody progressed nicely. Both our team and the UNC team had fairly sedate evenings, and they were well-deserved with the amount of work we've done here in the first week. In addition to setting up the OR and the ICU, we've done 7 OR cases (or "theatre" cases, as they are known here), over 110 echocardiograms, multiple teaching sessions with nurses, surgeons, and pediatric residents, and a balloon atrial septostomy. It's even more significant when you consider that our team has been passing around some variety of flu bug that we can't seem to shake. Still, so far, so good.

We are preparing for our Saturday OR case right now, a VSD. There's no screening today, so we can catch up on some other things, like posting pictures. Oh, and taking care of our own - our perfusionist just got a nasty electric shock from one of the bypass pumps. Perhaps we will choose to use another one...

Anyway, here are a number of photos from the week's activities.





Reuben, Craig, Stephanie, and Bill share a moment in the operating room.

Stephanie, Laura, and Lowell participate in a "group echo" in the Special Care Unit (NICU) on Thursday. Laura did the real work, while Lowell held the machine and Stephanie kept the baby from crying (and took pictures, of course).

So that little girl you see below getting an echo? That's Patricia, who had a PDA ligated. Here she is 48 hours later, causing havoc and dancing around the UHI. She's definitely the star of the show so far!

We arrived here on Sunday night after leaving DC at 6 PM on Saturday. We escorted two Ugandan children, one mother, and a translator back home from DC, where the kids underwent interventional catheterizations. After a dinner with our colleagues from the University of North Carolina (who include respiratory therapy, ICU care, CT surgery, and perfusion) and a stay near the airport in Entebbe, we drove to the capital city of Kampala and quickly went to work.

We’re working at Mulago, the main medical school and teaching hospital in Uganda. It’s an enormous facility, and walking around, it feels more like a campus than a hospital. On Monday, after setting up the makeshift echo lab, we started screening children. I think we did 30 echos in 6 or 7 hours that day, and all of them had significant heart disease. Even the relatively simple stuff had sequelae we just don’t see in the US. Most of these patients were ones who were most likely to have surgery in Uganda, either on this trip or in the future. We did have a few “unscheduled” patients, including a one month old baby who was as blue as a smurf. He had transposition of the great arteries and severe pulmonary stenosis with almost no VSD or ASD. That's not the kind of thing you expect to show up in your clinic. His oxygen saturation was 40%. Peter Lwabi, the cardiologist here in Uganda, approached us about performing an atrial septostomy. Unfortauntely, there isn’t a stock of catheters in this hospital, as the thought of a cath lab is absurd. Essentially, the next 2 days were spent trying to find catheters, because this child wasn’t going to live very long without some type of intervention, but on this day, with nothing else to offer, we sent him home.

After the screening, we had a surgical conference to determine which kids we were going to operate on during this trip. Ten cases were scheduled. The first OR day was Tuesday, where an ASD and a PDA were repaired. Both patients were extubated in the operating room, and both did great overnight. We did more screening, and with the surgical candidates done, we saw far more bizarre pathology. There was a 15 year old with TGA/PS/VSD. There were lots of kids squatting in the waiting area, which meant lots of Tetralogy of Fallot. There was a truncus and a TOF/pulmonary atresia as well as multiple patients withtotal anomalous pulmonary venous return. Wednesday, had two more OR cases – a VSD and an ASD - and of course, tons of screening. Some of us were shown the pediatric ward by Peter. When a child is hospitalized here, the docs right a prescription for the medications, and the parent brings it to the pharmacy, pays for it, fills it, and gives it to the child themselves. That is, if they can afford the medicine.

During the day, we had located a septostomy catheter and the appropriately sized sheath, and the family of the blue baby was called to bring him in. The ICU was set up for the septostomy, which in addition to the many people required, also involved everybody else trying to watch. There were a few concerning moments, but overall, the baby did very well, and was easily extubated afterwards. His sats this morning were 75-85%, which is better than we expected. It’s hard to say how long it will last him, but probably longer than if we hadn’t done it. And of course, it was the first catheter-based procedure in the country, which in a way is more exciting than the surgeries we’re doing.

Thursday was a pretty slow day, because it was Ugandan Independence day. Some of us went to the NICU (“Special Care Unit”) today to do a few consults. We saw a large PDA, which is not that unusual, except that instead of IV indomethacin to attempt medical closure, they use oral ibuprofen. The NICU staff had some visiting neonatologists, one of whom wanted us to ultrasound a baby’s kidneys. The NICU has no laboratory or x-ray capabilities, so and ultrasound machine is out of the question. We obliged to the best of our abilities, but unfortunately, the baby was pretty much already dead when we got there. That was the second death of the day, and it was only 9 AM. And that’s not that unusual. That whole experience highlights all the growth that has happened with the pediatric program in the Uganda Heart Institute, but unfortunately, it also shows how much farther other areas have to go.

Inaugural Blog Posting

We're now on our fifth day in Uganda on the most recent of CNMC's trip to work with Samaritan's Purse Children's Heart Project. We'll be posting updates from this trip (and hopefully a summary of past activities as well) in the coming days. Keep checking back for updates.