Update from Rwanda

Pictured above from left to right: Cathy Jackson holding Hussein, Megan, Ceeya holding Joshua

Trying to see all patients is hard, they come from far distance, buses are unreliable. A few wish we could visit them and as much as we wish to do so, it is challenging. They all send greetings and well wishes to the team. They seem to remember most "their ICU nurse" and "their stepdown" and "their surgeon". They all remember John Connell, whom showed so much compassion as he pulled lines and liberated them from ICU. I have many messages to return with.
-Ceeya

Message from Ceeya in Rwanda

It is Sunday in Kigali, and hot. We spent a lazy morning, due to a wicked jet lag sipping coffee overlooking Kigali. Yes to all who know Rwanda, I was at Bourbon Coffee. (One of Team Hearts favorites spots.) Jennifer, Kathy, and I sat and chatted about how special it was to see Erneste smiling at the airport with Dr. Mucumbitsi. Erneste joined us for dinner.

We met up with the Australian team, admiring the handiwork of Dr. Ian Nichols and team.... normal ups and downs of early ICU, which is why patients need ICU.... Already they have 8 in ward- couple looking close to going home! It was good to see Ali and her team moving competently with incredible compassion.

Today, organizational and planning meetings with the National Council of Nursing, King Faisal Staff...tomorrow Dr. Kaplan arrives-let the fun begin.

Claudine update

Gene Bukhman is back in Rwanda for a few weeks and sends updates from all patients. The small group returning in November is excited to see all of our patients. Gegeon sends photos of Miss Claudine (above) taken recently...ready for school in January. It is amazing to see the difference when your entire body is not using all the energy just to breathe and provide circulation...she is now gaining healthy weight and looks beautiful!

Thanks to Gedeon, a recent update about Genevieve

Genevieve

Gedeon writes:

Hi all, I would like to give some updates on Genevieve a post cardiac surgery patient followed here at Rwinkwavu. She is doing fine, physically comfortable, the left side weakness has resolved at this last examination, and gained weight appropriately. The follow up at home with accompagnator goes well. -Gedeon

Gedeon has been wonderful to send photos of the patients when he sees them and understands how important this is to us. Thank you Gedeon for being part of our team and including us in yours!

When you save a life, you also save the future at the same time.

Pictured above: Erneste Simpunga - 1 year anniversary of surgery at BWH

Dear Friends from Brigham and Women's Hospital,

I say hello to all of you. Today, it's July 29, 2009 where I remember and celebrate one year ago since my heart surgery!! My objective is to thank everybody especially doctors and nurses who have taken part in my life. This is like a thank-you letter and I would like to be clear that it is basically for Team Heart and it's members.

It is so nice for me to share my pleasure with you at this moment. Above all, Let us please get down to our knees and thank God for being with us. Now, allow me thank a lot of Team Heart members for helping me and my country. This team does what according to me, is called miracles. Their work and help is beyond human understanding.

Last year when it was their first trip to Rwanda, they saved 11 cardiac patients with the help of surgery. Now these 11 patients are feeling so much better and some of them have already reached what they dreamt as their performances after their surgeries.

1) Jean Paul is a very good taxi driver!

2) Djuma is one of the best soccer players at his school!

3) Alice is able to work on the farm in order to feed her family as she asked when she woke up after the operation.

4) KARUGANDA Jean Damascene is finishing his high school education this year in November and he will be at University next year! He is dealing with electricity and he has a very huge National examination on November 02, 2009. So pray for him.

5) Celestin GASAMAZA who became the first patient of this team said he will return to his university and get his masters degree and he is getting it at the end of this year!

6) Vedaste says he is again able to do everything he could not perform before. He also says when he drinks, he feels normal whereas before surgery when he tried to drink,he was feeling too tired and also dizzy.

Last April, I was very sick almost to die, Team Heart was so scared of my surgery but they never forgot me. They brought me to the United Sates. Staying with Ceeya and Chip Bolman, for several weeks after, Dr.Ralph Morton Bolman really shown he is the chief of cardiac surgery when he and his team successfully replaced my Mitral and Tricuspid valves! Since that day, my life is 7 times better than before! Thanks a lot.

Now, Erneste is full of beans. I would like to tell everybody that Team Heart really shows that every cloud has a silver lining or every difficult situation has a positive side. Team Heart also shows how life is more interesting! When you save a life, you also save the future at the same time.

I give thank you to:
- Doctors and nurses who were in the operating room with me on July,29,2008
-All nurses who care for me in the ICU and also in the Ward.(Two nurses were the first to take a very good care of me directly when i woke up.These are Kevin and Susan. Thank you so much.

I can not forget to thank:
-Dr.Gene Bukhman
-Leslie SABATINO.
- Dr. Pat Come.
-Amy and Mike (Thank you for being attentive with the use of heart -lung machine)
-Vlad and Louigi, i thank you too.
-Ceeya Bolman.
-Dr.Prem Shekar.
-Suellen (Thanks a lot for your help including your nice pre-operative education)
-Kayla Quin.
-Diane.
-Liz
-Sara
-Brenda
-Egidia (Thank you so much as well for a lot of things including translation.)
-Dr.James Rawn.
-Denise
-Marie.
-Dr. John Connell
and others.

Finally, this is how my life has changed:
1) Now, I have a very regular heart beats. Yesterday, I visited the cardiologists from India at King Faisal Hospital and they were so proud of my heart and it's functions.

2) Gain of 20 kg of muscles. When I came to Boston, my weight was 35 kg(78 pounds) where as right now I have 56 kg(124 pounds)

3) I am strong and energetic. Dr.Bolman said "At the end of November, Erneste, you could'nt hold him down! He rode between 12 and 18 miles." Now I have increased the distance, I ride 80 km within 6 hours and I feel normal.

4) I am back to school! This is my best performance. When I looked at myself the time I was very sick, I never expected to go back to school but now I am back there and the studies became much easier than I think or than before (Here I give a lof of thanks to Ceeya and her husband who pay my school fees and my medical treatments.

5) I am able to deal with every daily activities.

6) When Ceeya, Suellen and Kayla brought me home, they saw a mountain where I used to walk by using 1 hour, but we walked up that mountain and we used 10 minutes.

Thank you so much, I wish you the best and my God bless you.

Youngman from Rwanda, Always proud of you.

Much love,
Erneste SIMPUNGA

Jean Damascene's story

In picture, from left to right: Kayla Quin, Jean Habiyamana, John Connell, Jean Damascene, Denise Ricci and Terry Roche


A shy, young man with a large liver and shortness of breath presented through the Butare Medical Center to Partners In Health, the Boston based NGO in April of 2008. Jean, a striking, tall young man, almost gaunt, whom appeared to feel comfortable, spoke in limited English, though he is fluent in both French and Kinyarwandan. Said to be “in school,” his dark, bright eyes quickly assessed everyone in the room anxiously. He watched carefully as our nurse educator taught a younger student and listened intently as she read the pre-operative teaching booklet with the group having surgery. His fear was not of the pain that he might have having cardiac surgery. His fear was he might not be selected to endure that pain.

His parents and siblings were all killed in the genocide in 1994. He had been living in an orphanage since age 3—a very lucky young man. Not only had he had a roof over his head, but he had food as often as they could supply it and was sent to the local school. At sometime in his childhood he most likely had a strep infection, maybe a sore throat. Untreated, he developed rheumatic fever and it progressed to rheumatic heart disease. It wasn’t that anyone ignored his raw throat and fever. But it occurred at a time when medical care in Rwanda was in shambles as they recovered from the effects of the genocide in which less than 400 physicians and 3500 nurses were left to tend to 9 million people.

He was sick, maybe too sick, to do in Rwanda. Discussions about patient selections weighed in on both sides. In his favor, was he was very bright and said to be a good student. He would be able to participate and manage his own care….which would include long-term anticoagulation therapy. If selected, he would be able to return to school, complete it, and be a candidate for college education. Perhaps a teacher to educate others or to work in a business to support himself and a potential family.

With a great deal of relief, he did well through surgery, very well. Convalescence was compromised by the expected post operative heart failure that would take time to improve and time for the liver to return to normal. In retrospect, it is amazing how well he did…..on the day we left, as the other patients lined up outside for photos to be taken, he was missing. Found to be in his bed he was huddled under the covers, sheet over head and sobbing. For two weeks, he had had a staff full of Brigham and Women’s Hospital nurses addressing his ever need—more attention he had had in a life-time. He had completed post operative teaching about the future care and follow-up and what was expected. Much teasing was done about this group of handsome young men and their future. He was not so sure there was a future…still in an orphanage until they pushed him out; no one had time for him to be the center of their universe, as most of us do for our children.

I had reports periodically that he was doing well. He was managing his Coumadin, although he had not shown up for appointments because he had no money for transportation. Money raised to support this aspect was tied up in paper work. His liver was said to be shrinking, his mitral regurgitation decreasing …

On a recent trip to return to Rwanda, I saw a tall, very handsome, still almost gaunt, young man walking down the hall with a smile to light up the universe. One year later, he was doing well and was surviving in a way we find hard to imagine here. For the moment he has a bed to sleep in and sometimes food. He says the governmental support for genocide survivors is delayed so he has been out of school. A quick Western Union transfer got him back in school and food for the month. Discussion ensued about eating as healthy as possible, at least one meal a day, and continuing follow-up care. We talked of plans to send an allowance and forget the paperwork that appeared to be perpetually tied up. As I felt a stab of concern …was he telling me the truth? I felt some faith in the world was a good thing. I asked him about college….he was speechless. He asked if he could call me Mummy.

This young man is an integral part of Rwanda’s future and ought to deserve a chance at success, not merely survival, for himself and his country as much as anyone else. When his college education is completed, he will become a valuable part of country’s future economic growth. An allowance now can provide him access to important benefits that most take for granted, such as healthy food and instructions on how to prepare, mentoring to teach a healthy life style, how to manage a small allowance, lessons that can teach him how to make the most of what he’s been given……and perhaps the knowledge that people really care about what happens to him.

He is one of the patients we have been given the opportunity to work with. You can help.

Last patient is discharged!

Hello all!!

To add to the picture show, I've attached a picture of Genevieve OUR LAST PATIENT as she will be discharged TODAY!!!!! She looks great and is walking and smiling.

Thanks everyone for all your hard work... the patients (the results) speak for themselves. It will be amazing to see how they look next year when you visit again....

Special thanks to the KFH staff, doctors, nurses, residents, pharmacists, everyone. They've been very gracious and have done a great job taking care of our patients.

It's been so fun to be a part of this miracle and to end with Genevieve is really poignant.

Thanks again all! Be well and hope to see you soon,

Smitha

Genevieve is with Dr. Smitha Phillips, Cardiology Fellow from Georgetown, and Dr. Maurice Musoni, medical officer hoping to train in cardiac surgery

Book donation

Suellen Breakey in the Connell School News:

http://www.bc.edu/schools/son/AnnounceNewsEvents/news/rwanda_books_web.html

Message from Warren Harthorne, M.D.

The trip was extraordinary and life changing. It is hard to put into words: the depth of poverty in the countryside is alarming; the average income is $220 per annum. Children are in rags and bare feet in the countryside with considerable illnesses including rampant active and chronic rheumatic fever and tuberculosis. Our echo technician, Jennifer and I visited five community hospital for diagnosis of children as young as 9 years with advanced active rheumatic heart disease on the threshold of death from congestive heart failure. It was heart breaking to see these attractive kids for whom there is no treatment within the country. I am now approaching 50 years of involvement at the Massachusetts General Hospital in Cardiology. My training mentor was Paul Dudley White who emphasized clinical cardiac evaluation and definitive treatment. I had not seen a case of acute rheumatic fever for the past forty years yet saw multiple cases during this two week visit to Rwanda. I was not totally inexperienced in "Triage" medicine, having spent a year with a MASH Hospital in Korea (I am not Hawkeye) though this was the same MASH hospital from which that program evolved. To witness patients with diseases that no longer exist in our own country such as acute rheumatic fever and its consequences was, for me, as a trainee of Paul White, (who is responsible for describing the diagnosis and treatment of this disease) especially remarkable. In an African nation that has an average income of little over $200 per annum; it was evident that the children have little opportunity to avert the ravages of streptococcal infections. While it was a privilege to participate with Team Heart in this venture, it was, at the same time, depressing to leave behind young children with life threatening valvular heart disease that would be "duck soup" to treat in our own country. My tears of frustration and inability to help these beautiful children were suppressed with difficulty and I had many occasions to find myself in a quiet corner in which to regain my composure.

We saw a 20 year old woman in her third trimester of pregnancy with acute cardiac failure caused by ruptured chordae of the mitral valve from prior bacterial endocarditis. The woman will be sustained to 34 weeks of pregnancy to ensure a successful birth and the baby (a boy) will be delivered by Caeserean section, yet the mother, in the absence of reparative cardiac surgery will surely die leaving the infant as an orphan. This scenario was the subject of one of the first papers that I published nearly forty years ago and left me feeling impotent in saving this young woman. A young, 12 year old girl in the pediatric ward of the Central Hospital of Butare (CHUB) whom we visited was in acute cardiac decompensation with triple valve, rheumatic heart disease. Her mother, distraught at the bedside, was unable to pay for the drugs to bring this young girl out of incipient death from acute CHF. My visit to the pharmacy to purchase the appropriate drugs (Spironolactone, Metolazone) was a simple temporizing solution to her near death experience yet eventual death lurks in the near future without corrective surgery. Such experiences left this participant depressed and feeling helpless in applying half a century of easy solutions to a cardiac crisis. Is there not a way in which such children in advanced heart failure can be accorded the necessary valvular replacement surgery to return them to useful lives?? Do we not have a global obligation in following such human beings to intervene at all costs to ensure that they, as we, are eligible for reparative surgical interventions? Too often, the proverbial observation of "not what you know but who you know" applies to those fortunate enough to be sent for corrective surgery.

This respondent has felt enormous gratitude for being included in this humanitarian enterprise and has great respect for the leaders of this venture yet is left with a great sense of guilt both because the western world (us) did not respond when the genocide was ongoing, leaving hundreds of thousands to die horrible deaths by machete and now in the presence of a virtually absent interventional health care program leaves it citizens to the whims of chance and non treatment. The program of Partners In Health strives to reverse this trend and all of us should be willing participants. We should all look, not only toward the immediate problem of the individual whom we have saved but toward the larger population at risk in the community in whom an early death from correctable cardiac disease is their ultimate expectation. The Rwandan people are friendly and seemingly happy though one wonders why. Those women who were raped during the genocide and acquired HIV/AIDS are given jobs sweeping the streets; the country is lush, remarkably clean, and reminiscent of the State of Vermont.

Warren Harthorne

Thank you from Chip and Ceeya

Ceeya writes:

Today, Egidia returns home and Team Heart will be home in full. I want to take this opportunity to thank each and every one for the incredible job. Always rising to the challenge and characteristically with an offer to help before being asked.

From the moment we landed and the volunteers helped unpack and set up, thank you Andy, Katherine and Natalie, Paige and Sofia to the patient work up with Gene, Les, Warren and smiling Jen and Meera (hey hey).....From the moment patients reached theater into the competent hands of Daljit, Luigi, and Nelson with Dr. Bonaventure we were on track, even with some very fragile patients to induce. Thanks to Chip and Prem for doing what they do best with a very competent support team Katie, Laureen and Terry. Barry always steady, always competent and calm shoring up where it needed to be and never complaining....Even getting Leslie M and Judah into OR...What a wonderful addition the MGH and Minnesota team makes to Team Heart!

Thanks to Amy and Mike--the dynamic duo. Cannot imagine a better perfusion team anywhere for this type of work. ICU was led by ever competent Jim and Zara and of course the ever present John Connell who received the ultimate compliment...the ONLY person the Rwandan team wants to make certain returns....(a reflection of John's willingness to always help out and not judge or treat people with anything less than full respect!). ICU nursing is a group of the most competent people Ahsley, Barbara, Bridget, Kevin, Leslie, Lindsey, Lisa, and Sue and thank goodness for Brenda and Jane.....what would we have done without them--they never complained of all the hours they worked.

Stepdown was busy and packed for several days, but still time for teaching and in Kinyarwandan...no less.With Egidia, Carol, Denise, Kristin, Marie, Monica, Sara, Terry-- and Sofia when needed....Thank you Liv, you were great--next year we want you to stay longer....

I am so glad George was with us...no fair sneaking off in the middle of the night.....no one was able to say good-bye.

We cannot forget to include thank yous to the Rwanda based team, Drs. Betty, Mugisa and Mucumbitsi and Juliet--with leadership of Maureen.....thank you to the warm welcome and preparations of Rosemary--thank you to Campbell for making things fit together and Clare, John McCally and Dr. Innocent for listening.

Last thanks to the volunteers in Boston, there at the beginning counting meds and planning and there at the end....Bonnie, Pharmacy, Anne and Julie and of course Ms. Leslie, who procured and packed what I had forgotten and listened to my panic stricken midnight emails and calls...

Smitha--many thanks for being there and helping to take care of the patients in hospital now...I knew you were an answer to a prayer when I first heard from you.....between you and Drs. Betty, Alex and Maurice and Dr. Narish, I know the patients are in good and competent hands.

And Hal we learned much from you because of the questions you asked--we will stay in touch (as soon as my voice returns)

Katherine will be scheduling a debriefing, so stay in touch. If there is information that did not get placed in the green reminder book, let me, Katherine or your team leader know..... Jim has volunteered to find a central photo sharing spot....more on that later....

KFH team is doing a really really good job. Anastasie is off dopamine, might have left ICU today, Genevie is getting better, Claudine has had some syncopal epidsodes and getting a neuro work up to rule out seizures, Jean la dieu is having fevers and will be in hospital for a time--there are others diruresing but progressing. We are lucky to have you all---


Chip writes:

Please allow me to add my heartfelt and sincere thanks and appreciation for all the hard work and dedication once again displayed by every member of the team. Ceeya speaks for both of us in expressing our deep pride in being associated with such an outstanding group of human beings. You are an inspiration to both of us. What we have accomplished, all of us together, is a wonderful start toward an eventual self-sustained heart surgery program in Rwanda. You should all be justifiably proud of your contributions. It could not have been done without you. Thank you, and I am already having Rwanda withdrawal, and looking forward to next year.

Team Heart 2009

Message from Jennifer Neary

My apologies for the delay in writing. Sadly I am now back in the states and away from the patients and members of Team Heart.

I departed Kigali on Tuesday evening, sad to be leaving, and was back to work in Boston Thursday morning. 
The last few weeks have been full of emotions, eye opening experiences and encounters and a few surprises...but I guess that's to be expected when you fly with a dedicated team of 46 to do heart surgery in sub-Saharan Africa.

Rwanda is a beautiful country full of beautiful people. The land of a thousand hills. It’s very green and lush with red dirt like Hawaii. The streets are bustling with people all hours of the day and night. Rwandans are friendly and polite…a pleasant change coming from Boston.

In my time in Rwanda I visited four other Hospitals, one in the city center and three others in the country. King Faisal certainly is at a higher level as far as available resources, cleanliness and patient care. During these visits I traveled with Dr Harthorne a cardiologist from MGH and saw things on echo that I have never seen before. He felt and heard things on physical exam that he hadn’t in 50 years. It was difficult for both of us assessing these patients. The Rwandan physicians have all been wonderful and are eager to develop their skills but they don’t have the resources to do so. They don’t have the experience or equipment to treat many of their patients and look to us for help. They make a diagnosis with a physical exam and prescribe the right medication but without cardiac surgeons in Rwanda, treatment stops there. The operative list is long and many of the patients needed help months ago. In our trips to the University and Community hospitals we were essentially just confirming and documenting the severity of their disease. Walking away was difficult, knowing that the next surgical team isn’t set to arrive until November. Many of the patients will either not survive that longer be too far into the disease process that surgery will no longer be of use. The most difficult part is that the patients see us "muzungu” with an ultrasound machine or a stethoscope and they appear a bit more hopeful and seem to think that we're there to help and we're going to save them. The reality is that we're there to assess them, and pass their info on to the two doctors who have the daunting task of creating the list. There are 20 patients to be selected to undergo surgery in Sudan and less than that for the Australians and Team Heart 2010.

I would like to give thanks and Kudos to all the dedicated individuals involved in this project: Ceeya who organized this whole endeavor, the surgical, anesthesia and perfusion teams who worked tirelessly through complex cases in an environment with limited resources and daily power outages (and a backup generator that takes a few seconds to kick on). The ICU team of doctors, nurses and respiratory therapists who stayed up all night watching over and tending to the patients in their most critical hours.  The step-down nurses and PA’s who also worked hard day and night caring for these patients. They were all rock stars, as Sue G would say, and there are 13 patients whose lives have been forever changed as a result of their dedication and humanity.  Thanks to Sarah Fostello and Jim McCarthy from GE for providing me with the Vivid I.  And a special thanks to Dr Warren Harthorne, without him I would not have had the opportunity to be involved in this wonderful project.

Chip said it …this truly is the best thing we do in our lives. 
It was a true privilege to be a part of this team.

Jennifer Neary

From Lindsey Couture

I am sitting in the hospital as the ICU is starting to close down and reflecting on the past two weeks here in Rwanda. I joined team heart at the last minute, two weeks before they departed so I was unsure of what to expect. In many ways this is something that is hard to describe. The nursing was very difficult at times due to equipment malfunctions, lack of supplies and limited varieties of medications. The patients were very sick and many times we came very close to reaching the limits of what we could provide. It has been amazing to see the patients transition through this process and the excitement on their faces as they are walking and doing things they haven't been able to do in so long. The smiles and hugs just make you melt. Every single person on this team has worked so hard and given hours upon hours of dedication and time to make this possible. I just want to thank everyone for this amazing opportunity. I am very blessed.

From Prem Shekar, M.D.

We have arrived in Boston. It is 7pm EST. It has been a long 32-hour but fairly uneventful journey back to the US. Most of us are quite worn out. The only highlights of the return trip were the interactions with Newark Customs (needed to be bailed out by a fellow missionary Customs Officer) and a 6-hour layover in Newark.

We have completed our second trip to King Faisal Hospital, Kigali, Rwanda. Once again, it has been a rewarding and humbling experience. We have successfully operated on 13 patients this time. We raised the bar and were able to perform more valve repairs on more complex patients with Rheumatic Valvular Heart Disease. We have learnt from our past experience that durable valve repairs are ideal in Rwandan patients for their long-term after care. We have had one complication with a cerebrovascular accident but we are hopeful that she will recover adequate neurological function in the long-term.

The most memorable event of this trip was seeing all the patients that we operated on last time. They are all healthy and most of them, had successfully returned back to school/work and other activities.

Once again, the dedicated team that I have traveled with came through. It has been a great experience working alongside these colleagues of mine, some of them for the second time. I would like to commend and thank all members of the team - Cardiac Surgery Fellows, Residents, PA's, Cardiac Anesthesiologists, Cardiac perfusion technologists, OR, ICU and floor nurses, Cardiologists, Intensivists, Echocardiographers, Respiratory Therapists and Volunteers.

I would like to specifically thank Chip Bolman - I have greatly enjoyed working with him on both trips.This trip has been a great learning experience for me and an example of collaborative work.

Needless to say, this trip would not be feasible without the dedication, commitment and drive of Ceeya Bolman. She has already asked me to keep time aside for the next trip. Her dedication is truly amazing.

Kigali continues to be a fascinating city. It is very safe and scenic. We able to discover more of it this time even with the limited spare time that we had. Our visit to Rwinkwavu was, once again, memorable.

"He who saves a single life saves the world entire" - Quote from the Genocide Museum, Kigali.

Prem Shekar MD - April 22, 2009.

From Smitha Philip, M.D.

Today is the first day after our last day of operations. What a week it has been! Drs. Bolman and Shekar have done what they do best and as it were done it both gracefully and cheerfully. Now, we're in the ICU doing our best to make sure these patients do as well as they possibly can post-operatively. So far, so good.

As an outsider to the team, I've had the great pleasure and privilege to watch this group give generously and be amazed at how well they do it. It's not just enough to say that they do their jobs extremely well or with the greatest care for their patients. That's to be expected. It is another thing to be able to say that they have done it with abundant generosity and overflowing spirit even in the generally dicey situation of working in a foreign country of limited resources. It has been truly humbling for me and a welcome reminder of the true meaning of caring for people. It has trickled down from the top leadership through all the branches of this operation ultimately touching each patient's life in an awesome way. I am in awe and speechless at times in thinking of how much of a miraculous endeavor it has been and how it was realized.

Sincere thanks and appreciation to all the people I have had the honor of working with and getting to know as colleagues this past week. I hope we will do it again soon!

Sincerely,
Smitha Philip, MD
Pediatric Cardiology Fellow
Children's National Medical Center

Message from Dr. Bolman

Today is our last day in the OR on our second year mission to Rwanda. The people have been most warm and welcome, and we all immediately felt right at home at King Faisal.   The patients have been much sicker and more challenging this year.  For example, to quote our friend, the estimable Erneste Simpunga, we have done 11 double valve operations, and one triple valve operation out of a total of 13 surgeries. That is compared to only one double valve operation last year out of 11 surgeries. As one might expect, the longer times on the heart-lung machine have been associated with more bleeding in several patients. We have definitely pushed the envelope of what is possible here, in this environment. I was reminded of this one night about 1 a.m., when a young girl I had operated upon was very unstable with low blood pressure and a very erratic heart rhythm. We came very close to losing her, and I thought to myself that, if she had to return to the operating theater, or have her incision reopened in the ICU, then what was I going to do? There is no OR facility here at night. All our surgical team had left, and, even if I had needed them, it is doubtful that they could have responded quickly enough to make a difference.  Fortunately, she settled down and has improved slowly but surely over the next days. That is very sobering, and a reminder of all we take for granted at home.  My next to last patient, Criserie, motioned me to her bedside this afternoon. She took my hands in hers, and said "Merci Beaucoup". Needless to say, she knows the way straight to my heart. 

I have to leave early morning for Japan to speak at a conference- not my best ever move, as there is almost no way to get there from here. I will close by saying that this is the best thing we do in our lives. I think I speak for almost the entire team when I say that.  It is an awesome privilege to take care of people who don't even share our language, and yet are brave enough to trust us with their lives, in exchange for a chance at a better, longer life. As a healer, one can ask for no greater gift than that, that we might be able to make a difference for people in such desperate need.

I thank everyone who has helped make this such a wonderful experience- my fellow BWH mates, the MGH contingent- Warren, Terri and Jen, Leslie Macho and Sofia Ormaza  from the U of M, Andy Willett, who was a super volunteer, George Shortis from Operation Open Heart, Australia, my daughter Paige, Jim and Zara and the ICU team, my friend and colleague, Les Miller, Katie and Laureen in the OR, and everyone else. I have to mention Meera Kotagal, who was basically the surgical intern, doing all the patient workups and generally being a positive force.  John Connell has done a great job, and is a tireless worker. Barry has been the Ironman in the OR. Thank you, and thank everyone. Thank you to Gene Bukhman, cardiologist for PIH, who did case selection. Mostly, thank you, Ceeya, for organizing this whole enterprise. You have been the one constant this past year- picking the team, fundraising, procuring the equipment, labeling, boxing and shipping over three tons of equipment, not to mention the trunks we brought along on the flight here. It has been a labor of love, the work of at least 3-4 people, and you have never complained of faltered. You are truly amazing, and Team Heart and the people of Rwanda are lucky, indeed, to have you. As am I, for that matter.

That's all until next year in Kigali.

Chip Bolman

From Sara Stankiewicz, RN

Greetings from the Team Heart Stepdown Unit! Today is the last day of surgery. We have successfully operated on 14 Rwandans, and there are currently 8 patients in the Step Down unit, which is keeping Marie, Kristen, Carol, Terry, Monica, Egidia, Denise and I very busy.  There are many challenges to providing nursing and medical care here at King Faisal--losing power mid surgery with a 15 second delay on the back up generator, running low on supplies, language barriers and a difficult paper documentation system are just some of the biggest ones we face each day.  The entire Team Heart group has become very resourceful in the face of all these challenges...and I know all of the nurses on Team Heart will think twice before complaining about eMar at BWH! Our days at work are very tiring. All of the Team Heart members are putting in extremely long hours, but our patients are so appreciative, it makes our exhaustion all worth it.  We are managing to appreciate the beautiful city of Kigali and the Rwandan landscape on our days off. Many of us have been fortunate enough to travel to Akagera Park for safari and also to Volcanos National park to see the mountain gorillas-both were unbelievable!

The first group of Team Heart members left yesterday, and are already missed terribly.  We will say goodbye to the OR team on Tuesday and then the Step Down unit and rest of the ICU staff and physicians will leave this Saturday.

Thanks to everyone back at home for your kind words and continued support.   See you all next week!

Sara

From Brenda and Jane

Brigham and Women's respiratory therapist have done a wonderful job in a sometime challenging setting. Although always with grace and a smile on their face. It is Brenda Graham's second trip to Rwanda and Jane Bartholomew's first.

As we are about to admit the 12th case into the ICU, we can certainly recognize how much we take for granted. Coming from a major medical center and having everything at your fingertips...Let's just say we've learned to be creative. This years patients are finding a great deal of comfort from last year's patients as they visit, giving them support & hope for the future. We are anticipating our 1st discharge tomorrow, (exactly 1 wk. from Easter). The rwandan staff have been so helpful and eager to learn. We are grateful that they tolerate us varying from their customs. A big Thank-you to Ceeya & all the "behind the scenes people" for helping to pull it all together. Well Wishes to the angels in the step-down unit who will stay extra to get all the patients well on the road to recovery. We are proud to work alongside this entire team... You are truly an amazing group. Thank-you for allowing us the opportunity to "pay it forward". or as the rwandan's say.. "Mwakoze cyane"

From Meera Kotagal

Nearly a year ago, I left Rwanda after 10 months working in the Eastern Province for Partners In Health (PIH), with no idea of when I might make it back to this remarkable country.  But through Team Heart I was fortunate enough to make it back this April to work as part of the cardiac surgery team.  And I can't even begin to explain how wonderful it is to be back.  Rwanda is a country of incredible beauty and generosity, but also a country with great need.  There is no cardiac surgeon in the country, but there are many patients who are in need of surgical interventions.  It is a privilege to be here as a member of a team that is working so hard to change the lives of 14 Rwandans this year.  The work has been hard over the past week -- long days, lots of patients to see, and challenging operations and post-operative care.  But everyone has really responded with incredible enthusiasm and worked exceptionally hard.  My role within the team has been a little bit like that of an intern -- I have been helping to get patients ready for surgery, writing up histories and physicals on each of our patients, and making sure the preoperative evaluation is complete for each patient.  And I've gotten to spend a little bit of time in the operating room.  As a soon to be general surgery resident with a strong interest in global health, it has been a great opportunity to learn about surgical evaluation and interventions in resource-poor settings.  And it has been a great chance to come back to a place that feels a lot like home -- to reconnect with old friends and colleagues from last year, to practice my French and Kinyarwanda, and to think more about how Rwanda can continue to figure into my life and career as I go forward.  

One of the most striking features of this trip has been seeing the patients from last year and witnessing how dramatically different there lives are as a result of the surgery they underwent.  It definitely leaves me excited for each of the patients we have operated on this year.  Above all, I am extremely grateful for the chance to have been part of Team Heart this year, and look forward to seeing how our patients do as they recover from their surgeries...  

-- 
"Yes we can to justice and equality.  Yes we can to opportunity and prosperity.  Yes we can heal this nation.  Yes we can repair this world.  Yes. We. Can." 
-- Barack Obama

From Zara Cooper, M.D.

April 18, 2009

Greetings from the equator! Today is my last day here. The first group of us are heading home tonight and I for one am ambivalent about it. This has been an incredible experience and I am so grateful for the opportunity to come and serve in such a remarkable place.

Rwanda is a beautiful country, and it is difficult to fathom what has taken place here in the recent past. The beginning of our stay was during Genocide Remembrance Week. During our first night in the ICU two young Rwandan nurses were singing to each other at 3 in the morning. The sound was so sweet and so haunting. When we asked them what they were singing, they explained that they were praying for the genocide. They explained that even though they go on, and appear happy, they are still grieving. There is always sadness. It just brings tears to my eyes. My impression is that this country is deeply committed to reconciliation and a bright future. The streets are clean, I feel as safe here as I do in my native New York City, and the people are incredibly proud and hard working. It would be hard to imagine that so many of these people spend their nights on mud floors with only candles to light their homes. There seems to be no self-pity.

As I understand it we are operating on patients who are quite a bit sicker than last year. Some of these patients would have been challenging at BWH - double valves, on multiple pressors, after multiple bypass runs. Not a small feat when it takes almost 24 hours to get STAT blood! Everyone has risen to the occasion and kept their spirits high. Despite long hours, and unfamiliar territory we continue to work as a team, and are doing the best we can for our patients. Many of us are working 18 hour days but the patients inspire us. They are all small, many are pediatric, and some are quite malnourished from poverty and prolonged heart failure. But they are all so thankful and quick to show us a smile. It is difficult to imagine that timely treatment with penicillin could have averted  much of this suffering. 

This is my first year in Rwanda but, I hope not my last. I have been touched by the journey and I think I will continue to learn from it. Finally, I want to thank all of my incredibly thoughtful co workers who gave me and my fiancee a beautiful hand carving to congratulate us on our upcoming wedding. The group here has become and extended family.

See you stateside!

Zara

Pics

Paige Bolman writes:

Following a long day yesterday with no shortage of successfully met challenges, today has run pretty smoothly. Last night's case lasted until the wee hours of the night and so we decided to take on just one surgery today to give some people a bit of a rest. Our newest arrival seemed really uncomfortable throughout the morning in the ICU, but upon grabbing the services of a helpful interpreter, we learned that she just really, really, really wanted an orange Fanta! We were obviously happy to oblige her with such a simple request (but only a little!).

A few Team Heart members went on a safari yesterday in Akagera and this morning some others trekked out to see the gorillas in the Virungas. We're so lucky that we have enough team members so that everyone has been able to get out and see some of this beautiful country.

This afternoon brought another pleasant surprise: Celestin came to visit! Celestin was the very first patient of last years inaugural visit and being such a nice guy, he was also the handsome subject of many a photo. He looks so healthy and all of us were so excited to see him! He is currently finishing up his last year of school for accounting. He showed up with a dashing smile and lots of news. With a roomful of hopeful patients that are still very early in the recovery stages, Celestin was extremely generous with stories of his positive experience. He undoubtedly put numerous fears to rest. Todays patient should be arriving from the OR any time now. He is an extremely happy guy who reportedly had a smile on his face until the very moment he went under. We are looking forward to his arrival in the ICU.

We'll post more as it happens and we find the time! Until then, we leave you with a picture of the sunset. Coincidence? I think not.

OR Day 5

Nelson and Jane, nurse manager of the OR theater

Nelson Thaemert joined Team Heart this year as part of the anesthesia team. A native of Northern Virginia, he did all his medical education in the Boston area. He has been a member of the Anesthesiology staff at the Brigham for 2 1/2 years, which has a strong focus on global mission work. "Doing mission work is a way to give back for all that we have"

Nelson Thaemert, M.D. writes:

Greetings from Rwanda!

It’s taken several days for me to get a chance to come up for air, so to everyone who has been following things on the blog, please accept my apologies.


We’re on OR day number 5, and have been working from early morning until late at night, so finding time to send greetings and updates has been challenging.

We are currently doing our 8th case, and the team tells me that the patients are sicker and more fragile this year than last. In fact, 7 of these 8 cases have been double valve repairs or replacements. Most have pulmonary hypertension, some are malnourished. All have markedly abnormal hearts. Many are teens that have been too short of breath or undernourished to grow.

The patients all have amazing stories. Our youngest patient is a 14 year old boy, our oldest to date is 37. Our smallest patient has been a 29kg 16 year old, who is roughly the size of skinny 8 year old in the US (we weren’t planning on doing kids, so some of this has been on the fly!) All have sequelae of rheumatic heart disease, and all have been living with this for enough time to develop advanced symptoms of heart failure. Most speak Kinyarwandan, although a few speak some French and a little English.

We’ve operated on a mother of three (6, 3 and 5 months) who is a school teacher for 11 year olds and too fatigued to continue breast feeding her infant. Another is a university student whose father was killed in the genocide and is currently studying biology and chemistry, but the school wants him to drop out because they think he’s going to die of his heart disease. Each story is differently tragic, but strangely similar.

Most of the patients that we have cared for live in poverty that is difficult to comprehend, and digesting their stories becomes very emotional. I hear from Dr. Gene Bukhman, our cardiologist at Parnters in Health, that there are two types of poor people here – dry poor, and wet poor. If you can afford to live in mud hut with a dirt floor and a tin roof, you are likely the former. If you live in mud hut with a dirt floor and a banana thatch roof, you are likely the latter.

All of our patients have done well, and some are beaming during their recovery. Our most challenging case of the trip was last night, when an exhausted OR team left off a critically ill postop patient that we weren’t sure was going to survive the night. Amazingly this morning, she has made dramatic improvements, mostly thanks to our friend Dr. Zara Cooper who was running the ICU overnight.

From a surgical standpoint, we've done significantly more valve repairs than replacements, which is good news for the patients because tissue replacements wear out in 15 years, and mechanical valves require anticoagulation. I do hope we have enough rings! We weren't planning on doing this many double valves, and certainly not this many repairs, so keep your fingers crossed. If anyone is counting, we've done one mitral commissuroplasty, one mitral bioprosthesis with tricuspid ring, one mitral mechanical prosthesis with tricuspid ring, four mitral repairs/rings with a tricuspid ring, and one mechanical aortic & mitral replacement. I continue to be impressed with our surgical collagues' abililty to do a repair to a rheumatic valve, which is notoriously difficult and problematic. From an anesthetic standpoint, bringing our own portable transesophageal echo has been instrumental. Thanks to the folks at Phillips for the loaner, and the screeners in the airport for being understanding! [Quote: WHAT is that?? as I put the echo probe in its carrying case through the scanner]

The hospital is quite advanced by African standards, but there are still the blips that one would imagine. We lost power a number of times in the OR, but the emergency generator kicked in within a few seconds and we never had to hand-crank the bypass pump. Oxygen pressure falls on occasions, so we’ve encountered anesthesia machine alarms that we never hear in the US. One day the air conditioner in the OR mounted high on the wall let out flood of water for unexplained reasons, but luckily nothing got contaminated. We have been doing our best to ration the supplies that were previously shipped or packed in our luggage – it takes an incredible amount of “stuff” to care for 14-15 patients having heart surgery, so stretching it to make it last has become an art form!

After three 15 hour OR days in a row, we slept in and had a late start today. Our original goal was to do 15 cases in 8 days, but between a full ICU and a fatigued OR team, we are only doing one case today and our overall schedule will decompress to only fit in 14. Those who don’t get operated on this year will hopefully survive until the Australian team arrives in the fall, or can be sent to Khartoum, Sudan where an Italian organization has set up a hospital for African cardiac surgery.

Kigali is a clean and vibrant city. The topography looks like a mix between Tuscany and coastal California, with homes built all over a series of lush, green rolling hills. There is a vibrant middle class in the city, most roads are paved, streets are regularly swept (by hand, by the way), food is restaurants is generally good, albeit slow, and the locals are friendly and fairly well dressed. I have yet to have time to venture out as much as some of our non-operating room colleagues, but we stop operating on Sunday evening, so I’ll have a day and half to get out and explore.

I’ll get pictures posted to Facebook when I can, but in the mean time I want everyone to know that we're doing well and thinking of everyone back home. Thanks for all of your kind words of encouragement!

Best regards,
Nelson

Busy days

Paige Bolman writes:

It has been a busy few days here in Kigali! The first patient is doing great and has already been transferred to step-down. Her husband Vincent has been quite a delight to have around with his positive attitude and his handy trilingual skills. I think everyone has thoroughly enjoyed his presence.

Two more patients were successfully operated on yesterday, one more this morning and yet another is in surgery as I write. Everything is running relatively smoothly though we have had our share of minor challenges, if you will. The power at the hospital has a tendency to flicker and/or go out for short periods of time in the evening. Although concerning, the expected electrical flickers are well managed by an extremely well prepared staff of perfusionists, surgeons and anesthesiologists. The hospital generator and back up generator work very smoothly. All in a day's work...

Although the two-a-day surgery schedule is tiring for all involved, everyone seems to be in high spirits, and those were undoubtedly bolstered by a lovely afternoon surprise. In between surgeries, some of the patients from last year's trip stopped in to say hello. Just a few hours after liver for lunch (not my cup of tea), Erneste strutted down the hall trailed by a handsome Jean Paul, Vedaste, Samuson, and an at least 3-inch taller Djuma. To any passerby, they looked like a group of regular, healthy guys and each beamed with smiles from ear to ear. Even for those of us that were not here on the first trip, it was an incredibly emotional reunion. In contrast to the physical state of the current patients, to see these men looking so healthy was easily enough to make me cry like a baby. The reality of what Team Heart is giving to each patient became as palpable as the incoming storm in the air as we snapped pictures with Kigali's hillsides in the background.

The second surgery should be getting done in the next few hours and the ICU will be bon-a-fide busy with patients instead of with just paperwork and trying to keep the machines working... As if that doesn't provide the nurses with enough to do! Pizza, which has come to be a common staple here in Rwanda, should be arriving in the ICU in the next hour, courtesy of Andy and Natalie. The rest of us are off to find something to eat and attempt to rest before another busy day tomorrow. Send good wishes for the two patients going under the knife if you have a spare moment, and thanks for reading.

Ceeya's Postscript: My daughter, Paige, said it beautifully. I would only add that there are moments in one's life where one realizes that an experience is likely to be as rewarding as an experience can be. When such moments occur, it is important to recognize and savor them. Today, for me, and for the members of Team Heart, was such an experience. Having just completed a challenging operation on an incredibly sick 15 y.o. girl, and then seeing several of our patients from last April, all looking healthy and having returned to productive and happy lives, was highly emotional and gratifying. I only hope for my daughters that they, too, are able to experience such a feeling in their lives.

Message from Dr. Bolman

We have operated on our first three patients. The first had a mitral commissurotomy, and is doing well. Yesterday, we did two double valves- a mitral and tricuspid repair, and a mitral replacement-tricuspid repair. All are doing well.

The stepdown team has arrived and is setting up today to receive their first patient. Today, are doing a double valve in a 16 yo 65 # girl. The team is a bit concerned regarding her size, but she is very sick and we are going ahead. This afternoon, we are actually doing a familiar case- an aortic valve replacement in a middle-aged woman with calcific aortic stenosis. Everyone is working very hard.

Yesterday, the events in the OR included a brief loss of electrical power, which is expected and was extremely well handled. Fortunately, it was very brief, as we were sewing in a tricuspid ring at the time. At Mike's behest, however, we did proceed to finish expeditiously. Seems the oxygen system is fixed, but the electrical system is a bit spotty. Oh, well. No place is perfect.

All-in-all, the experience has been very positive. Everyone is much more comfortable, and it just feels smoother, as everyone has some sense of what we can and cannot do. The patients are quite a bit sicker than last year- many more double valves, etc. It is such a privilege for all of us, and it is still pretty overwhelming to be doing this. Everyone feels that this is the best thing that we get to do in our lives. That's about all you can ask. Hope everything is good at home. More to follow.

Suellen writes:

It's 10:40 pm Kigali time. Another long, yet rewarding day. Two cases today--the first case of the day is doing well. The second had not come from the OR when I left the hospital at 7:30. It feels as though the team is coming together and getting into a comfortable rhythm. The step down unit nurses will join us tomorrow after returning this evening from their adventure in gorilla country and patients will begin the next phase of their recovery out on the ward. Our Rwandan/KFH team members -- nurses, doctors, and other staff--have been extremely helpful, supportive, and collaborative. It's been great to reunite with familiar friends and meet new colleagues here at the hospital.

For the most part--at least so far-the patients this year seem to be younger and perhaps sicker than last year. But this perception could be a case of selected memory. On this second trip with Team Heart, I find the personal reward of providing this life saving surgery to a few is tempered by the realization that so many others here are afflicted with this preventable disease and that factors such as hunger and poverty only complicate an already complicated issue.

But the fruits of this mission have not gone unrealized. Of course there's Erneste. Looking healthy and thriving. It's so good to see him and his big smile and spend time with him again. A few days ago, a group of us were reminded of why this mission is important. As we were leaving a coffee shop in the center of Kigali, we happened to run into Jean Paul, a patient who received an aortic valve replacement last year on April 8. He is working as a driver, financially supporting his wife, and looking and feeling great!

That's it for now. Time to rest up for another day.

Ceeya writes:

Today we successfully operated on our first patient. The second team arrived yesterday in Kigali at 6:45pm and after all was said and done with shipping and checked bags only one box didn't make it! Immediately upon their arrival, the newest team met up with the 'old hands' on the veranda at Sole Luna for a lovely dinner of delicious pizza.

The first case was meant to begin at noon and virtually the entire team came in early today to make sure everything was in its place and ready to go. Pulling into the OR around one, the OR team expertly finished the first patient at 4pm. all in all, it was a short case and it went as well as could be desired. The nurses, and a few of us others, eagerly awaited the arrival of our first patient in the ICU. We decided with the ratio of 16:1 medical personnel to patient, we may be providing the most thorough post-op care in the world!

Thanks to all the well-wishers and good vibe-senders; you are each appreciated!

Welcome to our blog for Team Heart 09!

Team Heart is a volunteer group of nurses, physicians, perfusionists, respiratory therapists, physicians, bio-medical engineers, and lay volunteers traveling to Kigali Rwanda for our second surgical interventional trip. Excitement and hard work has been building for 6 months as plans for this year have developed.

This year we are privileged to have volunteers from Brigham and Women’s Hospital, Mass General Hospital, Tufts Medical Center in Boston, Mayo Clinic and University of Minnesota, Georgetown Medical Center in DC and Sydney Australia. In addition, we have a volunteer from one of our valued corporate partners, as well as volunteers bringing special contributions. Each volunteer brings such unique talents and the Team is stronger for their involvement.

Over the next two weeks, we will introduce you to each and describe the role that each will play as we fine tune this trip.

On the other side, our Rwandan counterparts are doing the same preparation with emails flying to and from as we check and double check our supply lists, hotel accommodations and plane reservations.

Weeks have been spent with key team members involved in procurement. Anesthesia, perfusion, OR and ICU and step-down polished their list to ensure we have what we need but not a surplus. Volunteers spent several weeks checking expiration dates and packing equipment safely. Friday morning our shipment was picked up ---- next stop Kigali!!!


PS….. the little chick featured in many of the packing photos was donated by one of the children of our volunteers. Watch closely as the chick accompanies us on our trip for luck!