Hearts Around the World: Project Kenya/Vietnam

By David O’Halloran.  October 2011.  Ho Chi Minh City, Vietnam

The Cardiac Intensive Care Unit at Cho Ray Hospital never loses the capacity to surprise, astonish and sadden. Twelve beds with patients in critical condition. Inadequate supplies and a chaotic working environment for doctors and nurses. A ward with upwards of 200 patients (two to a bed) just outside – most of whom would be in an intensive care in the United States. Elderly patients with end-stage cardiovascular pathology and young patients with acute, severe illnesses all clamoring for attention and care. Unfortunately, due to lack of resources, the physicians at Cho Ray often cannot provide the necessary care. Faced with such a swelling tide of human misery, with their hands tied by lack of resources, the doctors can sometimes feel defeated. Patients who are potentially salvageable with relatively minimal interventions die because the medical teams are constantly rushing to deal with the next near-catastrophe.

Every now and then, however, things work out. Earlier this week we met a young boy of 16 who had been admitted with shortness of breath and cough. His chest X-ray had shown congestive heart failure, an echocardiogram showed that his cardiac function was severely impaired. He was intubated and placed on a ventilator. It was almost certain that he had severe myocarditis – but from what? It became apparent that he needed diuretics to remove the excess fluid that was building up in his lungs. We were getting the medications ready when suddenly he deteriorated. His oxygen saturations were falling. Normally these should be more than 95% but now they were 80%, 70%, 60%. He was agitated and uncomfortable and looked like he was about to have a cardiac arrest.  Something else was going on. What could it be?

His mother, who was at the bedside was frantic with grief and worry. His sister, who had been waiting outside the ICU had a severe anxiety attack and needed to be placed on a stretcher – we could see the spasm in the muscles of her hands that came from the hypocalcemia (low calcium levels in the blood) that was a result of hyperventilation. She was given oxygen, a sedative and some intravenous calcium and began to improve. A mother frantic, a sister anxious, a young man dying. What was the reason he was so ill?

We then noticed that his neck was swelling – we felt around his neck and could feel the unmistakeable crinkly crackling of air under the skin. The reason for his deterioration was now clear – the ventilator was blowing air into his lungs at too high a pressure and had caused part of his lung tissue to rupture. So now, instead of oxygen going into his lungs to help him to breathe, it was passing through the lungs and getting trapped under the skin and also between the lungs and the chest wall. As the oxygen built up in this space, his lung was being slowly crushed. It was clear what needed to be done – he needed a chest tube placed as soon as possible. It was then that events took a turn for the bizarre.

In order to get a chest tube, the patient would have to pay for it. The cost was $10 (which is about two days wages for the average Vietnamese). We offered to pay ourselves right away but that was not acceptable to the powers-that-be. His mother had to go downstairs to the financial office, queue, pay the $10 dollar fee, receive a coupon which she then had to bring back to the ICU to prove she had paid before the tube could be placed. So we waited. And waited. While we waited, each breath the boy took crushed his lung just a little bit more. After what seemed an eternity, she came back, coupon in hand. The chest tube was placed by a thoracic surgeon and he started to improve.  The combination of intravenous diuretics to remove fluid and the chest tube to reinflate the lung meant that in short order he was breathing well enough for us to stop the ventilator and remove the breathing tube. He looked weak and short of breath but was clearly on the mend.

I will never forget the expression of relief and joy on his mother’s face.

The whole episode was emblematic of what is needed in the Cho Ray Cardiac ICU. They need better ventilators. But, more importantly, the doctors and nurses need the training and insight to be able to manage these critically ill patients to give them the best chance of survival. One major focus of Hearts around the World is to help the doctors and nurses gain this insight.

The next day, he was no longer in the ICU. We asked our colleagues where he was. They told us that he was now in an isolation ward. He was continuing to recover well. The likely cause of his myocarditis had been found and was being treated – his test for influenza had come back positive for H1N1. Remember that? It hasn’t gone away you know!

David O’Halloran

There is a controlled chaos that meets you on the streets of Ho Chi Minh City, an ebb and flow of traffic accompanied by an elaborate symphony of honking horns and the bustle of motorbikes loaded with everything from families of four (I have heard the record seen so far is five, with one of the passengers an infant being breastfed by its mother) to two people carrying a table and a set of chairs. Somehow, miraculously, everything flows without the aid of many traffic lights or even street signs.

At Cho Ray Hospital this early Sunday morning, the sense of chaos is conspicuously absent. The Hearts Around the World team meets with our Vietnamese colleagues to discuss some of the patients who will be seen later in the week. As a cardiology fellow-in-training, many of these patients have conditions I have only read about in textbooks, as these diseases have either been nearly eradicated in the United States or are treated in infancy. All of the physicians work as one team now, exchanging ideas on management and learning more about the different treatment options offered in Vietnam as well as in the United States.

Once the conference is completed, we are taken on a tour of the hospital. The difference between Cho Ray Hospital and the hospitals I have been at in the United States is vast. We begin by walking past the outdoor lobby, which is relatively deserted as compared to how it will be later in the week. It is normal for the lobby to be filled with patients and their families waiting to be triaged. Although the hospital has 2500 beds, these beds are often shared and there are usually over 3000 patients being treated at any given time. At this time of the year, the lucky patients are lying in beds outside of the large shared rooms, where they at least have the benefit of a breeze. Throughout the hospital are bamboo mats with families biding time as they wait for the patient to receive their treatment. Here, the families play a vital role in tending to their patients, even acting as their respirators for days at a time if needed. We are taken to see the CCU as well as the modern cardiac catheterization laboratories. The hospital remains quiet for now and we are treated to lunch.

At lunch, we are told that we have been invited to the wedding of one of the physicians at Cho Ray Hospital. The evening concludes with the festivities of a wedding, including an amazing 7 courses of traditional Vietnamese wedding fare. The cheer of “mot, hai, ba, yo,” roughly translating to ‘one, two, three, in!,” is heard throughout the hall as the guests drink the accompanying glass of never-ending cold beer. The evening eventually winds down and we head back to our hotel for some sleep prior to starting the week. I eagerly anticipate working with the fantastic physicians from Hearts Around the World as well as the doctors of Cho Ray Hospital, and look forward to everything the week will hold.

Mot, hai, ba, yo!

Jacqueline Bradley, MD

Cardiology fellow-in-training and first time team member with Hearts Around the World

    The Vietnam team arrived last evening.  The Vietnamese doctors not only picked us up at the airport but met us at the gate.  Passport control collected our passports at the gate so we didn’t have to wait on any long lines — the VIP treatment.  Not bad compared to my first trip 5 years ago when I was escorted out of the country for a visa problem.  We collected our luggage and the boxes of medical supplies at the carousel and we were out of the airport in under a half hour.  Not bad compared to our last trip when it took me 5 days and 4 trips to the airport to convince customs to release our medical supplies.  Within 2 hours of touch down we were eating Pho with our Vietnamese brethren.  Today is Sunday.  We spent the morning introducing our team to everyone at Choray Hospital and the Vietnamese surgeons presented the cases for tommorow morning.

     Our team consists of some old timers as well as some newcomers.  Let me introduce them to you:

Dr. Ali Shahriari – our cardiac surgeon.  Ali is from Indianapolis and he specializes in aortic surgery.  This is his first trip. Ali was born in Iran, grew up in Sweden and now lives in the U.S.

Dr. Phi Wiegn – our electrophysiologist.  Phi is Vietnamese and he came to the U.S. as a child.  He now lives in Dallas.  It’s his first trip and it’s an opportunity for him to explore his native country and to give something back.

Dr. Manuel Fontes – our anesthesiologist.  Manny is my brother in international work.  He was born in Cape Verde and I was born in Brooklyn but we somehow think we are brothers.  Manny has shared his time and knowledge for 20 years with me in Russia, Africa and Vietnam.

Dr. Lawrence Fisher- one of our cardiologists.  Larry is now on his second trip to Vietnam and brings back tremendous enthusiasm from last year.  Larry and I both practice out of Danbury Hospital in Connecticut.

Dr. David O’Halloran – one of our cardiologists.  David was born in Ireland but not hails from Boston. He’s here for the second time and along with several of his compatriots from Beth Israel New England Deaconess Medical Ceneter David has become an integral part of the Hearts Around the World teams.

Dr. Duane Pinto – one our our interventionalists.  Duane is also part of the Beth Israel New England Deaconess Medical Center group. It’s Duane’s second trip here and even before we started our work this week, he has already made major contributions by obtaining much of our medical supplies.

Dr. Tom Tu – one of our interventionalists.  Tom is also Vietnamese American.  He trained in Boston and so indirectly Tom is also part of our Boston connection.  It’s Tom’s second trip.

Dr. Jacqueline Bradley – a cardiology fellow in training at Danbury Hospital.  Jackie is the first fellow to travel with us.  Thanks to a scholarship fund established at Danbury Hospital in memory of Dr. Warren Sherman who passed away earlier this year.  Warren was a superb cardiologist and teacher whose greatest joy was teaching cardiology to the residents and fellows at Danbury Hospital.  He will be missed but hopefully his goals will live on in our international training of our fellows.

Dr. Robert Jarrett – I can’t leave myself out.  This is my 51st  international medical mission over the past 25 years.  It never gets tiring. It never gets boring.  I continue to learn from all of my American colleagues as well as the physicians in every country that I have visited.  Thanks to all of my American and Vietnamese colleagues.

Menoo Afkari Jarrett – My wife and partner in life.  She is not here with us on this trip but she is still the most vital member of the team.  These missions cost money and take a lot of organization.  Menoo is the backbone of every team.  I could not do this without her.

Tomorrow we start our first full day of work.  I hope you will get to know all the team members better as the week goes by.  Talk to you soon.

Robert Jarrett MD, FACC

The road has minimal potholes, no throngs of people walking on the streets and weaving through the standstill traffic and dust is replaced by patches of snow. We are back in the United States exhausted from the 19+ hours of travelling. My mind reminisces on the past week that the team of Hearts around the world has spent in Kenya; the initial encounter met with skepticism, meeting the leading cardiologists in Kenya and most importantly interacting with the patients. It is amazing to see how the message of Hearts around the world has been received albeit through a process of minimal resistance, from mzungu (white person) without a bad or good connotation to a rafiki (friend) by the end of the week. The atmosphere at Kenyatta National hospital is full of hope and optimism. The same atmosphere is reflected in Mater hospital and is shared by the cardiologist/cardiothoracic surgeons in Kenya. One of the doctors told me that this was the first time they felt that a group had gone to Kenya and had an approach that was genuine and inclusive. Once again, I want to thank everyone involved in making this happen. Dr. Jarrett, Dr. Passik, Dr. Gelfand and Greg all worked tirelessly. Your efforts are worthwhile, the ground work has been set and I cannot wait to see the gradual transformation of the healthcare and the impact this organization will have on the people of Kenya. Thank you for heeding the call to come to Kenya, you have touched and are about to change positively these Hearts around the world.

Moses Wananu.

Thursday was a busy day at Kenyatta National Hospital. While the cardiologists went to the echo lab and clinic, I went to the OR where I met William, the surgeon I would be helping on a 43 year old lady with rheumatic valvular disease and in desperate need of two new valves. It also introduced me to two complications I  have never personally experienced.  The first thing of interest was  her left atrium was full of clot, typical of patients getting inadequate anticoagulation with chronic atrial fibrillation. The mitral was severely stenotic and obviously in need of replacement.  A modern St. Jude mechanical valve was inserted without too much difficulty. We then turned to the severely stenotic aortic valve  and replaced it with an older generation single tilting disk valve not sold in the US for several years. We then had  difficulty separating her from the heart lung machine and noticed two dreadful things. First was brisk bleeding from the back of the heart, which any surgeon knows usually represents LV rupture that can occur after mitral replacement. Also, William astutely noted that he couldn’t feel a reliable click in the aorta! We first tried to repair the back of the LV with a few reinforcing sutures, but we both knew this rarely works- the standard treatment is to remove the mitral valve and fix the defect from the inside of the heart, but we both knew that our myocardial protection was less than optimal- they only have crystalloid cardioplegia  given from the aortic root, whereas our standard technique is blood cardioplegia  delivered from  both the aortic root and coronary sinus- they don’t have any sinus catheters available.    We did  put  a couple of sutures in the back, but it looked fairly discouraging. Then I asked,

“Do you have any Crazy Glue?”

I think they thought I was crazy, but I have used this on occasion to repair a contained LV rupture after a heart attack, and it an accepted technique after a report from Spain in the 1990′s.

First they didn’t know what crazy glue was. I kept on insisting-

“You know the stuff that sticks your fingers together.”

“Oh, you mean  Superglue.”

“Yes-exactly- run to the hardware store or  hospital repair and get a tube, stat”

“No hardware stores” was the response.

Then, one of the residents said,

“I think I have a tube in my car.”

He ran to get it.  Supposedly you don’t even have  to sterilize the stuff because nothing can grow in it.

Next we needed a felt patch to glue on.  Nothing was available so someone came in with some neurosurgical patties which looked about right and we glued them on. Next, we reopened the aorta, and sure enough could’t get the disk to open relaibly. NowI saw why that model valve is no longer sold in the US!  We excised some tissue under the valve that we thought may have been holding it up and since choices and valves  are limited put back in the same old valve.

As we were closing the aorta again, I recounted the story of the well known heart surgeon in NY who had a special cabinet in his OR stocked with all manner of  religious artifacts that his team brought back from all over the world- you know- dashboard Jesuses, Celtic crosses, menorahs, Buddahs and the like. Anytime he was in a really bad spot he would say,

“Open the cabinet” to get all the power of all the religions into play.

The story was met by laughter, but perhaps just the retelling it was of value. We now safely got thre patient off the heart lung machine, and thankfully, no bleeding!

Then I realized it was quite late and  I was stranded at Kenyatta- the rest of the team was at The Kenya Heart Society meeting across town where Dr. Jarrett was presenting our hospital’s large experience with Takutsubo cardiomyopathy- so called” broken heart syndrome.”

Fortunately, Sussy, the “sassy” echo tech who probably should be the next minister of health of Kenya had called the anesthesiologist  during the case to inquire where I was and arranged for the local Pfizer rep to pick me up from  the now dimly lit, seemingly deserted hospital, and got me to the talk in time for the end and brisk question and answer period.

I didn’t sleep well that night wondering how the patient was doing and realized that I didn’t know how to call the ICU if I wanted to find out.

Friday morning I went up first thing to the ICU and thankfully the patient had done well with stable vitals and no bleeding overnight.  I subsequently found out from the other surgeons that they all had several cases of sticking mechanical single disk valves. So now I was added to their ranks! I  would like nothing more than to think of a well patient in Kenya with a crazy glued and neurosurgically patty posterior LV!

We then went to a busy cardiac surgery clinic packed with over 100 patients, perhaps 30medical students in a relatively small area. Many patients had traveled for several days to reach Kenyatta- where they would simply get an INR in followup for their mechanical valves.We thought that there must be a simpler and less expensive way to do it at a local level, but it seems the poor always return to Kenyatta. One patient was dressed in full prison garb, striped pj’s and round striped hat. I found it humorous that his guard, equipped with automatic weapon asked him to click his open handcuff which was only closed on one wrist  and he dutifully obliged.

Other patients were babies, brought in by their mothers with outside echos diagnosing congenital heart issues and were dispatched for admission to the pediatric wards for admission. Dr. Munene saw a lady with mechanical valve on Coumadin(which is teratogenic) and she held her 6 month old baby in her arm. The mother was concerned that the little one was  a bit floppy and Dr. Munene phoned the pediatric cardiologist to see her later to make sure she was OK.

Amazingly, the clinic was over in a couple of hours, with all patients dispatched and taken care of, without  the wonders of electronic medical records!

Friday afternoon, our hosts took us to an traditional outdoor restaurant.

There we sat under a spreading Acacia  tree, sharing freshly grilled meats and  drinking beer. In that moment, I realized that we  were enjoying the essence of life.  Being out in nature, eating meat and beer,  and enjoying the company of good friends, both old and new.

Cary Passik

Last week has been an amazing experience for all of us.  We arrived knowing only the basic facts, and gradually, piece-by-piece, assembled one corner of a large jigsaw puzzle that is – healthcare in Kenya.  At this point, we have not yet planned the full scope of our future work, but we have a good idea about the very next steps.  At this point, I know I learned more from my Kenyan colleagues than I’ve given them, but as I left Kenyatta yesterday afternoon, I promised them to come back and share more of my experience with the team.

I want to thank Bob Jarrett for organizing the trip and for inviting me – I sincerely hope to come back very soon.  Thanks also goes to Moses Wananu for planting the idea of helping Kenyan health workers – without him, the trip would not have happened.

The Hearts Around the World team with our Kenyan colleagues

     It’s Saturday morning .  We will be heading home later today.  I feel we have accomplished all that we set out to do - assessing the political climate, determining what services and equipment are lacking and what strengths the Kenyans already possess.  This was the easy part of our mission.  The more difficult part was relationship building.  By yesterday afternoon, our goodbyes were accompanied by handshakes, hugs, smiles and the words “when are you coming back?”

    I will have wonderful memories of this country. It’s vibrant, it’s growing and the people are dedicated and have hearts of gold.

     Yesterday, I quoted Sonny and Cher.  Today I will quote from another great American, Arnold Schwarzenegger “I’ll be Back!!”

Regards,

Robert Jarrett MD

     Each day we meet additional cardiologists and cardiac surgeons.  Each day we acquire a few more clues required to solve the mystery.  Miss Marple would be proud of us.  We are very close to solving the mystery “How to best assist the Kenyans.”  The biggest problem is a maldistribution of services.  The big government hospitals have enormous numbers of patients but inadequate facilities. The smaller private hospitals have the better facilities for cardiac catheterization, open heart surgery and postoperative intensive care but not enough patients to keep their facilities busy.  I am convinced (and the Kenyan cardiologists and cardiac surgeons are starting to get it as well) that the key to success for everyone is partnering of all the hospitals.  This will take some governmental and administrative wheeling and dealing but I think it can be done.

     Our relationships with the Kenyan physicians are evolving.  At the beginning of our week, the Kenyans were not sure what to make of us.  Five days later, they are bringing their relatives to see us as patients.  First mission accomplished – they trust us, we have broken through the ice block of unfamiliarity.  It makes our work so much easier. We can cut through the niceties and get down to solving problems. 

     When I return home, I will take a few days to get over my jet lag and begin the second stage of the mission – putting together a full team – a cardiac surgeon, an anesthesiologist, an interventional cardiologist, a non-invasive cardiologists, an echo tech and a few nurses.  We will have to raise the funds for this trip but I believe in my heart it’s a great cause and worth it.  As those great philosophers Sonny and Cher once said — The Beat Goes On!!!

Regards,

Robert Jarrett MD