Christ the King and His Rain

Sunday was the Feast of Christ the King, which is also the last Sunday of the liturgical year.  In this region, it is common to have Eucharistic processions to celebrate.  Here, Sacred Heart Parish in Shisong had a procession from the parish to the cathedral.  

Below, you see Maribel encouraging the young people to sing about the kingdom of God as they walk and dance, and the priest carrying the Blessed Sacrament in a monstrance.
 

 

 

I have been getting lots of weather reports from home.  It seems that it is unseasonably cold and there is an expectation of snow.  I thought I would include my own weather report, since there is not much weather available on-line for Shisong.  It is currently the dry season.  Usually this season is aptly named, as I have never really seen rain here when I was here in the dry season.  This year there is rain.  On Sunday after the procession, the skies opened up with heavy rain, thunder, lightning, and even hail.  This keeps the dust down and of course is good for growing things and for the water supply, but not good for those trying to do dry season activities such as build (which often includes making bricks from the local soil) or travel.  Oh well.  I do not get to order the weather.  Here are some picture’s of one of the convent gardens (“farms”) which is benefiting from the rain but also from diligent watering by the sisters, as well as the nearby hillside which I find to be particularly pretty. 
 

Possible, but difficult, revisited

We have been able to operate on the two patients that we delayed last week due to a lack of blood, plus one more Wednesday.  The blood bank went out and had a very successful blood drive in the surrounding villages on Sunday.  There is another patient (17 years old) awaiting surgery who has been acutely ill and requires further evaluation prior to mitral valve surgery.

Many of the readers of this blog (if there are many readers of this blog) know for the last 8 years I have been the director of the Quality Improvement and Patient Safety program in my department at the University of Rochester.  This was challenging and often frustrating, and along the way I learned many lessons and developed an interest in errors and their prevention.  Although when I arrived here, I was relieved to be able to work and “not have to fix everything,” I guess I should not be surprised that I cannot just turn off the constant thinking about how to make things better.  The cardiac center does many things well, especially for a place that has only been open for four years.  Like every place, though, there are opportunities to improve communication, reduce the risk of error, and provide more patient-centered care.  There are many challenges for me in this environment.  These include but are not limited to: an incomplete understanding of the medical-legal environment of Cameroon, an incomplete understanding of the culture as it pertains to working on improvement, significant language barriers at many levels, a different education process for the nurses and staff, and significantly more limited resources than we had at Strong.  Even in the U.S. it is always challenging to identify the resources to implement our ideas for improved safety; here it is even more difficult to improve infrastructure to make care safer.

In the news I saw that Great Britain appears to have taken a step backwards in safety by criminalizing certain failings.  I am hoping that they will be very clear about what behavior is criminal and not include errors in these prosecutions as many places have done.  I have been reading Sydney Dekker's The Field Guide to Understanding Human Error.  It will be interesting to think about how to apply his ideas to medicine in Cameroon.

Feast Day and Feasting

Sunday November 17 was the feast day of St. Elizabeth of Hungary.  Here in Shisong there was a celebration on Saturday to celebrate this patron saint of the Tertiary Sisters of St. Francis.  St. Elizabeth was a princess of Hungary who married into a German noble family and developed a great dedication to caring for the poor after being introduced to Franciscan friars of her region.  The feast was complete with Mass (including offertory processions from all of the groups of the hospital), followed by speeches, a skit of the leper who returned to give thanks for his healing presented by the patients of Surgical 2 (ward), traditional dances, and of course, food.  

Two of the patients on Surgical 2 and their guardians have been here for over 6 months.  A "guardian" is a person, usually a family member, who takes care of the patient's non-medical needs, including providing food and doing laundry.  They stay at the hospital with the patient and often sleep on a mat next to or under the patient's bed.

On Sunday, the important activity was to watch Cameroon defeat Tunisia in the World Cup qualifier match that was played in Yaounde.  The victory was decisive, 4-1 so everyone could be happy on Monday.  At least in Cameroon.

Day by Day

When I was in high school attending youth retreats, our retreat leader used to play a mix of music during the morning while we were eating and getting started.  I still remember this mix as being uplifting and relaxing, while motivating me to participate in the day.  One of the songs in this mix was “Day by Day.”  The song was from Godspell, but it is based on an ancient prayer.  The words of the chorus are:

     Day by Day

     Day by Day

     Oh, Dear Lord, these things I pray:

     To Know Thee more Clearly

     To Love Thee more Dearly

     To Follow Thee more Nearly

     Day by Day

It is still a good prayer.

Possible, but difficult

On the last night of the Italian Mission, Drs. Giamberti and Cirri shared the story of the beginning of the mission.  They were always cognizant to try to speak English if Falan or I were present, even if they were primarily speaking to their own Italian-speaking group.  Early in the relationship between San Donato and St. Elizabeth’s, patients would be transferred for Italy for surgery.  There was a desire to perform surgery on these pediatric patients here in Cameroon.  The first year they decided to operate on 3 patients with patent ductus arteriosus.  For my non-medical readers, this is a condition in which a structure that is necessary for fetal life fails to transition to life in which oxygen is provided by the lungs instead of by the placenta, creating too much blood flow to the lungs, and too much work for the heart.  If it does not close spontaneously shortly after birth, it can be closed surgically.  The reason that this procedure was chosen to begin heart surgery in Shisong is that it can be done without the use of the heart-lung machine.  Dr. Giamberti said that they wanted to show that it would be possible to perform cardiac surgery here in Shisong, but that it would be difficult.  They then proceeded to share the adventures that occurred during this first mission.  Although we laughed at how silly the problems seemed and marveled at the genius of some of the problem-solving that occurs here in Cameroon (this is not so different than occurs when we look at the history of medical advances in the U.S.), the fact of the matter is that many barriers remain to high level care here in Africa.  It remains true that it is possible, but it is difficult.  The Italian mission organizations have built a beautiful, modern facility for the delivery of high-level cardiac care.  We do not have to worry about having to cancel an operation because the operating room is full of butterflies, as happened during that first year.  There are automatic generators to provide constant electricity so that the perfusionist (the specialist who runs the heart-lung machine) does not have to choose between keeping the patient alive and providing the surgeon with suction, as happened during that first mission because the person whose job it was to start the generator was not immediately available.  There is water, and commercial scrub solutions, and sterile instrument pans for each case.  What is keeping patients from accessing necessary heart surgery today?  Today the problem was a lack of blood availability for a patient with A+ type blood.  There is a volunteer donor program, but it is still in its infancy.  The patients must bring family members with them to donate blood.  This blood might not be appropriate for the patient having surgery, but it is expected that they will contribute to the blood bank.  The blood bank will go out on Sunday to the surrounding villages to encourage blood donation and have what we would call “blood drives.”  The blood bank is also establishing a component program.  Currently only whole blood is available.  The component program will allow us to be more selective with the way that we use blood, and reduce exposure to antibodies in patients who only need red cells, as well as treat coagulopathy (bleeding) more effectively.   I have already described the financial problems that many patients face in preparing for surgery.  Soon I will describe another organization that is raising funds specifically for these patients.  I am hoping that they will soon have 501c3 status in the US, as well as a US donation website.  In the meantime, I would like to encourage my readers who pray to continue to pray about these issues and particularly if there is a way to support these needs.  For my readers who don’t pray, you can still think about whether there is a way to support these needs, and if you are thinking about giving prayer a try again, here is a place to start.

In the pictures, you see Mr. Thomas who is the director for the blood bank, and the chairs for the volunteer blood donors.  There is also a small lounge where they can have snacks and drinks after donating.

Lifebox

One of the gratifying things about becoming involved in international missions is the number of people you meet involved in other programs.  The number and magnitude of the problems can be overwhelming, but becoming involved does not mean that you have to solve all of them.  In fact, it may not be possible for any individual to solve any of them.  However, many different organizations teamed up with the local populations are managing to make an impact.  I would like to continue to draw attention to some of the people and programs that are active here in Shisong.

Lifebox (www.Lifebox.org) is a program founded by the World Congress of Anesthesiologists and and the World Health Organization and promoted particularly by the American Society of Anesthesiologists and the Association of Anaesthetists of Great Britain and Ireland.  In many developing countries there is a serious deficit of anesthesia safety and a high incidence of morbidity and mortality related to anesthesia and surgery.  There is a significant relationship to maternal, infant, and child mortality as these populations are disproportionately impacted by the needs and the deficits in availability of expert care.  There are numerous causes of these problems, not the least is a lack of trained personnel.  However, in trying to identify problems that can actually be addressed, the WCA and the WHO identified the availability of monitoring, particularly pulse oximetry, as an area that can be addressed in an organized way.  Lifebox seeks to make pulse oximetry available in operating rooms world wide, as well as to promote the use of the Surgery Safety Checklist (http://www.who.int/patientsafety/safesurgery/ss_checklist/en/) and education in other areas related to safe surgery.

In the small world category, it turns out that the anesthetist leading much of the work of Lifebox is a nurse anesthetist here in Shisong, Mr. Benson Nfon Tanjong. Additionally, Dr. Falan Mouton from our residency program at the University of Rochester, currently on a rotation here in Shisong, has become a leader in the Lifebox organization at the level of involvement of residency programs in fundraising.  As I mentioned in an earlier post, I was able to participate in the Lifebox distribution program in early October in Yaounde at the National Congress of Anesthesia and Critical Care.  At this program, one hundred pulse oximeters were distributed along with checklists.  Below, you see Mr. Benson presenting the Lifebox workshop and me passing out pulse oximeters at the end of the session.

November 6, 2013

There are several hospitals that have entered into collaboration with the cardiac center here.  These hospitals send teams once or more than once per year to serve the cardiac surgery needs of adults and pediatrics, and several have done so since prior to the opening of the center in 2009.  One of these teams was here last week, from Modena, Italy.  We performed 5 successful operations on adults ages 15-27, and including mitral valve/aortic valve replacement, Bentall procedure, and pericardial stripping for severe constrictive pericarditis.  The patients have all been discharged from the ICU to the cardiac ward and some have gone home.   This week there is a pediatric team from Milan led by Dr. Alessandro Giamberti and Dr. Sylvia Cirri.  This team has been extremely committed to this project and is significantly responsible for the existence of the center.  They have trained most of the clinical and support staff and see to it that they receive ongoing training.  They will perform around 15 operations for congenital heart disease including atrioventricular canal defect, Tetrology of Fallot, and hypoplastic left heart syndrome, and perform a number of diagnostic and interventional catheterizations.

A side benefit of having an Italian team here was the dinner invitation.  Dr. Giuseppe Gramegna prepared his special sauce and pasta from Rome and the local cooks prepared the rest of a delicious meal.  After the picture below, Carolina (a perfusionist from the Modena team who stayed to assist the pediatric team) did agree to share.

November 2, 2013

One of the Italian Mission Teams was here this week for a very successful mission which I will write more about soon.  I thought it was time for some lighter fare and to share some of the beautiful scenery around Shisong, as well as an opportunity to show the people I have been spending time with. 

This dog apparently lost a friend who left the weekend that I arrived.  She was very sad, and started following me everywhere.  The sisters call her “Rambo.”  I do not know the origin of the name since it might be the most docile dog I have ever met.  

Sr. Ruth, who is an ICU nurse, and Dr. Daniel (pharmacist) and I went “trekking” to the St. Francis Comprehensive College and had a tour of their dairy farm.   

Another day, we “trekked” to the bishop’s house on a hill near the village of Squares.  We stopped in at the convent there to greet the sisters, and found them watching “Sister Act.”  On our way down Sr. Ruth decided to try out flying. 

Logan and Eric Horne and their 5 children live in Squares above the bishop’s house at St. Augustine College.  You can follow their mission here:  http://hornefamilymission.blogspot.com.   You can see that Logan has mastered the art of carrying her daughter the African way. 

If you arrive for 2^nd Mass (9 AM) before the 1^st Mass ends (begins at 6:45 AM), you have to wait in this not-so-disappointing setting. 

Dr. Falan Mouton is a senior resident in anesthesiology at the University of Rochester.  She is here on a one month rotation at the cardiac center and in the main operating room of the hospital.  We have found some nice places to walk.

By the way, in my previous post I mentioned the NGO's and generous donors that make the Cardiac Center successful despite multiple challenges.  One of the founding organizations and driving force behind the effort is Bambini Cardiopatici nel Mondo, whose English language website can be found here: http://www.bambinicardiopatici.it/english-website/the-association.php.

October 28, 2013

Okay, so I think the blog issues are sorted out and I should be able to post a little more often.  The last couple of weeks have been somewhat quiet as we have been trying to get patients ready for the operating room.  The primary issue is financial.   There is great need here, for treatment of the usual acquired and congenital heart diseases that we see in the US, in addition to a significant burden of rheumatic heart disease.  Thanks to some NGO’s, there is funding for many of the pediatric congenital cardiac patients.  There is much less funding, though, for the adult patients.  These “adult” patients may be as young as 9 years old or may be the parent of many children who will be left without a parent without the necessary cardiac surgery.

I used to rationalize that in countries where there is significant or extreme poverty (recall that a large portion of the world’s population lives on less than $2/day), that things are less expensive.  In my experience in developing countries, this is generally untrue.  Things of similar quality are as expensive or more expensive than they are in the U.S.  Local produce is generally inexpensive, but comparable with public markets in the U.S.  Anything that is packaged or imported is quite expensive.  What is different is the way that people live when they are living on a very low income.  Houses are built without building codes and frequently without electricity or running water.  Cooking here is often done on a wood fire (indoors or in a separate building near the house).  Protein sources, including beans, are expensive and therefore not eaten every day.  Schools all require tuition, so if a family is able to generate an income a significant percentage goes toward school fees, books, and uniforms; if the breadwinner gets sick the children may have to withdraw from school.

We are able to perform cardiac surgery for costs somewhat lower than the U.S. for a few reasons.  Of course, salaries are lower in general.  We do not have liability insurance, although the hospital does pay taxes on its staff.  We do not have $30,000 ICU beds, $8000 Operating Room tables, brand new equipment, or infinite disposables/single use equipment.  Due to generous donations from various foundations, hospitals, and individuals, we are still prepared to deliver high quality cardiac surgical care.  However, medications, prosthetic cardiac valves, cardiopulmonary bypass supplies, and so forth are still expensive and must be purchased if they have not been donated.  The staff must be paid regardless of the number of cases that we are doing.  Therefore, cardiac surgery is still either prohibitively expensive or a great sacrifice for patients and their families.  It is quite humbling to know that the patient that you are about to care for might have sold land or even their house in order to have surgery.