Day #8: Wednesday, October 31st 'Stripping & Cranking in Kenya'

Case #5:  Mitral Valve Replacement
Case #6:  Mitral Valve Replacement
Case #7:  Pericardial Stripping with Pump Standby

So Wednesday was a long day, but a very productive one .  There is so much Rheumatic Heart Disease that we could do valve repairs every day all day long.  Today we had 2 mitral valve replacements and a very unusual case of a gentleman with a previous history of tuberculosis.  The TB caused the pericardial sac that surrounds his heart to calcify.  In other words it was as hard as rock.

When you typically split the sternum or breastbone, your heart is exposed immediately behind it.  You can see the heart pumping away, but it is covered by the pericardial sack, which contains pericardial fluid to lubricate the heart as it beats away every minute of every day (hopefully).  I learned from Dr. Ron on this trip that your heart beats a million times every ten days.

Anyway, this gentlemans pericardial sack had become hard as rock and was compressing his heart to the point that he was experiencing symptoms of heart failure.  So the procedure was to remove the pericardial sack so the heart would not be compressed and could fill properly.  It was a highly unusual case, as you can see from the photo above.  Dr.'s Luke, Mary and Jenny all had their camera's out to catch the procedure.

Dr.'s Mary and Jenny watching the pericardial stripping.

At one point, the cardiac surgeon had to use orthopedic instruments to chip away the pericardial sac.  It was a very interesting case.  I hope the photo below is not too graphic for your lay people, but the pieces of pericardium are laid out on the mayo stand after the procedure.  The pericardial sac is supposed to be very thin and pliable.  The pieces below were very thick and felt like bone and gristle.

Johnson and I did the first mitral valve of the day and finished just before noon.  We were getting ready for our next case in our room while the team did another mitral valve in the other cardiac room.  Now that we have more than one heart-lung machine, we officially have a second cardiac room and we used it today for the first time with our new heart-lung machines.

The picture above shows Shadrack, one of our Kenyan perfusionists running the case in the second cardiac OR.  While I was setting up for my next case, Johnson came running into my room to tell me that Bob the other perfusionist in the other room needed some help.  As I opened the doors and entered Shadrack's room, Bob was furiously hand-cranking the arterial head by hand.  Something you never really want to do, since that means the heart-lung machine roller head that is providing blood flow to the patient while his heart is stopped during the procedure has stopped working.  The simple solution to the problem is to insert a handle into the roller head that has stopped working and turn it... non stop until the surgical procedure is completed and the patient's heart has been restarted and warmed up and ready to come off on their own.

Sounds pretty simple, but some 'pump runs' last for 2-3 hours.  That's a lot of hand cranking and one person couldn't do it for more than 10 or 20 minutes without relief.  I got a quick report from Bob about what he thought happened and what he thought we needed to do to rectify the situation.  We weren't really sure why the arterial roller head stopped working because (of course) the other roller heades were still working just fine. 

We have a spare roller head on my pump in the other room, so as Johnson got to experience his first-ever hand cranking during bypass and took over from Bob so Bob could catch his breath.  Meanwhile I ran back to my room to remove the spare roller head on my pump and run it back over to Bob and Shadrack's room.  After deciding with Bob what would be the best thing to do, I disconnected the cable from the roller heads under the pump right where Johnson was standing during his hand cranking (of course)... so he was kind enough to stand back while leaning forward to hand crank so I could remove the cabling from the defective pump and plug in the cabling for my replacement pump.  Bob (still catching his breath, while I'm losing mine) informed the surgeons that we were going to have to stop the pump momentarily for less than a minute while we clamped the arterial circuit, removed the tubing from the roller head, removed the defective roller pump from the base and replaced my working roller head in it's place, replaced the roller tubing into the new pump head, release the clamps and restart blood flow to the patient.

While I'm waiting for him to finish explaining to the surgeons what was going to happen, I remember thinking how nice it was to be working with someone with such a positive outlook on the situation... one minute, really?  I really didn't think we all of that so quickly, and I was hoping (and praying) that the new pump would start up when we had it all reconfigured with all the electrical circuit boards that had been assigned to the defective pump.  No time like the present to see what we can do as Bob told the surgeons we were going to start the trade-out and I started the timer so we could document the actual time off pump (turning the pump off during bypass is akin to a heart-attack, where there is no blood flow... at all).

Everything was going fine, I was able to remove the pump, replace the other one, lining the pump up on the pins on the base without any problem.  As Bob was replacing the tubing through the new roller head, he told me the clamps were off and I could start the new pump... which I did... and it started turing a lot faster than what I had dialed it to do, and I quickly tried to turn the flow down, but it didn't respond... at all!  So did something I never thought I would do 5 minutes earlier... I turned off the roller head because it wasn't responding, thinking I could then reset it and turn it back on.  Of course, Bob couldn't hear what I was thinking in my head, and although it seemed like we were moving in slow motion (in miy head), it all happened in a couple of seconds.  

Bob then turned on the pump as I told him I wasn't able to regulate the flow, and then he found out that he couldn't either, but the flow was appropriate for what the patient needed (and it didn't require anyone to hand crank) so we both just stood there turning the knob with nothing happening looking at each other like, now what?  Bob kept playing with the knob and removed it to find out that the pins on the back side of the knob had been broken off so it wouldn't communicate with the pins it was attached to and Bob was able to regulate the flow by manually turning the potting mechanism below the knob as I ran 'back to my cardiac room' one more time to retrieve a knob from my pump to replace on his so he could finish the case and get the patient off bypass.

Sheesh!  What a series of unexpected events, but glad that there was a happy ending to it all.  We need to get Bob and Johnson T-shirts that say "I cranked in Kenya!".

Shadrack and Bob shortly after replacing the roller head.  We found by communication with the pump vendor in the States that there are some issues with the 50 cycle current in Kenya (vs. our 60 cycle current in the States) with certain modules in the pump.   We were able to have the vendor overnight the parts we needed to replace to someone from the Vanderbilt team in Nashville the next day before they left to fly to Kenya for our second week of cardiac surgery.

Prayers answered multiple times today... and by the way... to my surprise, we replaced the defective pump and got blood flow reestablished to the patient today in less than 1 minute, as Bob estimated.  ;)