November 12, 2012 Farewell Kenya

Our van leaves for Nairobi in about 30 minutes.  We just received word that there is a "slow-down" at the Kenyatta airport in Nairobi - similar to a strike.  Hopefully our flight this evening at 10:30 pm will leave on time.

It is always bitter-sweet to say good-bye to our Kenyan friends and family that we continue to work with and get closer to each visit.  I will be traveling for the next 48 hours (probably without wifi access) so this will be my last post for a few days.  I will try to continue posting photos and stories when I get home, if I can keep my "Kenyan calm" going once I get back to the rat-race of the states.

I am always so thankful for this opportunity to return to Kenya and use the skills and talents the Lord has provided to our team, and to serve those less fortunate than us.  The funny thing is, that every year our team and myself specifically, will leave after 2 weeks of hard, hard work feeling like the Kenyan medical teams and people that we interface with have given more to us than we have given to them.  Their love of the Lord and simply life is very appealing to me and the thing I love the most about these trips is that I get to do what I love the most... clinical work that I've been trained for without all of the politics.  We just get up every day and do what we all do best - care for our patients.  The gratitude and love we feel from the Kenyans is undescribable.  It's what keeps us coming back each year, and it's what I try to adapt to and take back to the States with me.

The precious little girl above is one of our pediatric patients from our second week at Tenwek.  'She' is what our trips to Kenya are all about.  Thank you to all of you out there who have been supporting us spiritually and/or financially, because you have been a part of what we have accomplished here in Kenya also.



Here is the Vanderbilt Tenwek team of 2012:

From left to right:  Dr. Dave, Bob, Johnson, Malik, Rick David, Tony, Agneta, Lewis, Leah, Dr. Mike, Kari, Dr. Tom, Dr. Jenny, Kristen, Dr. Nelson, Rebekah, Anna, Dr. Russ, Dr. Mary, me, Brittany and Michael.

Stay tuned for more posts in a few day!  Blessings to you all.

November 9, 2012 Here Kitty Kitty Kitty,,,

So check out the coolest thing we saw on safari this year.  While we were on safari this year we saw all of the "big five":  elephant, rhinoceros, water buffalo, lion and the leopard.  When you add the cheetah, we saw the "big six".

The video above is of the one and only leopard that we saw on our second day out.  It had killed a small gazelle and carried the carcas up into a tree to keep it from the other carnivores.  When we approached the tree the leopard was in, there were hyena's under the tree eating the scraps (i.e. limbs) that fell from the tree.  

When we saw the leopard in the tree, he was looking us straight in the eyes, and didn't like the fact that we had found him.  It's not like we were going to confront him for a piece of the kill.  The smell of the fressh kill was very strong and pungent. 

The following morning, we went back to the same tree and there were a pride of lions laying under the tree because they could smell the carcas, but lions cannot climb trees, so they just sunned themselves after a long night of hunting.

Enjoy!

November 10, 2012 'Masai Mara'

Today we left Tenwek for the Fairmont Mara Safari Club in the the Masai Mara.  We arrived in time to get unpacked, rest up (from the 4 hours of sleep I got last night finishing up details in the Tenwek OR before packing to leave at 8:00 am this morning) and go on an afternoon safari.  The Masai Mara is 'just what the Dr. ordered' since the last 6 to 9 months have been so hectic.  Wide open expanses of the most beautiful scenery and amazing wildlife.

Baby Zebra's like the one on the left have more fur than a mature zebra.

Are you dizzy yet?



 The Cape Water Buffalo

As dusk started to set in, the colors were amazing.  The hawk above was sitting in the top of a tree looking for dinner.

Day #9: Saturday , November 3rd, 2012 'Tenwek Dam'

Saturday was the first day that we weren't either in the OR setting up to do cases, or in the OR 'doing' cases.  The first week is now over with, we had done 14 cardiac cases and it was time to get out of the hospital and see some of the surrounding landscape (and take some more pictures)....

Dr. Luke and I were roommates last year at Tenwek and he wasn't able to stay for the 2nd week of pediatric cases.  He was leaving later today so he, Johnson and I took off for the Tenwek dam, a 15 minute walk from the hospital.  The dam is where the hospital gets it's electrical supply.

The landscape around Tenwek Hospital is beautiful.  We are at the end of the rainy season, and the hillsides are gorgeous.

Nothing compares to the Kenyan clouds on a clear day.

Along the way, we crossed paths with a woman on the way to market.

 

... and some children

... who love dorks

Our first view of the dam.

Dr. Luke and Johnson as we walked past the dam to the top of the hill.

There was as home at the top of the hill with a family working outside.  They were more than happy to pose for a few pictures.

The boys and their dog have been following us the whole way...

so I kept taking their picture

On the way back home to Tenwek

Day #9: Thursday, November 1st: 'A Really Really Long Pump Run'

Case #10:  Aortic Root Replacement with Composit Graft and Saphenous Vein Graft x 2

This year I was able to bring a Vanderbilt University perfusion student with me on the trip.  Johnson is a senior perfusion student and will be graduating from our program in May 2013.  He has performed over 150 open heart perfusion procedures so far in the program at various rotational sites in Nashville.  He was due to start his pediatric perfusion rotation with my staff and I at Vanderbilt Children's Hospital the day we left for Kenya.

Although our primary objective was to work with the Kenyan medical staff to train them how to manage the patient during cardiopulmonary bypass, Johnson was 'chomping-at-the-bit' to do a case or two of his own.  Today he got to do his first Kenyan open heart entirely on his own (with me at his side).

The perfusion circuitry we were using during the adult cardiac week was completely different than any circuit he'd been exposed to in Nashville (soft-shell venous reservoir vs. the hard-shell venous reservoir systems), so he has been able to get a lot of great experiences prior to graduating that he otherwise would not have had.

Johnson was very attentive to patient management during the procedure as well as anticipating the needs of the surgeon and responding to the directions he received from the surgeons and anesthesia staff (and me).

The procedure was done on a 21 y/o patient who had a weakening in the wall of the aorta where the blood flow enters the left coronary (sinus of valsalva aneurysm).  This procedure is a very big procedure that requires cooling the patient down further than usual and removing the entire portion of the aorta, the large vessel that carries the blood out of the heart.  The circular structure you can look down into in this picture is an artificial aorta that was sewn in to replace the patient's native aorta.  The surgeon will eventually sew the open end of this graft to the patient's remaining aorta that has not been removed.

View of the OR team during the surgical procedure



The photo above is of Johnson weaning the patient off of bypass about 7 hours and 10 minutes after bypass began.  The patient was very very sick, but as things usually go at Tenwek, after we 'treated' the patient for about 12 hours in the OR, 'Jesus healed' him and he was extubated and sitting up in bed the following morning.  It was a truly amazing day in the OR and the patient continued to do well and was discharged from the post-op ICU within a couple of days.

Day #10 Friday, November 1, 2012 'Special on MVR's'

Case #10:  Mitral Valve Replacement
Case #11:  Mitral Valve Replacement
Case #12:  Mitral Valve Replacement
Case #13:  Mitral Valve Replacement

Today is the last day to operate during our adult week of cardiac surgery.  The week has gone by very quickly and today we will complete 4 open heart procedures.  That's almost half the procedures we were able to do the first week we operated at Tenwek hospital  5 years ago when we started developing the cardiac surgery program.  To my knowledge, that is the most open hearts Tenwek has ever done in one day.

This is our first patient of the day.  A 21 y/o patient scheduled to have a mitral valve replacement due to Rheumatic Heart Disease.



Dr. Luke and Shadrack praying with the patient prior to starting the procedure.  Dr. Luke is leaving tomorrow and won't be staying to do pediatric patients with us this year.  We'll miss you Dr. Luke!  See you next year???

Day #9: Thursday, November 1st 'Stanley'

I received the following email on October 22nd, 2 days I left for Kenya.  It was sent to my personal email address which I only access about once a month.  I happened to see this email about an hour after it was sent to me...

Subject:  Tenwek Information

Tom,

I apologize if you are not the right source of information on the Tenwek Heart Surgery mission trips.  Your blog is the first hit on Google when I searched for Tenwek Cardiac Surgery, so this e-mail is just another burden of that popularity.

I just spent five weeks in Western Province Kenya as a medical volunteer, and one of my patients has an exam and x-ray that are incredibly suggestive of Tetrology of Fallot.  I am currently trying to explore options for the family to get care for this heart lesion and would love to learn more on how I can hook them up with Tenwek.  Currently some local contacts (a bungoma clinical officer and a bishop in the local Anglican church) are going to try to get the boy to Moi Teaching hospital in Eldoret for an echo, but I'm trying to look down the line on how the boy can get surgery.

If you have any idea on who to contact for this information I would greatly appreciate it.  Thanks so much.

Rob
Medical Student
The Ohio State University College of Medicine


I replied to Rob to let him know that his timing was impeccable since our team was leaving in 48 hours for Tenwek and would be there for 2 weeks of cardiac surgery.  The pediatric week would be the second week so that might give his patient more time to make arrangements for travel to Tenwek and get the appropriate pre-op testing.

There were a couple of follow-up e-mails between Rob, Dr. Mike and myself regarding the cost of transportation to the hospital and clinic for the required exams and tests.  I inquired if there was a way I could help with the expenses to get the little boy to Tenwek to be evaluated, but I never heard back from anyone.

Last Thursday evening we were finishing up in the OR around 7 pm and some of our team were asked to attend a dinner at a remote site.  So Dr. Mary and I walked over to the cardiology clinic to wait for some of the docs that were finishing up in clinic.  When we arrived in the clinic, Dr. Mike heard me outside the area he was evaluating a patient in and asked me to come inside.

When I walked into the exam area, he introduced me to 'Stanley' who was the little boy the medical student had contacted me about through my blog.  He and his father had made it to Eldoret for the required testing and then on to Tenwek Hospital.  I was shocked that he had made it to Tenwek, and Dr. Mike told me that he would probably be one of our patients during our pediatric week.

Dr. Mary and Michael's daughter Cille provided our team with over 100 soccer balls to give to our patients and families at Tenwek Hospital.  Many of the children playing soccer in the immediate area around Tenwek hospital use plastic grocery bags and plastic bags wadded up together and tied with rope.  In past years when we gave soccer balls to the children post-op they would get so excited and then ask if they had to give it back or if they could keep it.  Kip, one of our patients last year never let the soccer ball go while he was in his ICU bed recovering.  These children are so precious.

Dr. Mary is explaining to Stanley that this ball is for him to keep. 

Then it was time to take a picture of Stanley... but we couldn't get little Stanley to smile.

There were no smiles from Stanley until we told him to... show us your teeth!

Dr. Mary, Stanley (& his new soccer ball) and me. 

Stanley and Dr. Mike, his cardiologist.

Precious little Stanley.  What are the chances that a patient's doctor would find a contact for cardiac surgery at Tenwek Hospital through my silly little blog, and that he would send a message within 48 hours of our teams departure from the United States?  It's a God-thing for sure!  You just have to believe...

Sunday, November 4th 'Church'

On Sunday a small group of us went to church with a friend of ours who has been a scrub nurse from Tenwek on all of our cardiac cases over the years.  I usually attend church at Tenwek Hospital, but wanted to attend Daniel's church this week since he is the pastor and I haven't been able to before.  They had just built their church on this site and had over 200 members in attendance the week before.  This photo is me with some of the new 'friends' I met at church that day.  It was a great experience and I have a bunch more photos, but have to get off to the OR for our cases for the day.  More later....

After the service, we all stood in a line and were greeted by everyone (including the chicken!).  Following the greeting anyone who could not afford to donate to the collection on that day brought vegetables or produce (or chickens) to be auctioned off by the pastor so the money could be put in the collection plate.  LOVE these people. 

The older woman in the photo is Rebekah.  We just implanted a pacemaker in her a few days before and she showed us the scar before church ;)     She worked at Tenwek Hospital for over 35 years and told us that she 'learned by doing, not by going to school'.  She was such a powerhouse of positivity and worship. 

Each of us gave our testimony in front of the congregation on Sunday.  We all come to Kenya to serve their people and we leave every year being the recipients of so much more after interacting with these precious people.

Off to the OR.  Pray for us!

Pointsettias and Palm Trees

There are these crazy big pointsettia bushes on the hospital grounds that are over 6 feet tall.  This one caught my eye with a palm tree in the back ground reminding me of Southern California

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.  ;)