I have to say I am so humbled by all the responses I've been getting from all of you. I received 50 emails just today (how many of you are out there anyway?) I don't care about the limited computer time here, I'll get to them eventually, just keep the emails coming. Susie and my small group leaders told me before I left on this trip that it would touch me in ways I would never imagine and I had no idea what they were talking about, but it's been happening to me all week ever since I arrived at Tenwek hospital. Before I get on with my blog, since so many people are following along with my adventures here in Africa, I want to let all of you know that I am serious about doing some kind of fund-raising for Dr. White and Tenwek hospital when I return home. His faith is unfaltering and what he is doing here is amazing. He is looking to churches to support a percentage of the different units in the hospital (pediatric ICU, neonatal ICU, etc) so that he can continue to do his work and build the residency training program. I'm not sure how I can help, but I've gotten so many great responses from everyone that I just wanted to let you know that I'm willing to look at ANY opportunity that could support Dr. White's efforts here in Kenya financially. Yvette, thanks for your emails, please send me the info about publishing my blog. I'll talk with you when I get home. I could give the most incredible talks geered toward school children (I'll talk to you also Vivian), medical staff, church groups, etc. I've gotten over 1200 photos so far that really put a "face" to what is happening here at Tenwek. I"ll just throw that out there and wait and see what the Lord does with it. Let's get creative people!
I wasn't able to get computer time yesterday because we had 2 cases in surgery and I didn't get home until 11 pm. Since I only had 4 hours of sleep the night before, I scribbled down some notes for that days blog and went to bed. I'm going to just get to that day sometime in the next few days and go with today's event's before I forget them entirely.
So today started out kind of like my usual Nashville mornings. I was exhausted when the alarm went off but had to get down to the hospital because my perfusion partner sent me home early last night (11 pm) and finished the case I was doing because I had another early pediatric case to do this morning. He's an adult perfusionist so I've had to do all the pedi cases (which have been a total blessing). The hard thing about doing cases in surgery here is that all the equipment that was donated to Tenwek is coming from all over the country and everybody everywhere does everything every which way, so none of the tubing packs are really what we need here, and NONE of them are pediatric. So the adult cases are easy to set up because you can open a couple of different packs and get all the stuff you need. But for the pediatric cases (i.e. "my" cases) I have to pick and choose through a myriad of packs, running all over the hospital to get the stuff I need t o do my set ups with. Cutting and pasting (literally) pieces here and there. We have loops and loops of sterile tubing, but it all has to be pieced together with connectors in Lincoln-log fashion until the end product will sustain the life of my next precious little patient. So every day, when I leave the guest-house I transform into "Camera-Guy" until I enter OR #2 where I become "MacGyver Guy".
I have done things here in surgery that I would never even consider doing in the States. Not dangerous stuff, but in order to get the right size circuit put together on the heart-lung machine that's small enough for these little patients I'm able get my creative "juices" flowing. The last 2 days I've had to tape the oxygenator (the artificial lung keeping the patient alive after I've stopped his heart) to the side of the heart-lung machine. We have none of the brackets we need for the supplies we have, so if you give me a string, a piece of tape and a bamboo stick I'll keep a kid alive with it! Seriously, all of us (including the ICU staff) are breaking every rule in the book just to get the cases done every day and to care for the patients post-op. I can get a pump set up at Vanderbilt in about 30 minutes, here it takes me over 3 hours. If the work wasn't so rewarding, and the stakes so high it would be very frustrating for the "old" Tom th e perfusionist. But the new-and-improved MacGyver Guy Perfusionist is really enjoying the challenge.
So on with my day. Remember little What's-His-Name? First of all, I feel terrible that I don't know these children by name and I had to refer to him as I did. But honestly, I have trouble remembering common names like Bob, Bill, Joe or Mary, so you'll have to excuse me. His name is Kiprono Langat. We operated on him the day before (the day I never left a post), the first case of the day. So let me back up to his surgery. We didn't do the usual repair for his problem since there would be no follow up care for him after we leave in a couple of days, so the cardiologists and surgeons decided to do a palliative repair that would take care of his problem (not enough blood flow to his lungs) but not really fix the all the problems that he had with his heart. This smaller procedure could be done off of bypass but we knew it was going to be a risky procedure since he had lived with the cardiac defect for 10 years and most people die before getting to that age without surgical intervention.
Although we had decided not to put "Kip" on bypass, my surgeon wanted me to have the heart-lung machine set up in case he "crashed" (i.e. arrested) and needed to be put on bypass urgently to keep him alive. OK, so the hard thing here is that I never ever get to meet my patients in the States. I just show up every morning about an hour before they bring the patient into the room. I set up the pump and in a matter of minutes, the child is asleep and there are about 6 nurses and anesthesiologists hovering over them putting in arterial and venous lines, intubating, prepping and draping this little body, so that the only thing left to visualize after an hour or so is a square patch of skin about 6 inches by 5 inches. There's no more baby there, just a sternum (breast bone) that we cut through with a heart underneath, usually about the size of a walnut. That's easy to do.
Knowing that "Kip" is under those drapes makes all the difference in the world. I held his hand the night Deidre put in his IV for his exchange transfusion and he was being such a strong little Kenyan warrior by not screaming, but you could see the defenseless little boy underneath by his big crocodile tears streaming down his face. Later that night we were laughing together (you have GOT to see this little guys smile - of course I have several pictures of that to share) as I was complimenting him on how well he could stay inside the lines while coloring Mowgli in his Jungle Book coloring book. The next day as I was running around setting up for a case I ran across him squatting on the floor in the hallway and got to talk to him about his family (he's the number one student in his class - I'm so proud of him!).
So the day of his surgery I was there to hold his hand as they put him to sleep and the pump was set up extra early and extra careful incase we needed to use it on Kip. We had 2 biomedical guys with us from Samaritan's Purse that were on standby for each procedure to make sure all the equipment is working as expected. So the case was moving along as expected. His little body was prepped (painted with a brown antibiotic solutions) then draped with sterile drapes and the surgeon made the incision through the skin, then cut the breast bone with a saw (yes, that's actually what they do). His little heart was dark looking because his red blood cell count was so high (the reason they took blood out of him and replaced it with blood with a lower red blood cell count pre-op) and his coronary arteries were protruding from his heart in a way I usually don't see, since his blood was so deoxygenated because his pulmonary arteries (that carry blood to his lungs to be oxygenated) were way too small. The procedure that we were doing was suturing a small 5 mm tube (about the size of a straw, but flexible - not stiff) from his subclavian artery to his really small pulmonary artery. This shunt would push the additional blood he needed in his lungs from his arterial system and make him "all better".
Very soon after that Kip had a "Tet Spell" on the table. His cardiac lesion is known as Tetrology of Fallot. Tetrology (meaning "4") means there were 4 things wrong with his heart, but the main problem is that he needs to get more blood to his lungs to get oxygenated, so his heart can pump the oxygen rich blood to his 10 pound, 10 year old body. There are a variety of things that can cause a Tet Spell in these patients, but the end result is that their oxygen saturations drop and their blood pressure drops and they can ultimately die. I was in the other OR room where the heart-lung machine was set up when I heard the surgeon call for the defibrillator to shock his heart because he was having an arrhythmia from the Tet Spell. I ran into the room and opened the pacing cables for the surgeon and passed them to the table so he could pace his little heart after he defibrillated it. Kip wasn't recovering his blood pressure or his oxygen levels. The surgeon then said that he thought if he obstructed the aorta (the main vessel carrying blood out of the heart) he thought it would the back pressure from the obstruction would force blood into his very small pulmonary arteries to stop his Tet Spell.
Let's back up to the prior day when I ran into Kip squatting in the hallway... He was having a Tet Spell in the hallway when I saw him. If he wasn't African American his lips, fingernail beds and skin color would appear blue because of his lung issues. These kids have learned over their lifetime that when they "Spell" as it's called, they can increase their pulmonary blood flow by squatting down on their haunches. Squatting increases the afterload of the heart (like the obstruction the surgeon made on his aorta) which forces blood into their lungs which allows them to breath.
Back to surgery now. So the surgeon placed a small piece of flat surgical "string" around Kip's aorta and cinched it down around the aorta, choking it to about 1/2 it's normal size. He got the desired effect and Kip's blood pressure and oxygen saturations rose to normal levels and the pacemaker was in place so if it was needed now, all they had to do was turn it on. OK, so I'm kind of a mess at this point worrying about my little buddy under the drapes, but things are looking fairly well controlled and the surgeon proceeds to suture in the "straw" between his subclavian artery and his pulmonary artery.
After finishing the shunt and testing it, it didn't appear that it was carrying enough additional blood flow to his lungs, so they added an additional shunt and the surgery finished up about 3 pm. Much later than expected, since we had a second case to do that was expected to be about twice as long as this one.
Later that afternoon I checked in on him in the recovery room to see how he was doing, and he was awake from anesthesia, but had an oxygen mask over his nose and mouth. When I walked up to his bed he started talking to me, but I couldn't understand him, so I held the mask out from his mouth and nose and he said he wanted some water, please. Of course I'm going to take care of that! So I went to one of our Vanderbilt ICU nurses to inform her that little Kip needed some water (I have to admit I was a bit alarmed that they didn't already know the poor child needed some water), only to be informed that he couldn't have water until he was awake from anesthesia for 4 hours, and he still had 2 hours to go. The nurse went on to say that all the nurses knew he was thirsty because he was pleading with them for the past hour, "Please give me some water. Oh Jesus why will you not let me have water. God please send me some water". How many kids do you know that would go to the Lord for something like a drink of water? So now what am I going to do? I couldn't just leave and not go back to his bed, but how do you tell this sweet little kid that he couldn't have something as simple as a drink of water? Anyway I did it, and tried to explain that he could have it soon just not yet, and the nurses would make sure he got it as soon as possible, and I left the ICU feeling like I had really let him down.
So then we did the second case, I got home at 11 pm. On my way into the OR this morning I went through the ICU to check on Kip and was told that the additional blood flow to his lungs had shocked his lungs (since he hasn't had that kind of blood flow his entire life, even though that's what he needed) and he was coughing up blood. The ICU team thought they were going to have to reintubate him (put a breathing tube back down his throat and breath for him) until his lungs healed. So I went in to do the set up for my patient this morning hoping everything would sort itself out.
After my case, the nurse who was there when he was getting intubated said he was struggling to talk to her before they put him to sleep so she pulled his mask off and he said to her, "Please pray to God for me". Long pause...... He was struggling so hard to breath, his little 10 y/o mind knew he was in trouble. So he's been intubated all day now, sedated and paralyzed. The doc's say that this kind of reperfusion injury gets worse before it gets better, but at 48 hours he should start doing better. 48 hours is tomorrow morning (8 to 10 hours from now). You know what you all have to do. Pray that little Kips lungs are on the mend so tomorrow I can help him color another page in his Jungle Book coloring book.
Oh yah, Susie... breakfast was a quick piece of PBJ toast, lunch was fried chicken, collards (colored greens?), and mashed potatoes, and dinner was homemade pizza (with peas on it???). Beautiful clear skies all day except for a short scattered shower. Oh yah, we "bagged" another newborn today. I just laughed when I saw the nurse running down the hallway with her arms hidden in a bag, because this time I knew what she was doing and I could hear the baby crying.
It's 2:30 am and I need to crawl under my mosquito net and get some sleep.
Talk to you all tomorrow.
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