A Very Challenging Day

I know, I know, it's been over 24 hrs since my last post, but rest assured I've got the photos and the stories to go along with them all stored away for later distribution.

The last 48 hours have been incredible in a lot of different ways. First of all we've been very busy in surgery (the reason for the "missing post"). There have been a lot of patients that are still coming into clinic; each one seems sicker and more adorable than the last. We've come to Tenwek to bring what we do (and most days probably take for granted) to an area of the world that is so different than ours that for me, it's hard to even be able to put myself in their place because we expect so much and take so much for granted every day.

There are so many patients that we could help but have such a limited time to do it in (6 surgical days). We have to prioritize based on their disease, analyze how far their pathology has progressed, decide whether or not it is even possible to accomplish a successful repair, and those patients selected have to be able to be recovered and discharged from the ICU that we've "created" because on Tuesday of next week our team is packing up and leaving, taking most of the ICU monitors and equipment with us.

Then there are the patients that we can help and by our standards we know what the "right" thing to do is...  replace the mitral valve and put in a mechanical valve. But in this part of the world, if you tell the parents that their young daughter can have a successful operation and live a long life, but will not be able to go through child birth as a result, they will remove her from the hospital and not allow her to have the surgical repair because she must get married and have children. We can use a porcine or bioprosthetic valve, but that type of valve will not last as long, which would require a repeat operation much sooner, and the chances of our team being here when she needs the repeat operation mayb be slim. Either way, there is a less than desirable outcome (by our standards). All of these decisions weigh heavily on the team because you want to help everyone, and some of these patients may not survive until our next trip to Tenwek. To make it even harder, we see them as people, adorable young people standing in our hallways, going through our clinics, squatting in the hallways because that is the only way they can breath and get blood flow into their lungs.

Every day there are additional patients to see and changes to the surgery schedule. Yesterday was a very busy day because there were 2 patients to do and both patients were children. The schedule was changed during cath conference late Wednesday night and I had 2 surgeries to do instead of one that day. Of course I got to meet patient #1 Thursday morning before surgery. Of course the little guy stole my heart. Of course I wanted to do the best job ever for him during bypass that morning to do my part in helping to make him better. I usually try not to meet or focus on the children prior to surgery because its too easy to get attached and if the surgery doesn't go as well as expected then its not so hard... for me - it's kind of a selfish protection mechanism that I've mastered over the years. One of my biggest concerns about a medical mission trip like this is for the equipment to work properly so that the patients surgery can be done safely and successfully. You never know what is going to happen, but you have to always be prepared to handle everything. It's especially important for perfusion because when we're in the picture, the patients heart is stopped and our machine is the patient's life support - literally. If bypass is interrupted for any reason while the patient's heart is stopped, it's no different than a cardiac arrest. Every time we go on bypass the pressure is on...

The photo at the left shows the physicians praying for our patient prior to surgery.  The patient's father is in the background.

I took the video above on Thursday morning at the beginning of the bypass portion of the procedure. It shows my Tenwek perfusion partner and good friend Eric from Brown University running the pump while I assisted him and fufilled my responsibilities as "Camera Guy". I thought it was a pretty cool video showing us in action. No one really understands what it is that we do because it's so abstract. It's pretty hard to explain so I typically just say I "work in a hospital". I thought this video would give people a good idea of the pump we run, where we're situtated in surgery and of course thought it would be an awesome addiiton to this blog.

Shortly after taking the video I relieved Eric at the pump and continued to run the case. Then electricity went off in the entire OR. We could tell immediately because there is a certain "noise level" in the OR at all times... alarms, monitors, machines running, a certain level of "white noise".  Listen to the background noise in the video and then imagine the deafening silence when the electricity goes out. 

Suddenly with a loud "click", everything went completely silent and dark. All the monitors stopped, All the beeping stopped, the room was completely silent. That's never supposed to happen. That's when everything went into slow motion for me... we're trained for this type of thing. We know exactly what to do. But you never ever want it to happen. As I looked at my arterial head (the part of the pump that is acting as the patient's heart, pumping blood to the patient keeping him alive) it was stopped. This is equivalent to a cardiac arrest. I have to restore blood flow to the patient immediately... but in my mind I'm moving much too slow.

I immediately reached for the hand crank (in slow motion) while announcing to the surgeon and anesthesiologist that the pump was off. While I was reaching for the crank to manually restore blood flow to the patient, Eric had raised the cover on the roller-head, took the hand crank from me and started to hand crank the arterial head so I could check the rest of the pump to make sure the oxygen supply hadn't shut off as well and to inventory the damage that we may have to deal with. Momentarily, the electricity was restored but our pump wouldn't start when Eric stopped hand cranking. Being the trained professional that he is, he shut off each roller head and turned them back on to reset them and they started back up. We immediately sat back looked at each other feeling like we needed to be put on the heart-lung machine to recover from this little incident. But we did everything we were supposed to and in reality, the patient was never without out circulation because of our strong work.

By now I've reported to the surgeon that everything is fine, we're back on bypass so they could continue with the surgical repair and life is back to normal in our perfusion world in OR #2 in this little corner of Kenya. Just as we're settling in to the rest of the bypass run with a much heightened level of acuity, running our lab tests and manipulating all the parameters for the patient we hear an alarm go off. It's coming from our pump. Its a familiar alarm that we hear every morning for almost 30 years when we're setting up the pump. We have to plug in oxygen and room air gases into the pump. The alarm sounds from the time you plug in one gas line until you plug in the other gas line. if there isn't equal pressure on either side of the blender from both gases it will alarm. Every perfusionist knows that, we hear it every morning when we plug in the gas lines... but I've never heart this alarm during bypass before. It had to mean that we've lost one of the gas supplies to the pump used to oxygenate the blood that we're pumping into the patient.

In the US we would have an oxygen analyzer in-line to tell us what percentage of oxygen we're delivering to the patient's blood. That monitor is not available to us in Kenya, so we look at the color of the blood through the clear tubing to make sure it's oxygenating appropriately ("I think we're OK"). At first glance it looked like it might be red enough but the longer I looked at it (in slow motion) the more dusky it became ("I think we might be in trouble"). This all happened, of course, in slow motion. All bad things in perfusion happen in slow motion. By the time we informed the surgeon that we think we've lost our hospital oxygen line the blood is looking much much too dark and that sick feeling began to creep into my stomach (you guessed it, in slow motion). Several people were sent from the room to get oxygen cylinders STAT! Of course they're in my nightmare now and they're all moving in slow motion too. We were toward the end of bypass, the patient's heart had been repaired and closed so anesthesia was able to ventilate the patient to oxygenate the portion of the blood that was being shunted through their lungs. We could tell that the patient's saturations didn't drop too low by having me pump the deoxygenated blood into the patient while Dr. Malik was oxygenating the blood that was shunted through the patient's lungs.

Needless to say, I had met the patient and his family prior to surgery, I felt like I knew them and my well developed self protection mechanism had failed. I was very upset after surgery hoping that the child would be OK. I knew that we had done everything possible under the circumstances, but you never know until they wake up... I went to lunch by myself feeling terrible, knowing that I would have to go back and do it all over again on another patient.

When we went on bypass with the second pediatric patient we didn't have to worry about losing power and oxygen again because this time it happened in reverse order. Shortly into the pump run the gas alarm started sounding again. Well we knew exactly what it was and resonded immediately. The oxygen tank was in the room and Eric got it connected in no time flat just before the electricity went off again and the hand cranking started. 100% oxygen was used through the rest of the case and the electricity came back on before too long.

In the end, both patients did very well as a result of everybody's efforts that day. By the time we were done and finished with the day it was around 11 pm and Eric and I were numb. Both of us have had to hand crank during bypass when electricity had gone out more than once in our careers.  However, neither of us had ever had the oxygen go out on us during bypass before with the almost 60 years of expereince we have between us; and it happened to each of us twice today!  The picture below was taken as we walked out of the hopsital hoping that Friday would be much better than Thursday.

It had been a very challenging day...