A Better World

Hurricane Mitch was the most powerful hurricane of the 1998     Atlantic hurricane season, with sustained winds of 180 miles per hour.  Mitch formed in the western Caribbean Sea, and with favourable conditions rapidly grew to peak as a Category Five Status, which is the highest rating on the Saffir–Simpson Hurricane Scale.  When it came ashore on October 29th, this slow moving storm dropped historic amounts of rain on the Central American country of Honduras.  Unofficial reports of up 75 inches of rain resulted in catastrophic flooding throughout central America, and brought the death toll to nearly 11,000, another 11,000 people missing, and roughly 2.7 million left homeless.
 

Teams from across the globe, including a family physician from outside of London, Ontario who was born in Honduras, rush in to offer assistance.  Amongst the survivors a young child, who was thought to have a congenital heart defect.  They were brought back to London for further assessment and possible surgery, however, the child is deemed medically unfit for surgery at the time, and is returned to Honduras.
 

Touched by the situation, a team from Victoria Hospital, in London Ontario was formed to carry out a mission of general and plastic surgery in the storm–ravaged country of Honduras.  Coming from an NICU and Operating Room nursing background, I was excited to join the team; which would soon become the first of many medical missions for me.
 

Shortly after returning from the mission in Honduras, I was attending a conference and, as luck would have it, I met a perfusionist from the Children’s Hospital of Philadelphia who had just returned from a pediatric cardiac surgery mission.  I made the remark, one that I went on to hear from a number of my allied health professional colleagues back home as I recanted my mission experiences, “If there was ever a chance to do a cardiac surgery mission, I would love the opportunity to get involved.”   He asked for my contact information and told me he would keep me in mind if he heard something.
 

Six weeks later, serendipity.  Duke University contacted my new friend at the Children’s Hospital of Philadelphia wondering if they have someone who could join them on a mission to do pediatric cardiac surgery.  They reply “We don’t have anyone at the moment, but we know someone” and I get the call to go on what becomes the first of two missions I do with Duke University in Nicaragua.  This was a purely a pediatric mission.  The team brought all of the disposables they needed to do the cases they were planning to do.  They had established, in concert with the Texas Heart, a fleet of heart lung machines to be used at the centre.
 

Through conferences and networking, I quickly come to learn that there are many more groups who are doing pediatrics, versus adults on these missions, and some do combinations of both.  It was at yet another conference that I met Dr. Thomas Pezzela, a cardiac surgeon, who was also a field surgeon in the Vietnam War.  After seeing the plight of people in developing nations, he dedicated his career to advancing cardiac surgery in these developing nations.  Dr. Pezzela put me in touch with an American Non–Governmental Organization (NGO) known as Project Open Heart who was looking for a perfusionist.  I had the fortune of travelling a number of times with them to Mongolia and Tanzania to do adult cardiac surgery.  Shipping containers of disposables were sent along which we unloaded upon our arrival to the hospital.
 

Funding and administrative shortfalls ended the work of Project Open Heart.  This lead to the cancelation of a planned third return mission, as well as all future missions and the team disbanded.
 

Disappointed over the cancelation of the mission, I could not help but wonder if perhaps a team could be assembled from my hospital.  Certainly, I have had a number of people I work with say “If there was ever a chance to go on mission, I would love to go!”  Knowing the contacts in Mongolia, I asked them “Would you be interested in a team from Canada come to Mongolia to carry out this mission?”
 

A team of medical professionals from the London Health Science Centre, loosely known as The London Cardiac Outreach Team, is born. Through Serendipity and networking, the London Cardiac Outreach Team has gone on a total of 10 missions to Mongolia, Peru, and to China for almost exclusively adult cardiac surgery.
 

Volunteer’s pay their way to the destination and take from their vacation time to attend the mission.  When you are returning a number of times to the same location, understandably, it becomes difficult for people from one hospital to continue to devote their time year after year. This has resulted in the team from London to invite volunteers from across Canada to join their mission, and this has been a wonderful opportunity to be able to share with the perfusion community.

Through networking I have been associating and volunteering with other NGO’s, including CardioStart International, and The VOOM Foundation, both from the USA, and the Australia Open Heart International.
 

From what I have seen, the missions fall into one of about three categories. The first is a scout mission where a small group will go to the centre that is inviting the them. The objectives are to go and look at their facilities and program to see if they can support what might be required for the program.  This could mean a shipping container of items being sent in to help facilitate the mission happening.
 

The second type of mission I refer to as the satellite mission.  Here a team returns on a fixed schedule. The local team will carry out the selection of patients, and their long term follow–up care.  The mission team comes in to carry out the surgical procedure and their immediate post–operative care.
 

Then there is the “teach them to fish” missions.  A group will enter an agreement with the host hospital with a long–range plan to expand the experience of the local team so that they can provide the service locally, thus creating a long range impact on the region.  These missions can range from a simple come to assess what they are doing, provide in servicing and mentoring, to building a program from the ground up.
 

There are pros and cons to various mission groups.  Larger groups, such as Cardio Start and Open Heart International, have the ability to send shipping containers full of items required to carry out a mission.  They do have a large network of people to draw upon, and often they are reaching across boarders and often across oceans to find the staffing they require to carry out a mission.  This means those attending frequently have to get to know everyone’s strengths and abilities while in the trenches.
 

Smaller teams, such as the London Cardiac Outreach Team, can only bring items that fit in their luggage.  We have adopted what I refer to as the “wagon train” method for bringing in supplies.  We send the host hospital a list of items we need to perform the case, they will look at the stock they have, and let us know what they are missing.  We in turn will then make up a pack for each individual case from the needs of anesthesia straight through to the ICU.  One kit is then made up which has all of those supplies.  We make up kits for aortic valves, mitral valves, bypass surgery, and will have a couple of additional kits made up.  By doing this, in the event someone’s luggage goes missing, we do not lose all of the cannulas or all of the valves, which would bring the mission to a quick stop.
 

The advantage for a smaller local team is that the team members know each other’s strengths, and can hit the ground running when they arrive.  We have seen, especially if we return to the same hospital for a number of years in a row, recruitment tends to fall off a bit.  This is understandable as people have limited vacation time, thus the need to widen our net from only members The London Health Science Centre to other hospitals from both within the province and throughout the country.  We have had the opportunity to experience the mission with a number of our colleague’s from within Canada.  This in itself, has created a Canadian core, or as I will often refer to us as, Team Canada.
 

Occasionally there is a role for non–medical personnel.  Some teams such as CardioStart and The London Cardiac Outreach Team, will in addition to the cardiac surgical program, have a community outreach program that provides the opportunity for non–medical volunteers to join the surgical team.  Often these volunteers find themselves assisting at orphanages who have a long list of projects, including sweat equity construction, making sunscreens, drapes, general maintenance, and mural painting and programs for the children.
 

These opportunities open the doors for people back home to also make a difference by donating the needs of these children.  In addition to some cash donations for projects at the orphanage in Peru, The London Cardiac Outreach Team has received backpacks embroidered with the children’s names, sporting goods donated by colleges, quilts made by seniors, and sweaters made by church groups.  Thus, people who might not be able to travel with the team can also make a difference in the lives of those less fortunate, which in itself is a dividend making a difference in the lives of people back home who know their efforts are going to a good cause.
 

On occasion, disaster relief has spurned clinics for these teams who have had scheduled mission trips planned for the region.  For example, the London Cardiac Outreach Team after a surgical mission, went on to open a clinic which supplied medical assessment and free prescriptions to a small town outside of Cuzco, Peru, where torrential rains washed away homes made of mud brick.  The residents of the town were evacuated to a tent city.  Armed with physician travel packs that provide, for a nominal rate of about $500 which covers paperwork for customs, shipping and handling, a pharmacy worth of over $5,000 of in–date, location relevant, drugs which would cover the 10 top ailments in the local area.
 

More recently, CardioStart International had people on the ground when the earthquake hit Nepal.  With more staff arriving, the mission changed from a cardiac surgical mission to an emergency aid mission for those in need in the face of this disaster.
 

The numbers I have been told that we need to remember, is that 90% of the world’s population does not have access to cardiac surgery.  Thus, be it a young child born without access to have a congenital heart defect corrected, to a mother or father who has been affected by rheumatic heart disease because they had no access to antibiotics when they were younger, and now who now find themselves in need of valve surgery, are the things that we take for granted back home.
 

As health care providers, there are opportunities for us to give a child a full and happy life, to return a parent to their family to help raise the children, or to return them to the work place to contribute to the family’s over all wellbeing, all by simply volunteering a week or two of our time.  If the opportunity ever presents itself I would encourage you to do it.  You will be challenged, and will have to break out your McGyver skills.  You will see things that you only read about in text books, and you to will often learn a skill or two from them.
 

You get to see and experience some far off sometimes exotic lands that are developing. While you are there, you will change the lives of individuals and their families.  Impart new knowledge to our counterparts which will assist them on their journey in healthcare, build new friends, and experience some “how did I ever get here?” once in a life time moments.
 

I know you will find it a transfusion for the soul.

Steve Taylor is a cardiovascular perfusionist and lives in Halifax, Nova Scotia, in Canada.  After learning about ICHF (International Children’s Heart Foundation) from a colleague, he began volunteering in 2008.  Steve was looking for an opportunity to contribute to an organization that not only provided surgery to pediatric patients but also worked to equip local doctors and staff with the knowledge and tools necessary to perform complex procedures, something many developing countries don’t have adequate access to.
 

His first trip with ICHF was to Honduras, and he’s now visited the country nearly every year with the Babyheart team. Last year, he traveled to Jimaní, Dominican Republic, and he will be joining the team later this month in Georgetown, Guyana, for ICHF’s very first medical mission trip in the South American country.
 

As an ICHF volunteer, two moments stand out to Steve.  He recalls seeing the pediatric intensive care unit at a local hospital full of children who had just received surgery over the past few days.  The room was buzzing with activity, filled with patients and family members who would soon be taking their children home.  He knew their lives had been forever changed.

And once, back in Halifax, Steve remembers speaking with a fellow ICHF volunteer from his home hospital about a trip she had just returned from.  After hearing about her experience, he understood ICHF’s mission was to leave a legacy in each country and hospital they visit by not only performing life-saving surgeries but also by training and educating local surgeons and nurses to perform procedures they weren’t skilled in before.
 

Steve encourages all volunteers to have an open mind about trip experiences. “ICHF brings you for your knowledge and skills, which are vital for the success of these trips, but what you gain from your interaction with other volunteers, patients, families and local staff is very rewarding as well,” he said.
 

A big need ICHF must fulfill is medical equipment.  Steve frequently works with his home hospital to donate equipment that still has many years of use left to utilize.  We are very excited to share that for our very first trip to Guyana, Steve was able to secure the donation of a heart lung bypass machine from his hospital in Halifax, IWK Health Centre, to send to the hospital where the ICHF team will be operating!  This machine supports the body while the heart is stopped during surgery, and Steve prepared it to be shipped, sent it all the way to Guyana and will now be the first person to operate it in the country.
 

Donating equipment is one more way our amazing supporters can help ICHF!  We thank Steve and all of our wonderful volunteers that help us do what we do!

Hangzhou, China

 

In November 2014, a team from the Mazankowski Alberta Heart Institute was invited to the People’s Specialist Hospital in Hangzhou, China for a cardiac surgery mission. The purpose of this mission was to perform 3 days of cardiac surgery cases, and participate in an education symposium for the hospital’s cardiac surgery program.
 

Our visiting team consisted of cardiac surgeons Dr. Shao-Hua Huang (team lead), Dr. Rod MacArthur, anaesthesiologist Dr. Blaine Achen, OR nurse Allison Ross, and yours truly as perfusionist.
 

The team was greeted at the hospital with an exceptionally warm welcome, and a little more fanfare than we had anticipated. We were next led on a tour of the facility, the operating rooms, and intensive care unit, followed by a meeting with hospital administrators and medical leadership.

The final part of the afternoon was spent reviewing the patients proposed for our surgical team. And here’s where the plan all changed. The original invitation was for our visiting team to perform straightforward, isolated CABG cases, and educate the local team in the technical aspects of these procedures, which they performed relatively infrequently. While we were presented with one CABG case, it was on a very sick patient with a recent MI. The remaining cases presented to us were more complex than we had originally anticipated or been led to believe – an aortic valve + CABG, and an aortic root replacement/Bental. After much discussion and deliberation, and recognizing the limitations of our equipment and resources, we agreed to proceed with the challenging cases presented to us, as these patients had little chance of survival without the expertise of our team. How could we come all this way just to say no?
 

In the operating room, the equipment was a disparate blend of both old and new. Some aspects of the capital equipment and supplies were quite modern and sophisticated, while much was antiquated, makeshift, or absent altogether. The heart-lung machine itself was a bare-bones unit equipped with nothing more than an oxygen blender. Safety devices, what safety devices? No level, bubble, temperature, or pressure sensors. Arterial line pressure was displayed from a transducer on a transport monitor. One single-tank heater-cooler allowed for control of either systemic temperature or cardioplegia – a real challenge for a potential deep-hypothermia case. Patient rectal temperature was the only monitored temperature. Our circuits were a mish-mash of components, with two venous lines for bi-caval cannulation. What was more modern was the OR environment itself, and very strict attention was paid to sterility and infection control. Anaesthesia machine and monitoring were also state of the art. Surgical suctions were a couple of glass bottles on the floor, and the "sharps" container was a clear plastic produce bag, disposed with the biohazard materials at the end of the case.
 

The next morning proceeded with the more "straightforward" CABG case. My role was to assist and advise the local perfusionists during the case. Despite the obvious language barrier, we were able to communicate our ideas and manage a pretty good understanding throughout the case. The perfusion staff were all trained on the job, but had developed a pretty solid understanding of the fundamentals of CPB. The afternoon was spent in a long session of interdisciplinary lectures and educational presentations from our team – surgeons, anaesthesiologist, and perfusionst. My presentation focused on the building blocks of a quality-oriented perfusion practice and department. All our lectures and presentations were very well-received and greatly appreciated by a large auditorium of attendees.
 

The following day we tackled the CABG+AVR case, and although successful in the end, we struggled with limited cannula selection and the limitations of the CPB system itself. Now the perfusion staff were observing my practice and technique, with me explaining every step from circuit modifications and assembly to priming and case management. A smattering of their English, Google Translator, hand gestures, and diagrams eventually got our questions, ideas, and recommendations across the language divide. A few of the OR nurses provided invaluable translation assistance at key points during the procedure. This case only served to highlight the challenges we needed to overcome to take on the more complex aortic root/Bental case the next day.
 

On arrival to the OR the next morning, I was amazed to find that a second heater-cooler had been borrowed from another hospital, and the circuit had been assembled exactly as I had modified it the previous day. The perfusionists were quite proud of their accomplishments and I conveyed my gratitude for their diligent efforts to accommodate our needs. Suffice to say, despite struggling with the vagaries of cannulas, jury-rigging the circuit, and white-knuckling a complex DHCA case with no safety devices, the patient left the OR in very stable and satisfactory condition. We left after a very long day for some well-deserved adult refreshments,...but that's another story for another time!

We closely followed the progress of our patients post-operatively as they recovered in a very well-equipped ICU under the care of some very skilled critical care nurses and physicians. At the end of our week stay, we were pleased to learn that all of our patients were extubated, recovering well, and expected to be transferred to the ward and discharged within the week.
 

During the entirety of our stay, we were treated like celebrities. Every dinner was a feast, drinks and toasts flowed freely (sometimes a little too freely?), and we were showered with gratitude and gifts. We were treated to evening gala shows, a riverboat cruise, and a tour of a Buddhist temple. The morning before our departure we spent on a bicycle tour through the city and the beautiful lake park. I'm amazed any of us survived cycling in the crowded chaos of the city traffic!
 

In summary, I will confess that I was initially very reluctant to participate in this mission. I was too busy at work, too many Board of Directors items needed attending to, it was too soon after our AGM, I was missing family time and using valuable vacation time and Airmiles. All just empty excuses. Because in the end, the whole experience was a life-changing adventure and a highlight of my career. Looking back, I wouldn't change a thing (except maybe some pump alarms!), and can't wait to return. I would whole-heartedly recommend the challenges and rewards, the professional and personal growth, the friends gained and camaraderie shared to anyone presented with the opportunity. No need to wait for the opportunity to come to you – they are out there just waiting for you to step up and take the plunge!
 

I am pleased to report that the People's Specialist Hospital of Hangzhou has invited this same team to return in the spring of next year to help further advance the quality of practice and patient care in their cardiac surgery program. Enjoy the photos!