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16 February 2015
The mission had ten patients to choose from and only six surgeries planned. On Monday we went to the Cardiac Centre to see what supplies they had, check out the ICU, and start screening patients.
Wells, Sandy, Adessa, and I went to meet our patients before the screenings to get some of their personal info and photos of everyone. The kids are so shy! When they saw their own photos they would smile or laugh, then hide their faces. It made me sick to think we wouldn’t be able to operate on everyone and sometimes I couldn’t make eye contact with them because I knew the tears would start flowing. We all agreed next time we should come for two weeks (and bring more Atriums). A German team is coming in three weeks so we ended up deferring some patients to them but it’s still tough. Wells’ youngest daughter gave him a teddy bear to give to the youngest patient, a thirteen year old girl, K., who was by far the shyest of them all. I just wanted to scoop her up and run away with her. But, like rescuing ducklings, I have to remind myself they’re better off where they are than with me. So let’s meet them, shall we? Or at least get their photo and a first initial.
I don’t mean to play favorites but these two were mine. Big G. 16 yo and Little D. 13 yo. G is so handsome and D is so ornery!
D. 15 yo and A. 17 yo, both previous repairs.
A. 23 yo. Laughing at her own picture.
D. and A., the two previous repairs’ valves had gone bad, most likely because they had stopped taking their antibiotics and their hearts had become infected again. One of the main concerns with these kids is that once they have their valves replaced or repaired they may not have access to the medicine they need after surgery, like antibiotics and anticoagulants (blood thinners). Some of the patients we screened live in Addis, but some lived 300 and 400 km away. Who knows what they have access to and who knows what local physicians are telling them about continuing their treatment.
Surgeons have two choices for treating bad valves- either replacing or repairing them. The Children’s Fund missions are unique in that they try and repair as many valves as possible instead of replacing. But when a repair just isn’t possible, there are two choices for replacing valves- tissue (cow, pig, or human) or mechanical valves. While mechanical valves can last a lifetime, tissue valves need to be replaced every 3-15 years, depending on the patient. But mechanical valves require a lifetime of Coumadin, which is a big commitment for anyone, let alone Sub-Saharan kids living in the bush. And Coumadin is contraindicated in girls because girls get pregnant and Coumadin is teratogenic which can be very dangerous to the fetus, particularly in the first trimester. Teratogenic agents can cause birth defects, growth retardation, delayed mental development, or miscarriage and stillbirth. In fact, when taking Coumadin two forms of birth control are recommended. Again, these are Sub-Saharan kids, some living in the bush, so you have birth control to think about on top of everything else.
So what’s a surgeon to do? Try and repair as many valves as possible without replacing, which still requires prophylactic penicillin until the age of 30, or use a new On-X mechanical valve which studies have shown to be effective with aspirin and Plavix instead of Coumadin, or make these young girls swear they’ll never get pregnant and stop their Coumadin if they have regular mechanical valves, or set these kids up for multiple tissue valve replacements over the years. What decisions! I felt like that kid throwing starfish back into the ocean. We can’t save them all but we can save this one and this one and this one… Let the screenings begin!
After screening everyone and much discussion we finally whittled our list down to just six patients, with a seventh add-on who was a re-op for recurrent pericardial effusions. After inspecting the ICU and OR we discovered what basic necessities we were missing, namely IV fluids. No lactated ringers to run during the case and prime IV tubing, no normal saline to flush meds through IV lines. A few of us pooled our birr and sent anesthesia to find a pharmacy and hopefully fluids. Cattaneo said he had been up coughing all night and I felt the thickness of a cold settling into my throat but luckily Tahta’s wife sent him with a miniature pharmacy so I grabbed some Dayquil from him and a Z-pak from the Canadians, just in case.
The Canadians made out like bandits at the other hospital’s pharmacy and managed to get boxes and boxes of LR and NS. Adessa and Sandy had grabbed a full box of NS flushes from home, but here in the ICU they just tap into the same liter bag of NS whenever they need a flush. I asked if they had any alcohol swabs and one of the nurses handed me a liter bottle of alcohol and some gauze. America: Land of Convenience and Waste.
After setting up the OR anesthesia invited us to go with them to an organic, fair-trade textile shop that had been recommended to Doug by someone back home. I’m sorry, Greg, but I spent 4 Gs there. 4000 birr. Everything was so gorgeous I couldn’t put it down!
Pizza for dinner and a lovely cool evening. Rain on the way home and surgeries start tomorrow!