2011 Reflections

People asked, “How was it?”

It was amazing!

In the largest sense of the big picture……

The first answer is all encompassing… We operated on 17 patients – 5 with congenital heart disease and 12 with Rheumatic heart disease.  Ages ranged from 11 to 54, with an average age of 20.

All patients were doing well as we departed Rwanda even after the very last patient, who had seizures post operatively. She did have a seizure disorder not previously described to us by her local physicians.

That case not withstanding, the other 16 were doing well and included some very challenging cases.  Two young women, one 16 years old and one 17, who had severe leaks of both aorta and mitral valves – both had small aortas and for optimal results required mechanical valves.  Not only would their heart perform better with the mechanical valve, but in addition, if a biological valve were implanted, they could require repeated operations due to valve degeneration in approximately 8 years.  Mechanical valves however, require continued treatment of coumadin or warfarin.  This blood thinner can cause birth defects were these women to become pregnant.  Therefore….. a decision to use a mechanical valve for all intents and purposes means that these 2 women would not be able to have children. In rare circumstances, injections could be given during pregnancy to allow child bearing, but this would be challenging to impossible in Rwanda.

`Theses were heart-wrenching discussion with moms and patients in a society were motherhood often defines a woman. These would be strained and challenging discussions in English, but even more challenging in Kinyarwandan. The Rwanda nurses assisted us with translating for the patients and answering questions. There was a bond that developed between us as we shared the challenge and responsibility of obtaining a truly informed consent.

We went through the process of informed consent with a patient who was estranged from her mother. It appeared that genocide and relationship issues had played a roll that we could not begin to understand.  Look at her and see the pain in her eyes. Rarely, a child’s enthusiasm would overcome this while watching kids movies on the laptop.  The light that was so dim in her eyes would occasionally burn bright – the human spirit is very hard squelch.

The evaluation of patients for surgery was the most challenging for our team, both before arrival and after we were there. Who is sick and needs surgery? Who will do well after surgery? Who is sick, but can wait? What does the patient who is told she can wait believe deep down about her chance to have surgery by the time the next team arrives? Who is too sick with congestive heart disease that has caused changes in the lungs that mean it is too late?

We had information before arrival from our screening team in January. New information could indicate a change and help be a tiebreaker.

Do we operate on someone who we operated on last year, replacing two valves and now needs a third valve replaced? She has severe tricuspid regurgitation. Last year, notes clearly documented the tricuspid regurgitation was only mild.  Equally important to the question of whether she gets a second surgery while someone else does not get a first, is why she developed a new problem. Is this more disease from Rheumatic heart disease?…is her right ventricle the problem?, is something wrong with the lung artery pressures causing severe tricuspid regurgitation? A right heart catheterization can sort out the pulmonary artery pressure issue, but I will tell you, is somewhat challenging with imaging quality. Normally, schwan ganz catheterization can be done under hemodynamic monitoring without fluoroscopy…however, fluoroscopy is more important when the patient has significant valve problems.


The what do you do part is easy  – It was great… we did 17 open-heart surgeries…5 congenital cases…..

The why do you go there part is answered in a much more meaningful way…

…In the visit by Joyuse on day 2 of our stay. Joyuse walked into the ICU at about 5 pm… sun is barely still up… Sunrise and sunset….6am and 6 pm at the Equator. She walks in and initially I don’t recognize her, until she restates her name and indicates that we operated on her last year for valve surgery. She stirs her image in my mind when she begins to talk about her baby. Yes, Healing Hearts Northwest operated upon her, just 3 months after having her baby. Somehow, she made it though her delivery and yet was extremely symptomatic afterwards with her valvular disease from rheumatic fever. Caring for her in February 2010, we dealt with the unusual problem of finding a breast pump in the post operative period….We planned for a lot, but that did not include being prepared for a breast feeding Mom. Besides the postoperative issues of rhythm and fluid excess that we worry about for all patients, we were struck by her apparent lack of bonding to her baby. Grandma and the baby clearly had bonded, but not Joyuse. In retrospect, it was because she was not well enough to care for the baby. But, now with enthusiasm, she described her life as a mother of a 17-month-old baby. She was ebullient as she described her life as mother of a 17 month old. She looked so good that day and told us how well she felt and she thanked Healing Hearts Northwest for giving her life back to her..

“God bless you”.  Her words and her appearance were inspiration to making certain that the next 2 weeks would go well.