Medical / doc's perspective

Yesterday marked the last surgical day. It was marked by 2 unexpected events: first the 16 year old female, whose mitral valve was replaced yesterday, developed seizures, evolving into status epilepticus. It was determined that she had a heretofore unknown seizure disorder, quiescent for 3 years and on no meds. She finally responded to the addition of midazolam drip, after failure of diazepam and midazolam boluses to control seizures, to the dilantin drip (after a one gram loading dose.) We were able to text message with Dr Jimmy Nguyen, epileptologist at SHMC, who graciously advised us at midnight, PST. We were able to find valproic acid, but only in oral form. Therefore we loaded her via nasogastric tube and will wean the benzodiazepine. She is stable but still on ventilator and sedated at this time.

Secondly, during placement of a permanent pacemaker in a 22 year old male with complete heart block, asystole ensued prior to placement of the ventricular lead. He was intubated, underwent CPR for about 30 minutes, and developed mild pulmonary edema and hypoxemia. As a result, his body temperature was lowered, beginning while still in theater. We used ice bags in axillae and groins and achieved about 34 degrees celcius in 3-4 hours. He remained chilled for 18 hours, then warmed, and is now awake, alert, extubated and mentating well. To the best of our knowledge, we dare say he is the first cardiac arrest patient in Rwanda to undergo hypothermia protocol, albeit with "primitive" means of cooling.

Our final case tally is as follows:
males: 7 (39%)
females: 11 (61%)
age range: 11 - 54
average age: 20.6 years
median age: 17 years


Cases:
Atrial septal defect repair: 2
mechanical valves: 7
bioprosthetic valves: 5
pacemaker placement: 2
Tetralogy of Fallot repair: 3
Right heart cath: 2 (one for undexplained severe TR in patient who received a mitral valve replacement last year, and another for pulmonary hypertension with VSD, w/ finding of a previously undiagnosed PDA)


One case required re-exploration for bleeding, with repair of a small pericardial bleeder and was extrubated several hours later: she is now out of bed, on room air, and is doing well. There were the usual post-op fevers and ateletasis, but less prevalent to that seen in the US, probably due to the absence of comorbidities in these patients. There have already been multiple discharges to home from hospital.

We are now preparing for departure, packing and doing inventory on a huge volume of equipment. Much will be left in secure storage for the next visit. After-action meetings and reports will be done in order to improve our already successful missions.