March 17-29th, 2018 PEDIATRIC HEART SURGERY
Hospital del Nino Dr. Francisco de Icaza Bustamante, Guayaquil, Ecuador.
On this occasion, CardioStart’s International mission team made a return visit to the Hospital del Nino Dr. Francisco de Icaza Bustamante in Guayaquil, Ecuador on invitation by the Fundacion El Cielo Para Los Ninos del Ecuador. This was designated as a two-week mission, but administrative hold-ups with documentation and Ministry approval it was only able for the patients to be assessed during the second week. Accordingly, only a few cases could be undertaken. Three of the cases were emergency presentations and it was felt by both teams that these patients would shortly die without an attempt to resolve their presentation surgically.
The Children’s Hospital Dr. Francisco de Icaza Bustamante received gold level accreditation by Accreditation Canada International (ACI) on November 20, 2014, after meeting international health care standards of quality, but has struggled since to retain specialist services in some areas. The hospital has 442 beds, some modern equipment, as well as several clinical and surgical subspecialties.
Services provided by the hospital include cardiology, endocrinology, genetics, dermatology, gastroenterology, nutrition, hematology, oncology, infectious diseases, nephrology, neurology, pulmonology, neonatal intensive care, intensive care unit, pediatric outpatient palliative care unit, pediatric gynecology, and emergency medicine.
Despite these facilities the hospital lacks the manpower and funding to support a full time heart surgery program for children with congenital heart disease and depends on visiting teams to receive the support for helping heart patients in need.
The department led by Dr. Antonio Fernandez is well organized and offers a high standard of clinical and echo evaluation. There is no cardiac catheterization facility there. The Echocardiographic department has been supported previously by several visits by Dr. Tom DiSessa (representing CardioStart, and other humanitarian cardiac mission groups), and on his own initiative. This has led to the efficient admission, evaluation and preparation of patients who can be managed medically and those who are screened for surgery. Other facilities are still lacking and need more financial investment for this department to reach its fullest potential. The hospital’s aspiration to become a regional referral center is realistic and is possible.
Cardiac Surgery, Perfusion and Anesthesia
The surgeries, led by local surgeons, Dr. Montero and Dr. Maldonado, were of an excellent standard, and a similar standard was applied throughout the peri-operative care – despite several shortcomings in equipment and regular shortages in vital disposables. Regular staff support during the operative day and night cover to permit more complex cases be taken on, is recommended, but essential staff are sometimes not available. These surgeons, anesthesiologists and perfusion staff come from another hospital location to support this developing program. Recently, a dedicated cardiac anesthesiologist has been appointed so that more frequent cases can be accomplished, and with greater complexity and she was supported by the CardioStart anesthesiologists.
The OR nurses assigned to cardiac surgery were also excellent; they need strong support from their OR department to continue their specialist skill knowledge and efficiency. Several educational advances were made in bedside one-on-one teaching to help advance techniques and management styles, including ensuring sterile procedures prior to patient transfer at the end of the cases.
The Unit is supported very strongly by an excellent local Intensivist, who handled expertly the complex cases during the second week. As previously found, the nursing staff in the Cardiovascular ICU at the Hospital del Nino Francisco de Icaza Bustamante were knowledgeable and their eagerness to learn enabled them to develop great assessment and critical thinking skills to care for the very ill postoperative cardiac surgical patients during the course of this mission.
The continual shortage of nursing staff and the unsafe workload placed on the few nurses within the unit remains a serious challenge to sustaining optimal results.
SURGICAL CASES ACCOMPLISHED
There was one early death despite surgery being conducted appropriately. Untreated Total Anomalous Pulmonary Venous Drainage has a very high mortality in the first month of life. Despite demonstrating satisfactory venous return, a sudden decompensation occurred after surgery. There was no evidence that this was due to insufficiency of blood return to the heart.
All cardiology echo evaluations were teaching opportunities and all operations by the CardioStart volunteers were conducted entirely as teaching cases. Formal rounding and bedside teaching took place each day and during the mission all ICU rounds were led by the local nursing team, supported by the local surgeon, cardiologist, and respiratory therapist. A morning was devoted to teaching nurses from ICU and the departments on principals of cardiac nursing care, and cardiopulmonary resuscitation techniques using a mannequin.
- Marc Rebel MD, Pediatric Cardiothoracic Surgeon
- Nicole Burnham RN, PICU
- Jennifer Koch RN, PICU
- Dra. Zorayda Figueroa M. Psych Ecuador (Executive Director, Fundacion El Cielo Para Los Ninos de Ecuador)
- Dr. Renzo CiFluentes MD, (Medical Director, Fundacion El Cielo Para Los Ninos de Ecuador)
UNITED KINGDOM / USA
- Aubyn Marath MD, Cardiothoracic Surgeon
(CardioStart Mission Director)
- Rebecca Brunelle RN P-NP, PICU Nurse
- Stephen Cain, Anesthesiologist
- Tom DiSessa MD, Pediatric Cardiologist
- Natalia Franco RRT, Respiratory Therapist
- Diana Gonzalez RN P-NP, PICU Charge Nurse
- Alexsa Gormley, CardioStart Mission Coordinator
- Douglas King MD, Pediatric Cardiologist
- Amelia Lewis CCP, Pediatric Perfusionist
- Keith Levitt MD, Pediatric Anesthesiologist
- Melissa Oliver CCP, Pediatric Perfusionist
- Tyler Thorne, Database Collator
- Frances Younger CST, OR technician
A number of individuals and corporations facilitated this mission and/or made generous in-kind and/or financial donations:
- Accuware Consultants Inc., Ohio, USA (equipment)
- The Amy Lauth Foundation, Virginia, USA (freight logistics)
- CardioStart Administration Team, Tampa, Florida, USA (logistics)
- CardioStart ReSale Thrift, Oregon, USA (Database funding support)
- CorMatrix Inc., GA, USA (Pericardial Membrane)
- Cryolife Inc., donation of human tissue grafts
- Eugene Southtowne Rotary Club, Oregon, USA (Equipment donations & Logistics – Matt and Amanda Adams & colleagues)
- Dr. Farah Rahman, USA. (Donation of surgical hand-sewn hats)
- Scanlan Surgical Instruments, Minnesota, USA
- United Methodist Church, Lake Oswego, OR, USA) (Children’s doll gifts)
- RiverPoint Medical– suture equipment donation
- Dan Woodward MD & Pam Hayes (OHSU) (Medication procurement at cost).
- Warm the World – Donation by Rachel Weinbren, hats and blankets for premature/dysmature children