Mission Report – Pediatric Heart Surgery Mission in Guayaquil, Ecuador
Mission Report – Pediatric Heart Surgery Mission in Guayaquil, Ecuador
MISSION REPORT
PEDIATRIC HEART SURGERY MISSION TO GUAYAQUIL, ECUADOR
March 3-16th, 2019 – Hospital del Nino Dr. Francisco de Icaza Bustamante, Guayaquil, Ecuador.
MISSION OBJECTIVES
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 hospital Administration, arranged 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 delayed permission to enter the hospital so it was only possible for the patients to be assessed at the end of the first week, when the first operation was accomplished.More were accomplished 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 and surgery, 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 often depends on visiting teams to receive the support for helping heart patients in need.
Pediatric Cardiology
The department led by Dr. Antonio Fernandez is well organized and offers a high standard of clinical and echo evaluation but on this occasion, Dr. Fernandez could not collaborate on this mission through personal health issues. There is no cardiac catheterization facility there. The Echocardiographic department has been supported previously by several visits by Dr. Tom Di Sessa (representing CardioStart, and other humanitarian cardiac mission groups), and on his own initiative.The hospital’s aspiration to remain a regional referral center is challenged by the severe budget constraints it is currently enduring which threaten patient safety and general operational standards of care.On this occasion, both Dr. Tom Di Sessa and Dr. Doug King led the evaluation of those patients who presented for cardiological assessment and Dr. King also saw patients in Dr. Figueroa’s primary care Clinic.Cardiological, echocardiographic and general evaluations were provided to over 75 children drawn from the community, arranged by Fundacion El Cielo. Dr. Doug King led this initiative.
Cardiac Surgery, Perfusion and Anesthesia
Local surgeons, Dr. Montero and Dr. Maldonado, who are also employed by a private hospital in the city, have been forced to recently reduce and almost completely stop doing surgeries because of major equipment shortcomings, including blood gas analyses, sterilizer units, insufficient ventilators and shortages in disposable products.Regular staff support during the operative day and night cover to permit more complex cases be taken on has not been possible and owing to these financial constraints, and some essential ICU nursing staff had been let go from the service. Those remaining were supported by CardioStart nurses during the mission.
The local OR nurses assigned to cardiac surgery were also unable to continue their specialist skill knowledge and efficiency due to the lack of cardiac surgery cases being scheduled.CardioStart team members provided many ICU and OR disposables used during the mission: a Cryolife homograft, two bio-prosthetic valves (Edwards Inc.,), patch membranes and Goretex tube grafts to help the operating list be accomplished.A portable autoclave was brought from the CardioStart warehouse by our Biomedical Engineer who also repaired one of the main sterilizers for the hospital.A dedicated local cardiac anesthesiologist had been appointed and provided the essential cardiac care for the two week’s operating schedule, which was addressed entirely by CardioStart surgical team members. The Ministry of Health required a second letter of approval for the donations to be brought as gifts, so the CardioStart team were not allowed in to the hospital until Thursday of the first week.They began operating on Friday, 8th March.
ICU
The Unit is supported by a local Intensivist, who handled the admissions of all children requiring ICU support.The available ventilator status was limited to one only.As previously found, the local ICU nursing staff 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 and has led to very low morale. The available nursing and medical support at night was also substandard compared to previously.
SURGICAL CASES ACCOMPLISHED
NAME *
Age
Diagnosis
PROCEDURE/Date
30-DAY RESULT
Week One:
D.E.C.Q.
13yrs
Tetralogy of Fallot: Re-operation, from pulmonary valve erosion and incompetence
Re-operation: replacement of pulmonary artery with Size 24mm aortic homograft
Satisfactory
Week Two:
M.P.P.
7 yrs
VSD & Subaortic Membrane
Resection and Closure 3/14/2019
Satisfactory
C.A.
9 days
Pulmonary Atresia/ Fallot’s Tetralogy
BT shunt 3/13/19
Post-operative ICU Death 3/14/2019
G.V.L.
15 yrs
Pulmonary Stenosis Fallots, Tetralogy
Repair and reconstruction of the pulmonary valve 3/12/2019
Satisfactory
J.C.C.
11 yrs
ASD
Patch closure 11/03/2019
Satisfactory
D.C.Q.
13 yrs
Pulmonary Stenosis Fallots, Tetralogy
Closure of the VSD and repair of the dysplastic pulmonary valve. 08/03/2019
Satisfactory
There was one early post-operative death despite surgery having been conducted appropriately. It may have been due to bronchial suction trauma.
Note: All operations were performed by the CardioStart volunteer surgeons because Dr. Montero had hurt his back.
Education
All cardiology echo-cardiography evaluations were used as teaching opportunities and formal rounding and bedside teaching took place each day and during the mission all ICU rounds were led by the local nursing team.Sessions were devoted to teaching nurses from ICU on principals of pediatric cardiac nursing care, and cardiopulmonary resuscitation techniques, using a mannequin.
Outreach
This was conducted at a clinic in Guayaquil: it included preventative healthcare measures, teeth brushing, hygiene and primary medical care.Cardiological and general medical evaluations were carried out on certain days which included echo-cardiography screening.
Primary community healthcare workshops to educate on basic preventive health concepts using the materials developed by CardioStart and the World Health Organization. CardioStart’s Outreach nurse volunteer, Nicole Mauriello, taught approximately 60 participants (mostly children, some accompanied by a parent or caregiver). The schools were on extended vacation prior to Ash Wednesday so attendance was high.
The topics that were covered included: recommendations for optimal oral hygiene, pediatric tooth brushing techniques, link between poor oral health and disease, hand hygiene (demonstrations as well as practice), link between poor hygiene and common illness.All topics were reviewed at the end to assess learning acquisition. Following the workshop, every attendee received an appropriately sized toothbrush, toothpaste and a mini soap bar.
First Week Team
CardioStart Team:
AUSTRALIA
Andrew Cochrane, PediatricCardiothoracic Surgeon (CardioStart Mission Director)
ECUADOR
Dra. Zorayda Figueroa (Executive Director, Fundacion El Cielo Para Los Ninos de Ecuador)
Dr. Renzo CiFluentes MD, (Previous Medical Director, Fundacion El Cielo Para Los Ninos de Ecuador)
A Medical Report has been generated by CardioStart volunteers who visited the hospital to help Administration and department leaders. It is hoped these recommendations will help the local team choose and apply those measures that might save the hospital from further loss of clinical programs and possible closure.It is available on request.
Since CardoStart’s previous visit in March 2018, the Children’s Hospital has suffered several economic cutbacks and is now in a very precarious state: Cardiology, surgery, and their supporting department staff each have to confront daily threats to patient safety and effective delivery. These have worsened. The Medical Report is presented to recommend measures that are economically realistic within the limited budget available.
Acknowledgements
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)
Americares Inc., USA donation of certain medications.
The Amy Lauth Foundation, Virginia, USA(freight logistics cost)
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