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:

DAVIDE EMILIO CASTRO QUINTIGUINA

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:

MAYKEL PAGUAY PILCO

7 yrs

VSD & Subaortic Membrane

Resection and Closure 3/14/2019

Satisfactory

CABRERA AVILEZ

9 days

Pulmonary Atresia/ Fallot’s Tetralogy

BT shunt 3/13/19

Post-operative ICU Death 3/14/2019

GEOVANNY VINCES LASCANO

15 yrs

Pulmonary Stenosis Fallots, Tetralogy

Repair and reconstruction of the pulmonary valve 3/12/2019

Satisfactory

JOSE CHICAIZA CHIMBAY

11 yrs

ASD

Patch closure 11/03/2019

Satisfactory

DAVID CASTRO QUINTIGUINO

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

First Week Team

CardioStart Team:

AUSTRALIA

  • Andrew Cochrane, Pediatric Cardiothoracic 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)

UNITED KINGDOM / USA

  • Aubyn Marath, Cardiothoracic Surgeon (CardioStart Mission Co-Director)

UNITED STATES

  • Tom Karl, Cardiothoracic Surgeon
  • Rebecca Brunelle, PICU Nurse
  • Denise Ronek-Welch, PICU Nurse
  • Rachal Dorvall PICU Nurse
  • Frances Younger, OR technician
  • Jocelyne Kizziar,  Surgical Technician & Database Collator
  • Jerry McEwen, Biomed engineer
  • Natalya Shumylo, Echo technician
  • Kelsey Lopp, Respiratory Therapy
  • Nicole Moriello, Outreach nursing
  • Tom DiSessa, Pediatric Cardiologist
  • Douglas King, Pediatric Cardiologist
  • Neil Casey, Pediatric & Adult Perfusionist
  • Melissa Oliver, Pediatric & Adult Perfusionist

Healthcare provision and future growth:

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)
  • CardioStart Administration Team, Tampa, Florida, USA  (logistics)
  • CardioStart ReSale Thrift, Oregon, USA  (Database funding support)
  • CardioStart Logistics teams (Aron Boesl, Dr. Don Steely and colleagues (Eugene, OR); Darlene Crook, Tampa, Fl)
  • Children’s Lifeline, California, USA – funding support for oxygenator systems and medications used.
  • Cryolife Inc., donation of human tissue grafts
  • Dr. Farah Rahman, USA. (Donation of surgical hand-sewn hats)
  • Edwards Life Sciences Inc., (Donation of bioprosthetic heart valves).
  • United Methodist Church, Lake Oswego, OR, USA) (Children’s doll gifts)
  • Mending Kids Inc.,Burbank, CA, USA. Support for perfusionist attendance.
  • RiverPoint Medical– suture and headlight equipment donation
  • Dan Woodward MD & Pam Hayes (OHSU) (Assistance with certain medications procured at cost).
  • Warm the World” – Donation by Rachel Weinbren, hats and blankets for premature/dysmature children