Introduction: Between March 9th and 16th, an international group of volunteers visited Jakaya Kikwete Cardiac Institute (JKCI) in Dar Es Salaam, Tanzania. The group consisted of cardiac surgeons, anaesthetists, nurses, perfusionists, cardiac sonographer, and a critical care doctor. The group travelled from the USA, Australia, and Ireland under the auspice of a charity called CardioStart International. The basic mission of CardioStart is to educate and assist local medical teams in providing heart surgery and cardiac services to adults and children in underserved regions of the world, with a vision of a world where access to cardiac care can be realized by everyone. The following article will discuss the personal and professional experience of intensive care nursing, perfusion and cardiac sonography gained during this mission.

United Republic of Tanzania is the largest country in East Africa with a population of over 65 million people (United Nations, 2022). Even though Tanzania is one of the most politically stable African nations, it is an impoverished country, with over 25 million of the population surviving on less than 2 USD per day (World Bank Open Data, 2020).

The hospital that CardioStart International is linked with, known locally as JKCI, is the only available cardiac surgery centre in the country. It is a government owned hospital which accepts patients from all over Tanzania and surrounding countries, from regional referral and designated hospitals, for cardiovascular intervention. On average they cater for 700 outpatient appointments per week and have over 100 inpatients at any given time. There are three operating rooms, an eight bedded adult intensive care unit, a paediatric intensive care unit, and several floors of inpatient wards. This was the fifth visit made by CardioStart to the hospital.

Intensive Care Experience

The main observation I made in my time in intensive care in JKCI, was that teamwork was abundant. The severe lack of resources extended to every consumable item you can imagine, including all medications, dressings, syringes, needles, monitors, infusion pumps etc. However, this did not affect the primal desire within nurses and medics which is to improve the patient experience and outcomes. Despite having very minimal supplies, the intensive care staff were extremely attentive, excellent advocates for their patients, and quick to point out their observations to the medical staff. I was positively surprised at the lack of negative hierarchy that exists, everyone was listened to respectfully and discussions were open and transparent.

One element of postoperative cardiac surgery care which is central to practise in the developed world, is the idea of “fast track extubation” (Wong et al, 2016). There are multifaceted benefits associated with this concept, including reduced length of stay in ICU. Whilst on this mission, I was initially surprised to see that both pain relief and sedation were given reactively to patients, via bolus injection. It is routine in intensive care practise to provide these medications via a continuous infusion pump during the first hours post-surgery. However, there was discernible positives associated with the methods witnessed in JKCI. The primary reason for giving a PRN bolus of medications in this context was a simple lack of infusion pumps. A maximum of three pumps were available for each bedspace, these were usually administering inotropes or vasopressors for cardiovascular support. By administering only bolus of sedatives, the nurses were highly attuned to the patients’ needs and communicated continuously with them in a calm and professional manner, in order to maintain endotracheal tube tolerance. This made it likely that the patients were suitable for extubation at a very early stage postoperatively. An aspect of holistic patient care which was accommodated throughout the patient’s journey was open visiting of family members. The visitors were made to feel welcome, encouraged to be involved in the basic care of their relative and kept updated to their condition with little prompting. This had the added effect of reducing anxiety for the patient in ICU, during a lifechanging experience for them.

Physiotherapy is a very important element to the recovery process following cardiac surgery. The physiotherapy offered to the patients, was as good as any developed country. The physiotherapist was calm, patient, and took a long time to go through the exercises with each patient. There was a good flow and routine to their practise, and this culminated in early mobilisation where suitable.

Naturally there were some areas of ICU care that needed some polishing, that was the purpose of the mission after all. It’s important to acknowledge that the hospital functions in the absence of charitable input for most of the year. It was obvious though that the staff were very receptive to learning and the nurses had questions about every aspect of care that they were providing, and how this is carried out in Western hospitals. Didactic training was given over the course of the week, in many different subjects. Advanced physical assessment such as chest auscultation, perfusion status, neurological assessment and skin assessment skills were practised. Methods of assessing fluid responsiveness was a subject of great interest to the staff, as there is no access to advanced haemodynamic monitoring or point of care testing for lactate. Thus, passive leg raises, central venous pressure monitoring and mixed venous gas exchange were employed instead. This highlighted a resourcefulness and willingness to learn in the staff which was unlike anything I had witnessed.

The impact of the mission overall was obvious for the patients, several underwent coronary artery bypass grafting and others had repair of secundum atrial septal defect. The impact for the patients is that they can now go back to their daily lives in comfort. The impact on the volunteers is perhaps even more great. From a personal point of view, witnessing healthcare workers succeed and excel in such hardship was a privilege. The care provided was genuinely the best possible, within the resource constraints of a severely underserved environment. Staff were kind, inclusive and communicative. It was truly amazing to see how they do so much with so little.

Perfusion Experience

When you hear the word “luxury” your mind will wander to a mansion set back in the woods, the front seat of a Lamborghini throttling around curves on the side of a cliff in a faraway country, or to a fantastical land with birds and animals of bright colours. Never would your mind conjure up an image of an operating room with minimal supplies in a hospital regularly combating the heat and humidity of the typical weather of East Africa. For the people of Dar Es Salaam, Tanzania, arriving at Jakaya Kikwete Cardiac Institute (JKCI) for heart surgery is a luxury that most in the surrounding areas cannot afford.

The first day in the operating room was approached with caution, as there were bound to be barriers. As with any developing country, there are deficits of both supplies and medications; fortunately, the mission team was able to travel with a small mountain of suitcases filled with donated supplies and medications, even those that were expiring, which were so gratefully used. Despite the varying countries and years of experience that the team brought to the table, the eclectic combination of equipment, ventilators, and cardiopulmonary bypass machines forced a sense of teamwork to navigate and troubleshoot each machine.

It is important to recognize that the JKCI team has been functioning to the best of their ability prior to the mission team coming in. However, the team was able to help perform necessary complex cases, provide much needed supplies, and instil further knowledge on more efficient techniques and even more evidence-based approaches that can enhance both their future cases and outcomes. For example, employing vacuum to the cardiopulmonary bypass machine was not in the routine wheelhouse of the JKCI perfusion team. On complex cases, vacuum is an essential component to ensure adequate venous drainage and a bloodless, motionless field for the surgeon. Perfusionists of the mission team were able to rig together a useful vacuum system for these cases as well as MacGyver together and introduce the idea of a recirculation-priming combination line. This line typically serves to recirculate air and fluid from the oxygenator, transfuse fluids, medications, and blood, and to remove blood or fluid from the circuit and displace it to empty fluid bags in the setting of volume overload as to avoid pressurizing the reservoir.

Another vital component of cardiac surgery that was harnessed is cardioplegia. This is used to stop the heart and provide myocardial protection during cardiac surgery while using the cardiopulmonary bypass machine. The CardioStart mission team was able to provide a researched formula and education on how to make cardioplegia each day including dosing, shelf-life, and crystalloid alternatives to be used. This helped to combat previous complications with ineffective cardioplegia administration, unknown dosages, and a lack of supplies. This equally instilled a sense of independence with the ability to constitute their own cardioplegia for each case.

Coupled with this came the education on haemodilution and effective interventions and methods to prevent and combat this as it can lead to unnecessary post-operative complications and risks of volume overloading and requiring blood transfusions both intraoperatively and postoperatively.

As is easily imagined, the language barrier was one of the largest hurdles as this ranged from languages spoken, to what device was used, to protocols and anticipation of next steps. However, all these fears were quickly dissipated by the hospitality that was extended by the local team. The operating room staff at JKCI was not only welcoming but encouraged the Cardiostart medical mission team’s involvement and input. Both the local and traveling teams understood that communication (and candy) would be their biggest ally and used this to their advantage to create a cohesive, seamless team. One of the most enlightening attributes of the team at JKCI was their sense of comradery with their local team and visitors alike. This continued even through the longest case of the week- a partial arch replacement, Bentall procedure, and coronary artery bypass graft (CABG) which included a 13-hour cardiopulmonary bypass run. Throughout this procedure the team did not lose their spirit nor their dedication to the patient, even far into the night. As the hands of the clock passed into a new day, team members would alleviate others so that they could rest, snack, or grab a fresh bottle of Coca-Cola. The support, encouragement, perseverance, and devotedness that was felt so strongly is something that we can only hope to emulate in the future.

While this procedure was the longest and most complex, there were a variety of additional procedures performed. These included atrial septal defect (ASD) repair, CABG, aortic valve replacement, and a combination of these procedures. Unfortunately, JKCI had seen a recent reduction in cardiac procedures performed due to an interruption in supplies. Considering this, the impact of the visiting mission team will be felt for months to come as they will be able to perform more cardiac surgery cases with the donated cannulas, tubing, sutures, valves, grafts, tools, and medications that the team was able to supply. This trip has provided a sense of pure appreciation- both for what we have, and for what amazing things the local team is able to accomplish with the tools and equipment at their disposal. However, the privilege of joining this team was held in the hearts of the CardioStart medical mission team. Needless to say, this newly formed team definitely has the beat!

Cardiac Sonography Experience

Tanzania has a limited supply of resources, high rates of HIV/AIDS, pneumonia, malaria, and maternal and child deaths. Additionally, Tanzanians have some of the lowest rates of global access to medical professionals. This is due to low medical school output, outmigration due to poor compensation, and adverse working conditions. HIV/AIDS has increased demand for skilled health workers but reduced their availability. An urban-rural imbalance also exists, with more staff in urban centres. To improve productivity, solutions include improved management measures, local-specific training, strengthening enabling factors like equipment and skills, and introducing financial incentives to increase workers’ efforts.

Rheumatic heart disease is still prevalent in Tanzania. Rheumatic heart disease affects 40.5 million people globally, with up to 80 million having asymptomatic cases. Despite almost eradicated in developed countries, rheumatic heart disease continues to affect children and young adults in sub-Saharan African countries like Tanzania. Tanzania also has a severe shortage of specially trained medical professionals. To ensure improved access and improved medical care, their health infrastructure needs to be improved.

During my two-day echo clinic, I was able to examine 39 patients with cardiac ultrasound. I found that 16 of these patients (roughly 38%) had abnormal cardiac findings on their echocardiogram. They desperately need an advanced training curriculum specifically geared towards echocardiography. Every cardiac illness assessment and treatment revolves around echocardiography, or “echo.” Ultrasound waves are used to create a moving image of the heart during an echocardiogram. The inherent benefits of this technology— sound waves are painless and safe, and portable devices offer convenience and quick, repeatable results—allow its application to spread far beyond conventional medical settings. Numerous kinds of cardiac disease can be identified by an echocardiogram. Among them are congenital heart disease, cardiomyopathy, infective endocarditis, valvular disease, and pericardial disease. Additionally, an echo can reveal changes in the heart that can indicate an aneurysm in the aorta, thrombi, or a tumour of the heart. Notwithstanding any possible benefits, echocardiography requires training and ongoing professional development to be used safely in any healthcare context. The risk of patients being harmed by unskilled personnel utilizing subpar equipment is considerable and must be reduced in the absence of a strong certification, accreditation, and revalidation procedure.

Hypertension was another finding that was seen frequently with the patients I examined. In urban Tanzania, hypertension is said to be the most common cause of heart disease. Reportedly, most patients do not receive treatment prior to echocardiography and most have advanced stages of cardiac disease. To identify and treat heart failure and hypertension in urban Africa, there is an immediate need for greater infrastructure, knowledge, and awareness.

Taking all of this into account, the chance to use your skills where they are most needed can be one of the most fulfilling parts of participating in a medical mission trip. In addition to being a great opportunity, it was an honour. When I went to Tanzania, I was joined by other professionals who shared my enthusiasm for medicine, empathy for others, awareness of the global community, and a sense of adventure. My fellow volunteers encouraged me, tested me, and some will end up as lifelong friends.

Conclusion

The aim of this article is twofold: to delineate the profound experience of participating in a medical mission and to ignite a passion for such endeavours among our peers. While acknowledging the challenges—both logistical and financial—the accrued learning is immeasurable. From the point of view of personal and professional development, it is invaluable. Reflecting on the impact of our efforts, we recognize that the true value lies not only in the lives touched but also in the transformative journey it ignites within ourselves. Beyond the operating room, outreach clinics, and the intensive care unit, the lessons learned in empathy, collaboration, and resilience reverberate far beyond the borders of any country. May this narrative serve as a testament to the power of compassionate action and the enduring spirit of humanity.

Acknowledgements

All of the equipment which was donated to JKCI during this trip was very kindly donated by medical companies and hospitals in the volunteer’s localities. We would like to thank the following for their continuing support:

• Ciara Power, Aerogen for the donation of Aerogen Pro controllers
• Damien McCann, LivaNova for the donation of perfusion supplies
• Denis Coakley, Vygon for the donation arterial line catheters
• Deirdre Kileen & Marion Grady, Galway University Hospital for the donation of PPE
• Mary Maguire, biomedical engineering Galway University Hospital for the donation of expired ICU equipment
• Keystone Perfusion for the donation of perfusion supplies
• Thomas Jefferson University Hospital for the donation of perfusion supplies
• Cooper University Hospital for the donation of perfusion supplies

For more information on volunteering: grainne.warren@hse.ie

Written by:

Grainne Warren – Grainne Warren, a cardiothoracic intensive care nurse at Galway University Hospital for 5 years, holds postgraduate degrees in intensive care nursing and clinical trials.

Amanda Tirone – Amanda Tirone, with seven years as a registered nurse in intensive care and a forthcoming Master’s in Cardiovascular Perfusion from Thomas Jefferson University, is graduating as a Certified Clinical Perfusionist in Norfolk, Virginia.

Sarah King – With eight years as a Registered Diagnostic Cardiac Sonographer and ongoing studies for a Master’s in Healthcare Informatics, Sarah King is currently on assignment as a travel sonographer in California with Aya Healthcare.

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