Inside the outbreak: Prepared hearts

On a March morning at Tenwek Hospital, cardiothoracic fellow Dr. Keith Dindi scrolled through an Excel spreadsheet, blocks of green, yellow, and red going by. It was a list of patients waiting for cardiac surgery. Green meant they were waiting for an operation, yellow meant they had had an operation and might need follow-ups, and red meant the patient had died.

As he scrolled, Dindi read off the patients in red.

“A 25-year-old recently died. We lost a 12-year-old. … Another 12-year-old. Seventeen-year-old. Fourteen-year-old. Fifteen-year-old. Twenty-one-year-old.” He stopped reading. Most of the heart patients here in rural Kenya are young, between ages 10 and 30, suffering from rheumatic heart disease that develops from untreated strep throat.

This is the rare rural hospital in sub-Saharan Africa that offers heart surgery, with a highly trained staff led by Dr. Russ White, a longtime missionary doctor at Tenwek and a cardiothoracic surgeon. Many patients here would never be able to afford heart surgery elsewhere.

The waiting list for heart surgery at Tenwek is consistently several hundred patients long, and surgeons here can only do a few cases a week because of how resource-intensive open-heart surgery is. It usually requires about 12 highly trained staff in the room working on the patient.

Most of those on the waiting list had a particular heart failure classification: They would likely die within a few months without surgery. The cardiothoracic team members, when they call to schedule appointments with family as slots open, often learn the patient has already died.

While the novel coronavirus hasn’t yet arrived at this rural hospital near the equator, the coronavirus’s secondary effects are sentencing to death some patients awaiting these life-saving surgeries. White, in a meeting with hospital administrators, talked about outside heart surgery teams canceling trips to Tenwek because of travel lockdowns: “I suspect it’s going to get worse. We’ll be short-staffed in coming months, quite a bit.” The hospital will also face other supply and staffing shortages. But doctors do find hope in patients who are recovering and the possibility of a new facility.

About 700,000 people live in the county where Tenwek is. Based on projections from other outbreaks, doctors estimate that 250,000 would contract the novel coronavirus. Of that, 5 percent will require hospitalization, and about 1,200 will need an intensive care unit. Tenwek has the only ICU in the county, and it has 13 beds—beds usually full with patients suffering from other maladies.

At a staff meeting about the coronavirus, interim CEO Shem Tangus got up to pray: “We thank you, Lord, that you will never leave us or forsake us. How we pray, Lord, that our hearts will be prepared to help our people.”

Hospital administrators already decided to halt all elective surgeries to clear space. They began looking for good isolation areas and screening everyone coming in.

The heart team also had to make the difficult decision not to see any new patients for now. Related, they will have to decide how to portion out their four ventilators. They are normally for heart patients but likely will be in high demand for virus patients. They’re also worried about key staff contracting the virus, then being out of commission.

This week a heart surgery team from the United States was supposed to visit so the Tenwek team could clear some of those critical patients from the waiting list. But a call came: The team was canceling. Not only was the Kenyan government requiring visitors to quarantine for two weeks upon arrival, but U.S. hospitals were also ordering their staff not to go abroad.

The dominoes began falling. The result was fewer surgeries at Tenwek, which handles a large portion of the open-heart cases in the country. More of the patients on the surgeons’ waiting list would soon change from green to red.

“Reducing our [operating rooms] will lead to the deaths of people,” said White.

The Tenwek heart team performs surgeries on kids as small as 30 pounds. But heart surgery on babies is another category altogether and requires different training for surgeons and additional staff in the operating room and in recovery. So the heart surgeons at Tenwek rely on visiting pediatric cardiothoracic teams from the United States to help operate on babies. The waiting list for surgery for congenital heart defects is long too.

The next cardiothoracic team to operate on babies was supposed to arrive in April. Parents were already expectantly waiting. But that team canceled last week, and the Tenwek heart team staff now has to call family members to deliver the news.

“These little kids can’t wait,” said Dindi. “Most of the babies on that list will not be alive.”

As COVID-19 cases slowly progressed in Kenya, from one case to two cases to seven cases on March 18, the heart surgery team faced more obstacles. The Kenyan Ministry of Health issued a directive that those who had arrived in the country in the last 14 days must self-quarantine. The team’s only perfusionist, who manages the bypass machine that supplies blood and oxygen to the rest of the body during open-heart surgery, had just returned from the United States and had to self-quarantine.

White didn’t know how they would be able to perform the heart cases they had scheduled for the week. After some phone calls, he found a perfusionist who used to work at Tenwek and who could come work for two days. Then he would have to figure out how to get operating room space for those days: Space is so tight that different services have to share the operating room and coordinate schedules.

But more problems popped up. White learned the hospital was out of calcium chloride, an essential ingredient for open-heart surgeries. He investigated and learned the entire country had been out since November, except for whatever hospitals had stockpiled. White discovered a nearby hospital was willing to share its calcium chloride, so the scheduled surgeries could go forward.

One heart surgery case went forward in the first week of virus chaos: that of 28-year-old Rafael Kiptoo. He’s a driver from nearby Kericho who learned he had rheumatic heart disease in 2018 when he found himself out of breath whenever he moved. Typically, those with rheumatic heart disease only make it to age 26. He had come to the hospital several times since October hoping for surgery, but the staff kept pushing it back. He persisted because he had heard about Tenwek from friends who had had heart surgery: “I know that everything is possible here,” he said.

Finally this past week, the team rolled him into the operating room. Rafael’s open-heart surgery—doctors stopped his heart for a few hours, worked on the intricate valves, then restarted the heart—lasted all day. When they opened his heart up, they found a pile of clots that could have caused a stroke at any moment. They cleaned the clots out and replaced two damaged valves. The next day he was sitting up in a wheelchair in a corner of the recovery room, tape on the incision down his chest, talking about how he loves soccer and wrestling.

Others were waiting as doctors tried to figure out how to manage the upended schedule. One morning Dr. Agneta Odera, who is training under White, looked at the waiting list and asked the team as they sat filling out paperwork: “So who is a higher priority?” Part of the difficulty for her and White is determining how long a patient will need to be in the ICU, which is always full and demands a lot of resources. “It’s deciding who you’re not going to operate on,” White said. Some patients are “too sick.”

Odera, who knows more about pediatric cardiology than anyone on the team, is on her way to being one of the first board-certified cardiothoracic surgeons trained in Kenya. She wanted to do as many of the scheduled surgeries as possible. The staff met in White’s office to figure out how they could fit two cases into a day (operating time for one case could take three to eight hours or even longer, depending on complications). White said he would call the anesthesia team to start earlier so they could cut earlier. The staff would work longer hours. They already don’t eat lunch, grabbing a cup of chai between cases if they can. Odera and Dindi alternate being on call, and White is on call all the time.

The next morning, Odera and others had to do CPR on a patient the cardiothoracic team had operated on—an esophagectomy, to remove cancer from his esophagus—six days earlier. They couldn’t save him. They weren’t sure why he died—he had been doing mostly well. Everyone was demoralized, because immediately they had to perform another esophagectomy that morning. Dindi prayed a one-sentence prayer as they gathered ahead of the next surgical case, having just come from examining the man’s body, and talking to his relatives: “Lord, help us to deal with the issues we have to deal with.”

Odera soon scrubbed in and worked on the next esophagectomy in the operating room, and reflected: “No one teaches you how to grieve with a patient … you invest in them a lot emotionally. … Until Christ comes back and we have a perfect world, there will always be hardship and pain and tears, and we have to find a healthy way to deal with that.”

With all the bad news and difficult decisions, the heart patients returning for post-op check-ups were a parade of hopefulness: A bright-eyed 17-year-old wearing an “I Heart NY” shirt and sneakers bounced into her check-up with her mom, a year out from her heart surgery that replaced two valves. A 20-year-old woman came in next, two weeks past surgery, feeling right as rain and with a good echocardiogram. A 10-year-old boy with his father came in, also two weeks after surgery. Doctors gave him a clean bill of health.

The surgeons also checked on a recovering baby. A visiting team had performed the baby’s surgery. As Odera examined the baby, the mom wrapped her arms around Odera and leaned her head on her back affectionately.

The Tenwek cardiothoracic team finds more long-term hope on a field just down the road from the hospital, where a construction team worked on a site for a new cardiothoracic center. If the economic impact of the virus doesn’t dry up donations, it will have six operating rooms for open-heart surgery and 125 beds—and hopefully no more long waiting list.