Authors: Dr Nanthini Pillay (Consultant) & Dr Hwang Kai Yin (Senior Resident), Department of Anaesthesia, National University Hospital, Singapore.
Drs Hwang Kai Yin, Nanthini Pillay, Rex Joseph Morais and team reflect on their first mission trip to Fiji.
In Singapore, approximately 90% of infants born with congenital heart disease (CHD) survive to adulthood. Sadly, the majority of children in the world born with CHD live in locations with little or no access to cardiac care.
The Pacific Islands is one such region. With a total population in excess of eleven million people and CHD affecting approximately 1% of live births, at least 2500 children are born every year in the Pacific Islands with CHD. With no high quality pediatric cardiac centre in this region, the majority of these children die or become debilitated.
On the 27th of April 2022, hope emerged for these children and their families with the establishment of the Sri Sathya Sai Sanjeevani Children’s Hospital in Fiji. With state-of-the-art infrastructure and a model of compassionate care that is completely free of charge, this is the largest project ever undertaken by a non-governmental organization in the history of Fiji.
National University Hospital Singapore (NUH) has been collaborating with the Sri Sathya Sai Sanjeevani Children’s Hospital since 2022. As the hospital in Fiji currently lacks trained local health professionals, NUH sends teams of pediatric cardiac surgeons, anesthetists, intensivists, nurses and perfusionists to Fiji for surgical missions. In addition to performing surgeries, we also provide educational and technical support so that the hospital will eventually have a fully functional, independently operating pediatric cardiac service. We feel fortunate to be able to help these children and support a hospital which has an important role to play in global cardiac surgery.
Dr Nanthini Pillay
Sunset on the 17th September saw the beginning of a new adventure, and many more travels under the light of the moon. A team comprising staff from NUH Anaesthesia as well as our Cardiothoracic surgeons, perfusionists, PICU, nursing and cardiology colleagues took a 10-hour flight and 5-hour bus ride to Suva, the capital of Fiji, where 5 Australian PICU nurses joined us to run an intense eight-day free-of-charge cardiac surgery service for underprivileged children at the Sri Sathiya Sai Sanjeevani Children’s Heart Hospital. This charity hospital had opened its doors to the people of Fiji and South Pacific 5 months ago, where children born with congenital heart disease have no access to surgical treatment and the majority, being unable to afford treatment in Australia and New Zealand, do not survive. Having previously episodically hosted teams from the US and India, it was put back into operation for our mission trip. It was extremely exciting to set up our work space and translate theoretical knowledge into real life application, as equipment and workflows we take for granted in NUH had to be sought and created from scratch.
Ensuring our anaesthesia machines and transport monitors were up to acceptable standards of safety was an exercise in itself, as the oxygen sensors failed just days before our trip and had to be sourced, EtCO2 monitors were in limited supply, and there was no end-tidal anaesthetic agent monitoring on the Drager anaesthesia machines which only supplied isoflurane. Furthermore, three different monitors with disturbingly loud alarms had to be used during each case in order to visualize all the parameters needed for bypass. Although the hospital had ordered new Philips monitors and sevoflurane vaporizers after feedback from the Indian corps, the benefit gained from these will be left to future teams as the monitors arrived two days after our surgeries concluded, and the sevoflurane bottles provided were not compatible with the vaporizers. Fortunately, we had brought a SedLine monitor for EEG and cerebral oximetry monitoring during pump cases. We
also recreated our drug and airway trolleys from memory, and devised a stepwise workflow which trained the locals for a seamless postoperative transfer to PICU. Our surgical nursing colleagues had brought over some of their own equipment, but had to oversee the CSSD sterilization and packing process daily to ensure the sets were ready to match the fast paced turnover.
The working day started at 6.15am with a short van ride from the accommodation in the early twilight of the rising sun, and almost invariably ended with a return trip in the dark after the sun had set at 7pm. Daily case load averaged three a-day and varied from off-pump PDA closure and aortic coarctation repair, to ASD and VSD closures on bypass. Casemix and timing were important considerations as the local nurses could not provide care after the mission trip concluded, and complex cases could not be done too late in the trip. Additionally, initially planned cases were cancelled due to intercurrent illness and increasing severity of pulmonary hypertension (intra-operative nitric oxide and prolonged PICU care not being available). Despite the last minute changes to the list, we were able to bring new patients in time to fill the gap and maximise efficiency of the operating theatre. In order to accommodate the caseload, one or two anaesthetists would induce and insert lines for the next patient in the adjacent cardiac catheterisation lab, when rewarming had started for the patient on table. In this way, we managed to have sufficient time to do procedures such as paravertebral and erector spinae plane blocks for the patients undergoing thoracotomies, and also gave the local trainees a rare opportunity to practice ultrasound-guided vascular access. In view of the limited nursing manpower and ventilator capability in the PICU, we fast-tracked most of the children for extubation on-table, or just after
transfer to PICU, to shorten turnaround time. This included omitting redosing of paralytics after bypass, using opioid-minimizing techniques, and early stoppage of long-acting sedative medications.
Due to the cozy layout of the hospital, it was easy to follow up and participate in the post-op care of our patients and gave us a more holistic picture of how our anaesthetic management affected the challenges faced by the ICU. It was especially rewarding to watch the patients go from taking their first breaths postextubation
and tentative steps during physiotherapy in the ICU, to rushing headlong into the TV room of the post-op ward. On discharge, each child had a Gift of Life ceremony dedicated to their new life free from the risk of Eisenmengers and pulmonary hypertension.
During our brief opportunities for rest the team took the chance to soak in some vitamin D, and managed to visit the nearby beaches and shopping malls. As we go back to our daily work in Singapore, it is heartening to know that somewhere on an island in Fiji, the scars on a child’s heart are healing and he or she will grow up with a normal lifespan to fulfil his or her potential on this earth. As the Fijians say, Sota Tale! Till we meet again!
Dr Hwang Kai Yin
Mission Trip Report: National University Hospital Singapore
Paediatric Cardiac Surgery Charity Mission
17 SEPT – 03 OCT 2022. Author: Dr Hwang Kai Yin, Dr Nandhini Pillay
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