Ghana Journal

Monday 8 February 2010
Unpacking our suitcases. Getting to KATH. Where did all this come from? And where the heck do we begin ! A quick introduction to the ICU staff, to the equipment. Draeger Evita ventilators. Oh… good, I had an introduction to these like six years ago when OHSU considered buying them. Really no issue. A vent is a vent. And these are supposed to be straight forward hearts. The Draegers do non-invasive and invasive BiPAP mode. APRV. Independent Lung ventilation. Dr David Morrison and I agree to start everyone on AC, when awake transition to PSV, get a blood gas, assess SBT-ish things and extubate when there is a Cardiostart Anesthesiologist available to re-intubate. Ok. Not the way I would do things. We generally prefer to start on a high rate SIMV, wean the rate as tolerated overnight to CPAP –PSv and extubate when awake. (I do agree with the blood gas/ SBT assessment). I definitely agree with Anesthesia in house rule! We have to extubate to NC’s no aerosol’s available. They use reusable humidifiers for NC’s. Also, I just discovered there are no Incentive Spirometers. Not completely true. There is ONE! Plan B. The anesthesia circuits have two filters on them. I will ask the Brits to bring the circuit with them to the ICU. I will use the filters from the Anesthesia circuit, a mouth piece from a nebulizer and we will reuse the IS. Seriously??? I have bubbles, but no PEP. I have Duoneb and Atrovent, but no ALbuterol. I even have Pulmicorte ( seriously??) Hell I can do this. Oh and by the way…. We are adding a 24 kg 13 year old ! There are infant circuits, no peds circuits….back to the ‘storage room’. I swear I have been in every box in this room. I am good to go. I have a plan. Circuits, self inflating bags for the nurses, flow inflating bags for the Brits, nebs…well I had to borrow from KATH, but I am good…. Plan for IS, plan for Non-invasive, NC, non-rebreathers, and a control of ISTAT machines and cartridges!
The RN’s seem to be getting things together as well. Hmmmmm…no adhesive tape, but a tone of that damn pink tape that Anesthesia loves. There is so much unnecessary stuff in the back storage room. There is unnecessary stuff in my suitcase! Make a list: Circuits, HME’s. inlines, Try to find Draeger ETCO2 cable and cuvettes, nebs, Spacers, MDI’s, IS, Aersol masks, Aerosols.

Oxygen is also a problem! Interesting….. there is a single oxygen source at each bedside. And no T-bars! So we need at least a tank for each two patients.

Tuesday, 9 February 2010 Lecture Day. OK…. Last night Uday walks into the bar and states, rather simply: “ Marie, tomorrow you will give your lecture on ABG’s”. I hope that is not a problem. …gulp…. Problem? No not really !! Not a problem except that I had not even begun to put it together yet! So After dinner I disappeared into my room for a night of computer time. Fortunately…. GOOGLE ABG Powerpoint….. Someone else has already done all my work. All I need to do is put it in the order and format I want. I take the KISS approach to interpretation of blood gases. ( KISS = Keep It Simple, Stupid) pH, ….then PaCO2 ( Ventilation) then HCO3, then PaO2 ( Oxygenation) Uday wanted it to last 30 minutes. 32 minutes later, I was done !

A Day of walk throughs… Starting in the ICU. Everyone seems OK. Monitoring…. This is the issue. Where the heck are the Draeger monitor cables. According to the report, they were here last year! Edwards monitor…. Something missing…. Well not really, but we only have 6 catheters and plan to do 8 patients.
Plan B… use Boson’s HP…well we would if we could get in their storage room. Holy COW ! They have everything…or so it seems, well…not quite, but they are very organized, or so it seems. We take what we need, and make a workable solution. But the transport from the OR to the ICU remains the problem. I cannot really believe what I am hearing! A pulse oximeter, and a hand on the carotid to assess the pressure of the pulse! I am just glad it is not my hand that needs to be there. Giuseppe is taking on that responsibility. The man knows no fear or limitations.
I sit in on the discussion ( errr walk through) with the two main surgeons (Aubyn is missing, he is continuing to do pre-op data collection and assessment) and the two anesthesiologists. Personally, I just happen to be here, but it is too interesting of a discussion to miss! These four powerful personalities somehow come to agreement, sometime by availability of desired drugs, monitors, etc, sometimes, by consensus, once, by director decision! Missing are the perfusionists, the ICU Doc, the Charge nurse….. so I manage to take a few notes and pass on to those people things they might want to know about decisions made. Interesting, one cools to 26-28 degrees, the other cools all the way to 22. One comes out on Millrinone, one on Dobutamine ( OK no offense, but isn’t donutamine just plain old school?)
Back to the hotel, tomorrow we go into the OR. I decide to come in late. That allows me a few drinks in the bar with the team.

ADDED THOUGHTS! Looking back, this day was stressful, without a doubt. Building trust with people you plan to work with for only 14 days. Trying to make a team where there once had been just names on a piece of paper.
The interesting thing. The team came together so well. Strengths shine through the most when adversity is in the air. Yes weaknesses were noticed, but overlooked when the strength made the team better than the sum of the individuals.
WOW what a team !