Toomas SärevConsultant CardiologistNorfolk and Norwich University HospitalHonorary LecturerUniversity of East AngliaNorwich, United Kingdom

Kardiologiska och Hjärtkirurgiska Erfarenheter Från Khartoum

Ingen intressekonfliktImages used in this presentation originate from my own, Dr Lindblom’s, Dr Puntila’s and Emergency’s archives

How Did I Get Involved In This Project ?

Till: Toomas Särev/DS/SLL@SLLFrån: Dan Lindblom/Karolinska/SLLDatum: 2009-10-07 16:06Kopia: g.strada@emergency.itÄrende: Why not work in Sudan?

Dear Toomas...

You’ve got mail ...

Te

stin

g th

e “

lim

its”

Why did I do that?

• to work in an International Multilingual, Multicultural Team is enriching, inspiring, challenging and makes you humble

• To test myself

Sudan

Sudan• Population: about 39 400 000

– Khartoum 8 900 000

• BNP: 1 630 USD

• Covers 2 505 813 km²

– six times larger than Sweden

• Estimated life expectancy 57 years

• 62 % of population can read and write

• Expenses of health care 21 USD/capita

• 0,2 physicians/1000 inhabitants

• Most of the inhabitants are followers of Islam (70%)

• Arabic

Emergency NGO

The Organization

• Non-political, neutral and independent humanitarian Non-Governmental Organization established in 1994 in Milan, Italy –under leading of Dr. Gino Strada

• Over 3 200 000 patients treated in 15 countries

• Approximate budget 25 000 000 €/year, with administrative costs of 6%

Gino Strada

Emergency – the mission

• To provide high standard and free of charge medical and surgical assistance to victims of landmines, war and poverty

The Salam Centre forCardiac Surgery

Facilities and Staff• 3 fully equipped OT• 15 ICU beds• 48 beds in Ward–16 sub-ICU beds

• Echocardiography• Lab and Blood Bank• Cath Lab• CT scanner• Out-patient clinics• Guest-house for 50• Compound for the

international staff• Services• Meditation Hall

International staff 60National staff 306

Volume of work April 2007 - March 2011

• Patients triaged 30 692• Cardiological examinations 21 967•Hospital admissions 5 053• Patients admitted 4 051• Patients operated 3 391• Cath Lab procedures 932

Primary diagnosis

• Valvular Heart Disease 72.7 %• Congenital Heart Disease 22.1 %• Ischaemic Heart Disease 3.9 %• Ascending Aorta & AV 0.7 %•Other 0.6 %

Multiple Valve 44 %

Mitral 45 %

Aortic 10 %

Tricuspid < 1 %

Surgery for Valvular Heart Disease

The Salam Centre for Cardiac Surgery

Early complications

• 30-days surgical mortality (91 pt) 2.81 % (”Expected mortality” Euroscore standard >3.7 %)

– most common causes of death•Low Output Syndrome (45 pt) 49%•Multiorgan Failure (17 pt) 19%

• Re-op for bleeding 6.3 %• Late pericardial tamponade 2.5 %• Permanent pacemaker 0.4 %• Mediastinitis 0.001 %

My Personal Input and Experience

Work Profile:• worked six days/week under four months– Friday - The day of Prayer

• Clinical meeting every morning • Clinical work in the Sub-ICU, ward rounds, on-calls–teaching of national staff

• Diagnostic and Interventional Work at the Cath Lab• Support for OT & ICU, opinion requests, TOE’s• Outpatient Clinics–postoperative follow-ups–workflow of patients with coronary artery disease

Cardiological Challenges• management patients with extremely advanced

combined valvular disease combined with advanced pulmonary hypertension–decompensated heart failure very difficult to

manage both pre- and postoperatively• different pattern in hemodynamic response– air conditioned hospital with “low” room temperature

causes vasoconstriction and deterioration– some patients do not develop pulmonary

hypertension and have extremely fragile hemodynamics

• arterial spasms very common (radial, coronary)

Surgical Challenges• mitral valve repair/plasty in rheumatic MVR • multiple valve operations– above two especially challenging in young patients and

children

• re-operations in emergency situation for thrombosis of valve prosthesis (especially in gravid women)

• extremely advanced pulmonary hypertension with RV involvement

• surgery of cachectic patients• patients suffering of congenital problems with late

presentation (in adulthood)–adults with TOF (Tetralogy of Fallot’)

Challenges for the Future(my own subjective vision)

• to develop Locally Tailored Guidelines

• to improve infrastructure with modern solutions for managing hospital information – PACS archive, electronic records etc.– research database

• to make Long-term follow-up better

Clinical MeetingSalam Centre

Ward Round, Sub-ICUSalam Centre

Operating TheatreSalam Centre

Cath LabGE Innova 2000Salam Centre

Cath Lab TeamSalam Centre

Most used combination of vasocactive support, Sub-ICUSalam Centre

Outpatient ClinicETTSalam Centre

Relaxing moment atMeroe PyramidsSudan

Wildlife - DaytimeSalam Centre

Wildlife - NighttimeSalam Centre

lessons learned:

generating and optimizing local resources

Complex health projects are feasible in Africa

with clinically outstanding results

Do You Need More Information?

Email me:

kardiostar@mac.com

Visit:

www.emergency.itwww.salamcentre.emergency.it

"You've got to find what you love, and that is as true for work as it is for lovers..... Don't settle.

As with all matters of the heart, you'll know when you find it."

Steve Jobs - Founder and CEO of Apple

Thank you