Volunteer doctors and nurses from Australia will arrive today for the 2006 Operation Open Heart Program.In the meantime Port Moresby General Hospital’s operation theatre doctors are busy performing closed heart surgery. more infor
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In simple terms, CLOSED Heart Surgery is a heart surgery in which a small incision is made without the chest cavity being opened. OPEN Heart Surgery is surgery that involves opening the chest and heart while a heart-lung machine performs for the heart.
FYI
Rishika
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In simple terms;
The heart is a pump and the immediate big blood vessels carrying blood to and from the heart are the pipes (plumbing).
Closed heart surgery mainly deals with correcting the piping faults which usually does not need opening of the pump itself. Open heart surgery deals with correcting the faulty pump which needs to be opened up to see the inside parts and fix the malfuntioning ones.
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We cannot or at least not possible yet because of the following reasons:
1. Political
a/ Old Drs do not/never encourage young Drs to do/introduce something new
b/ Team surgery is not a norm in PNG (one man job-'I can do everything' mentality)
2. Academic (*Our surgery trainning program do not allow)
a/ We are only trainning general surgeons (or 'supersurgeons' who think they can do everything
by themselves-the reality in PNG is that one has no choice but to do that)
b/ So when one man does everything then there is less quality & risky especially in major
operations
c/ Australian system do not allow us:
-The 2 years visit by our PNG general surgeons to Australia is like a 'blasphemy'
because they don't allow us to fully enter their program (one remains a general surgeon,
who knows a little bit about cardiothoracic surgery etc.)
d/ I guess one has to find/make your own way.
3. The component of the team
a/ The perfusionist: someone who operates the heart-lung machine
b/ Anaesthetist specializing in cardiothoracic-anaesthesia
c/ Cardiologist
d/ Nurse specializing in caring for cardiothoracic patients
e/ Cardiothoracic-surgeons
4. Equipement
a/ Heart-lung machine (operator=perfusionist & someone to maintain it=technician)
b/ ICU equipement & space (at the moment in PMGH ICU is always full)
When the Aussie team comes, they come as a team (all of the above) not just a cardiothoracic surgeon. Cutting & suturing is easy but very risky without the above team to provide optimum care for the patient. Nowadays, major surgeries are well planned & executed, team work in a well equiped centre.
Out of the above, we only have one local cardiologist. We don't even have a young, up-coming cardiologist so how could we have all of the above or even a cardiothoracic surgeon.
Someone wrote, 'we will never run if we don't know how to walk yet'.
Thanks!
WNM
ah! 1 more thing take note that closed heart operations are difficult & risky:
1. Profuse life-threatening bleeding which may be impossible to control
2. It is hard to work on a moving thing. The thing had to be kept steady
3. Thromboembolism & its complications (stroke etc.)
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Dear Good Medical Doctors Contributing to this thread and especially to all readers.
DR. Who, Dr. Mol, Danny, Cynthia and those that contributed, I regretfully inform you that the latest treads posted have encounted a glitch beyond my control. There was an error with the service provider. Iam very sorry. I cannot compel you to continue, but It was a highly read thread and discuss by all visitors all over PNG and the rest of the world. If you have the energy to continue with the postings it would be great, otherwise is it is understandable.
My deepest, and sincere apologies to you all readers and contributors. I'm working to get the lost data back, but I, unfortunately, do not have any guarantee.
Mi sori stret, it was beyond my control.
vb
Forum Owner
This message has been edited by kolwan on Apr 13, 2007 10:40 AM This message has been edited by kolwan on Apr 13, 2007 2:08 AM This message has been edited by kolwan on Apr 13, 2007 2:02 AM
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Thankyou VB, message acknowledged, and especially to the contributors, it was very helpful information, please continue discussing issues of such importance for us public.
Regards
Dan
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The conclusion was clear: PNG can't have an open heart surgery team yet!
1. Current ongoing, annual visit from Aussie group is sufficient
2. The current service provided by this Aussie team is mainly for kids
3. We have 2 local pediatricians trainning in Australia in pediatric cardiology to support screening of patients, headed by Prof Terfuarani
4. We have a local surgeon trainning in cardiothoracic surgery in Aussie to joint the volunteer team
5. Our surgeons can only do closed-heart operations
6. If adults require heart operations, who are not selected for operation by the screening team then, they have to find their own way to Aussie
Thanks!
WNM
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The conclusion was clear: PNG can't have an open heart surgery team yet!
1. Current ongoing, annual visit from Aussie group is sufficient
2. The current service provided by this Aussie team is mainly for kids
3. We have 2 local pediatricians trainning in Australia in pediatric cardiology to support screening of patients, headed by Prof Terfuarani
4. We have a local surgeon trainning in cardiothoracic surgery in Aussie to joint the volunteer team
5. Our surgeons can only do closed-heart operations
6. If adults require heart operations, who are not selected for operation by the screening team then, they have to find their own way to Aussie
Thanks!
WNM
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The conclusion was clear: PNG can't have an open heart surgery team yet!
1. Current ongoing, annual visit from Aussie group is sufficient
2. The current service provided by this Aussie team is mainly for kids
3. We have 2 local pediatricians trainning in Australia in pediatric cardiology to support screening of patients, headed by Prof Terfuarani
4. We have a local surgeon trainning in cardiothoracic surgery in Aussie to joint the volunteer team
5. Our surgeons can only do closed-heart operations
6. If adults require heart operations, who are not selected for operation by the screening team then, they have to find their own way to Aussie
Thanks!
WNM
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1. Paediatric cardiology trainees and surgeon and anaesthetist not yet in
Australia but arrangements have been completed.
2. 1 surgeon already undergoing cardithoracic training
3. 1 adult physician has gone for a further 1 year training in cardiology
and there may be one in Australia who has done FRACP who may be doing
full cardiology training (I stand to be corrected on the latter).
4. Adult patients with congenital cardiac disease are selected for
surgery. The highlight last year was an adult with Fallot's who was
successfully operated on. Valvular diseas is operated on but only to
a limited extent as if likelihood of repeated surgery or use of
anticoagulant therapy then are likely to be rejected.
5. Surgery for coronary artery diseas will have to be performed in
Australia. As this is most amenable to prevention a more concerted
effort is needed for clinicians involved to shift their thinking to
Public Health efforts in this area in PNG which will be more cost-
effective.
6. Open heart surgery could be possible in PNG in the near future but
unrealistic as in terms of health priorities not high on the list.
Ta
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We cannot or at least not possible yet because of the following reasons:
1. Political
a/ Old Drs do not/never encourage young Drs to do/introduce something new
b/ Team surgery is not a norm in PNG (one man job-'I can do everything' mentality)
2. Academic (*Our surgery trainning program do not allow)
a/ We are only trainning general surgeons (or 'supersurgeons' who think they can do everything
by themselves-the reality in PNG is that one has no choice but to do that)
b/ So when one man does everything then there is less quality & risky especially in major
operations
c/ Australian system do not allow us:
-The 2 years visit by our PNG general surgeons to Australia is like a 'blasphemy'
because they don't allow us to fully enter their program (one remains a general surgeon,
who knows a little bit about cardiothoracic surgery etc.)
d/ I guess one has to find/make your own way.
3. The component of the team
a/ The perfusionist: someone who operates the heart-lung machine
b/ Anaesthetist specializing in cardiothoracic-anaesthesia
c/ Cardiologist
d/ Nurse specializing in caring for cardiothoracic patients
e/ Cardiothoracic-surgeons
4. Equipement
a/ Heart-lung machine (operator=perfusionist & someone to maintain it=technician)
b/ ICU equipement & space (at the moment in PMGH ICU is always full)
When the Aussie team comes, they come as a team (all of the above) not just a cardiothoracic surgeon. Cutting & suturing is easy but very risky without the above team to provide optimum care for the patient. Nowadays, major surgeries are well planned & executed, team work in a well equiped centre.
Out of the above, we only have one local cardiologist. We don't even have a young, up-coming cardiologist so how could we have all of the above or even a cardiothoracic surgeon.
Someone wrote, 'we will never run if we don't know how to walk yet'.
Thanks!
WNM
ah! 1 more thing take note that closed heart operations are difficult & risky:
1. Profuse life-threatening bleeding which may be impossible to control
2. It is hard to work on a moving thing. The thing had to be kept steady
3. Thromboembolism & its complications (stroke etc.)
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We can't afford to have an open heart surgery team yet because, basically it is an economic reason. 'We haven't walked yet so we are too far from running'.
We lack the basics to support a cardiothoracic patient:
1. Not enough space & equipement in ICU
2. No ultrasonography or doppler equipement or no technician & money to fix/maintain them (what we have in Sir Buri kidu heart institute is
old & often breaks down)
3. Heart-lung machine & technician to care/maintain it
4. Staff
-specialist nurses
-another cardiologist to support Prof kevau
-perfusionist
-cardiothoracic surgeon
I suppose to have the above in place it would cost more than a CT scan or a radiotherapy machine, that are currently our top priorities.
Simply saying, more people are dying from not having a radiotherapy machine or CT scan (indirectly) rather than not having a open heart surgery team (but I don't know the exact data).
We are not yet in an economical position to enjoy the luxuries of modern (latest) medical technologies. The Drs in the so called 'developed' countries are talking about the QOL of patients. Our Drs don't know what it is. We are still doing the basics of medicine, only to prolong survival.
Thanks!
WNM
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Sir Buri Kidu Heart Institute asseses the heart condition of patients. It primairly does this by:
1. ECG tests - recording electrical activity of the heart to look for abnormalities in heart beat, rythm and others.
2. Stress exercise tests - patients run on a thread mill to put stress on the heart and measure its electrical activity using ECG.
3. Echocardiography - using ultra sound techniques to visualise the inside heart and measure its function and blood flow.
4. Other heart related research activities.
I did a one year research program (BSsMed) with them to study the effect of betel nut chewing on normal people, high blood pressure patients, and patients with chest pain. Here is the URL link to the absbract of one of the studies presented at the Cardiac Society of Australia and New Zealand.
In response to many queries on this issue let me make a few comments about the cardiac surgery in PNG.
The current “Open heart surgery” program is a program that almost entirely operates outside the PNG health department budget. Also the Sir Buri Kidu Heart Institute is not responsible for the program though its facilities are used for screening patients.
The history of the open heart program is almost entirely a Paediatric one (children) as from an economic and cost benefit point of view operating on children gives the best returns. It started for many years with children in PNG with congenital heart disease (those born with a heart abnormality) being referred to a Children’s Hospital in Sydney for surgery. Because of the cost involved the children were carefully screened by an Australian cardiologist and selected for those with the greatest chance of surviving and having useful lives without needing further operations.
Subsequently an SDA hospital in Sydney organised for a Cardiac surgical team to come to PNG as this would result in more patients being operated on. This however meant bringing a huge team with all their complex equipment. This arrangement has flowered into an ongoing annual event that continues to improve and transfer skills to PNG health workers.
The Australian team consists of doctors, nurses and other staff who come from hospitals all over Australia. They pay their own airfares but other needs in PNG are looked after by funds raised for the program. All their equipment is flown up by the RAAF.
Funds in PNG are raised by the PNG community and many generous donors contribute. The Health department also contributes a substantial amount.
Patients are screened throughout the country. Most of them are children who are screened by local Paediatricians and 2 PNG paediatricians with extensive cardiology training and experience travel to the base hospitals and screen all identified children and select on predetermined criteria children who would most benefit. These children are referred to PMGH for final screening by the Australian cardiologist 1 week prior to surgery. The screening of adults has also occurs but numerically they are fewer.
The PNG team last year started operating on closed cases before the Australian team arrived so that more open cases could be done by the combined team. It was a huge success not only medically but on another level where it has brought two groups of people together. Several members of last years team from Australia were PNG born and bred.
The key organiser is an Australian who was born and brought up in PNG. The key organiser in PNG is Assoc Professor N Tefuarani (Paediatric cardiologist) who has been involved in this program for many years.
A/Prof Tefuarani has recently returned from Australia where agreements have been put in place for two paediatricians to go to children’s hospitals in Melbourne and Sydney for cardiology training. Also a surgeon is now in Victoria (? Geelong) undergoing cardiothoracic training. Another PNG surgeon and anaesthetist will go for further on the job training in Chennai, India and from there go to Royal children’s Hospital Melbourne for further training in the Cardiac Surgery Unit and Intensive Care unit respectively. Specialist nurse training has already been in place.
Though the program has run for over a decade the local PNG surgical team involve were not consistently the same ones so that training of local surgeosn in a consistent manner was lacking until the last 3 or 4 years when it looks as if a dedicated team for the long term looks finally possible
I hope this satisfies people’s queries about training the heart program and training for PNG.
As to whether open heart surgery is performed in PNG is another question. There is no doubt that in terms of manpower skills in a few years it will be feasible. The big question is an economical one.
The cost benefit ratio of such a program is very low. With the limited PNG health budget one has to weigh the ethical question of whether to spend money on one patient with heart disease or protect several hundred thousand lives by buying vaccines for preventable diseases instead.
Ciao.
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It seems we are progressing in terms of manpower trainning, but still can't do without a complete team. Don't know how long it will take. Right now we have much bigger worries, radiotherapy machine, malaria vaccine, HIV etc.
WNM
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The manpower training is progressing but obviously my gut feeling is that we will not have a full set up yet and we do not need to. The current set-up gives the best results, gives an opportunity for society at large in POM to participate in fund-raising and feel a part of the venture, creates a great feeling of partnership for PNG and Australian personnel involved (also this is a rare event for the best of Aussie cardiac personnel from different hospitals to come together which doesnt happen in Oz)for equipment to be left behind for use in PNG and does not eat into the PNG health budget. Last year added benefits included a team of medical engineers who fixed all the ICU equipment and then anything and everything fixable they could find in PMGH. The atmosphere at the end of the surgery farewell function is unbelievable.
Drawbacks for a PNG unit to be set up include eating into a huge slice of the health budget, results will always be initially poor (and potentially get better with time as learning curve improves), too few cases for a team to become really proficient in, need for ancillary staff such as perfusionists which we dont have, tying up of theatre time and space and ICU time and space which is a real problem nowadays (Snakebit patients had to be ventilated in another part of the hospital with second rate ventilators and setup at one stage in the past when cardiac surgery was going on)and the amount of blood needed for the whole program.
Therefore the current program is probably the most ideal one in which the event takes place once a year and increasingly more gets done in the same time as the PNG team becomes more proficient and starts early and then join in to do the open cases, greats a great diplomatic opportunity for health professionals of both nations and brings the public of POM together to participate in fund raising and looking after other non-medical aspects of the program.
Ta
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So if my mom or dad gets a stroke, what is the proceducers I should follow. I know I will rush him to Pom Gen, or will PIH be better? and after that what should I do?
Thank you.
Danny
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Let me reply to your question in 2 parts; firstly in relation to actual stroke in individuals and secondly in relation to the philosophical issues inherent in your question.
If you are worried about strokes or about heart attacks the best course is prevention because for a certain number of these patients death occurs before help is reached and for others the outcome may not necessarily be good even in the best treatment centres.
Fortunately the commonest causes of strokes (blockage of a blood vessel supplying critical areas of the brain) are either high blood pressure or narrowing of blood vessels by fatty deposits. They can be prevented by getting adequate treatment for high blood pressure and changing lifestyle patterns (more exercise and healthy low fat diet).
If however they do get strokes the patients are better off getting into the A&E department of PMGH (which is often very difficult to get in and be seen). Once seen in the A&E department depending on how critical their condition the patients get admitted to the intensive care unit (ICU). The level of care there is now much better than it used to be due to the flow on effect of the cardiac surgery program where ICU nurses are much better trained and the anaesthetist will have undergone training in looking after critically sick patients. (Believe me in some of these situations the level of nursing care is more important than the level of medical care (doctor related)).
If you go to PIH you will still end up in ICU PMGH because they may have a cardiologist but they will not have the same level of ICU and nursing care.
Only a very tiny proportion of strokes may be due to inherent abnormalities of the blood vessels and may require surgery; in that case it is usually performed by a neurosurgeon and not a cardiac surgeon.
As the previous discussions have shown many of the closed heart surgical procedures can be performed by PNG surgeons with the facilities we have. Some of the fine plumbing (angioplasties etc) of blood vessels and open heart surgery would need to have a very expensive and very well equipped unit; the cost of which this country can simply not afford.
This leads me to the question of why can’t we afford to spend money on these facilities if we really need them. That question is a heart rending one that is often very difficult to deal with not only for relatives but for health personnel who are involved as well. I have watched my patients die of cancer or watched them dying from kidney failure because we do not have the money or the equipment to treat them. (I have watched my closest friend die of blood cancer because we cannot do bone marrow transplantation in PNG).
However when we have scarce resources we need to prioritise them and spend where they can be of greatest benefit. The greatest priorities are in preventative approaches to dealing with illnesses. The greatest returns will be from vaccination programs, good water supplies, HIV awareness programs/general health education etc and ensuring that aidposts and health centres are functioning within walking distance of every citizen in this country.
In terms of heart diseases in adults the onus is on us the medical fraternity to carry out huge health awareness campaigns, promote healthy eating and exercise and take every opportunity in big events to provide educational material, do spot blood pressure checks and spot blood checks for diabetes etc. In the long run these will pay huge dividends.
Once the situation is reached where somebody has a stroke or a heart attack the person may still die or be debilitated no matter how expert the medical and nursing care there is at that point in time.
There is such a huge outcry about the radiotherapy machine in Lae. I agree that having that facility is important. However certain facts are being overlooked. For instance the great majority of women who have cancer of the cervix come very late when the cancer has reached an untreatable stage. You can have the best cancer treatment facilities but if you do not have a program in which women are seen much much earlier and referred to the treatment centre much earlier all you are likely to have would be the best centre which will not improve the death rates from cancer of the cervix. It would be best to have a huge educational program as well as have the centre and campaign very hard to get the vaccine that should shortly be available to prevent these cancers.
Sori long mauswara tumas.
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stroke is a different entity from open-heart surgery. Many cases of stroke ( a blockade or rupture of a blood vessel in the brain resulting in damage of a certain part of the brain) in PNG are preventable. They are mainly related to diabetes & hypertension & cigarette smoking. If the hypertension & diabetes are diagnosed early and the medications are taken regularly then the risk of stroke is very low. A few cases of stroke are unavoidable.
To make it easy, stroke can be thought of as a temporary blockade or a permanent (a rupture of the vessel or it is called hemorrahgic type). The first step is to differentiate between the two. A CT scan is less traumatic & less risky and quick method (but expensive) to quickly differentiate between the 2 types of stroke.
The management of hemorraghic type is difficult and the prognosis (outcome) is bad. It doesn't matter which hospital or which country you are in. There are different variations of the temporary type. With conservative management, some might recover or not recover at all. With further, highly specialized investigation one might differentiate between the subtypes of the temporary stroke. But the precise management of each subtype is difficult and the outcome is usually uncertain or hard to predict even in a well equiped hospital.
again, I see the advantages or the idealness. Not only in health but in all other sectors there may or could be such idealness. The fact is that we simply can't do without the Aussies. The health sector is benefiting alot from the AUSAID as well as their volunteer groups.
I hope these discussions has made it clear why we cannot yet have a open-heart surgery team of our own.
WNM
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Just as will realise at a personal level when you are working in Japan with health personnel there. so is the level of relationships we have built on a personal basis with our colleagues in Australia. For our own benefit (quality control) we still need to keep those contacts and relationships going and the heart surgery is one example. Other areas of expertise such as paediatric surgery is still ongoing ( the Melbourne team was here last week and are in the country with our own two paediatric surgeons and one from solomon islands).
When and if you choose to return to PNG hopefully you will maintain links with colleagues in Japan and we can benefit enormously by maintaining those links.
In terms of AusAid funding and projects overall there needs to be a certain level of decisive input by PNG experts. That is lacking sometims and occaionally the crowd in NDoH seem to agree to everything AusAid says. SOmetimes we have to tell the donor agencies that we need to take ownership of these programs.
For that to adequately happen we need qualifed manpower with adequate training and experience in policy making and program management. Clinicians need to come out of their tunnel visioned engrossment in clinical medicine alone and diversify into other areas of expertise and training and the ability to undertake critical analysis and participate in research in areas of health economics, systems research etc etc.
As long as we continue to be blind we will be led by the blind.
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I agree 100%. I was looking from the broader economic & political aspects. But the key in succeful healthcare system is HUMAN RELATIONS. When health workers work as a team, wherever, you are locally or oversea, this is the key to success.
From my experience, building a good human relationship, starting from the social aspect wether it be playing sports together or dinning together, has enabled the establishement of good relationships. Once, I've built that, then I get their trust then all barrier is broken & they can allow you to do anything.
I encourage us to strengthen these ties (human relations) we have with Australia, we also have benefited alot from Chinese, Indian & African Drs. Now, recently, we are trying to establish some ties with Japan.
All the best in the future of our healthcare system.
WNM
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Information and advice on identify a person having a stroke and the proper first aid method for treating a victim of a suspected stroke.
How would you know if someone you were in the presence of were suffering a stroke? How would you react in this type of emergency situation? What could you do to assist the victim of a suspected stroke until emergency medical assistance arrives?
To answer these questions, you first need some background knowledge about strokes.
A stroke also known as a cerebrovascular accident or CVA, is a condition, which occurs when blood vessels that deliver oxygen-rich blood to the brain rupture and part of the brain does not receive the blood flow it requires. The nerve cells deprived of oxygen in the affected area of the brain are then unable to function causing them to die within minutes. The traumatic effects of a stroke are often permanent, because brain cells are not replaced.
Here are the most common signs and symptoms to look for related to strokes.
-The victim of a stroke commonly experiences weakness, numbness or paralysis of the face, arm or leg on one side of the body.
-The victim may express that their vision has blurred or decreased, especially in one eye.
-The victim may have problems speaking or understanding.
-The victim may complain of having a severe, sudden and unexplainable headache.
-The brain may be affected by a lack of oxygen causing the victim deviation of the eyes. Therefore the pupils would become unequal in size and non-reactive to light.
First aid for a victim suffering from a stroke is limited to supportive care until medical assistance arrives. Yet, do not underestimate this role. Caring for the victim with a calming presence and collecting important medical data to pass onto emergency medical personnel is very important. You can do this by taking mental notes of the above signs and symptoms and by following the steps below.
-Call to alert emergency medical services immediately.
-If you are trained in CPR, check and monitor the victim’s airway, breathing, and circulation using your CPR and First Aid training skills.
-Lay the victim down with their head and shoulders slightly elevated. This will reduce blood pressure on the brain.
-If the victim is unresponsive but breathing place them on their left side with their chin extended. This serves as two purposes. It will assist in keeping the victim’s airway open and allow vomit and secretions to drain from their mouth.
-Never give a suspected stroke victim anything to eat or drink. Their throat may be paralyzed restricting them from the ability to swallow.
-Encourage the victim not to move and reassure them help is on the way to care for them.
TIA’s or Transient Ischemic Attacks are often referred to as “mini-strokes”, because the signs and symptoms are much the same. CVA’s, are closely associated and have similar symptoms, the difference is that the symptoms of a TIA are short lived. Victim’s symptoms normally last from a few minutes to a few hours, followed by a return to normal neurological function of the brain. Victims of a TIA should consider this a warning sign of a potential stroke since approximately one-third of TIA cases are followed by a CVA two to five years after their first TIA.
If you have any of the signs and symptoms of a TIA you should report it to your physician immediately. Your health care provider can help you to understand the possible causes of experiencing a TIA and can assist in changing diet, living a healthier life style and in some cases prescribe medication.
The common condition of high blood pressure can lead to many dangerous medical conditions including a stroke. One out of every four adults in the United States suffers from high blood pressure.
Just because a person feels well doesn’t mean his or her blood pressure is normal. In most cases, individuals with high blood pressure have no symptoms to warn them they have this condition. Having your blood pressure monitored often can alert you early on to this medical condition. High blood pressure is not something that can be controlled by staying calm or relaxed. It is a physical rather than emotional condition that can be treated by routine changes in diet, unhealthy habits and medication though it cannot be cured in most cases.
Using less salt in the foods you eat, losing weight, getting more exercise and stopping smoking can help lower your blood pressure in many cases.
If your doctor prescribes a medication for high blood pressure, take your pills everyday to keep your pressure down and possibly avoid having a stroke.
One last health related tip…
If you have not completed a First Aid and CPR training course, be sure to seek emergency medical attention in any type of emergency situation. Improper care can sometimes be more harmful than helpful. A few basic courses in CPR and first aid are recommended for preparation before a medical emergency exists. These training classes are neither time consuming or costly. Community groups all across the country provide this type of training and these training courses only require a few hours of your time. You could help save a life. Think about it!
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