Toomas Särev was invited by Dan Lindblom in 2009 to work as a consultant cardiologist at the Salam Centre for Cardiac Surgery in Khartoum, Sudan run by the humanitarian NGO Emergency. The Salam Centre performs over 300 cardiac surgeries per year, mostly for valvular heart disease, with a low 30-day mortality rate of 2.81%. Särev's work involved clinical duties in areas like the ICU, catheterization lab, and outpatient clinics. He also helped with challenges like managing patients with advanced valvular disease and pulmonary hypertension. Särev learned that complex health projects are feasible in Africa with outstanding clinical results by optimizing local resources.

1. Toomas Särev
Consultant Cardiologist
Norfolk and Norwich University Hospital
Honorary Lecturer
University of East Anglia
Norwich, United Kingdom
Kardiologiska och
Hjärtkirurgiska
Erfarenheter Från Khartoum
Ingen intressekonflikt
Images used in this presentation originate from my own,
Dr Lindblom’s, Dr Puntila’s and Emergency’s archives

2. How Did I Get Involved
In This Project ?

3. You’ve got mail ...
Till: Toomas Särev/DS/SLL@SLL
Från: Dan Lindblom/Karolinska/SLL
Datum: 2009-10-07 16:06
Kopia: g.strada@emergency.it
Ärende: Why not work in Sudan?
Dear Toomas...

4. Testing the “limits”

5. Why did I do that?
• to work in an International Multilingual,
Multicultural Team is enriching, inspiring,
challenging and makes you humble
• To test myself

7. Sudan

8. 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

9. Emergency NGO

10. 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%

11. Gino Strada

12. Emergency – the mission
• To provide high standard and free
of charge medical and surgical
assistance to victims of landmines, war
and poverty

13. The Salam Centre for
Cardiac Surgery

14. 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 60
National staff 306

15. 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

16. 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 %

17. The Salam Centre for Cardiac Surgery
Surgery for Valvular
Heart Disease
Multiple Valve
44 %
Mitral
45 %
Aortic 10 %
Tricuspid <1%

18. 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 %

19. My Personal Input and
Experience

20. 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

22. 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)

23. 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’)

24. 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

25. Clinical Meeting
Salam Centre

26. Ward Round,
Sub-ICU
Salam Centre

27. Operating Theatre
Salam Centre

28. Cath Lab
GE Innova 2000
Salam Centre

29. Cath Lab Team
Salam Centre

30. Most used
combination of
vasocactive support,
Sub-ICU
Salam Centre

31. Outpatient Clinic
ETT
Salam Centre

32. Relaxing moment at
Meroe Pyramids
Sudan

33. Wildlife - Daytime
Salam Centre

34. Wildlife - Nighttime
Salam Centre

35. lessons learned:
Complex health projects are feasible in Africa
with clinically outstanding results
generating and optimizing local resources

36. Do You Need More
Information?
Email me:
kardiostar@mac.com
Visit:
www.emergency.it
www.salamcentre.emergency.it

37. "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

38. Thank you