Invasive Cardiology Training in Pakistan: One Technologist’s Adventure

Earlier this year, Dr. Mansoor Qureshi and I were invited to provide interventional cardiology training at the Tahir Heart Institute in Rabwah, Pakistan. At times, I felt totally lost, as if suddenly thrust into a square dance. Everyone else knew the steps and followed the caller. I was reduced to imitating what I saw, a couple of beats behind the rest. With the backdrop of daily violence, it was a heady experience. The objective data are strongly filtered through my subjective experience. Be warned. The Beginning My name is Dave Hartman. Although my training and licensure is as a paramedic, I have been employed as a special procedures technologist by Saint Joseph Mercy cath lab in Ann Arbor, Michigan, for eight years. Prior, I have worked the road as a medic, been a surgical assistant for several oral surgeons, and taught emergency medical training in Central and South America. In short, I never could decide what to be when I grew up, so I made the simple decision to simply not grow up. Approximately a year ago, I heard that Dr. Mansoor Qureshi was planning on a trip to his native Pakistan to do cath lab training. Since it sounded like fun, I asked to be included. The trip would be to the city of Rabwah. Rabwah is approximately 100 miles south of Islamabad and 60 miles west of Lahore. It is a city of 60,000 people, 97% of which belong to the Ahmidah sect of Islam. The Jamaat Ahmadiya believe that the messiah promised by Hinduism, Judaism, Christianity and Islam has in fact returned. This brings them to believe in universal tolerance and love of their fellow man. Unfortunately, this also seems to bring them the title of heretics and a considerable amount of hate from a great many people. (More about that later.) Now comes the hard part. How to get to Rabwah? All my previous projects have been funded by grants, so accordingly, grant requests were sown to the wind. The Abbott Foundation obliged with a generous grant, for which the people of Rabwah, Pakistan, and I are immensely grateful. Next, a leave of absence was obtained from my hospital so I would have a job upon my return. A visa was obtained from the Pakistani Consulate in New York. I also did a lot of reading about Pakistan, both current events and ethnology. Loads of expired equipment were donated by various companies and duly sorted through for shipment to the Tahir Heart Institute in Rabwah. We are all set! The Trip My first reminder of the potential danger of the trip came when Dr. Mansoor cautioned me to keep our departure information secret. I hadn’t really considered that someone here in the U.S. would feel strongly motivated enough to cause problems. Next, in a conversation with one of my Muslim stepsons, I was informed that the people of Rabwah are “heretics.” In my previous travels, I have been endangered by the color of my skin and my country of origin. Now I have to add in the beliefs of myself and my hosts. I departed Detroit just short of midnight on New Year’s Eve and arrived at Heathrow Airport in London some 9 hours and 5 time zones later. I realized, hmmm, there is no one here to meet me…and I had an eight-hour layover before the flight to Islamabad. My paramedic/traveler training took over. Always eat, sleep, and er, defecate, when you can, because you don’t know when you’ll get the next chance. I grabbed a sandwich at the terminal’s Starbucks, and a few hours sleep at the local Yotell. Then, off to Islamabad, another 9 hours and 5 or 6 time zones later. Pakistan After clearing customs, I was met by a driver from Tahir named Nood. Nood is 25 years old and speaks some English. His driving skills are gained in and perfect for Pakistani traffic. What he may lack in knowledge, he makes up for in enthusiasm. The goal is to pass as many vehicles as possible. I have been passed by someone else while we are passing a slower vehicle, which is swerving around a pedestrian/bicycle/burro/camel (or any combination of the same) before we all dive back into our lane to avoid being smashed by an oncoming truck. Oh, and did I mention that it’s all on the left side? I haven’t felt anything quite like this since I sat in the front row watching 2001: A Space Odyssey in the old Cinerama Theater. The final two hours were traveled on poorly maintained paths, just wide enough for one car. Opposing vehicles must dive onto the nonexistent shoulder while avoiding the bottomless potholes. A couple of times we were halted by a do-it-yourself toll booth that closely resembled a lemonade stand set up across the road. Nood paid the few rupees and we were then again on our way. Soon, we are in farm country. Mud-walled houses predominate. Cow pies are hand-patted on the walls to dry for future cooking fuel. Burdens are either carried on the head or stacked at impossible heights on the uncomplaining burros and motor bikes. Men in robes and women in burkas walk the road. Many of these people have never traveled more than 50 miles from their place of birth. Many cannot read. Some peer curiously at us as we pass, some stolidly continue with their lives as their parents and grandparents did before them. Huge trucks occasionally roar past us, forcing all to give way. Finally, we arrive in Rabwah, a bustling city that appears to be ancient even though I know it is only 60 or so years old. Tahir Heart Institute in Rabwah Tahir Heart Institute is a beautiful six-story red stone and marble building attached to Fazl-E-Omar Hospital. It is the creation of the renowned architect Mr. Majid Kahn. Inside, it is kept immaculate by an army of sweepers and cleaners. The capital equipment is top-notch and current. This is unlike any facility that I’ve ever seen in a third-world country. I am puzzled until I realize that this facility is a non-profit organization solely supported by the Ahmadiya people themselves. What isn’t available are the day-to-day expendable supplies. The cath lab is somewhat sparse. There is a beautiful Toshiba 5-axis fluoroscope that has more capabilities than the Philips systems that I routinely use in the U.S. This unit has the ability to offset the C-arm so that peripherals can easily be done. There are also around 70 pre-programmed positions available in the system’s repertoire. In the control room, there is a virtual angiography option that works directly off the measurements taken from the angiograms. With a minimal understanding of the system, I was able to produce nicely detailed stenotic vessel images that a patient could easily understand. DICOM format images are stored on-site. As I mentioned, what was notably absent was expendable supplies. Our ubiquitous cath packs are not possible in Pakistan. Even assuming that the packs are ordered from a foreign source, importing them into the country would be impossible. Before our trip, we put together several boxes of expired catheters, wires and sundry. Pakistani customs, angling for a prohibitive duty, refused to release them to us on the grounds that they were too “fresh” or hadn’t expired that long ago. I was told that if we weren’t able to somehow obtain our supplies, they would be sold on the black market. New supplies would probably simply be diverted. Since necessity is the mother of invention at the Tahir Heart Institute, the packs are made up on site. Patient covers have been made from bed sheets with the fenestrations sewn in. Kidney pans, hemostats, a manifold and towel clamps complete our pack. Syringes and an extension tube complete the patient setup. One pressure manometer is used for multiple patients. Care must be taken to not inadvertently contaminate the manometer and necessitate its premature replacement. I learned the hard way to be careful with my dye injections. A standard syringe often breaks, and it is easy to drive the broken ends into your hand. Since our sheets are permeable, a rubber sheet must be placed between them and the patient. After each case, they are washed and hung to dry for the next patient. Reusable supplies are sent to the laundry and packed for sterilization along with used groin towels. Typically, patients are not sedated. They are brought into the room and allowed to move to the table. With all in readiness, the lights are turned out. If the patient is male, the female nurse must leave the room. If the patient is female, male attendants must leave. The patient is attended to by a person of the same sex. The patient’s pants are pulled down and the rubber sheet is placed inferior to the groin. The groin is prepped with betadine and the sheet is placed by the sterile operator. Once this is done, the lights can be turned back on and staff can return. The actual cath is the same, no matter where it is done in the world. Lacking trained staff, the cardiologist, Dr. N. M. Nuri, was typically assisted by his son, Dr. Khaled Nuri, who is also the cardiothoracic surgeon. During my visit, I was honored to assist Dr. Nuri and Dr. Qureshi in their procedures. While we had the typical Judkins catheters, special bends had to be manufactured on the spot. Dr. Nuri repeatedly demonstrated his virtuosity in modifying one catheter into another shape to suit the needs of the patient. Interventions can be a challenge when you have a short renal stent and only long guide catheters. On one occasion, Dr. Nuri manipulated the guider at the sheath, Dr Qureshi manipulated the interface of the cut catheter and device, and I did the guide shots and inflations. Extreme measures, but we achieved a beautifully-stented renal artery. I admit to some trepidation regarding sheath pulls on female patients. The nurses had little understanding of technique, and poorly understood English, but were willing to try. Nurse Ayeesha did well with her first patient and I was able to stand by and direct her. Unfortunately, our second patient was a bit heavier, and it proved impossible for Ayeesha to control the bleeding. With a silent prayer, I took over and achieved hemostasis. I asked Ayeesha to translate what I was doing to the patient. Visions of international incidents and painfully humiliating retributions ran through my head for the next 15 minutes. Despite the cultural prohibitions that I had broken, however, the patient and her family were incredibly grateful for my ministrations. Over the course of my stay, I had to intervene three more times with female patients. In each case, the patient was fervently grateful. Two invoked the blessings of Allah on my head. Culture aside, I have come to believe that professional care and courtesy are universally recognizable. In spite of being a cynical old road medic, I was deeply touched. Since the construction of the operating suite wasn’t finished, we put off high-risk procedures when possible. Abrupt closure could easily mean death to our patient. On one occasion, the first thing we noticed was a sudden fit of coughing. The patient insisted on sitting up and continued a fairly constant bout of coughing. To minimize groin pressure, I placed my hands against his back. To my surprise and dismay, I could literally feel his lungs filling up with fluid under my hands. As the pulmonary edema progressed, I no longer felt the ronchi under my fingers. A plaque had ruptured and closed off his circumflex. Unable to reopen the artery, we loaded him onto a bed and ran for the critical care unit. As I entered the elevator, I could hear the agonizing ululations of his female relatives. In the CCU, we put all other thoughts aside and began fighting for the patient’s life. As a paramedic, I’ve been here numerous times. We were able to entubate the paralyzed patient and begin bagged ventilations. Foley and N.G. were placed, and a ventilator brought in. Medication relieved the pulmonary edema, and the patient’s pressure was stabilized. The following day, the patient was weaned off the vent and subsequently was discharged. He had an infarction, but survived thanks to prompt care. I am proud to have been part of his care team. Somewhere around 30% of the patients are hepatitis B or C positive. This is due primarily to a cultural belief in the efficacy of injections and vitamins. Scam artists routinely travel the countryside selling “vitamin” injections. I shudder to think just what these people are being injected with. Sterility is unknown and irrelevant to these criminals. There is no potable water in Pakistan. In Rabwah, the ground water is too saline. River water is pumped to the town minimally, or frankly, untreated. One of the greatest puzzles to my hosts was my failure to succumb to the “Pakistani Trots,” a polite euphemism for possible diseases ranging from giardia to hepatitis A, amoebiasis or cholera. Although I used my Miox water treatment system, I tend to put it down to a combination of several years living in various areas of the world and blind, dumb luck. Approximately three million children die yearly of diarrheal diseases around the world. A rather grim footnote. Although there are alcohol foam distribution stations around the hospital, I rarely saw anyone besides Dr. Qureshi or myself washing our hands. This is particularly curious when you consider that ritual ablutions are an integral part of Islamic practice. Since my return, I have given a fair amount of thought as to whether washing in contaminated water is efficacious. I tend to think the reduction of physical filth should be of some usefulness. I would imagine that my Pakistani colleagues felt me to be somewhat obsessive about hand washing. I did notice that flu-like symptoms were rampant in the hospital and community. Coupled with the universal custom of shaking hands with everyone in a room on entering and leaving, and the fact that I avoided getting sick, I’ve got to believe that my hand washing did some good. During my stay, I saw patients with conditions that heretofore I had only read about in old medical texts. One 30-year-old man was in end-stage pulmonary cardiomyopathy from rheumatic fever. His heart was so terribly enlarged that it covered his entire left side of the chest. I could see jugular venous distension (JVD) from across the room. Even though the patient spoke no English, I felt embarrassed when at grand rounds the physician baldly stated that he would die soon. I’ve also never seen so many three-vessel disease patients that would remain untreated or simply be patched up with a stent in the worst vessel. Even though compassionate treatment and bill forgiveness is practiced at Tahir, equipment must be husbanded to provide the greatest good for the largest number. Medical insurance and Medicaid do not exist here. This is the real world. Peace and Religion in Rabwah Both my best and worst experiences in Pakistan were connected with the Islamic faith. I was invited to attend prayer services at the Ahmadiya mosque. It was very impressive to see 10,000 men attending services. It was even more impressive to realize that, as a non-believer, I was never ostracized. Although I was invited inside by the Iman, I felt more at ease with my friends on the periphery. The only part of the service that I understood was the important part, “Salaam Alikam,” or “Peace be with you.” As a precaution, I noted armed guards patrolled the edges of the crowd. Cars were inspected for bombs, and everyone was searched before coming onto the grounds. I was there during the first month of the Islamic year, Muharram. During Muharram, the Shiites observe a commemoration of the death of the prophets’ nephew, Alli. The 10th of the month, called Busharra Muharram, is observed in Iran and in some parts of Pakistan by the practice of self-flagellation with sticks, chains, knives or swords. I am told that sometimes the self-flagellation becomes “other” flagellation. Services are also sometimes held where retribution is called down on perceived enemies. During Busharra Muharram, I had been invited on a canoe trip by some of my resident friends, but the trip ended up being cancelled because of the timing. I mentioned that I fully understood my hosts’ reticence to be seen with an American infidel on the Shiite holy day, but I was informed that I didn’t understand at all. It had nothing to do with me. If they were seen and recognized as Ahmadiya, their lives might be forfeit. Well, I’ve heard Protestant bigots swearing at “Dammed Papists” before. Any noble practice can be perverted by small minds. I also saw holy writings on the Ahmadiya mosque and graves defaced by zealots who seem to feel that they and only they have the way to heaven. Salaam Alikam. Home Again Before I knew it, I was homeward bound, sitting again with Nood in traffic. We artfully dodge around trucks, camels, oxen and pedestrians, and zip past potholes and mud houses. A tape of Punjabi songs is playing, a wailing melody with finger cymbals and flutes playing. I feel like I should be wearing one of those Anzac hats that have the one side pinned up with a bandolier of express bullets and my trusty elephant gun in my hand. Hey Ma! I’m in a Stuart Whitman movie! I give in to the urge to simply breathe in the sights, sounds and smells of a beautifully alien landscape. This is why I love to travel lesser-known paths. That night, we stop at the Ahmadiya guest house in Islamabad. No hot water in the morning, but Nood and I had tea and toast for breakfast. Then we spent the whole day exploring Islamabad. This is my first day actually walking about. I was supposed to take a day trip to Lahore, but that was canceled by tragedy: two bombs that killed 30 people. We look through many shops that have exquisite scarves for my lovely wife and some wool Afghani caps for my grandsons. I am approached by a beautiful little beggar girl who doesn’t look more than five years old. Any foreigner in the market is an open invitation to beggars. I almost ask Nood to tell her to stay away from strangers who might hurt her. I stop to reflect on different cultures where a child is safe, and steer away from the darker thought that her parents might not care about her safety. At the airport, I’m treated to a VIP routine. The airport manager is a friend of a friend. His assistant comes out and guides me through an exit. We proceed through different stations with a simple, “He’s a guest of the sahib.” I’m delivered to the departure lounge and offered coffee or tea. By this time, I’m not put off by his request for baksheesh. I tip him and sit back to await my flight. In London, I’m met by another Ahmadiya who takes me to the London guest quarters. I am warmly welcomed by people who seem to know all about me. I am also informed that the Caliph, His Holiness, will grant me an audience. I am honored. When I am ushered into his presence, he welcomes me to London. He is an impressive man of regal bearing and the religious leader of 10 million people worldwide. He puts me at ease and we talked for 30 minutes. I later found out that the normal audience is 10 minutes. I have met heads of state with less presence and humanity. Finally, back in Detroit, I’m tired, but glad to be home. The immigration officer seems unimpressed with my odyssey. “What were you doing in Pakistan for a month?” I almost give in to the urge for a wisecrack, but simply answer, “Teaching cardiology.” Orifices and baggage unsearched, I’m released back into my everyday life. Six months later I am asked, Was it worth it, and Would I do it again? Absolutely! I’m relieved to have gotten out unscathed, yet am ready for my next trip. I’ve been invited back in a year or two. Hopefully, the area will be more peaceful. If not, I’ll once again have to weigh the odds. In closing, I want to once again state that this is a subjective account of my experience. I thank my gracious hosts, the Ahmadiya. They made a stranger in a strange land feel welcome among them. I am always happy to talk with anyone about my experiences. As for my next trip, who knows? Do you know of somewhere they might need a peripatetic paramedic? Salaam Alikam. Dave Hartman can be contacted at wdh@acd.net

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