Saturday, October 31, 2009
I left this morning for Kosovo where I will be working with the American International Health Alliance (AIHA) as part of their program to improve maternal and infant care in that country. I have two primary assignments while there: to assist in repairing some medical equipment in five hospitals around the country and to assess a potential pediatric ICU/Emergency Room at one of these hospitals. I was last in Kosovo in March 2009 where I visited these same hospitals and did a general assessment of the equipment needs. This is a follow up to that initial visit.
I will be working with Greg Johnson, who is a volunteer biomedical engineer from North Carolina. This will be his first volunteer mission and I look forward to working with him.
It’s never easy to leave home. The past few months it seems that I have been away more than I’ve been home. I’m glad this will be my last overseas trip of the year—at least that is the plan. Leaving home never gets easy. I miss my family immensely.
Sunday, November 1, 2009
My celebration was too early. I should have waited before raising my arms in triumph as I saw my first suitcase come into view. I had some initial doubts about my bags actually making it. When I checked in at San Francisco yesterday morning, the counter attendant told me that I couldn’t check my bags all the way through to the Kosovo because my airline didn’t have an agreement with Croatia Airlines, which I was flying on the last part of my journey. So I would need to pick up my bags in Amsterdam and then re-check them with Croatia Airlines. I then flew to Portland and went to the NW/Delta desk and asked them to double check on this because it didn’t seem right. Sure enough, NW/Delta does have an agreement in place with Croatia Airlines. The attendant was extremely helpful and personally went down to make sure that my bags were routed all the way through to Kosovo. Great service.
But I still should have waited to celebrate the arrival of my baggage. But when your bag is the first one on the conveyor, it’s like your team scored a touchdown and you can’t stop yourself from raising your arms in celebration. That was me as the first bag (my bag) came down the conveyor. But the celebration didn’t last long. The suitcases shimmied by one by one. Greg found both his bags (no wild celebration on his part). I waited. The baggage claim area emptied of people and suitcases. Two bags left on the conveyor—neither of them mine. The baggage conveyor screeches to halt. Greg and I are left alone with ¾ of our bags. I feel like my touchdown was just overruled by the instant replay official. No touchdown. No bag. I settle for a field goal—one bag.
But it isn’t just any bag. It’s the suitcase that has most of the medical supplies and parts that I brought for the hospitals—not the bag with my clothes and toiletry items. But as a seasoned traveler, I am not worried. I always pack a toothbrush, toothpaste, deodorant, and an extra set of clothes in my carry-on bag so I’m good for at least a day. And I’m sure that my bag will show up tomorrow…
Our taxi driver didn’t speak English but he was fluent in German and so we had a good conversation on our drive to the hotel. I learned that ex-President Clinton had just left about two hours before our arrival. He was here for the dedication of a statue made in his honor to commemorate the U.S.’s support of the Kososvars during the war with Serbia. The bronze/gold image (the driver wasn’t sure which) of the President depicts him with his left arm raised and in his right arm he is holding a binder that is engraved with the date of the first bombing run by the U.S. against Serbia. Interesting choice of dates to remember but the people of Kosovo are truly grateful for the role America played in their protection and their eventual independence as a country. According to our driver Americans are greatly loved, a sentiment that I heard many times when I first visited in Kosovo in March.
I also learned from the driver that the people of Kosovo have long memories. “We will never forget what the Serbians did to our women, our children, our elderly,” explained the driver. “In 20 years we will still remember; in 30 years we will still remember; in 40 years we will still remember. We will never forget.”
Monday, November 2, 2009
I should introduce the cast of characters for this week’s activities:
Dr. Kate Schechter – Senior Program Officer for American International Health Alliance (AIHA)
Dr. Mary Packer – Program Coordinator for AIHA program in Kosovo. Mary and her husband Alan have lived in Kosovo for eight years.
Greg Johnson – Volunteer biomedical engineer, president of Southeastern Biomedical Associates in North Carolina.
Clay Buttemere – Volunteer biomedical engineer living in neighboring Macedonia (he will join us on Wednesday).
Valentina – Our translator and primary contact for the week. She works for AIHA Kosovo.
Nazmi – Our driver for the week. He speaks excellent German and only a little English. All around good guy.
Greg, Valentina, Nazmi and I went to Prizren Regional Hospital today. We also took with us the Chief of Biomedical Engineering from the University Hospital in Pristina, the primary hospital for the country. We started in the Labor & Delivery department evaluating and repairing equipment. As we started repairing some of the fetal monitors the nurses brought in more and more pieces of broken equipment in hopes that we could somehow miraculously resuscitate them. While we were able to repair or service many pieces, most remained broken. We had brought out parts and accessories for those items that we knew needed service. All we could do for these other pieces was find out the problem and then make a list of parts to send back.
We then moved to the neonatal intensive care unit (NICU) and serviced some of the equipment in that unit. The hospital biomedical engineer worked with us and was very skilled. He knew in most cases what the problem was and what was needed to fix it. Unfortunately, he has virtually no authority to purchase parts or accessories that would make the equipment operable. There were several fetal monitors that needed a new transducer in order to function. They have not been used in almost two years because the engineer cannot get approval to purchase $200 transducers. We had brought some of these with us and so we plugged them in the units and now they have two additional fetal monitors. In the NICU they had a pulse oximeter that is used to measure oxygen in the blood, a vital piece of information for doctors and nurses. A sensor that goes on a baby’s foot is needed to measure the blood oxygen, but they didn’t have any. They had a couple of sensors that they had kept serviceable by using electrical tape to hold them together, but finally they had stopped working. The sensor costs $120, but there is no budget for these items and so the engineer cannot purchase any. So a perfectly good piece of equipment, a vital piece of equipment, sits idle for the lack of a small but required accessory.
I felt bad for the engineer. He knew the problems, he knew how to fix them, but his hands were tied. Greg and I come in with our bag of goodies and leave looking like heroes. There were several things that Greg was able to show the engineer on several pieces of equipment, but if the engineer had a service manual, he would have been able to handle the repair himself. That’s another common problem: medical equipment is donated to these hospitals but they do not come with operator or service manuals. Once the equipment breaks down, the engineer is forced to repair the equipment in the dark. [Assist International always provides manuals with any piece of medical equipment that we donate]
Still no suitcase but I went out and did a little shopping so I’m good for another day. I’m sure my bag will show up tomorrow…
Tuesday, November 3, 2009
This morning on our way out to the Peja Regional Hospital, we stopped by the airport to see if my suitcase arrived. Croatia Airlines has a website that enables you to track your missing bags. I discovered the site yesterday evening and saw that my bag was scheduled to be a flight that arrived late last night. I checked the website this morning and, though there wasn’t a confirmation of arrival, I figured it was worth a try. Thankfully, it was there.
Of course the thought arose in my mind, “If they have the technology to track a lost bag, wouldn’t it be better to employ that same technology before the bag gets lost?” I was just thinking.
Peja is a beautiful city surrounded by mountains, most of them covered with a thin layer of snow. It was raining and the clouds were low so we didn’t get the full impact of the beauty like I did the last time I was here. The hospital has some great views of the mountains and if I had to be sick in Kosovo, I would want to stay at this hospital in a room that looks out on these mountains.
Greg and I started working in the NICU. It is a well run unit with excellent staff. The unit is clean, the doctors and nurses are engaged, and the atmosphere is very positive. The equipment is suffering. Same story as yesterday’s hospital. The engineer and staff do all they can to keep the equipment functioning without spare parts and accessories. One example is they took an adult SpO2 sensor, cut it in half carefully, and then taped it around the infant’s foot so that it would work. It’s a $100 sensor. There are two very good patient monitors that wouldn’t work because the battery in each was dead. No way for the engineer to buy the batteries. His hands are tied. He has requested funding for the batteries for a couple of years now. Nothing. Two monitors are working but they only had some of the cables. I opened up the our supply case and pulled out two sets of ECG cables, two blood pressure tubing sets and four boxes of infant blood pressure cuffs. It was like Christmas.
Greg had an interesting experience with some new infusion pumps that had been recently purchased. The NICU director was ready to send them back because they kept giving the same two error codes. She wanted Greg to check them out. He watched them place the tubing, set the parameters and alarms, and then press the start button. Sure enough, after a few minutes the alarm sounded, the error message came up. The unit was obviously broken—the same with the other four units. Well, not exactly. The infusion pumps were delivered by the local distributor and he gave a quick five minute demonstration and then left the devices. Ten minutes after he left, the error codes started showing up. He never came back. Repeated calls were placed to come and service the equipment. The distributor claimed it was operator error but wouldn’t come and show how the operators were in error.
Greg watched the doctor set up one of the infusion pumps and within 30 seconds he knew the problem. It was operator error but they didn’t know that because they weren’t properly trained on how to set up the infusion pump. Greg spent 30 minutes doing an inservice with 4-5 staff (what should have been done in the first place), watched them as they set it up, gave them some pointers, and finally did a test run with all five units. No problems.
After we returned from Peja we were invited to a jazz concert featuring Nicole Henry from Miami Beach. There is a jazz festival in Pristina this week featuring nine different artists. She was very good and the pianist was excellent. It was a nice way to end the day.
Wednesday, November 04, 2009
I was awakened this morning at 2:30 by a call from a technician in Uganda who couldn’t find the driver sent to pick up from the Entebbe airport. While I am in Kosovo this week, Jim Stunkel (a long-time Assist friend and volunteer) is working with a team of GE technicians to install equipment at Mbrara Regional Referral Hospital and Kabuyanda Hospital in Uganda as part of the GE Global Health Initiative. The engineer had my number and so when he couldn’t find the driver he called me. As I’m talking to him he sees his name on a sign—the driver is indeed there to pick up him and his colleagues.
I didn’t fall asleep again until 5:30 AM only to be awakened by the alarm at 7.
We spent our day at the University Hospital in Pristina (UCCK) repairing medical equipment as well and assessing equipment and design considerations for a pediatric emergency unit and pediatric intensive care unit (PICU). We again experienced the frustration that the hospital biomedical engineers in Kosovo have to live with each day. On malfunctioning medical equipment the engineers know what the problem is and how to repair it. They are able to troubleshoot effectively on most things and figure out exactly what is needed to get a piece of medical equipment operational again. But if a replacement part is needed to repair the equipment, forget about it. The engineer has a better chance of buying a whole new piece of equipment than buying a part to repair it. I wish I was joking.
For example, in the UCCK ObGyn NICU department there are three infant incubators that require batteries. Each incubator costs about $8,000. Batteries run about $400 each. The biomed was able to order 20 new incubators for the hospital’s NICU departments (they have two NICUs) but has not been able to order batteries for the three units sitting in the corner room. The NICU is desperate for more incubators but getting three batteries will take a miracle. The biomedical engineer must first submit a bid request to three vendors since the part costs more than 100 euros. Once he receives these three bids he then submits the request to the procurement officer of the hospital. If there is funding available the procurement officer selects one of the vendors that submitted a quote and issues a requisition for the part. The part is then purchased. It seems pretty straightforward. The breakdown occurs in the bid request process. The hospital must use approved Kosovo businesses to purchase their parts. If the local businesses do not have the parts, the hospital engineer looks for the part in Europe and finds a vendor for that part. He then goes to the local vendor and suggests where the part he needs can be found in Europe. He cannot solicit a bid from the European company himself. He must use a local Kosovo business. But many times the local business have no interest in providing the part because it isn’t worth their effort for a few dollars in profit. They make a lot more money selling new pieces of equipment to the hospital. UCCK isn’t the only hospital experiencing this. Prizren and Peja also have great difficulty getting parts.
I realize that this is only one perspective and that the procurement office and local vendors may have another viewpoint. But based on my experience in March and what I’ve heard and seen so far on this trip, when it comes to obtaining parts it’s mission impossible.
So we were able to repair a few pieces of equipment with some parts and accessories that we had brought with us, but there is so much more that needs to be done.
Later in the afternoon I looked at a potential area for a pediatric emergency unit and then did a needs assessment in the PICU. I use the word PICU lightly since it was virtually devoid of any equipment whatsoever. I admire the doctors and nurses in this unit who are trying their best but lack even fundamental intensive care equipment such as monitors or infusion pumps.
Thursday, November 5, 2009
We visited the hospital in Gjilan this morning and were able to fix several pieces of equipment and train the doctors and nurses on a infant warmer that had been sitting in a corner not being used because it lacked a sensor, which I brought with me. We ran into the same issue with supplies and parts. The biomedical engineer knew the warmer needed a sensor but he could never get approval to purchase it.
Later in the afternoon we drove to the small town of Kacanik where two donated ambulances were being stored. These ambulances were donated by Northern Ireland and are part of the AIHA program to provide transport for critical newborns from the regional hospitals to the tertiary hospital in Pristina. Currently there is no way to transport infants that require special care from the regional hospitals to UCCK where more acute care can be given to the baby. If a baby needs to go to UCCK, the regional hospitals put them in a car or ambulance without the necessary medical equipment to transport the baby. Many times the baby doesn’t survive the trip to Pristina. These ambulances will be outfitted for transporting critical care newborns from throughout Kosovo to UCCK in Pristina.
After we finished measuring and detailing what the ambulances needed, Nazmi invited us for pasteries and tea at his home in Kacanik. It was a nice experience. His wife had made some bakalav, a local pastry that tasted wonderful. We sat in their living room that was heated with a small woodstove and talked about his time in Germany, his family, and his mother’s upcoming trip to Mecca. I had forgotten that Islam is the primary religion throughout Kosovo, but it is practiced differently than in other parts of the world.
Friday, November 6, 2009
We were in Gjakova today, which sits near the Albanian border. Visiting the hospital was a frustrating experience though we were able to repair a few pieces of equipment and train them on how to use some infusion pumps that were giving them problems. It was “déjà vu all over again.” Parts. Seriously, does it have to be this tough to get parts? Aren’t the hospitals and the Ministry of Health and the Ministry of Finance ever going to figure it out? The hospital has four very good engineers that are able to troubleshoot a problem on any piece of equipment down to component level. But when the engineer requests the part, he can’t get it. He’s frustrated, the doctors and nurses are frustrated, but nothing gets done. It’s beyond their control.
Another classic example. The Labor and Delivery department have a fetal monitor that isn’t working properly. One of the connectors is faulty and it is a relatively simple repair—once you have the part. But the department doesn’t want to give the unit to the biomedical department to fix until they have a replacement unit, after all, the fetal monitor could sit in the biomedical shop for six months awaiting the part. Good news though. The hospital has a brand new fetal monitor that the L & D department can use while their current unit is being repaired. There is a problem though—there always is—the new unit does not have any recording paper and they can’t get any. When the hospital ordered the unit from the local vendor, they ordered several cases of paper with the fetal monitor. But the vendor never delivered the paper because he couldn’t obtain it. So he delivered a brand new fetal monitor without paper and has never returned. And he was paid! That’s what really gets me. So the hospital is asking if I can get them some paper, so they can use this fetal monitor in the L & D department, so their current unit can be repaired. Unbelievable.
Of course we are glad to help all the hospitals with whatever supplies and parts we can. But it won’t solve the greater problem. We can repair everything that needs repair today, but next week, next month, there will be more equipment that requires parts or accessories.
