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Cover Story

Ibrahim Cardiac Hospital and Research Institute
Quality cardiac surgery at home

Imran H. Khan

Seven-and-a half-year-old Laboni has a hole in her heart. In medical terms it is Ventricular Septral Defect or VSD. She also has Pulmunation Standard (PS), a problem in the blood circulation since birth. To get better she has to undergo a 3 to 4 hour operation but one that may allow her to go home after 4 to 5 days after surgery. Her mother holds Laboni's younger brother in her arms and looks anxious. They heard about this hospital that will make her well from a close relative who had been here and have come all the way from Sylhet.

The first thing that one notices about the hospital is the glaze on the floors. The cleaners are constantly moving around the corridors to ensure that the place remains spick and

ICHRI is suitably located beside BIRDEM so it can get assistance from a multi-disciplinary hospital

span. Even the drinking water system in the hospital is totally distilled and comes with a purifier system. Such emphasis on cleanliness is not a common thing in most Bangladeshi hospitals, which is why it is so refreshing.

Snuggling right in between BIRDEM Hospital, the DAB (Diabetic Association of Bangladesh) Cardiac Centre, an example of what a hospital should look like, came into being in 2001. It was not until October 2003 when DAB was changed to Ibrahim Cardiac Hospital and Research Institute (ICHRI), an institute to provide international standard cardiac surgical services to the people of Bangladesh. Since the beginning of the hospital, the CEO has been M A Mokaddem. Established under the Diabetic Association of Bangladesh, the ICHRI provides quality cardiac surgical care right here in Bangladesh. Set up originally, with the help of the Bangladeshi government with some technical assistance from a Swedish organisation, it complements the state's objective of making expensive health care affordable to under-privileged people of Bangladesh. The

Laboni is seven and a half years old. She has a hole in her heart that needs to be repaired

people are benefited in many ways. Patients are saved from the strain and financial burden of going abroad and also have the benefit of being treated in their own country where they can communicate easily with their doctors.

The main departments in any cardiac hospital are the cardiology and cardiac surgery departments. At ICHRI, both the departments are of international standard and are equipped to handle all kinds of heart complications. According to Dr Masoom Siraj, Senior Consultant Cardiac Surgeon and the Head of the Centre, "in case of adult cardiac surgery, the bulk of the workload is bypass surgery and valve recessment surgery. These two are our main concerns." On a limited scale, paediatric surgery is also done here.

The forms of Adult Cardiac Surgical Procedures that are performed include Coronary Artery Bypass Grafts (CABG), Aortic valve Surgery, Mitral valve surgery, Tricuspid valve surgery, Combined procedures and many others.

ICHRI will soon provide paediatric cardiac surgical service on a full scale with all the facilities comparable to any foreign hospital. "We do not want to go into something half- heartedly. If we start something, we will start it properly, taking into account all of the complications that can arise and its proper backup services," continues Siraj. Operation on a full scale is not possible at the moment, as paediatric cardiac surgery is different from

Khair Hossain, 24 hours after undergoing a cardiac surgery

adult cardiac surgery. In case of the former, paediatric cardiologists have to be present in the picture. ICHRI has consulted with a cardiologist who will be joining the doctors at ICHRI and there are some special instruments that will be needed which are also being arranged.

In the field of adult cardiology, ICHRI is successfully performing all forms of surgical procedures that are available abroad. "We are fully equipped with the necessary instruments for all adult treatments," comments Siraj. Other hospitals claim to have the lowest prices compared to services but according to Siraj ICHRI has much lower rates. "We provide the complete package. The cost of a bypass surgery is Tk.130,000 whereas in other hospitals the cost is Tk.170,000," continues Siraj. Only the National Heart Foundation (NHF) has such a package at a lower cost.

Since ICHRI is under the Diabetic Association of Bangladesh, publicity is not a primary concern. They are not out to look for patients, claims one of the doctors. "We help those who come to us and here, both in cardiology and in surgery, we give our honest opinion to the patients. We do not fabricate anything. That is why most of our patients prefer us to other institutes," declares Siraj.

Dr. Jalal Uddin is the Senior Consultant, Department of Cardiac Surgery in ICHRI. He was previously in the NHF as the senior consultant of Cardiac Surgery. "We have not

advertised much in the media but the numbers of our patients are increasing," says Jalal Uddin. "I think that is because the people we have served are happy and are spreading our name."

Word of mouth seems to be the main advertisement for ICHRI as the number of patients have slowly increased over the years. Nearly 500 patients have been treated here since its inception in 2003 and the numbers are rising.

One thing that distinguishes ICHRI from other cardiac centres is the Cardiac Emergency Unit on the ground floor of the hospital. Here, the patients who might have suffered from heart attack or who have serious chest pains are brought in and are immediately treated. This is something not every hospital has. In emergency situations, the doctors are properly equipped to handle even small surgical procedures. The Emergency unit has nearly all the components as available in the ICU. The patients are then sent home or are sent to the Cardiac Care Unit.

Any cardiac centre can basically be divided into three segments. There is cardiac surgical services, cardiology and finally, outdoor facility. The outdoor facilities of ICHRI include a laboratory. "In the Department of Cardiology, there is angiogram, putting on pacemaker, etc," continues Siraj. "All these facilities are provided here and at a very affordable price." After cardiology, if any patient needs surgery this is provided by ICHRI. The centre offers a complete package in cardiac care.

Dr. Md. Rezaul Karim (L) and Dr. Tamzeed Ahmed

The centre's location is a major plus point. Being right beside BIRDEM, it can get all the assistance they need from the general hospital, especially one which has built quite a good reputation for itself. A patient coming with chest trouble may not necessarily have ailments of the heart. In such cases, if such complications arise, ICHRI has the understanding with BIRDEM that the latter's consultants will come to ICHRI to tend to the patients. "Even though we are saying that we are a cardiac hospital, we are not only mono-disciplined. We are getting the advantages of multi-disciplined services by being in

Abdur Rouf (L), ICU In-Charge, is seen tending to a patient

the same compound with BIRDEM," says Siraj. Precious time is saved as the patients get faster diagnosis and treatment. "In the field of cardiac surgery, we require help from the multi-disciplinary side as well. We have a well established hospital right beside us that provide us with assistant in the fields of neurology, neuro-surgery, diabetes management and others," says Lt. Col. (Retd) Dr. Md. Hamidur Rahman, Senior Consultant and Head of Anaesthesiology.

The rooms of ICHRI can be broken down to Operation Theatres (OT), Cardiac Surgical Intensive Care Unit (CSICU), Surgical Stepdown and Ward. ICHRI has two modern fully equipped spacious operation theatres that has the ablity to function simultaneously, complete with HeartLung machines, monitors, defibrillators, diathermy machines, Intra Aortic Balloon Pump and Hot Lab facilities. The speciality of the Intra Aortic Balloon Pump (IABP) instrument is that it can give support to the heart for about 12 to 16 hours. After an operation, if the heart cannot maintain the pressure of blood inside the body, this machinery helps to do so, hence keeping the body stable. This helps to save a lot of patients. This machine is not easily available in Bangladesh as it comes with a hefty price tag of around Tk 25 lakh to Tk 30 lakh. "On average we have two operations a day. We do not really want to do three to maintain the quality but we do so in case of emergencies," says Siraj. The OTs too have been made to suit international standards. A careful glance

Dr. Masoom Siraj
Dr. Md. Hamidur Rahman
Dr. Jalal Udding

at the ceiling will reveal that there are very little joints on the roof. This minimises the risk of infections in the OT.

On the surgery side, there is the surgery ward and patients are usually admitted into the wards two days in advance. Since the dates for the operations are fixed beforehand, the patients are properly prepared for the big day and their diets are maintained. After the operation, the patient is taken from the OT to the Cardiac Surgical Intensive Care Unit (CSICU). This unit holds 8 beds and is fully equipped with Ventilators, Monitors, Ducted medical gases and suction, Rewarming/Cooling Blankets and Emergency surgical procedure facilities. Moreover, there are nurses assigned for individual beds such that the patient is always kept under constant observation. The risk of infection in cardiac surgery is very high so the place has to have a very clean surrounding. According to M. Anamul Haque, Head of Cardiac Surgical Perfusion, there is almost 'zero chance of infection'.

Patients undergoing a heart-attack, receive treatment and are sent to CCU Chest Pain Unit step down, and finally to general wards. These are all in the cardiac medicine side or cardiology.

So what's the difference between a cardiologist and a cardiac surgeon. Cardiologists are physicians who practice medicine. They tend to the patient's initial problems, such as exercise tolerance, ECG, pains in the chest, angiogram. Cardiologists also administer 'stents' when an angiogram detects a blockage. They also put pace makers inside patients. These are just intervention procedures and not operations explains Siraj. Initial assessment, treatment and investigations are always done by the cardiologists. When the Cardiologists see that it is not possible to help the patent, they send them over to the Cardiac Surgery unit.

The cardiac surgical intensive care unit at ICHRI is a maze of state of the art electronic equipment, monitors and tubes

"Here, at Ibrahim, we do not give 100% guarantee about an operation's success. We do the best we can from our side and 100% guarantee is something only God gives, though there are people who give such false assurance", continues Siraj. ICHRI currently has a 0.5 % to 0.6 % mortality rate, as the reports from last year show. This means that the success rate of the operations is close to 99.4 %. The figures are as good as any foreign hospital but the institute is always trying to increase that percentage. "We only operate when the patient needs the surgery and we perform a maximum of two or three surgeries a day," states Siraj. "We tend not to work like conveyer belts in industrial factories as it will deteriorate our quality. We try to do the operations as safely as possible and in the most hygienic manner", he goes on. The total number of patients who had Cardiac Surgery during the year 2005 was 328 of whom only 2 patients died.

"Our main intention is to give service to the people while keeping up the quality of the hospital," says Rahman. "Hygiene is well maintained in all nooks and crannies of the hospital", Rahman states. The Security and the Cleaners have all been out-sourced. They work on contract because that way, they do good work and if "we are not satisfied with their service, we get a new service provider who can cater to our needs," says Rahman. In case of other hospitals, they have recruited their own staff. Here, the system is "hire and fire". At the end of the day, the cleanliness in ICHRI speaks for itself.

The Emergency at ICHRI is fully equipped to tend to all forms of heart related problems

The hospital's efficient set up is another commendable feature. There are about 78 beds in all in ICHRI. Keeping the numbers limited means that quality is maintained and all the patients get proper attention since nearly all the patients have heart problems.

There are roughly 130 to 150 nurses at this centre working continuous shifts. The doctors too are available around the clock. From morning to 4 p.m., there are doctors available and from then on to 4 a.m. the next morning. There are always three doctors present, both in Cardiology and in Cardiac Surgery. "The resident doctors too are on call 24 hours a day so there is never any short of good help," continues Rahman. The best thing about the doctors at ICHRI is that they do not practice anywhere else. Hence, they can allot all their time to this institution and to the welfare of its patients. Rahman was in the Army in Cardiac Anaesthetics. After retirement, he came here 2 years back and started his practice. He had been in the Combined Military Hospital, Dhaka (CMH) for the past 20 years, practising his skills at Anaesthetics.

ICHRI is the only centre in Bangladesh where all the staff is local. There once used to be a conception that if one was to do a bypass surgery, one had to go abroad for good treatment but now, that has changed. "Through our services we are earning a good reputation and giving confidence to the people of this country," says Siraj.

The team of doctors at ICHRI

It is hard to believe that Khair Hossain, a middle-aged businessman siting serenely in the Cardiac Surgery Intensive Care Unit has just undergone open heart surgery the previous morning. "I was taken to the operating room at 7:30 am and I woke up at 4:00 pm the same day", says Hossain, his chest bearing bandages from his operation. The main operation was probably two to three hours long but anaesthesia, recovery, etc. took up more time. "I have been told to stay on at the hospital for at least one week before being

Dr. Rezaul Karim checks the results of a surgery an angiogram monitor
The general Wards at ICHRI are all partitioned to give the patients ample privacy for recovery

discharged. The same day of my operation, I was given afternoon tea and a light meal," Hossain states, the pain from the operation still bearing

The Intra Aortic Balloon Pump is a special equipment that can give support to the heart for about 16 hours

heavy on him. "I don't remember most of the things but I feel much better now. Today, I had breakfast and lunch on my own," says Hossain.

"We start to feed the patients after just three to four hours of certain operations. That is something really wonderful as it is hard to imagine that the same patient had just had a heart operation," states Abdur Rouf, the ICU In-Charge. "There is really nothing to worry about when it comes to open heart surgery because we have some of the best surgeons in the country," he adds.

Md. Mashequr Rahman Khan, Manager Administration, is a man who is in charge of all sorts of supervision. "We have given the security to Group 4 and Property Care Services (PCS) services are doing all the cleaning," says Mashequr. "Our canteen has a Food Quality Control Committee. The individual patients have their own diets, provided by the nutritionists and the canteen cooks the food to cater to such diets. A representative from the Food Quality Control Committee is always present before each meal to make sure that the food's quality is of proper standards," he says.

Dr. Tamzeed Ahmed, Senior Consultant Cardiologist, Cardiovascular Medicine and Interventional Cardiology, is straightforward. "We are a non-government organisation and it is our duty to inform the patients the things we can offer the things we can't. We simply give our honest opinion," says Ahmed. ICHRI is also trying to improve its discharge system so that the patients who are leaving are not facing any problems and those clients on the waiting lists can be tended to.

In the long-run the hospital will also be a training institute. "Eventually, we plan to officially provide training, though, we are unofficially giving very good training right now," says Ahmed. ICHRI also plans to venture into the field of research on the cardiac side, for example preventive cardiology. "In the long-run, we will be aiming for preventive strategies in the cardiac field," concludes Ahmed.

The nurse to patient ratio at ICHRI is much higher than most hospitals. That way, all the patients can be carefully attended to

Early results are encouraging and validate that an institute such as the Ibrahim Cardiac Hospital and Research Institute can provide affordable surgical care in a clean and safe environment. "If there are too many patients, then they will have to go into the waiting list", said Jalal Uddin. So far the main attraction of the Centre is that doctors are honest with the patient; a basic requirement expected from any standard hospital but a rarity in most medical centres of the country.

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