As often is my practice, I (Kim) am en route home from another mission trip as I write this.  It’s always a good time to process what I’ve experienced in the preceding days.  I just spent a week in Ulaan Baatar, Mongolia for our third annual Mending the Broken Hearts week, a project led by For Hearts and Souls and Samaritan’s Purse’s World Medical Mission.  There were 30 of us on the team, including a CT surgeon, 2 pediatric cardiologists, 3 intensive care doctors, 3 anesthesiologists, a perfusionist, 9 ICU nurses, an OR nurse, a scrub tech, a nurse practitioner, a pharmacist, 2 biomedical technicians, 2 child life specialists, 2 extraordinary helpers, and the Director of World Medical Mission, who served as our chaplain.  The team did at least 10 cardiac catheterizations, including 2 atrial septal defect (ASD-“hole in the heart” at the collecting chamber level) device closures and we performed 8 surgeries on a total of 6 kids.  These numbers are significantly less than we had planned.  We had the biggest team we had ever taken, the most supplies, and the most medicines.  With these “dream conditions,” we had hoped to do 15 caths and 15 surgeries.  The theme of the whole week was the Lord’s ways are not our ways and His plans are not our plans.  We had a number of “firsts” that I would rather not ever experience again.

               The week started with our surgeon and two of our intensivists being stuck in Beijing en route.  They were supposed to arrive Sunday a.m. but did not arrive until Monday afternoon.  We were able to begin cases in the cath lab as planned on Monday a.m., but did not start our first operating room (OR) case until after 3 p.m. on Monday after these people arrived at the hospital directly from the airport.  This first case was a promise kept.  Kirk had found the child’s mother last year on the Searching week.  The mother has an inoperable heart condition.  After receiving this bad news, she asked if Kirk would check her daughter.  Kirk’s heart sank when he learned her daughter had an atrial septal defect and would need heart surgery.  He promised the mother we would perform this surgery when we returned this year.  I’m happy to report Anujin did very, very well.

               Tuesday we started the OR day with approximately 1 ½ year old Tsend, a boy.  He has Tetrology of Fallot and was very, very blue due to very little blood flow to his lungs.  He was at great risk of sudden death and was not a candidate to go to the U.S. for repair due to the extremity of his condition.  I don’t know how to explain it other than to say he “tried to die” many times during that operation in which the surgeon placed what’s called a central shunt to allow blood flow to the lungs from the aorta.  Staci (the anesthesiology resident that was my invaluable right hand woman all week) and I were extremely relieved to deliver him alive and stable to the ICU.  However, he “tried to die” many times over the next 48 hours.  The ICU team worked so very hard around the clock to keep him alive, including hand ventilating him over many, many hours as the ventilator kept ceasing to work.  The second case was a teenage boy with a ventricular septal defect (VSD-“hole in the heart” at the pumping chamber level).  Most children with VSDs are inoperable if they are not repaired by age 2 due to too much blood flow to the lungs which irreversibly damages the lung blood vessels.  His type of VSD allowed his lungs to be protected and for him also to do well with this surgery.  We had a big scare when we were trying to take him off the cardiac bypass pump though.  A normal part of the separation from bypass is to get the heart, which has been stopped, to start beating again.  Often the heart goes into ventricular fibrillation during this time and we electrically “shock” it out of this rhythm.  His heart went into ventricular fibrillation (a lethal rhythm when not on bypass) and we could not get the defibrillator to work for a good ten minutes.  We were giving medicines to try to help, but finally the Lord answered the fervent prayers of a lot of stressed out people in the operating room and the defibrillator worked.  He is now doing very well.

               On Wednesday, our first OR case was Bogi.  Bogi was 7 years old and looked like she was 3 or 4, in terms of weight.  The team fell in love with her when they met her at church on Sunday.  Bogi had an inoperable VSD due to the irreversible pulmonary hypertension described above.  She had actually been to the U.S. in hopes of having a repair 2 years prior and had been turned down.  Her mother became a Christian on that trip and was an active member of the church started by our missionary friends in Ulaan Baatar, Rita and Margie.  Bogi was taken to the cath lab for a diagnostic cath on Monday to assess how bad her pulmonary blood pressure was.  She got an unexplained heparin overdose and bled A LOT at the end of the cath lab case, a scary first that she survived.  The heparin had been mixed by the Mongolian team, so we had our pharmacist mix the heparin for the rest of the week.  We had a second heparin overdose on the second day despite this precaution.  We found ourselves repeating over and over throughout the week “it is Mongolia.”  We do a lot with their equipment, medicine, and supplies…and sometimes it goes far from smoothly! 

Anyway, back to Bogi’s condition, Kirk has lost count of the number of children and families in Mongolia he has cried with as he has had to break the news about inoperable VSDs.  I’m sure the number is well into the hundreds, or even the thousands, over his eleven trips there in six years.  This is something we just don’t see in the U.S. because our kids get repaired in a timely fashion.  This is a problem our team has made a concerted effort to do something about.  That is why Kirk leads a Searching week every year to try to find these kids before it is too late and to educate the Mongolians in different parts of the country about getting their kids seen early.  We have also been trying to teach the Mongolian doctors to place what is called a pulmonary artery (PA) band on these kids before they are 2.  This is a simpler surgery than a full repair and it doesn’t require cardiac bypass.  The mortality rate for the more complicated repair in Mongolia is easily 50 percent.  If the kids get a PA band, their lungs will likely be protected and they have more time to get to the U.S. for a full repair.  In fact, our first case 2 years ago was an approximately nine-year-old girl that an Australian team had put a PA band on seven years prior.  This allowed her to remain operable and we were able to remove her PA band and close her VSD…and likely save her life.  Bogi would be considered inoperable in the U.S.  I’m trying not to get too complex with the medical explanations, but despite her high pulmonary blood pressure, she still had what we call “reactive” pulmonary vasculature.  Our team has been trying to put PA bands on some of these kids in the hopes that their lungs will heal and they will become operable.  This, admittedly, is a last ditch effort that we don’t know will work.  It’s not something we’re familiar with doing in the U.S. simply because we’re blessed enough not to have to.  If it works, we have the chase to save countless kids.  Bogi’s parents had known for 2 years that she was inoperable.  They were well counseled that we didn’t know if this would help her, but it offered them a measure of hope and they were willing to proceed.

Bogi’s procedure went quite well.  It was actually quite straight forward and I even said so in the OR to the Mongolian anesthesiologist I was training.  I’ve learned nothing is straight forward in Mongolia and to take nothing for granted.  We took her breathing tube out in the OR.  She went to the ICU and was awake and interacting.  She was probably there for at least 2 hours when she medically decompensated quite suddenly.  You can imagine we’ve debriefed this and debriefed this.  The ICU team did everything rapidly and right.  We got her back into the OR as fast as we could.  Staci and I actually had another child asleep on the table with all her invasive lines in ready for her surgery, which had not begun.  In the U.S., you’d just go to another OR with an emergency case like this.  Problem was, there was no duplicate equipment in the other OR.  We put the child on the table on a portable monitor, placed her on a gurney, and Staci kept her stable in the hallway while we rolled Bogi into the still sterile OR.  Our surgeon got her chest opened and we performed a heroic, valiant “code” for a very, very long time and were never able to get her back.  Despite an autopsy, none of us can explain what happened.  In the OR, Kirk finally made the difficult decision that nobody wanted to make to cease our efforts.  That OR was full of praying people who had fallen in love with that little girl.  Kirk prayed a beautiful prayer committing her to Christ, which was translated into Mongolian.  There was not a dry eye in the room, Mongolians included.  That actually is very significant given they see death A LOT and those that work in the medical field are often quite stoic to it.    

Bogi’s parents’ reaction was indescribably miraculous.  Of course they were appropriately heart-broken and sobbing.  But Bogi’s mom, shortly after hearing the news, raised her hands to heaven and started saying “I praise you Jesus and thank you for every minute I had with my daughter.”  Her father told Kirk that he knew we did everything possible and how thankful he was that we had offered hope in a hopeless situation.  They came back the following day and gave everyone on the team a sheet of bookmarks on the back of which Bogi’s mom had hand-written for all of us the following 2 verses which she said God had given her to give to us:  “I thank my God always on your behalf, for the grace of God which is given you by Jesus Christ (1 Cor 1:4)“ and “Therefore, my beloved brethren, be ye stedfast, unmoveable, always abounding in the work of the Lord, forasmuch as ye know that your labour is not in vain in the Lord (1 Cor 15:58)“.  You can imagine how tremendously these verses ministered to and encouraged us.

We decided to cancel the case of the child who had been whisked out of the operating room.  I actually think that was one of Bogi’s many gifts of the week.  The child had had a “cold.”  In the U.S., I would have cancelled her surgery.  That’s a harder decision in Mongolia when you’re only there for a week and not doing a surgery might mean the child dies.  But she had pulmonary complications immediately after putting her to sleep and I think it was divine intervention that we did not proceed with a case that would have resulted in potentially another very sick child.

The surgical team arrived Thursday morning to a very tired ICU team and a very, very sick Tsend (the first case from Tuesday).  We decided to take him back to the operating room.  Lots of prayer required there.  We were going to put him on bypass to fix his shunt again, already a difficult proposition if you’re not starting with a very sick child.  We all knew there was a high likelihood this child could die in the OR too.  His case was an exhausting, hard fought battle.  When we were trying to get him off bypass, his lungs would literally not move—another “first” I’ve witnessed.  I suctioned them out I don’t know how many times, replaced his breathing tube twice, and used asthma medication over the course of an hour.  We came off bypass, because we had to eventually, with lungs that would barely move.  By the grace of God, his lung function got better and better over the next 2 hours.  Then he got better and better over the next 2 days, all in answer to a lot of fervent praying.  Another “first”:  we’ve never had a child still on the ventilator on Saturday of the surgical week.  We always try to do the difficult cases early in the week so we can have everyone out of the ICU by the end of the week.  So, for the first time ever we transported a child across town from the adult hospital where we do the surgeries to the children’s hospital.  Our 3 intensivists were leaving on Saturday, but, by God’s grace and planning, another intensivist arrived on Thursday for the Searching week.  Two of the ICU nurses were planning on staying for the Searching week and two more agreed to lengthen their trip.  I just learned from Kirk that through the Lord’s miraculous intervention his breathing tube has been removed!  It brings tears to my eyes to consider what a miracle this is!!  Our second case on Thursday was a 9-year-old ASD who, thankfully, did very, very well.

On Friday, we were supposed to do another PA band case and an ASD.  Given what happened with Bogi, I think we were all nervous to do another PA band, but, praise the Lord, it went very well.  The interventional cardiologist on our team had tried to close a patent ductus arteriosus (a vessel necessary for fetal circulation that should have closed after birth but didn’t) with a device in the cath lab, but the device size was inappropriate for this defect.  So, again not in keeping with our plans, we had to take her to the OR and close this defect operably.  She also did well.  It was then late in the day, too late to do another cardiac bypass case that would have to remain in the ICU when most of the team was leaving, so we had to cancel this case.  This patient will have a normal life span if we fix her defect by age 20, so we promised her, Lord willing, we would do her case next year.  This, however, was incredibly and understandably emotionally hard on her, her family, and those who had to break the news to her.

 So, 15 caths planned.  Only 10 done, and at least 2 with complications.  15 surgical cases planned.  Only 8 performed on actually 6 patients, with 2 “bring backs” and 1 death.  I only told you the stories and difficulties I know from being directly involved in them.  There are 29 other people who could offer you their stories and perspectives.  All of us would tell you it was one hard week, easily the hardest of the three surgical weeks we’ve had.  Not a great report.  Pretty discouraging.  So, what’s the lesson?  We’ve all processed that a lot.  Kirk and I spent what little time we had alone together processing it.  Is the lesson that we should quit?  I wondered that last year when Undurmaa died.  I wondered it again this year when Bogi died.  I don’t think that’s the lesson.  Neither does the team.  I in no way want to sound callous when I say this, but as Kirk has pointed out, pediatric heart surgery has been built on the deaths of many children.  Every new procedure, every new advance has come at a cost.  The pediatric cardiac surgery mortality rate in Mongolia is easily 50 percent.  In the U.S., it’s less than 1 percent.  We are slowly, agonizingly making progress in our training of the Mongolians.  We are offering hope to families that otherwise have none.  When you see the magnitude of the need in Mongolia and the number of families begging us to take of their children and sobbing when we can’t, you don’t want to quit.  I’ve marveled the last 2 years that, despite what we’ve been through, the team members keep talking about “next year.” 

One night I was unable to sleep, processing it all.  Two years ago, our container of supplies did not arrive.  We had a much smaller team.  We did 8 surgeries with only the supplies the Mongolians had to offer and what we brought in our suitcases…and all the children did well, with few, if any, complications.  I was expecting this year to be so much easier because we had a dream team and incomparably more medicines and supplies.  I couldn’t figure out how we pulled it off before.  Then I realized…we didn’t.  The Lord did.  Even last year, despite the conflicting fact that we had a devastating death, was “easier.”  The Lord gave us an incredible covering of grace.  Truly, it is utterly amazing that we accomplish what we do over there.  I think this year He drew back the curtain a little and showed us how much He had been covering us…and, in the process, continued to cover us.  All the “firsts” and complications made all the good outcomes that much more miraculous.  And, never ever wanting to minimize Bogi’s death, I can already see how the Lord is using it for good and to His glory.  I love the song by Tree 63 which goes “Every blessing you pour out, I’ll turn back to praise.  When the darkness closes in, Lord, still I will say, ‘Blessed be the name of the Lord.’”  I will never forget our entire team, on the morning after Bogi’s death, standing in the ICU and beautifully singing the song “Sing Hallelujah to the Lord.”  The darkness closed in and we were still able to say, with Bogi’s mom leading us with her example, “blessed be the name of the Lord.”  So, we will “not grow weary of doing good” (2 Thess 3:13) and, Lord willing, we’ll be back next year.

The week after the surgical week, Kirk led a team of thirty Americans and sixteen Mongolians to the south Gobi desert for the Searching for the Broken Hearts week.  They screened over a thousand children and found sixty-three with heart disease (6 were inoperable, 19 were added to the waiting list for the Children’s Heart Project, 8 will be taken care of in Mongolia by a visiting team from Japan, and the rest did not need surgery).  A group from Okinawa raised over $13,000 to buy 1,100 Bibles that were given out during the week.  Most importantly, close to 300 people came to Christ.  He is good!