Dhaka, Bangladesh - It takes a firm and steady grip on an electric saw that sounds like a drill to get through a child's sternum, and some deft stitches to pin and stop a bouncing little heart.
In the seconds that feel like minutes punctuated by quickening bleeps, a machine sprouting thick tubes of raspberry-red liquid takes over the heart's job and whirls oxygenated blood to patients who barely fill a third of the bed.
Nurses swab and provide countless pairs of slim scissors to surgeons whose microscopic glasses help them to slice and solder the tiniest vessels. Anaesthetists flinch when undulating lines etched out on monitors form sharp zigzags and adjust the rainbow of wires feeding little bodies.
Open-heart surgery on children weighing just a few kilogrammes or on babies only weeks old is so complicated that in Bangladesh, only a few surgeons can and will do it.
Congenital heart disease affects the poorest most. In Bangladesh, it costs around $2,000 to fix. In the absence of a miracle donation, many simply wither and die.
"They [need] expensive treatment but they can't afford it by themselves and most of them die due to a lack of money and facilities," says Nurun Fatema, a cardiologist at Dhaka's Combined Military Hospital (CMH). "Eighty percent of them are below the poverty line."
Even at the sprawling CMH complex, which usually deals with salaried military staff and their families, studies showed that of 1,000 babies born, 25 had congenital heart disease. This rate is around three times that of western countries.
A shortage of paediatricians
Through a private clinic and charity initiative, Fatema performs some procedures using a less invasive method than open heart surgery, free of charge.
Using a catheter running from the groin and large X-ray monitors, she can use a wire probe to get to the heart, inject dye to show where the blood is trapped or leaking, blow up balloons to open valves and stents to fix them.
It is still a risky process, and one that few paediatric specialists can do in a country the size of England and Wales but with a child population of 60 million.
Mohammed Abdul Hannan, CMH's cardiac surgeon, says that Bangladesh started doing heart operations in 1981, and that for the past 15 years the standard has gone up so that "adult cardiac surgery patients now need not go abroad".
"But for paediatric surgery we are lacking experts," for both surgical and intensive care, he says.
There are so few paediatric specialists that parents issue desperate pleas to strangers for help.
"I saw one advertisement in the paper asking [for] help to collect money so that they can take their babies abroad for treatment ... as this treatment is not available here," Hannan says.
|Anxious mothers wait, hoping their children will be selected to undergo life-saving heart surgery in Dhaka, Bangladesh [Owen Humphreys/Al Jazeera]
Little heart palpitations
Prodip and Shebaka Shil have come from the other end of Bangladesh to Dhaka with their nine-year-old daughter Fima to solve a problem that has haunted them since they found out that she had a hole in her heart at birth.
"When she was in pain, we were in pain," says Prodip, a barber from the poor town of Chittagong, 350km from Dhaka.
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He earns $70 a month and was told that it would cost $5,000 to mend Fima's heart.
"Tup-tup" is how Fima describes the heart palpitations that would shatter her if she tried to play and, more often than not, trap her at home or in hospital instead of at school.
Malnutrition is a common side-effect of heart disease, and Fima wears the symptoms on her frail frame that belongs to a child half her age.
Her thin limbs are covered in a soft downy hair normally seen on newborn babies or people with eating disorders who need extra insulation.
Fima was one of about 250 children who were chosen for surgery before a visit by medics from the British charity Muntada Aid, which runs a "Little Hearts" project providing free surgery.
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'Little Hearts' project
Since 2013, Little Hearts has raised more than $2M for surgeries on children in Bangladesh, Yemen, Sudan, Tanzania and Mauritania, where remedies for congenital heart disease are lacking or absent.
Bangladesh has one centre "with a couple of surgeons … doing complex paediatric cases, and that's not enough to cover one city, let alone the entire country," says Mohammad Shihata, a cardiac surgeon who usually does a few surgeries a week at a hospital in Jeddah, Saudi Arabia.
In Dhaka, he is performing back-to-back surgeries from dawn till dusk, as time is ticking for many patients deemed too small and high-risk by local surgeons.
"By waiting for the babies to grow up, natural selection will play its role and a lot of babies won't make it on their own and will die," he explains.
Fifteen of the children selected for surgery two months before the arrival of the team of 23 medics did not survive. Many others are so weak that parents wail and cling to them until the last moment when surgical staff take them away.
Fathers who appear stoic creep to doorways and windows to stare into the imaginary distance of a completely smog-shrouded city, then quickly wipe their eyes with a hand or sleeve.
|Saudi surgeon Mohammad Shihata, right, performs open-heart surgery with Bangladeshi colleague Abdul Hannan, left, who says assisting is the best training [Hannah McNeish/Al Jazeera]
Training auxiliary staff
Fima's parents are among those camping out in a courtyard metres from the surgical ward instead of their allocated hospital rooms.
The surgery can take hours and parents cannot see their children until they have come to and had tubes removed. But relatives still huddle inches from the ward entrance as they await news or a glimpse of their children being stretchered to the intensive care ward.
While heart surgery can be traumatic and dramatic to look at, the babies transferred to the ward resemble fleshy circuit boards, and it takes a well-trained intensive care team to keep them from crashing.
Muntada Aid now leaves intensive-care nurses for an extra week to provide more training, after some patients died at the hands of local staff who were not properly prepared.
"In one sense our babies are getting the treatment and getting cured but at the same time we are getting trained," says Hannan, who adds that he is "confident" that he can do all of these surgeries if the auxiliary staff are also trained.
Rawkon Are, an intensive care nurse at CMH, says many new skills are imparted, including "medication, infusion, patient management, dressing, everything".
She has 17 years of nursing under her belt, but says that on these charitable trips they see "a very quick improvement" in their skills from the "watch, see and then do" mantra of hands-on training.
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In Bangladesh, the local staff have improved so much since the first visit in 2013 that this time the Muntada Aid team has managed to carry out a record 94 operations instead of 50.
The charity has sent staff from developing countries for weeks or months-long training courses in Turkey, and plans to send people to Saudi Arabia for longer-term shadowing.
"We're hoping that it will get to a level that they say stop, we don't need you any more," says cardiac surgeon Mohammed Jamjoom, from Jeddah.
Kabir Miah, a Muntada Aid spokesman who moved from Bangladesh to Britain as a child, says the charity's aim is "ultimately, not to come here any more" as local staff take over.
In the meantime, doctors and nurses from Jordan, the Philippines, India, Saudi Arabia and beyond are lining up to give up and coordinate their free time to join the Little Hearts missions.
"The first time you'll do it you'll be addicted to it because, you know, it's a beautiful feeling", says Jamjoom, who has hung up his gloves and toured the final ward before children get to go home.
There, Fima's mother Shebaka is at her bedside, marvelling at the change in her daughter who still bears a huge T-shaped bandage from her operation two days ago.
"She's a completely different colour," she exclaims, as Fima now has enough oxygenated blood running through her system.
Before, Fima would miss three or four days of school a week, but now Shebaka can send her to school safe in the knowledge that she won't collapse.
"I used to see her heart beating furiously, and now it's calm," she says.
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Source: Al Jazeera