9UNP0179SD_Delora_Mount_WordPress

- Thanks for having me come back and talk again today about our experience with UW Division of Plastic Surgery and the international surgery trips that we do. I'm glad that Vincent started off by saying that this is not a mission, because there's no religious affiliation with this, which most people would think of with a true mission. So we're going to talk a little bit about what our group does, what kind of patients that we see, how do we actually get set up to do an international surgery project like this. And what are the long-term ramifications. But if you remember with your geography, Nicaragua sits right in the center of Central America itself. It's bordered on the north by Honduras and also by Guatemala over here. And then, to the south, Costa Rica. And Nicaragua has some very interesting things. It still has active volcanoes. 

And while you're there, you can occasionally see a little puff of smoke rise up, which is always a little nerve racking. And you notice the blackness of the sand here. It's the only beach I've ever been on that actually had truly black sand, because it's all ash from the volcano. But then also, it's a very beautiful country, with lots of hills, a mountain range that goes right through the middle. And I'll tell you why that's important, to know the geography, in just a moment. But the towns themselves are pretty sparsely populated throughout the majority of the country. Only in Managua is there really a large concentration of people in one segment. Now, the project itself, I consider myself to be a newbie with the project. This is me all dressed up ready to go to work. This is our main hospital that we work out of, which is really where the major university is for medical education. 

But Dr. David Dibbell, who was the former chairman of our division, really started this, as well as with Dr. John Noon, who just retired from Dean St. Mary's. They actually came up with this idea for an educational cooperative quite some time ago, in 1991, and have continued to be active participants, but sort of handing it over to us newbies. Then, the one constant in the entire equation is Dr. Gustava Herdocia, who is the plastic surgeon that we connect with in Nicaragua to make this cooperative work. So how do we actually set it up? And by the way, if you guys have any comments or questions, this is very informal today. I want everybody's input if you've got any comments. 

This isn't just the only way that things can get set up for an international surgical trip. And it's certainly not the only specialty. Certainly, other surgical sub-specialties may have very good and capable ways of doing things, such as ENT. I see a doctor shaking his head, "yes." They actually go to Honduras, as well as some of the other surgical teams, such as orthopedic surgery with Dr. David Mann, who also goes to Honduras and Guatemala, and I think will be branching out to China soon. But also for medical specialties, family practice, pediatrics, our university really has a very unique global health division, a very active global health interest. And that also goes across other aspects of the school, including the School of Veterinary Medicine, and some of the other humanities and groups amongst campus. So what do we do to actually get ourselves established in Nicaragua? First, we did a needs assessment. 

This kind of came out of a trip with Dr. Noon when he was a medical student, when he was sitting exactly where you're sitting. He took one summer and went to Nicaragua. This was right before the big conflict that occurred with the Sandinista and the Contras. And he went down as a medical student for basic purposes of immunization, general healthcare and hygiene education. And while he was there, he really fell in love with the country. He established some long-term contacts in an area named Bluefields. Then, when he did his residency here, he also talked with Dr. Dibbell, who was also becoming very involved with a lot of international surgical trips. They decided that they would choose Nicaragua as a focus for plastic surgery. 

Why did they choose Nicaragua? Well, actually, they did a lot of their homework, as far as traveling there, seeing if there is a role for reconstructive plastic surgery; what it is, where the deficits are; where the people are; what are the barriers to care. All of these things had to be delineated before starting the project. So they found out, really, the majority of the country outside of Managua was really kind of a remote area. The advanced reconstructive opportunities in that region for patients that had problems was very, very minimal. They also found that one of their major barriers was actually the supplies. And the reason for that is that Nicaragua is an extremely, extremely poor country. Certainly, the poorest country per capita of Latin America, and perhaps even the world. And because of this remote area, and this mountain range that I told you that sits right through the middle of the country, it makes travel there very difficult. The infra structure is still very immature. 

And it's a very difficult place to get around, even if you do have money. We also found that there was a place for education and training. So we partnered with the Universidad Unan-Leon. And the reason that they chose this university for partnership was because this was a university that had an adjunct medical school and they were very, very interested in learning reconstructive techniques in plastic surgery. In Managua, there is another very, very large and also a very good plastic surgery training program. They focus primarily on cosmetic surgery. And cosmetic surgery is important, but as you know, that's not all there is to plastic surgery. But then, most importantly, they wanted to keep this whole idea as really a cooperative. So there was going to be a consistent professional exchange of ideas, not just a colonialistic, like we know all of this medical knowledge, you know nothing, we're going to come down and demonstrate to you how to do things, and this is the way it is. We wanted it to definitely be a an inter-relational type of exchange, and certainly to try to minimize the colonialism. 

So the typical mission that we do lasts between seven and ten days. There are two trips. One in the spring and one in the fall. Actually, our spring trip participants just left, so they're down there and active right now. I haven't heard from them, so I think that they made it okay. Usually, we don't hear anything unless there's bad stuff going on. And this is one of our typical clinics in Jinotega. Now, Jinotega is a mountain town in the north central portion of the country. And it's in the mountainous region itself. The patients that come for this clinic really have to travel quite a distance, and usually with remote ways like through walking, hitchhiking, through mules, through horses. 

Some even take three or four days to get to the clinic. There's not really a set clinic time. So like when you go to see your doctor in your clinicals here on a rotation, you may notice that people are assigned a specific time to come in. You know, your appointment is at 9:00. Your appointment is at 9:10. Well, it's not like that. It's everybody just starts congregating. And it's not even a first come first served issue. It's usually, we try to triage the children that are in most need of surgery, and especially primary surgeries, meaning the first time they have surgeries, over children that may need a touch-up, or that live locally, or that are advanced age. And generally, there are about 50 to 75 clinic visits. 

This is done as a large cooperative. You can see, here's Dr. Vince's bald head, or almost bald head! Don't tell him I said that! We're getting ready to go into these small rooms over here. And basically, each of these children with their parents will come in and we'll examine them as a unit, including our anesthesiologist, to determine whether or not surgery is possible; whether they're healthy enough for surgery; and what day we're going to do it. And again, in this seven to ten days, we do see a lot of clinic visits. Although, you may notice these numbers aren't as big as Operation Smile, or these numbers aren't as big as InterPlast. Well, there's a purpose for that. During the time of the clinic visits, we also are involved in heavy teaching and heavy discussion amongst the two groups of surgeons, both the Nicaraguan surgeons and the United States surgeons regarding what is the appropriate thing to do; what do you think is going to have the best outcome. 

And so, we're actually doing that clinical teaching and education at that point. It boils down to about 25 to 35 major surgeries. These are, the majority, cleft lip and palate, and pediatric plastic surgery procedures. So I mention that Nicaplast, which is the core of our group in Nicaragua have faculty. But then, also, we're very keen on bringing our residents and staff, too. So the plastic surgeons usually consist of one Nicaraguan plastic surgeon and two American, sometimes three American. Anesthesiologists, one Nicaraguan anesthesiologist, sometimes two. And then two American anesthesiologists. The residents are actually the key, I would say benefactor of this educational cooperative. That includes both the residents here, as well as the residents there. 

Because the residents actually are also teaching each other during this experience. They're also in contact with anesthesia residents in Nicaragua. Nicaraguan anesthesia residents rotate with us while we're there. And then, as well, our surgical technologists, nurses that accompany us on the trip, also have a teaching opportunity and exchange with the Nicaraguan groups. So here's a few members of our team. This is Dr. Cari Meyer, who is a specialist in pediatric anesthesiology here at the Children's Hospital. And then here's one of her little patients that she's getting ready to put off to sleep, who has, as you can see obviously, a right unilateral cleft lip and palate. Here's our resident, Jay Lonner, who is an anesthesia resident working with the anesthesiologist from Nicaragua, Dr. Rubert. 

And again, once we arrive, we're really more of a cooperative than here's a student and here's a teacher. We try to mix it up, because certainly, I've learned as much from my Nicaraguan counterparts, including the Nicaraguan residents, as I have taught them. Here's some of our other anesthesia groups. And again, you can see, just friends, but you can see that everyone is smiling. It's really a great cooperative. These are long-term relationships. Like Dr. Cajina, for example, was a resident that we met when he was an anesthesia resident. Now he is anesthesia faculty, who is also doing more teaching in Bluefields, which is on the Atlantic coast. Again, this provides an opportunity for educational exchange that really is unmatched anywhere else. 

These are exchanges that can't occur in just a meeting or presentation. Literally, a hands-on procedure, where you may have a resident. This is our resident in plastic surgery from America, Dr. Malhotra. This is Dr. Herdocia, who is the faculty at Nicaragua. And this is Dr. David Dibbell. And so, this just really shows you, almost like a triad, of grandfather, father and son, as far as the educational process goes. Now here are two of our residents actually working together. 

And our resident, Dr. Stephen Delatte, who is now in practice in Louisiana, is actually learning from Dr. Jose Cruz, who is the Nicaraguan resident, who was just a little bit ahead of him. He's taking him through how to do a cleft lip repair. And again, as I mentioned, it's very, very important to include the entire process with our exchange, including everyone in the operating room. So I have learned all of the names in Spanish of the surgical instruments. I'm proud to say. It took me seven years, but I finally did it. It's really, really nice to work with different, you know, we don't just work with our own surgical technologists and our nurses that come with us, but we also mix it up a little bit more. We may be doing a procedure using instrumentation that they haven't seen. 

On the other hand, we may be learning substitutions and things, since their supplies are so limited. They truly are, I would say the thing that I learned the most is how to do a whole lot with very, very little supplies. In Nicaragua in particular, they don't even have suture in a lot of cases. How are you going to perform surgery if you don't have the appropriate suture? So they learn how to modify. They learn how to scrimp and how to save; how to re-use. They're the ultimate green, as far as medical care goes. That's why they're all wearing green. Just kidding. But they do actually have very sanitary conditions. 

Occasionally, we'll have a bug that crawls through, or a fly that comes in. But for the most part, very, very sanitary conditions, very up-to-date operating systems. This is one of the anesthesia machines that are there. The problem is just those supplies that you have to use on a daily basis. Their government can not provide, and the Ministry of Health, because the country is so poor. I don't know what exactly I was doing in this picture, but you know, we all work together. And this woman was helping us with turnover between rooms. And you can see that the rooms are very spacious. This was a picture in Bluefields of an operating table. It may not be exactly the same model as what we have here in the U.S., but it holds the patients. 

And it's really, really a great opportunity. This lady, for example, is the same lady that has been working there in the hospital operating rooms for the entire times that I've been there. And you get to know these people. You get to actually develop a lot of long-term relationships, which are great. So after figuring out what they wanted to do when they were there, it was time to get busy. So, we started seeing children that have all sorts of advanced issues that you might not see. Like for instance, this child with a bilateral cleft lip. This child in this picture is a ripe two or three years old. In the United States, this is a child that would get repaired at about six weeks of age. And so, I have to learn some different modifications. 

How do I close this around the teeth? Normally, I close this when there aren't teeth there. Or, how do I close it in that age of the terrible two's? Any of you that are parents know that it's a terrible time to try to get a child to do anything, and cooperate with surgery. And so, we do see a lot of advanced disease and a lot of older age, as far as seeing things. Another thing that we'll see are procedures that have been done previously, but maybe not so well. That's an area that we struggle with constantly. Is it better to have at least the lip closed so that this child can attend school and be more socially accepted in their environment, or when you come back and you see a patient like this that's been cared for by somebody that doesn't have a lot of cleft experience. Their nostril is completely closed. They're unable to breathe through this at all. 

They've got terrific asymmetry, and basically need a revision that includes taking the entire repair down and re-doing it. That's something that we struggle with a lot, because people will do what they can do, what they feel comfortable doing to try to better the care of this child. But in some instances, it makes the re-repair or the touch-up surgery much, much more difficult, particularly when it comes to palatal surgery. And there are some things that we see, for instance, this child with a burn, that are so advanced stage and so long-term sequelly. I mean, his tendons were all fused. His bone was all, you know, different angulation. It was just so dysmorphic that there was really nothing that we could offer this child, except for an amputation. And this child in particular would use this deformed limb as a helper hand. And so, he elected to keep it. Again, in the United States, or in other more developed countries, this would never occur, because at the time the scarring would happen, we would have special garments. 

We would have a different kind of burn care, initially. So you do see a lot of advanced processes that, unfortunately, you can't do much about. We also see a terrific amount of burns. In Nicaragua in particular, there are a lot of open-air cooking techniques that are still used in houses. And so, they'll have like basically little camp fires in the middle of the house. And the baby or the toddler, you know, mom can't be every single place to watch over the kid. And they fall into the fire, which is what happened to this child. And you know, what do you do with this? It obviously needs advanced grafting. We're not going to be there for very long. 

How do we actually overcome this? Well, it's basically working in cooperation with the surgeons there that are going to be more of a sustainable model for care of their own people. So, the majority of our trip, you know, the first issue is actually service. So we do provide service, particularly with the backlog of cases that have accumulated and help the local surgeons, sort of catch up with the volume of things that are coming and being presented to them. But then in addition, we are teaching more advanced techniques. And, you know, doing this educational cooperative with the local surgeons. And here I am with Dr. Cruz. Actually, I'm taking the picture. But I had just given a lecture on how to do a plating of the cranio-facial skeleton for people that have traumatic injuries or congenital bone deformities, showing them proper techniques of how to put on plate and screw fixation. 

In Nicaragua, unless you're in Managua at a specialist in oral-facial surgery, you're options, if you break your jaw, if you have a trauma and break your upper jaw or face, your options are no treatment or treatment with wiring your jaw together. Those are your two options. Wiring your jaw together itself is not acceptable, or not associated with great outcomes. But it's the best outcome they can get. Wire is cheap. People know how to put on wires like really quickly there. And sometimes, it can be done even without general anesthetic. But plating really kind of takes the whole bone healing, post-traumatic reconstruction to a new level of sophistication. I'm pleased that we've been able to really partner with them as far as teaching techniques, going over case examples, going over, as you can see with this model here, these aren't real bones, by the way. These are made out of plastic. 

They come with, you can actually make the fracture lines on them. You can give them plates and power tools, and show them how to actually place the plates. Again, the problem with this, even though they're very good now at plating, is the fact that there are very few plating companies that will give their product for free to underdeveloped countries. We're still working with them on that, as far as trying to get either low-cost or no-cost product into the hands of the surgeons there. They know the technique, but again, if they don't have the equipment or supplies, it's very hard to do. Here, you can see that they're very proud about their little save. They've done all this facial reconstruction. This is Dr. Noon. These are some of the medical students and residents who were there. 

So we not only teach, as far as some of the basic principles of reconstructive surgery, but we also go over some of the more advanced techniques in cosmetic surgery. You may say, well, that seems backwards. Why would you teach a little bit of cosmetic surgery when you're on a project that really is to help people who are under-served? Well, the reason is we want to make sure that all of the surgeons in Nicaragua basically are equipped to do both cosmetic surgery and reconstructive surgery. The reason is all the reconstructive surgery is reimbursed, albeit in very, very small amounts by the Ministry of Health. And if a surgeon with the best of intentions, said, "Okay, I am going to take care of only reconstructive patients in plastic surgery, and particularly, I'm going to take care of children," they couldn't afford to feed their family, their own family. So the cosmetic surgery education is also to help them survive and thrive in their own communities. So generally what happens is in the morning, the local surgeons will do their cases for cleft lip and palate, other reconstructive operations, trauma, limb deformities, things like that. And that's their work for the government. And then in the afternoon, they go to their private clinic and perform cosmetic operations. 

The cosmetic operations are not covered by insurance or the Ministry of Health, and so they would be paid outright for that. They're truly doing this Robin Hood thing in surgery, by not robbing from the rich, but providing a service for people that can afford it and then using that money to protect their family and take care of their family while they're able to provide these other services for the less fortunate. So really the goal for the Nicaragua experience, first is service. But we want to make sure the service is actually sustainable service. As you know, there are some groups that will come in and do a bunch of operations, take care of a lot of people that really need taking care of, with very complex problems, but then they have to return. There's not anyone to keep it sustainable. So our project in particular, that's been our goal from day one, to make a sustainable global health cooperative so that each of the residents that finishes the program in Nicaragua, as well as we hope each resident that finishes the program here, has a continued interest in taking care of the under-served population. This man is actually from Viet Nam from a trip that I took in January. And you can just see by the look on his face, and I thought it captured it so well. You know, he's here with his son. 

His son had his cleft lip repaired. And you can see his mode of transportation, which is going to be basically walking. And you can see this look on his face, like, you can see a little look of gratitude. You can see a little look of oh, my gosh, I'm really scared because my kid looks very different. And you also see, like, a little look of desperation, like, I still have a really long way to travel to get back home. This is a man that came from the mountains. It was going to be at least a couple days travel with his child that just had had surgery a couple days before. You can see the little baby. He's kind of going, yeah, whatever. Educational exchange, again, because of the sustainable nature of things needs to be paramount. 

And it's a two-way exchange. It is not a one-way exchange by any means. And the other very good thing about this is the ability to interact within a completely different healthcare system. This is a system that is either you pay cash for a service or you have the governmental healthcare, which is a very, very low reimbursement for the physicians. It's very intermittent, very spotty. And then there are not supplies adequate for the population that needs it. And then one of our final goals with this project is to foster a lifelong interest. And we're hoping that the next generation coming through, such as Laura, are going to continue to want to do these service projects, as well as global health, because we really are becoming quite a small world. We want to promote the UW idea, the Wisconsin Idea, global health. And some of the future directions that we're going into include using some of the techniques that really have made the globe a lot more accessible for everyone, including a real time Internet broadcast of our Grand Rounds presentations, which allows for educational exchange on a didactic level, and even case sharing level to some of our international audiences, including in Nicaragua, Ecuador and hopefully within the next year or two, Thailand. 

There are obviously some issues that occur with a global health interest in Thailand, that don't occur with Central and South America, mostly because of the different, completely opposite time zones, which is quite a bit different. If any of you guys do any stock market work, and you're looking at the markets that happen in Japan and Europe and looking at the time delay between our market here. Obviously, it's difficult with coordination between those two, especially for things like Grand Rounds that are broadcast. So we may think it'd be great to have a conference at noon. Well, guess what? It's midnight in Thailand, so maybe that's not such a great time to have a conference. And all these things need to be thought through as well as the travel issues. So anyway, thank you very much for your interest. And I hope that you're all interested in global healthcare to some extent. And hopefully, you'll also see that surgery in particular can be very, very nicely wedded between service, international education and basic human responsibility.