The Value and Weaknesses of Medical Mission Work in ARM

So for the next part, we have a little bit on international brigade or mission work regardless how you call it and uh this part, this first session is gonna be, we're gonna have some uh different presentations later but in this part we're just gonna have an open discussion with Mark about um international work. I'm gonna ask him some tough questions and you can also help me with coming up with questions and participating. And uh making this like a forum more than like a, a 1 to 1 interview. So Mark, Mark, as you all know, he has um a foundation, it's called CTO and he has a lot of experience with many years of uh international um work where he goes to different countries, teaches local surgeons, does some surgery, and as you know, um, a lot of people are critical of that kind of work. Uh, not specific of marks, but generally of medical admission work, especially in anorectal because of the worry that there may not be enough for good follow up, um, so. Mark, in your eyes, what, what is the biggest advantage of this type of trip and going to a different place and operating there? Yeah, I, I, I, I think the criticism is valid. Um, you have to You have to recognize what what are you trying to do. Um, and what? You have to, uh, that's too much almost you, you have to, um, ask yourself what exactly are you trying to do, and I think what my goal has always been to make the team, the local team better, um, to try very hard to be in a teaching mode, not to go there and do lots of complicated cases and then run away. I think you have to be aware of the burden you place on the institution because if you do lots of cases, they may not have the nursing care to help those many patients in the post-operative period. And if you do cases that require an ICU and there's no ICU, you've done the patient a disservice. So I think you have to choose carefully. I think you have to um bring a team. I never go by myself. I always bring colleagues in surgery and anesthesia and the nursing, um, and volunteers as well to try to have a total experience. But I, I will tell you, I, I go there sometimes with a lot of um uh trepidation. I'm nervous that I. Don't wanna do something that then requires postoperative care that they. Can't deal with. So, one of my uh criteria is whoever is the lead surgeon locally, I always have them come visit first, so I can get to know them and see if they're honest and ethical and understand the protocol and know how to do the workup and also are they good communicators. So, if I send them an email, do they answer the email? You may know maybe that I answer my emails quickly. Uh, do I, do I? Yeah, but sometimes I'm traveling and it's not 4 o'clock in the morning. I got an, I got a, I was in contact with, do you know, Summer, she, her quote, her paper was quoted today from, from China, and we were emailing and she says you should go to sleep. And I said, why? It's 9 o'clock in the morning. It's like just because you think it's anyway. Um, so I like to know that they have good communication. I mean, for example, our team was just in Armenia, and I would say we've had almost a daily email with the list of patients and all the postoperative issues, and it's been a month, and there are a lot of things to talk about. Patients are doing well, it's good news, but sometimes they need intervention. So I think the criticism is valid and you have to understand where you're going and you have to understand what you're trying to accomplish, but what is the alternative? The alternative is don't go, don't help. Um, I can't honestly do that cause I know there's an incredible need and the need will never be achieved. I mean, we. Could have 5 lifetimes and still not go to every country and operate in every city and help all the children that need to be helped and I strongly recommend you do this work, go see what's out there if you're at a, uh, every time I hear an American surgeon complain about their situation, I say, why don't you come on a trip and go see what. Real surgery is actually like and how hard it is for the surgeons and the nurses and how hard it is for the patients. And I promise you, you'll stop, immediately, we'll stop complaining. Great. And when you're traveling to different countries, each country has their own culture, a know different medications to use, different, uh, like specific things that are quite different. Do you prepare yourself before going there in those? Yes, so we have the, um, well, there's a surgeon to surgeon contact. We, so we know all the patients that we will meet in the clinic and all the patients that we will meet in, meet in the operating room. And I insist that the anesthesia speaks to the anesthesia and the nursing speaks to the nursing, um, so we're prepared, um, and, uh, usually most of the places have the basic necessities, but we often travel with surgical instruments. We, Lone Star, for example, they often don't have the correct cautery, they often don't have, we bring that with us. Sometimes gowns and gloves, and we always bring suture material because that's like made out of gold and we don't wanna take their supply. So that's all that stuff is usually donated, but that's important to think about. We have lists, so I mean we've learned over the years how to, how to do it right. I mean, you need flexible people. I mean, for example, I remember we were somewhere, I think we were in Ethiopia and the only anesthetic agent available was halothanee. And luckily we had a senior anesthesiologist that knew how to use halothane because most junior anesthesiologists don't even know what halothane is and uh it's very difficult, it's much easier. The anesthetic agents are easier these days because they reverse quickly. Um, so that's an example, like, I had no idea what to do, but luckily, I had a senior anesthesiologist said, oh yeah, I know what to do. So Do you have any statistics, how, how many patients you have been able to treat with your foundation since you started this work? I mean, I, I know, I know every place we've gone and I know how many patients we've taken care of at each place. Uh, I've never published that. Um, but, uh, yes, uh it's usually around, it's usually about 3 OR days, 3 or 4 OR days preceded by a clinic day. And depending on how many ORs they can run. 12, or 3, that's how many team members we bring, and then it's usually somewhere between 15 and 30 cases. And um another thing is because I think there are two advantages to those trips. One is the service to the patient who may probably never get this type of surgery if there is nobody coming there to do it. The other one is the teaching aspect of it. And I guess. Trips are different in the sense that in some cases you, the teaching is the more important or more prominent than in other cases or places is probably the service to a patient. Service to a patient is uh a very punctual service. You, you, you may be able to help them, but that's just a, a small number. If you are able to teach. You are able to uh help much more. Are there places you come back more often, or uh you, you're building up as a center? Yeah, I think going over and over again is a really important, um, a, a really important concept. I think the best example, at least in my experience, has been my time in, in Ghana, where they got better and better and better every year. We went. I'll, I'll tell you a, a great, uh, story. So do you, have you heard of the, um, Uh, it's called Operation Smile for cleft lip. So there's also something called Smile Train. So, um, a guy named, um, uh, Jim, uh, Mullany went, he was a volunteer, he was a businessman, he went with, um, Operation Smile. And they spent a week And he, as a businessman, was very frustrated because what he said was, they took care of 100 customers, customers, but there were 200 customers that they didn't serve, cause they were only there for a week. So, he didn't like that model. Like from a businessman point of view, there are 300 customers, you need to take care of 300 people. So he started Smile Train, which had a different concept, and that concept was to train the surgeons so that the 1st 100 was for training and the next 200 that didn't qualify for that week for whatever amount of whatever time was available. The new, the surgeons now have the capacity to help. So I, I bought into that. In fact, he was written about in the New York Times Magazine. This was probably 15 years ago, and I wrote him a letter. Businessman, multi-millionaire, and I wrote him a letter saying, I'm very impressed by your approach and we do something similar, and would you be interested in supporting us? I said, we bring smiles too. Right? Cause they only help cleft lip and palate, right, smiles. So, um, one day, the, my secretary says, Jim Mulaney is on the phone, wants to speak to you. I get on the phone, he goes, I was very impressed with your letter and we'd like to support you. So they actually gave us several years of grants. Um, to help with colorectal cases because it's a similar philosophy. I think it's really important. So, uh, you, I, you have to go there to, you have to create a sustainable model. Otherwise, you're just going there, you are providing a service to the patient, that's true. But then what happens to the patient that didn't make it to that OR day? What happens the following week? And the other story that I tell a lot is, you know, the story of the starfish. Yes, people are nodding, right? So there was a boy on the beach and uh the tide was low and all the starfish were. Baking in the hot sun. And he starts throwing the starfish back into the ocean, and an older fisherman comes and says. What are you doing? How could it possibly make a difference? Look at all these starfish, and the boy said, makes a difference to this one. Right? So, you are providing a service to that child, but the worst part of the experience by far is seeing other children that you, you can't help. But then you say, well, this patient can wait and then you come back, you come back the following year, so. It's a practical. I wish I could do it every day, but I can't. And my last question before I open the questions to the public is, uh, is there a specific case that um sticks to your mind as one of the most happy moments and is there a specific case that sticks to your mind as one of the saddest or bad complication moments and what can we learn from those? Yeah, it's sort of sad that I immediately knew the answer to that question because I, there are two cases that stick in my mind. One, should I say the good one or the bad one first? Oh good, so we'll end with something positive. So yeah, the bad one is I, we were, we operated on a, on a child and um. Somehow, Paula knows this case. We were together and um in the postoperative period, we were already home, we were getting emails about that the child was not doing well, and I kept saying, the patient needs to go back to the operating room. I don't know what's wrong, and they kept delaying and delaying and getting CAT scans and all this stuff, and every day I said, you need to do a laparotomy on this patient, and like 4 or 5 days went by and the patient died. And it was like a dagger in, in the heart for that, because had I been there, had I been properly invested in that patient's case and didn't have to fly away, maybe she'd be alive. That always sticks with me. And that's the kind of thing that you can be criticized for, I think, because did the patient get, get proper post-operative care? Maybe if you were there, the patient would have gotten better care. So, the other, the other side of that, uh, coin is the um I remember there was a girl. From, um, from Kenya. Well, there's two very good stories, and maybe I'll tell them both. One is a girl, a girl from Kenya with, um, complex, uh, with a cloacal atrophy, and she had, this is when I was in Cincinnati, and she had been approved for, um, for a charitable care. Um, but the waiting list was 5 years for charitable care. We could do maybe 1 or 23 cases per year, but they were approved and the cost was $120,000 120,000 dollars, and she was approved, but she had to wait for 5 years. And um the, the parents were great, very, and I said, listen, I'm, I'm going to be in Ghana. Could you come there? Let me at least look at the child, so I have a better plan for when you ultimately come to Cincinnati. So somehow from Kenya, the patient came to Ghana and we met them. And um we said, I said, you know what, this is not as complicated and I, as I thought, and we could do something very dramatic to make this child have a better life, but we have to do it here in Ghana. And in Ghana, if you're a child, you have healthcare insurance, but if you're not from Ghana, of course, they don't care to help a Kenyan child. So I said, how much would it cost to do the operation here in Ghana? And they, uh, they said it would cost $1400 OK. So I called my business person in Cincinnati and I said, I have a great deal for you. We have approved a $120,000 bill in the next sometime in the next four or five years. Can you wire me $1400 to Ghana? And I'll operate on this kid tomorrow, and then we don't have to spend $120,000 in 4 years. And he said, sure, let's do that. So we, they wired the money to the bursar of the Corlebu Hospital. Did anyone here from Ghana? No? And the money came, and then we operate on the girl the next day. And uh so it was one of those crazy international moments that I still remember and she did very well after that and never needed to come. So The other, the other story like that was a, um, uh, there was um an email from a general surgeon from Cameroon, a general surgeon who sent an email to the only pediatric surgeon he knew, which was his friend from the military. Uh, not me. And he sent an email and said, I took care of this baby. I don't know what's wrong with her. I did a colostomy and she survived and sent some picture. And that guy is a pediatric surgeon, says, I don't know what's wrong with her either, maybe Mark knows. So he copied me on the email. And I saw the picture and I said, yes, I think that's a rectal atresia. And it could be fixed. The families from Cameroon. In some village, and they never left that village, and I was on my way like 2 months later to again to Ghana, and I admit I opened up Google Maps to see where was Cameroon relative to Ghana. Does anyone know? Yeah, it's, I mean, it's like saying like, uh, I don't know, is Siberia close to Austria? Yeah, it's pretty close, right? Um, so I said, is there any possible way that you can get that child to Ghana? I'll be there in 2 months, all on email. And the guy said, Are you crazy? This family's from a village, they've never left, they don't speak the language, they need, they need to cross several countries to get there. I said, I can help that baby, but you need to get them to Ghana. And this is the, the power of mothers. I have a lot of respect for fathers, but mothers are. Mothers are. are different. So somehow this mother, I, I still am amazed, appeared in the clinic in Ghana with this beautiful baby with rectal atrisia and a colostomy. And um, so, um, we operated on the baby and the mother, it, it was fascinating because they, um, in, in Ghana they speak English. The mother didn't speak any English, she spoke a dialect. And had a little bit of French and Efo Jesse is the professor of surgery, pediatric surgery in, in Accra, and she trained in France, so they could communicate, which was quite beautiful. We operated on the baby and sent the baby back to Cameroon and the general surgeon closed the colostomy. So these are the kind of things that, you know, really get you in your heart and it's why you keep trying to do this um with all the hardship and difficulty and challenge and finances and all those kinds of things, but I think ultimately it comes down to we're here to improve the life of another person, so if you have the opportunity to do that, you should do that. Mark, thank you very much. Is there any? Anybody who wants to comment or question. So I have a question. Oh, OK. Well, uh, Mark, a message from Zagreb, the host next year. Well, I, I would say we, we were working on the rectum malformations and Hirsh spring and other things, and I must say that the, that the real, uh, uh, beginning of the new future of anorectal malformation was after the CTO visited, visited us in 2016. That's in fact when we started to work properly and when the Wider society see the problems and everything what they were facing before, but they didn't see. So I can just thanks very much to Mark and CTO that they visited us and to help us to improve our knowledge and to start working properly. Thank you. So Mar Marco is a perfect example of, of successful partnership. Marco visited. He was very committed. He was very good communicator. His colleagues like him and listen to, I mean how could you not like him? He's very lovable. His colleagues and the nurses, they all like him, they listen to him and they were willing to be excited about learning new things. I think that's really important. Not everywhere I've gone are the is the team excited to do something new, then you know it's gonna be a failure, but if they're excited to do something new as the Croatian team was. And then you start getting these emails like we did the first transanal and we did a redo PARP and it was successful and we did the first Malone in Croatia, etc. etc. then you really realized that you made a, a, a very positive impact. So you were a very good example. We look forward to visiting you again. Thank you, Mark, for helping us. Hello Stefan. Uh, I have two questions. So one would be, um, you mentioned that you invite the surgeons, the lead surgeons, and you, um, check them somehow. So what do you mean, uh, when you check them if they are ethical? Do you, do you check if they're honest, if they're attentive to results, or what do you check? The second question would be, um, you're talking about a lot of data that are Switched uh around like with emails about these patients. Am I correct? So, I mean, I, I don't want to be bothering, you know, but it's, it's the time of, you know, European Data Protection Act and all this stuff and we have to obey and, and we can't really, you know, send this and that anymore to our patients. So how do you deal with that? I mean, those patients, who is seeing these pictures and data that you send via email? Um, so thank you for making me nervous about something I wasn't nervous about before. Thank you. Um, now, usually, um, most of the communication is with, uh, just the initials of the patient, so there's, uh, in some way that's sort of a hidden, um, you don't need to put the full name. So we do respect that somewhat, but yes, if someone hacked my email in theory. There could be a breach of some sort. I, I, I agree, but we use just the initials of the name. As far as getting to know them, you know, it's like getting to know anybody. Are they, are they nice? Can you relate to them? Are they friendly? Do they follow their results? Are they honest? all of those things you, you go have a beer with someone, you can most of the time figure that out. It's like an interview. Um, and usually they come for 1 week or 2 weeks or 3 weeks or a month or sometimes even longer, and you get to know, you get to know them. So. I don't know. I've, I've, I've been a good judge. I haven't made a mistake yet. So there's some people in this room that have been on these trips, maybe they wanna make some comments. Maybe Stuart, Stuart is a regular and Paula comes a lot and anyone else here and, and I also really wanna hear from the nurses, uh, Stephanie um has made a very positive impact on the nursing component of CTO. I would never travel without a nurse. I'm useless without a nurse, um, and, uh, Stephanie here somewhere? Yeah, so maybe we'll have you comment about your CTO experience, Stuart. It has been a fantastic experience and uh there are many things I really appreciate. One thing is It is a group of people interested in the same topic, and it's like a brotherhood. And at each trip, everybody learns a lot, um. And I think the, the, one of the important things is, is, is, it's not about going to do fancy surgery. It is about communicating to the local surgeons. Working together with them. Um, and trying to make a difference at that place. And I think it is very important to have nursing personnel and having anesthetists as well because only by doing that, you're able to change all the, the, the, the surroundings who you're working with. And we ourselves, we learn a lot. So I, every time I learn a lot, I'm very, very thankful about that. So I, I wanna recognize someone in the room. Who was the first person I visited. Juan Craniotis, you know that, right? The first trip ever was in Honduras, and since that time, and Juan is, you cannot find a better human being and a better partner, but since that time. I would predict if you consider my time with you, then Carlos and Richard's time with you and I Alex is also Alex the urologist from here as well has come and some others in the room have been to Honduras. There must have been 7 or 8 trips to Honduras, right? And every time I think, uh, uh, the team, the local team got better and better and better and better. Um, that's the, that's the really the best example of sustaining, um, the model. So Juan, do you wanna say something? Um, uh, I hope everybody understand, um, my English. And thank you, Mark. I'll translate. I hope everybody understands my English um. Uh, I didn't know about this until I, I start reading the discussion and then I was there. You didn't tell me. Um, thank you, thank you very much what you have done. Um, what I remember is that I went to Cincinnati and I spent more than a month over there. And I attend the. The conference that you did with uh Doctor Pena. And then I show you. With the Motorola phone, but that time, I show you a 15 year old girl with a Cloeca. I think do you remember her, Ricky, yes, um, he got interested because we have a lot of patients and I didn't have really a training in colorectal surgery, but in my country we are very few pediatric surgeons. I was trained in Mexico City. And not. Maybe none of them like uh colorectal that I did, so I start, you know, to do colorectal surgery. So Mark came to Honduras and, and, and trained me and then um years later, Carlos came and uh Mark always busy. He didn't want to come back again, but he went to Honduras for about 3 times. Yes, I wanted to come back. I'm just kidding. Um, and then, um, I have been going to, um, now to Columbus. To the conference and um with Carlos and Richard. And uh Chris Christopher from South Africa, they I've been having more and more experience and what we do in Honduras is uh I formed the first anorectal clinic in the country. I do one day a week consultation and now about 10 years later, uh, patients come from all over Honduras. And sometimes from uh countries nearby El Salvador, Nicaragua. And um I checked the patient, we have a, a paper and I check everything kind of uh Mark sent me when with how to capture the patient and I, you know, omit a lot of things because in Honduras, I cannot, I have like MRI things like that and uh and then um I take pictures and, and I write, write all the notes and I prepared the patients for the, we discuss the email, we discuss everything and these days we have a, a group that is called uh Care one. So you can write, you, you have a password and it's very close, uh, group, and then you can, you can uh discuss cases before they go. And I take care of the follow up. And I'm writing a paper. Studying the the patients that I used to do with the help of students. And the patient we are doing and the result are amazing. Yeah, for me, for our country, this has been a, a blessing. And it works and uh we are very grateful and I now I send them uh uh videos with rectal stimulation and and sphincter contractions and things like that and I'm very proud to. To be here And uh thanks again, Mark and Carlos and Richard and everybody. So where the case you reminded me of that I think we ultimately operated on her when she was 18, that's a Cloaca patient with a colostomy and never touched until age 18, and she wanted to get married, so she wanted normal anatomy. That's something you don't see right in the United States, an 18 year old with a colostomy never touched, but we successfully, um, successfully repaired her. She's married now. So the surgery was OK. So thank you very much, Mark. uh thank you Juan. I think we've stretched, we're over time, but uh so we have to continue, uh, but I think this discussion was worth it. Thank you very much.