Resident Scholar Report: Dr. Heckman in Vietnam

IVUmed Traveling Resident Scholar Report

Jennifer Heckman, MD
University of Wisconsin
Hue, Vietnam
March 11 – 19, 2016
Mentor: Steven Kahan, MD

Sponsored by:  North Central Section of the AUA

Hue is a city in central Vietnam on the banks of the Perfume River, where I was fortunate to be able to spend a week working alongside local urologists.  While in Hue, I had the opportunity to observe and participate in the delivery of urologic care, from didactic instruction in conferences to teaching at the bedside and in the clinic to involvement in the operating room in a variety of surgical procedures.

Through my wide range of experiences, I was able to appreciate both the similarities and differences in urologic practice and training in comparing Vietnam and the United States.  Fundamentally, in both settings, the focus is on evaluating and managing medical and surgical diseases of the male and female urinary tract systems and male genital system.  Basic surgical principles and techniques, too, transcend geographic borders.

The burden of disease as well as the access to and delivery of health care, however, differ vastly between countries.  With regard to urologic disease burden, the diversity of cases I saw in Vietnam was very different from that which I have become accustomed to in the United States.  A large majority of the operative cases for stone disease, for example, were performed using open or percutaneous techniques (as opposed to endoscopic management), a testament to both the differences in presentation of disease as well as in the readily available technology and skills in Hue.

The striking difference in disease presentation was apparent not only in cases of benign urologic conditions, such as the finding of a four centimeter ureteral calculus, but also in cases of malignancy.  In making rounds with the local urologists on inpatients in Hue Central Hospital, I met a woman with advanced bladder cancer whose initial presentation was with gross hematuria, anemia, renal failure, and bilateral hydronephrosis.  She and her family had traveled quite a distance from a more rural area to seek care in Hue after the agriculture season (the family’s livelihood) was complete. 

Such a presentation is not an uncommon one to encounter in Hue.  As one of the local urologists explained, in Hue, as well as in Vietnam in general, patients often present with later stages of disease, as limited resources, including time, money, and transportation, often contribute to delays in patients seeking necessary medical care.  Many people must often continue to work and defer medical care in order to support their families, sometimes at the expense of their own health.

The urologists in Hue are well-trained, and in a city of about 350,000 people, there are 12-15 urologists who practice in three hospitals and numerous clinics throughout the city.  Training is different from that in the United States, with medical school graduates paying to participate in residency programs.  Urology residency, like other specialties, is three years in duration, and in early post-residency careers, one sees young urologists practicing and operating alongside more senior urologists.

Urologists in Hue face unique challenges in working in a resource limited setting.  While in Hue, I had the opportunity to observe and/or participate in 11 cases, ranging from ureteroscopy to open ureterolithotomies to an open radical cystoprostatectomy with ileal neobladder.  There were notable differences in accessible equipment.  In the operating room, for example, there were limited instruments available, and fluoroscopy, too, was not always readily available or reliable.  In addition, certain disposable items were often sterilized and re-utilized out of necessity.  Different surgical skill sets were also apparent.  While open stone surgery was commonly performed, flexible ureteroscopy is far less often performed, and urologists cite lack of equipment and training as reasons for this disparity.

Despite the material, financial, training, and infrastructure challenges faced by urologists in Hue, the practice of urology is well-adapted to the environment.  The capacity for fundamental urologic interventions exists, and while technology is not as advanced as it may be elsewhere, the surgeons have excellent technical skills, and though resources are limited, the urologists are very resourceful.

It was a privilege to have the opportunity to work alongside the urologists in Hue and participate in the delivery of urologic care.  I was able to view urology through a new lens, and through this experience, I gained practical experience in a new environment.  To see another country and its people and to begin to understand not only a different healthcare system and its challenges, but also a different culture, has afforded me a unique perspective.   I have made new connections with colleagues that will hopefully prove to be long-standing relationships, as I incorporate global health practice into my urology career.

Dr. Temitope Rude, IVUmed Resident Scholar, Travels to Uganda

Resident  Scholar:  Temitope Rude, MD; New York University

Location/Date:  Mbale, Uganda; December 5-12, 2015

Mentor: Eric Richter, MD

Sponsored by:  The New York Section of the AUA

Extract from Dr. Temitope Rude’s Report:

“This trip would focus on teaching endoscopic techniques to treat the significant burden of disease from urethral stricture and BPH. We were also delivering new equipment purchased by the Mt. Elgon Hospital with the support of Storz Company and private contributions.

I got my first sense of the depth of mutual respect and appreciation when we arrived at our hotel at 11 pm after significant traffic delays to meet many physicians from the hospital who had waited to welcome us in person. The following day, as we prepared the operating theatre for the surgical camp, I was struck by the commitment and ingenuity of our hosts. New state of the art endoscopic tools sat beside the urologic tools that Dr. Kirya had in many cases designed himself, employing local metalsmiths to fashion retractors and reliable irrigation.  The disease that we treated was quite advanced compared to what we typically see in the States.

As a surgical resident, I’m always happiest in the operating room. This was amplified many times over as the surgical team bonded throughout the week. There were the deeply rewarding moments where we were able to step back and watch Dr. Kirya perform endoscopic treatments with growing skill and confidence. And then there were the frequent times we relied upon the ingenuity and resourcefulness of our Ugandan colleagues to complete cases with our customary tools, learning a pocketful of new skills to share at home.

The friendships that we built with the nurses, anesthetists and medical trainees flourished. They started with a shared optimism and heart to serve, but grew with mutual respect and shared triumphs and good old-fashioned inside jokes.

The most transformative part of the IVUMed surgery camp for me, occurred as we rounded on our post-operative patients each night. After all the obstacles, sweat, focus and determination in the operating theatre, it was easy to fixate on what could have been different or better in the States. I would become preoccupied with these differences, hoping that we were really providing the best care for our patients.  Over the week, I learned the power of humility and observation as every patient continued to improve with the focused clinical care delivered by the staff at Mt Elgon Hospital. Our hosts’ creation of a system of clinical acumen to ameliorate the limitations of supplies and finances was excellent and inspiring.  Their families stayed in the walkway outside the wards, keeping constant vigil and support, greeting us as well.  I wished there was some way to let them know the gratitude I felt for them in turn and for this life-changing experience.”

Dr. Kovell Reports on Resident Scholarship Experiences in Vietnam and Mozambique

In December 2014 and May 2015, Dr. Caleb Kovell participated in IVUmed’s Resident Scholar program, traveling to Vietnam and Mozambique.  Dr. Kovell’s experience was made possible by the generous support of the Mid-Atlantic Section of the American Urological Association.   He was accompanied by Joel Gelman, MD in Vietnam, and Ryan Terlecki, MD in Mozambique. 

Reflecting on his experience, Dr. Kovell reported, “From these trips, I will take with me lasting friendships, mentors, and connections from here at home and across the globe.  Over the course of my IVUmed experiences, I had the chance to work with some incredible surgeons and innovators in the field of reconstructive urology.  (Joel Gelman, Johan Naude, Igor Vaz, John Lazarus, Sanjay Kulkarni, Aldo Marchesini, Pippi Salle).  These are names that I had always heard about and read about in the world of international reconstructive urology, but thanks to IVUmed, I have had the chance to meet them, learn from them, and count them as colleagues and friends.  During my two trips, I interacted with numerous urologists from Vietnam and specialists from around Africa.  We had the chance to share our teaching with them, and assuredly they taught us a great deal about their cultures, patients, and health care systems.   Most importantly, we formed lasting bonds with the patients who we cared for and their families that I will never forget.  Hopefully we have been able to change their lives for the better as well.”

He added, “Over the last year, I learned a great deal about urology and reconstructive medicine.  Thanks to IVUmed, I also was able to experience first-hand what it takes to successfully translate these skills to international locations.   These trips have confirmed for me that I will make international medicine a significant part of my urology career moving forward.  I hope that a large part of that will involve continued collaboration with an organization as wonderful as IVUmed.   I was truly humbled by the experiences.   Thank you again for everything.”

The Latest from Rwanda

As our IVUmed team wrapped up their week in Rwanda, Dr. Alli Greening reported,

“I’m now finishing up about 40 hours of air travel in a little over a week, am confused as to what time it is, and exhausted from a busy OR and teaching schedlue. I am also really excited to have identified some problems with the anesthesia education and hopefully our next steps in Rwanda. I am already figuring out how to improve anesthesia education there, and hopefully not only bring it up to a  level commiserate with their surgical capabilities,  but make it self sustaining by beginning to work with a core group of providers and develop a curriculum that they can then teach and disseminate to others, something both myself and Bob Nguyen feel is a key concept in this project.

Despite the jet lag and exhaustion, when Bob asked if any of us would like to return next year, every one of us immediately raised our hands. As I sat at the Hotel Des Mille Collines (former Hotel Rwanda) celebrating with a drink on the way to the airport with part of the team we remarked this was each of our favorite mission ever. The team dynamic had been phenomenal, we had seen really substantial progress in the two surgeons, and were talking about future direction with very appreciative and committed higher ups at both hospitals.

Cheers to Rwanda 2016!”

Reporting from Rwanda

Dr. Alli Greening reported the following regarding work by the IVUmed currently in Rwanda for a week-long pediatric workshop:

“Where to start… the first day in the theater at the military hospital in Kigali was today. Rather than a hospital for military personell this is more like a hospital run by the military for the people of Rwanda,  a place that attracts a number of high complexity cases from around the country. With this being the 4th of 5 trips we’re expecting the local team to be doing, well, most of the doing as we slowly step back.

We managed to meet our goal of getting 4 cases in each of our two rooms despite having an almost continuous string of roadblocks hurled at us.  As soon as I would start talking and drawing on a topic the Rwandans turned into rabid learners. At one point I could barely move, with two medical students,  two nurse anesthetists,  and a physician anesthesiologist all practically on top of me while I was talking about airway obstruction.  This is exactly why I love IVUmed so much, we’re not just swooping in, doing cases, and coming home, but are there primarily to teach and our Rwandan teammates are not going to let a morsel of knowledge get by them.”

– Dr. Alli Greening

IVUmed Resident Scholar Dr. Michael Amirian Travels to Ghana

Surgical Team

Dr. Michael Amirian’s IVUmed scholarship experience in Kumasi, Ghana was made possible by the general support of the Mid-Atlantic Section of the American Urological Association. During his time in Ghana, Dr. Amirian was accompanied by mentor, Carlos Angel, MD.

Regarding his experience in Ghana, Dr. Amirian reported, “I immediately felt the warmth and selflessness of the other team members upon my first meeting with them.  Some, like Dr. Carlos Angel and Michael Felber RN were international mission veterans, having done many of these types of trips. Our other attending, Dr. Christi na Ching, had participated in IVUmed as a resident scholar during her urology training and could not wait to return as an attending.  It was my first trip of this nature but knowing others had been in my shoes before made me much more comfortable.

In the OR – Ghana

While there were numerous complex cases of varying degree, one that I found particularly challenging was that of an 11-year-old girl. She was born with bladder exstrophy and had suffered her entire life with this condition.  Her bladder, after years of exposure to the environment, was ulcerated, and excoriated.  She was in constant pain.  She was completely incontinent. Needless to say, her quality of life was abysmal.  Many of the usual reconstructive options were limited as she would not have any long term accessibility to catheters. We reimplanted her ureters into her sigmoid colon, in a procedure named the modified Mainz II Pouch. It was remarkable to see her joy and big smile the next day when she looked down and no longer saw her constant source of pain.

Now that I have returned from my trip and have had a chance for introspection, I realize that I am included in the “many” of IVUmed’s mission statement, “Teach One, Reach Many”.   Thank you to the IVUmed organization for giving me the opportunity to be a part of this life altering trip as well as to the Mid Atlantic Section of the AUA for sponsoring me, and to Dr. Edouard Trabulsi for his mentorship and support.”

IVUmed’s Work Helps Combat Global Poverty

IVUmed experts provide hands-on training to build local capacity and increase access to quality healthcare.

According to the World Health Organization (WHO), 2 billion people lack access to basic surgical care. Access to specialized care like urology is even more restricted with critical shortages of trained personnel. The United Nations cites the unavailability of healthcare as one of the root causes of extreme poverty. Debilitating health conditions not only drain family resources, but also affect productivity and prevent many throughout the world from earning a living. A breadwinner unable to work due to illness, or family members obliged to stop working or attending school to care for a relative can lead to considerable loss of income and long-term poverty.

IVUmed works to make quality healthcare more accessible in resource-poor areas of the world. We build self-reliant surgical teaching programs capable of meeting the needs of their communities. By providing expert surgical training to physicians and nurses throughout the world, children and adults in need of care will not have to live for years with debilitating conditions that threaten their economic and overall well-being.

The Year Was 1995…Look How Far We’ve Come!

Twenty years ago, IVUmed was incorporated by its award-winning founder, Catherine deVries, MD, to address the enormous need for patient care and professional training in urology in resource-poor areas of the world. From common congenital malformations to pelvic floor injuries, various cancers and other diseases, urology represents a vastly underserved area of global health.

Initially established to help meet the staggering need for pediatric urology in developing countries, IVUmed has grown to include virtually all areas of urology and incorporates education for nurses, anesthesiologists, radiologists, pathologists and other related areas of medical and surgical care. IVUmed’s services have been requested in over 30 countries in Africa, Asia, Central America and South America. With a proven model that has helped to successfully build surgical training programs in countries as diverse as Honduras, Vietnam, Senegal and Mongolia, IVUmed tailors its efforts to the needs of each of its many partner hospitals and communities.  Our partners in these sites have demonstrated strong long-term commitments to IVUmed’s work and mission and will ultimately serve as a bridge between today’s investment of resources and our shared vision for access to quality healthcare in the future.

Our success is based on uniting peers and strengthening relationships among medical providers with a common shared purpose of ensuring access to quality urological care.

* We connect physicians and nurses in low-resource settings with experienced colleagues for peer to peer interaction.
* We provide hands-on education through ongoing on-site surgical workshops.
* We build self-reliant surgical teaching programs capable of providing local and regional education.
* We are the chosen provider of care and education in partnership with multiple global urological organizations.
* We identify, support, and develop future generations of IVUmed volunteers and host colleagues.

We have refined our capacity-building model over two decades and have become the go-to organization for urology training in developing parts of the world. Our intensive, onsite hands-on workshops equip physicians and nurses throughout the world with the skills they need to serve their communities. Meanwhile, the greater objective of IVUmed training is to develop future generations of medical personnel by building lasting surgical teaching programs. Your support helps ensure that children and adults in resource-poor areas of the world will no longer have to suffer for years with treatable conditions that greatly affect their quality of life.

Our surgical workshops are complemented by distance consultation and other means of instruction and support to help ensure that our partners progress toward their training goals. We also utilize telehealth technology for distance education and are collaborating on educational modules comprised of surgical video, lectures, medical animation, and testing.

Please join us this 20th anniversary year, on Facebook, Twitter, Instagram and Pinterest.  Together, we will make a difference!

IVUmed – Helping Children Around the World

IVUmed in Rwanda

IVUmed’s Pediatric Urology Capacity Building Program makes quality surgical care available to children around the world – especially in low-resource areas. We accomplish this by building a global network of train-the-trainer centers of excellence. There are no pediatric urologists in sub-Saharan Africa, Haiti, and many places in India, leaving millions of children without access to care for debilitating urological conditions.

Pediatric urology diseases, malformations and injuries are among the most common conditions affecting children worldwide, and are up to 10 times more common than cleft lip and palate. In the US, when a baby boy is born with a condition such as hypospadias (a congenital condition in which the opening of the urethra is situated on the underside of the penis instead of at its tip), surgery can be performed before the child is even out of diapers, and there are few to no lasting effects. In countries where this type of surgery is not available however, shame, poor self-esteem and secrecy surround this condition, which often results in adult infertility if left unrepaired.

IVUmed’s teams of volunteer physicians, nurses, and anesthesiologists provide hands-on surgical workshops, lectures, online educational materials, telehealth consultation, and impact measures to equip doctors and nurses with the skills they need to care for children in their communities. In turn, these newly trained medical professionals build future capacity for care by passing along IVUmed training to their colleagues, fulfilling IVUmed’s motto, “Teach One, Reach Many”.

IVUmed’s focus on education stands out among global health organizations, as does our focus on urology. Another unique element to IVUmed is our collaborative model. While IVUmed is guided by a dedicated board and staff, leadership of our programs stems from the dynamic doctors and administrators at our many partner hospitals around the world. Their priorities lead our efforts, which are put into action by our volunteer doctors and nurses. Together, and with the generous donations of many benefactors, we are building a worldwide system of pediatric training programs, ensuring that children everywhere will have access to the care they need.

With the help of supporters like the Ronald McDonald House Charities, the Societe Internationale d’Urologie (SIU), the American Urological Association (AUA), the Pan-African Urological Surgeons Association (PAUSA), and regional surgical associations, IVUmed is building a strong global network. Teaching hospitals throughout the world, skilled medical volunteers, ministries of health, local community leaders, international medical societies, regional colleges of surgeons, and charitable foundations combine strengths to give children everywhere the opportunity to lead the healthy, productive lives they deserve.

You can be involved too, whether a physician, engineer, photographer, philanthropist, medical student, etc.  We invite you to explore our volunteer opportunities here.  http://www.ivumed.org/how-you-can-help/

IVUmed in Vietnam

Surgical Groups Like IVUmed Can Help Combat Ebola Outbreak

“While the fear of Ebola delays efforts to treat surgical patients in need”, according to General Surgery News, “African surgeons do their best in time of fear and lacking resources.” See full article here.  For the last 20 years, IVUmed has sent groups of talented, dedicated medical volunteers into low-resource areas in Africa and around the world to teach local physicians and nurses patient care and management for surgical conditions in non-emergency situations. This training can also be applied to successfully manage public health emergencies like the Ebola outbreak. With strong surgical infrastructure in place, medical providers who have been taught by IVUmed already have the knowledge they need to meet the challenges of a crisis situation.

Local physicians and nurses are taught skills for acute care, patient management, sterile technique, and other key areas of surgical and infectious disease management. Additionally, successful treatment of the crippling effects of many surgical conditions builds the confidence of communities in their healthcare providers and hospitals to allow for more rapid and effective response to disease outbreaks. Since surgical success is plainly visible, local patients gain trust in the capabilities of their hospitals and hospital staff.

Through our Teach One, Reach Many model, IVUmed helps improve the overall strength of our global partner institutions.   Get involved and support the life-changing work of IVUmed today.  www.IVUmed.org