Humanitarian Surgery Trip: Yerevan, Armenia

Yerevan, Armenia, the site of our latest humanitarian surgery trip, is a city of about 1.5 million people located in one of the oldest regions of human civilization. The country sits on the north border of Iran, the east border of Turkey, the west border of Azerbaijan and the south border of Georgia. It has been continuously inhabited since early Old Testament times and was the first country to adopt Christianity as a state religion in 301 AD. The LDS Church’s humanitarian service, LDS Charities, organized the trip with Malayan’s Eye Hospital in Yerevan. Dr. Armine was our host. She is one of the few, if not the only trained oculoplastic surgeon in the country.

Eye surgeons in Armenia

Dr. Armine and Dr. Harris

Dr. Armine was fellowship trained in both the US and in India. However, being the only person among millions who does a particular job doesn’t give you an opportunity for collaboration or to compare your techniques and outcomes with someone else.  Our mission as dictated by LDS Charities is to teach what we know to others so they can become more self-sufficient and need our services less in the future. As such, we saw some of her more challenging patients and came up with treatment plans that she could carry out.  For the most challenging, we planned surgery so she could see how I was trained to do a procedure and incorporate those skills into her repertoire. It was great working with a surgeon that already had advanced skills and knowledge and just needed some extra help with complex decisions.  Her patients are in good hands.

Eyelid surgery in Armenia

Teaching eyelid surgery in Yerevan, Armenia

Armenia eye patients

Armenia eye patients

It just so happened that there was a holiday on Thursday and the hospitals and government buildings were all closed. We took advantage and drove out to a few sites.  About 35 kilometers from Yerevan is the town of Garni, where an ancient Roman temple was constructed around 125 AD. It sits right on the edge of cliffs leading down into a beautiful gorge cut out by flowing rivers.  Quite a site.

Garni Temple, Armenia

Garni Temple, Armenia

 

We then went up the road a ways to Geghard monastery, which was built between the 4th and 13th centuries, slowly carved out of a mountainside. A portion of the building is hollowed out rock with amazing domed rooms. A spring ran across the floor and light flowed in from oculi in the ceilings.

Geghard monastery, Armenia

Geghard monastery, Armenia

 

Our last day was spent visiting the town of Artashat, about 40 kilometers from Yerevan, where a beautiful clinic has been built. LDS Charities purchased some much needed equipment to treat advanced diabetic eye disease. I also spoke with the doctor in charge, Kristina Hovakimyan, about returning to teach her some basic oculoplastic techniques.  Hopefully, we’ll see her on a future project.  While there, we had an impromptu consult on a young boy with a tumor growing on his eye.  This was an immediate reminder of why they need instruction on how to deal with these issues. Of special note, nearly every ophthalmologist I met in Armenia was a woman, which is in stark contrast to the US, where until only recently women were entering ophthalmology in significant numbers.

Arteshat clinic

Artashat clinic, Armenia with Dr. Hovakimyan

Armenia is a beautiful place with wonderful people.  We hope to return again soon. The amazing doctors there are doing great work and their patients are lucky to have them. Our next humanitarian surgery trip – back to Haiti in September with my former partner Branson Call who inspired all this.  We’re looking forward to it!

 

 

I’m on my way back from another week in Haiti.  I had many profound, disturbing, humbling and enlightening experiences. I thought I’d share a few here and try and put in words what you would experience if you made a similar trip.

Eye clinic

Eye clinic in Port-au-Prince.

First, I wanted to address the title of this post.  The “Third World” is actually an outdated and useless term, which came about after World War II to describe countries that neither belonged to NATO or the communist bloc.  This third group of countries were very often also poor and the two labels become synonymous. What the term does however, is lower these countries to a status unbefitting of the people living there.  There is no doubt that Haiti is poor, but to cast it and its people aside as being in a different world is unfair and detrimental to understanding their plight.  It takes around an hour to fly from Miami to Port-au-Prince, hardly a world away (remember when Haitians were crossing to Florida in rafts). In truth, they live in exactly the same world as the rest of us, that world just hasn’t given them as much to work with.  As a kid, I never wondered if my next meal was coming, or if I’d have access to clean water. The power was on 99.9% of the time, along with either the A/C or heat.  And if, God forbid, I or someone I knew got sick, I knew every possible treatment was available to them.  These all seemed to be my right as a human.  So when you see people who have little to no hope of achieving many of these basic rights, you can’t help but wonder what is going on in this world.

The good news is, I also saw hordes of people, mostly from the US and France, visiting on mission trips.  Most were with church groups building schools and churches, establishing water sources and doing ministering.  Everyone was jazzed about the difference they made and many talked about what they were planning for their next trip.  You can’t help but think with all this help coming, more than 3 years after the earthquake, it is only a matter time before momentum brings real change to Haiti. Just sending money to their government won’t help, just ask Somalia, Ethiopia, Sudan….

Just a couple of stories of patients I met.  I saw quite a few children with facial deformities due to tumors or hemangiomas, but also due to trauma.  Trauma was the theme of the visit.  This great young kid had been hit in the face by someone a few weeks earlier and had a persistently swollen right eye. I was worried about a foreign body.  During surgery, I encountered a hard mass against his eye and tenting the conjunctiva out where it appears red and swollen in the photo.  It turned out to be a chunk of bone that had been dislodged from inside his eye socket. No one had examined him thoroughly and this had been missed.

orbital fracture

Young man with medial orbital wall fracture

The same day, we saw two men in the ER who had been assaulted. One stabbed in the eye, the other shot through the cheek, with the eye being the exit wound.  Nearly every face we saw seemed to have some sort of scar.

facial trauma

Several cases of facial trauma

The young man with the stab wounds above had 4 1-0 sutures closing all his lacerations.  1-0 suture is usually used to close very thick tissues, such as the abdominal wall, not delicate structures like eyelids.  I removed them and replaced them with about forty 6-0 and 7-0 sutures.  The young woman above had numerous scars dating back to the earthquake, which split her eyelid in two and left it retracted.

post ops

Several post op patients

Her repair involved borrowing skin from her right upper eyelid to lengthen her left upper eyelid, as well as a full thickness resection of her scar and realignment of her eyelid margin.

The cases we did were all difficult, but the cases we couldn’t do were the hardest to deal with. We saw several patients with large growths emanating from various parts of their faces. They had saved money and paid for a CT scan (around $300, average monthly income is $60).  The scans showed invasive tumors filling their eye sockets and often extending into their brains.  Surgery was not an option.  When I’d recommend an oncology consult, the residents would shrug.  They knew that even with a consult, the treatment necessary would not be available in most cases. As one resident said when I asked her to explain to a patient what we were seeing, “tumors don’t go over well here, everyone knows they are going to die.”

orbital masses

Orbital masses

Anyone interested in helping us out, can either donate to CharityVision or contact our office. Every trip we identify a slew of instruments and supplies we need to offer better care.  Any help with attaining these supplies is greatly appreciated.  My retired partner, Dr. Call, and I have committed to having one of us visit every 3 months. The needs are seemingly endless.

I was invited to accompany Dr. Branson Call, my recently retired partner, to Port-au-Prince, Haiti in late spring of this year.  He has been traveling there on humanitarian missions for about 10 years making several visits per year.  In January of 2010, Dr. Call was in the operating room, getting ready to start surgery on a Haitian man when he says the floor started rolling and the lights went out.  All in the room hit the floor and for the next few minutes were tossed around, rolling into each other.  When they emerged from the building, the city was in chaos and scores of thousands had been killed.  A nearby nursing school had collapsed, killing some 30 nursing students.  Dr. Call spent the next few days treating trauma patients with the most meager of resources.  He eventually made his way out of Haiti on a bus to the Dominican Republic, where he reunited with his wife.  Over those few days he had no communication with his family back home, so their relief at his return was momentous.  I give you this background story so you can appreciate his dedication to Haiti and its people.

Dr. Call performing one of many operations in Haiti

Dr. Call performing one of many operations in Haiti

Our arrival was relatively uneventful.  We were delayed a day after tropical storm Isaac blew through the Caribbean and past south Florida.  The ride from the airport was eye-opening for someone who had little experience with the third world.  Throngs of people everywhere among houses reduced to rubble (or in the slow process of being reduced). Trash strewn streets framed arteries of people flowing in all directions or huddled in clotted masses around impromptu markets and street-side restaurants.  The energy was palpable, but felt like it was racing out in all directions, but accomplishing little.

waiting for water

Waiting for clean water in Port-au-Prince

We arrived at the hospital early Tuesday, a single story concrete building with visible cracks and rents in most of the walls.  A large crowd of people was assembled out front.  We pushed our way through the mass, past a metal gate and into a small courtyard ringed in short banana trees with a central awning and concrete half-wall seating.  A small meeting room and a few examination rooms also opened onto the courtyard with the small operating theater near the back of the plaza.  The facilities were Spartan, but adequate.

Young woman with anthrax scarring

Young woman with anthrax scarring

We quickly went to work seeing patients, many of whom had traveled some distance.  I was immediately struck by the amazing variety of pathology.  Most every case was far advanced, or what may be considered end-stage in the US.  Tumors that filled eye sockets, horrific scarring from previous anthrax infections, scarred eyelids with eyelashes curled in and abrading now opacified corneas, all seemed commonplace in this unfortunate group of patient.  A parade of children with small and large tumors was brought in. Some thankfully were benign dermoid tumors, scary in appearance but ultimately harmless.  Others were huge and disfiguring causing destruction of the eye or indicating a serious pervasive, likely life-threatening neoplasm.  When a young lady walked in with a simple drooping eyelid, I felt relieved that at least on case would be straight-forward.  I would later retract my enthusiasm.

Teenage girl with tumor

Teenage girl with large orbital tumor

Once we’d filled our day’s schedule, we headed to the operating room.  The Haitians are very curious when it comes to sterility and behavior in the OR.  They are almost fanatical about certain things, such as not wearing scrubs uncovered outside the OR, while they use the same gown throughout an entire day of surgery.  They often pass instruments back and forth between operating tables (we are operating simultaneously on two patients just a few feet apart) as long as they perceive the instruments haven’t been contaminated, but they are able to effectively reuse many items we would consider disposable, stretching the articles life far past it viable use.

The adventure in third-world surgery comes when the patient is prepped and ready.  As a surgeon, you quickly develop a plan in your mind based on the pattern of disease before you.  A ptosis surgery will require a skin incision, exposure of the levator aponeurosis via dissection through several delicate soft tissue layers and measured advancement of the eyelid muscle tendon to raise the height of the lid.  In an ideal situation you’ll have delicate instruments for the task. In Haiti we had a literal grab bag of old, dull and oversized instruments to choose from.  This turned straight-forward surgery into difficult surgery and difficult surgery into extremely difficult surgery.  After a few cases, you just accept the situation and muscle through, which is easy when you see the joy you bring to patients with no other hope.

Tumor excision

Tumor removal in young woman

After 3 days of case after case our time was done.  We packed up, boarded our plane and headed out.  On our drive to the airport we drove through the biggest tent city left from the 2010 earthquake.  USAID tarps held up with old boards random pieces of sheet metal went on for miles.  I was heading back to my house in the mountains with A/C, fresh water and warm beds.  We may have helped a few, but thousands more still need our help.  You can’t leave Haiti without already formulating a return plan in your mind.

Post-op patients

Post-op patients

 

Haitian residents

Haitian ophthalmology residents with Dr. Harris and Dr. Call

Our second day of lectures and surgery was much like the first, only the Vietnamese doctors were eager to get their hands into the work and apply what we were showing them. On day one, a certain doctor followed me closely, recording with his cell phone several of my procedures.  He stood so close with his phone that at times it blocked my view.  I could tell he was paying close attention because he would comment if I did something slightly differently than I had explained in our lectures.  I would explain that every case is a little different and there is a time for following the textbook and a time for customizing your surgery for the patient. He wanted to know what prompted my every decision and was clearly a very perceptive and intelligent man.  On this second day, when I returned to start a particular case after scrubbing, I found him in my chair at the head of the bed.  I asked him if he was ready to lead the case, which he said he was.  I let him at it and he did a marvelous job.  He clearly had some surgical experience as he handled the instruments with confidence.  He would clarify the surgical steps with me just to be sure, but it was amazing to me how fast these doctors picked up our techniques.  I have no doubt they’ll be able to continue performing many of the surgeries we taught them. 

Dr. Call giving instruction

 
Recovery
 

Dirty feet, happy patient

 Our last day in Dong Anh was spent doing a few extra surgeries in the morning.  We then left our hotel there and moved to downtown Hanoi.  On our way we met with a few other hospital administrators.  It seems once word gets out that you are willing to come to Vietnam and bring equipment with you, lots of hospitals want to convince you to come the them on your next trip.  The following day we travelled out to Ninh Binh, an outlying area with a large eye hospital.  We looked at their needs and assessed what we could do on a future trip.  They then took us to a few of their nearby tourist sites, which was very nice.  We saw a thousand year old Buddhist temple and a newly built, massive pagoda.  The country-side was beautiful the people were all very gracious.  We look forward to returning soon.

 

God of Ninh Binh

 

Big pagoda

Vietnam 2012

Several months ago, my partner Dr. Branson Call asked me if I’d like to accompany him to Hanoi for a medical mission he and LDS Charities had been planning for several months. I jumped at the chance. After a few delays, we finally made our way to Vietnam on March 4th.

Me giving the wife a last photo op
 
Dr. Call and the rest of the throng boarding our last flight from Taipei to Hanoi.

 

Day one:

We arrived in Hanoi around noon on Tuesday the 6th. We came via San Francisco and Taipei. We were met by a couple of LDS Charities service missionaries, Brother and Sister Michel from Sandy, Utah. They have been in Vietnam for almost 16 months and have spent over a year organizing our trip. When you combine the church and a communist country, the amount of red tape required to accomplish anything becomes daunting. Nonetheless, they managed to secure a new operating microscope, several trays of oculoplastic instruments and other incidental supplies. They were a very enthusiastic couple and were a great help.

 

The Michel’s rode with us by taxi to Dong Anh, a town outside of Hanoi. We met the doctors from the hospital at our hotel, where they had a very fancy lunch for us, including barbecue pork, salmon, various soups, rice and lots of great fruit. One fruit called buey (sp?) appeared like the inside of a grapefruit, but was much sweeter. The dragon fruit was also very good. From lunch we went to the hospital a few kilometers away. The building wasn’t in great shape and due to the high humidity, most of the buildings start looking run down quickly. We went inside and had a planning meeting for the rest of our trip, which we were told would consist of lectures in the morning to various doctors from the area, followed by lots of surgery in the afternoons.

 

That afternoon, we proceeded to a small clinic next door, which contained 1 slit lamp microscope, a table and chair, and a few other random pieces of equipment. We were quickly introduced to the Vietnamese way of doing things. This seemed to involve a huge mass of people all entering a room at once listening in as each got a 2-3 minute exam. We saw 40 or so patients that had come, 31 of which we felt could use surgery. We saw several children with congenital drooping eyelids, older ladies with eyelid scarring from trachoma, a young man with a disease which causes all the eye and eyelid muscles to stop moving, and a baby with a blocked tear duct. There were a few young people with facial scars due to accidents that hoped to have them revised. We got through all of them by around 5 o’clock.

 

 
 
 

By now Dr. Call and I were pretty beat, so they took us back to the hotel and we sacked out. I woke up at midnight feeling well rested and ready to work, but had to will myself 3 more hours of sleep. After that I was wide awake.

 

Day two:

 

We arrived back at the hospital on the 7th and were taken to a room where a ceremony was to be held to hand over the donated equipment. It was essentially a photo op for both LDS Charities and the local government. Several local journalists were there along with the president of the province. We were given some nice gifts and thanked for our time.

Afterward, I gave two lectures to the doctors on surgical techniques and eyelid reconstruction. It was challenging because the translator, a kid named Dat who was a non-member home from studying at BYU, didn’t know medical terms. I have no idea how accurate his translating was, but the audience seemed to be getting some concepts as they asked insightful questions.

 

Afterward, we had a quick lunch and then headed to the OR. (Just a word about Vietnamese people: they are small. Dr. Call and I are both well over 6 feet. They wanted us to wear these sandals everywhere in the hospital, but only had a size 8 or smaller. Needless to say we walked pretty funny trying to keep those things on. Thankfully we brought our own scrubs.)

 

They had just one OR running for the two of us. Again, it was similar to our clinic experience: lots of people milling around who may or may not need to be there, all standing one inch away from you wanting to see what you are doing. They had two beds, one next to the anesthesia machine, the other solo. A few patients were brought in and laid down and the pandemonium started. 20 voices all shouting at each other in Vietnamese, people crisscrossing everywhere, doctors smacking nurses backs when they didn’t listen, the same nurses laughing at each other for getting smacked. In the US you’d be appalled at how unorganized it all seemed, but here you just couldn’t help but smile and see it as and adventure.

 

We proceeded to start cranking out surgery after surgery. We had a few kids wake up during their cases, people showing up in the room with scrubs asking if they could be added on, people answering their cell phones and talking while leaning way to far into the surgical field. One guy decided he wanted video of the ptosis surgery I was doing, so he whips out his iPhone and holds it 6 inches from the girls face the entire case. It never dawned on him that this might bother me, so I didn’t let it. We got through fifteen cases that afternoon, which was amazing considering what we had to work with. However, you can really motor when you don’t have to dictate, chart orders, or even change your gown. We no sooner finished one surgery before they had the bed ready for the next patient. It ended up being quite efficient.