Phnom Penh Heart Center, Cambodia, 2006
Following his successful trip to Cambodia in March 2005 to perform heart surgery on children with congenital (present at birth) heart disease, Dr. Jonathan M. Chen again led his group to Cambodia earlier this year under the auspices of the Surgeons of Hope Foundation. The trip undertaken by Dr. Chen's team of doctors and nurses from NewYork-Presbyterian Hospital (both Weill Cornell and Columbia campuses) was part of a larger initiative in which pediatric heart surgery teams from developed countries help to build surgical expertise in Cambodia.
In addition to Dr. Chen, the team included Dr. Alejandro Torres, a pediatric cardiac catheterization specialist; Dr. Stephanie Levasseur, a pediatric echocardiography specialist; Kevin Charette, a pediatric perfusionist; Dr. Johanna Schwarzenberger, a pediatric cardiac anesthesiologist; Jillian Kirkpatrick, a pediatric ICU nurse; Dr. H. Michael Ushay, a pediatric intensivist, and Ellen Moquette, a pediatric catheterization nurse.
Hefty dose of ingenuity
The group took on 12 cases in five days, with the procedures performed in The Children's Pavilion, the three-year-old pediatric unit of PPHC, which serves more than 240 Cambodian children a year at no cost to their families. Upon their arrival, Dr. Chen and his team had to use a hefty dose of ingenuity to perform the catheterizations, since the hospital's catheterization lab - undergoing renovations - was only a dirt floor. "We thought to ourselves, 'There's got to be something we can figure out,'" says Dr. Chen.
The team sent Dr. Torres and one of the nurses to nearby Calmette Hospital, a very under-equipped facility, according to Dr. Chen, where they borrowed an orthopedic X-ray machine that could provide still images of the heart for the catheterizations. Under normal circumstances, the procedure is performed by a cardiac catheterization machine that provides moving images of the heart. "It (the X-ray machine) was like a Jalopy to the cardiac cath machine's Ferrari," Dr. Chen says.
To make up for this lack of sophisticated imaging, "they did some wild things," Dr. Chen recalls. "Stephanie (Levasseur) had a video function on her digital camera and took videos of sequential X-ray stills during the catheterization procedure. This enabled Alejandro (Torres) to properly size and deploy the catheter device." Thanks to this makeshift method, doctors determined that three children had operable hearts. "Otherwise, we would have had to pass them over," Dr. Chen says.
Multicultural team finds ways to communicate
The cases this year were more complex than in 2005. Five children from a hospital with no operating room in the town of Siem Reap (which houses the ruins of Angkor Wat) three hours north of Phnom Penh arrived for treatment with a variety of complicated problems. One had Total Anomalous Pulmonary Venous Return (TAPVR), a congenital heart defect that usually kills babies as newborns. Due to abnormal development of the fetal heart during the first eight weeks of pregnancy, the vessels that bring oxygen-rich (red) blood back to the heart from the lungs in TAPVR patients are improperly connected. But this child, says Dr. Chen, did not have the pulmonary venous obstruction that usually is a part of TAPVR, a blessing that had enabled him to survive. The New York team performed a catheterization and then a complex operation to repair the TAPVR.
One of the incremental improvements in 2006 was the addition of two more junior Cambodian surgeons to the team. The teams used a combination of English, French, and hand signals to communicate. "Teaching the Cambodian surgeons wasn't unlike teaching residents or fellows here," says Dr. Chen, who instructed one on how to close a Ventricular Septal Defect (VSD), a hole between two chambers of the heart. (The septum is a wall that separates the heart's left and right sides; a defect between the heart's two lower chambers (the ventricles) is called a ventricular septal defect.) Says Dr. Chen, "He was surprised I asked him to do that."
All of the members of Chen's team donate their time and use vacation days to pursue these trips. Chen noted that one of the most important things the team could leave the Cambodian doctors and nurses were skills they could use. "It's never about the number of cases you do."
Phnom Penh Heart Center, Cambodia, 2005
In February 2005, under the auspices of the Surgeons of Hope (SOH) Foundation, Dr. Jonathan Chen led a group of nine cardiovascular specialists to the Phnom Penh Heart Center where they helped doctors there diagnose, catheterize and operate on children with congenital heart defects. In addition to Dr. Chen, the team included William E. Hellenbrand, MD, Chief of Pediatric Cardiology at NewYork-Presbyterian Hospital, and Charles S. Kleinman, MD, chief of perinatal cardiology at NewYork-Presbyterian. Also included were: Kevin Charette, a pediatric perfusionist; Dr. Johanna Schwarzenberger, a pediatric cardiac anesthesiologist; Jillian Kirkpatrick, a pediatric ICU nurse; Dr. H. Michael Ushay, a pediatric intensivist, and Ellen Moquette, a pediatric catheterization nurse.
The group took on 23 cases in five days, where Dr. Chen operated with the Cambodian surgeons on nine children in all. The procedures were performed in The Children's Pavilion, the two-year-old pediatric unit of PPHC, which serves more than 240 Cambodian children a year at no cost to their families.
Prioritizing cases, developing a strategy
Current estimates suggest that 100,000 children in Cambodia suffer from heart disease, and probably one-tenth of those are in need of critical cardiac surgery. Faced with this overwhelming demand and working on a very tight schedule, Dr. Chen and his colleagues immediately prioritized cases. First, they identified those children who would benefit most from a single procedure. Next, they prioritized the cases they believed might become inoperable within several months before a team of European physicians would arrive. Finally, they determined which operations would be low-risk enough that proper follow-up care could be administered, and straightforward enough that they could be replicated by the Center's own surgeons. "All of this is so PPHC can become a self-sustaining hospital that can really help these kids," Dr. Chen said, underscoring the strategy of the SOH foundation to establish hospitals in less-developed countries and train local medical staff to provide the highest quality care.
One of the operations Dr. Chen performed was a complete repair of a congenital heart condition called Tetralogy of Fallot. Babies with this condition are born with a hole between the left and right side of the heart and an obstruction of blood flow to the lungs, impairing the ability of the heart to deliver oxygenated blood to the body. Open-heart surgery is required to seal the hole. Dr. Chen also operated upon a child with a subaortic membrane, or area of fibrous tissue below the aortic valve that obstructs the flow of blood through the valve. The surgical repair for this condition requires stopping the heart, opening the aorta and removing the obstructing tissue.
"It's a whole new era"
In addition to heart surgery, the teams performed several cardiac catheterization procedures. A less-invasive approach, catheterization involves inserting a small, plastic tube through a peripheral vein or artery (such as in the groin) and threading it into the heart for diagnostic or treatment purposes. Dr. Hellenbrand used this technique to take pulmonary artery pressures to determine operability. He also repaired several cases of patent ductus arteriosus, an opening between the aorta and pulmonary artery that normally closes after birth. Using a catheter, Dr. Hellenbrand placed a small metal closure device over the opening, thereby preventing the abnormal outflow of blood. According to Dr. Chen, "The local medical staff had never seen pediatric cardiac catheterization. It's a whole new era. Today we can do a lot with catheterization that spares kids from open-heart surgery."
The pediatric patients ranged in age from one to 16. They came from all over Cambodia; some were referred from smaller satellite clinics where earlier diagnoses had been made. The Center allows them to stay with a family member at no cost, and even allows the children to attend school there thanks to funding from paying adult patients and donors. Dr. Chen reports that the working conditions were quite good, and the 50-bed facility was well designed, well equipped, and very clean.
All of the members of Dr. Chen's team donate their time and use vacation days to pursue these trips.