All right. We're going to go ahead and get started. Welcome to Global Outreach for Hand Surgeons. I wanted to thank everybody for being here 6.45 in the morning on the last day of the conference. Today we have a wonderful panel here today to talk about kind of the changing landscape of global outreach for hand surgeons and some ways to get involved. I'm going to start off by talking about the need in hand surgery. I think a lot of people here are obviously interested in global outreach, and we're going to talk about not only the need, but some ways to get involved and how to make the greatest impact. So we know that over 5 billion people lack access to safe and affordable surgical and anesthetic care. We know that over 150 million people lack additional services to save lives and prevent disability. Louder. Here? Okay. We know that trauma deaths account for a greater number of deaths than HIV, malaria, and tuberculosis combined. This disproportionately affects those in low and middle income countries, disproportionately affects those in the working class, and certainly has a great impact on morbidity and mortality. We know that the lifetime prevalence of upper extremity musculoskeletal trauma in specific has a lifetime prevalence of greater than 30%, and that hand and wrist injuries account for 20% of all emergency room presentations. We know that the cost morbidity of this is great as well. There's a very large direct, indirect, and intangible cost to upper extremity injuries. We know that the indirect costs account for the greatest amount of this, and we know that it's really hard to estimate intangible costs. These are rarely quantified and even less so quantified in low and middle income countries. Looking at the global burden of disease study from 2017, these are incidence numbers, so the number of hand and wrist trauma fractures was almost 200,000 and 100,000 patients, or people, and then thumb and non-thumb amps were 24,000 and 56,000 and 100,000 people. This burden is highest in South and East Asia, and we know that when looking at changes over time, that the change in the incidence is greatest in East Asia and low and middle income countries in general. So in thinking about making an impact, we know that the caseload is high, but in thinking about this equation, I think there's a couple different ways to approach this that are kind of changing how we're thinking about global surgical outreach, and we can look at this figure here that demonstrates surgeon density per 100,000 people in various different country groups, and you can see that the surgeon density is lowest, obviously, in low and middle income countries there. So there's a couple different ways to go about addressing this. Traditional mission trips, as we'll probably hear about today, typically address cases. You go to a country, operate, and maybe for a week or two, and then end up going back to your job, but we'll really try to focus here is on capacity building and how to make the greatest difference and try to change this balance of number of trained surgeons to cases to help treat those cases in a more sustainable manner. So this is our surgeon panel today, and I'm gonna go ahead and introduce our next speaker, who is Jim Chang from Stanford, also CMO of Research, talking about common and complex cases, when to and when to not operate. Thank you. Thank you. Good morning everybody. I'm gonna talk about when to and what not to operate. A lot of people get excited to go on trips and want to do good and you can also do harm, so we have to figure out when we can do good. So these are the ones you want, the easy ones. A little ganglion, a little extra polydactyly. So, the prerequisites needed for any trip include all of these things, obviously, but the most important thing, as Lauren alluded to, is a welcoming host, someone who wants to learn, someone who wants to continue this program over long term. If you really can't find the person to connect to or see as a future for that place, then it's really not worth going. Here are the problems you may encounter, inadequate equipment, no supplies, syndromic patients, no microvascular capabilities, poor communication, and especially no one to train. These are five cases to beware. When you go, sometimes there's a lot of pressure to do a case, but these may cause you a lot of pain. I was in Vietnam and a general from the Vietnamese Army came to me with a child with a missing thumb and asked for a total thumb transfer on the fly. It's very hard to say no to these situations, but you can imagine if I did it incorrectly and it fell apart, the type of problems I would get into. So, syndromic patients, patients with other craniofacial anomalies or heart conditions, of course, Volkman's contractures I'll talk about, severe contractures, needing free flaps and older children, as well as complex stage procedures, I'll go through these. So the first one to avoid are syndromic patients. The classic case is an APRT patient who has tracheal anomalies, sleep apnea, high secretions, and cardiac anomalies. You want to do that syndoctally, but your anesthesiologist may not be happy with the airway. A Volkman's contracture, so a lot of times you'll see these patients who've had non-orthopedic surgeons bind forearm fractures and they come up with, kids come up with a really shriveled arm, all the muscles are dead, chronic Volkman's contracture with extensive defects two to three years out. And really these take multiple stage procedures over time, it's a lot of surgery. Patients may expect a miraculous recovery, but as you know, at the most, even with a double gracilis, you get something like this. So it's probably not the one you want to embark on. Severe contractures requiring free flaps like this, you have to be aware of the extent of the defect and the need for a flap or something microvascular. Older children who have adapted, remember Adrian Flatt's quotation, functional triumph and a social disaster. This child was able to manipulate everything, go about doing her things, and it may not be the right thing to bring the finger back or to release that, reduce that central ray. And complex staged procedures, here's a cautionary tale. This is a child we saw in Cambodia. thumb. So I went in very excited the first year. Well I'm gonna come back next year. I'm gonna go we're gonna do a PIA flap, build up some tissue to that area. We didn't have a microscope so we did a PIA flap. Dr. Fox helped me. She was the resident. So oh my god we're doing the first PIA flap in Cambodia. We're so happy. So basically we put the PIA flap into that web space there to line it. That's the metacarpal of the thumb being prepared for the second stage. And you can see the flap being raised. Oh my god so great. We have all this. We're so much ready for the toe transfer to next year. We're coming back. And you can see how excited I am. But look at the patient. She's got like she's wondering I don't know if I want to go through this. And of course she never came back the second year. So if anyone wants to do a toe transfer I've set it up for you. But just be aware that you the secondary time they may not come back also. They have different things going on their lives. So those are things to avoid. The five great cases to do. Polydactyly syndactyly tendon injuries to nerve injuries. And I'll focus a little bit on burned hands. We see so much of that overseas. First polydactyly. Enjoy every minute. You feel so good when you take that. Look at that. I'm just hungry right now to do that case on the upper part there. I could just take it off. You look like a complete hero. Do these in the beginning of the case. It tests the system. Tests the anesthesia protocol. All that stuff. Pac you and everything. And then do the rest at the end of the trip because you know they'll be fine. Syndactyly cases. Everyone knows how to do syndactyly. Do them early in the trips. You can allow time for dressing changes. Tendon injuries. A lot of times there are tendon injuries like this that are easy to do in a secondary fashion. You can put those tendons together and recreate motion. I think this child had an EPL, APL, EPB out. And you can find them, dissect them out, and repair them. And do a lot of good even though they're delayed. And nerve injuries are great not only to reconstruct nerves but also to get rid of neuromas that are just torturing a patient as in here. You can get rid of a neuroma. So those are the easy ones. The better ones to do. And of course you're gonna see a lot of this. A lot of burn, hand, and skin grafting. I'll spend a moment on that. Like I said yesterday, don't underestimate the size of the defect. The size of the wound. Most likely you're not going to use microsurgery. It may seem that way but most of these do not need microsurgery. Use absorbable sutures obviously. Limit the extent of the operation. You may want to do just the elbow, just a wrist, or just a hand. And don't expect a complete release in full range of motion. Pain control is a major issue and so when we go on these trips we actually have pain regional catheters placed. They really help a lot in post-operative recovery. Teaches their anesthesiologists how to do regional anesthesia. And really the splint that you place So here's a wrist contracture and an elbow contracture. We decided to work on the wrist. And you can see just the power of scar control. This patient had a burned forearm and upper arm. And you can see where the normal skin is. That's all palmar skin that's into the mid forearm now. You just have to release and reestablish the original burn wound. You release along that dotted line. So the palm skin and forearm skin are different. As you can see there, that's all palm skin. Find a line of separation. Joints in these kids may seem deformed, but they're very limber. They'll be released. You don't need a capsulotomy. Diagnose where the skin is normal and cut along that line. And you can see from before, putting all that hand skin back into the hand. And then the defect there, of course there's lots of structures that all of you know to avoid and to keep covered with some tenosynovium. But you can see that defect goes all around posteriorly and you can simply skin graft that. So that's a great case to do. I showed this in my talk yesterday, but a similar concept of releasing the contracture. You may need to stage it. Now the nerves and arteries may seem scary in a burn, but they're really not. This is not Dupuytren's. Anatomy is not gonna be distorted. So once you start releasing the skin, the nerves will stay down. And make sure you stay right on the nerves. The arteries will stay down. So with a little bit of traction and gentle teasing, you'll be able to get that scar off. You don't need to worry about abnormal structures coming up at you. And I would avoid going into the joint because to get into the joint, you'd have to go through the flexor tendon sheath. And then you can't skin graft on that, on a naked flexor tendon. So just gentle stretching will usually release the joint to a good amount. And then you can use K-wires to maintain the position. So here's that thumb, wrist, and three fingers. You release it, see where the tightest point is, look at the normal versus the abnormal skin, take it back to its normal position. You know all about these structures to be aware of. Again, the nerves and arteries are usually down. They're not distorted, they're just burned. And this is the release that's seen here. There's always a level before you get to the nerves and arteries. Skin grafting, not trying to do everything in one stage. Coming back to next year to the same place, the importance of visiting. So this is the one you want to do earlier in a case so you can get to this point before you leave. Again, the last principles for a burn surgery, don't underestimate the size of the wound after contract release. Mostly just new skin grafting and local flaps. Pick a joint, don't expect complete release, and return to the same place. Now I'm going to have one minute on patient safety because we're all going on these trips and there are two important things to do. I work with an organization called Research International that sends trips to 14 different places. When I was at Stanford, in the outpatient center, I had a child with malignant hyperthermia and almost died. Luckily, they ran over and got some Dantrolene from the adult hospital, brought it over, packed the kid nice, pushed the Dantrolene in, temperature went from 40 degrees Right? Just a frightening thing is when the whole body is rigid like that. So I'm always afraid that will happen overseas on one of our trips. Right? I'll be at a death. So with Resurge International, as I show you, we do a lot on patient safety. We have the scenarios. So in the room, before you start, we go through all this stuff of what to do in case of a power outage, what to do in case of a medical emergency. If you guys want this script, I can give this to you. We do a class that has a palate bleed, but we go through all of these before we start the trip. In other words, where's the oxygen tank? You know, where's the flashlight in case the light goes out? All of those things. You just do those drills for about 45 minutes in the operating room with the entire team. So if you ever want that form, we can give that to you. The second thing is we pack these bags, one for each place, about the size of a small carry-on. And it's called the Educator Safety Kit. So when we go to places now, we don't bring all the equipment. I think the days are over where you send 20 people and 20 crates of Pelican boxes of anesthesia equipment to go somewhere. Think of the climate burden that causes also. So instead, usually you just go by yourself. We use the local equipment and the local supplies. But you want your own safety kit just in case. So this bag is brought into the operating room. It's not open, but it has Dantrolene. We spend $3,000 to have Dantrolene all the time. It has intralipid in case you have a regional anesthetic complication. So these are all the things that you have. Syringes, epinephrine, Narcan, all these things. And if you put it together, all of these things you have, hopefully you bring it back and never have to use it. Thank you. Thank you. So you just saw this slide at the end of Jim's talk, so this is from research, but really you can see, you know, why we go on these trips. And as Lauren mentioned, this is a really important thing that you guys are sitting here and we're all talking about this morning, that the need for surgical training in low and middle income countries is critical and persists, even when travel is on pause. These people don't stop getting burn injuries, they don't stop having fractures and serious injuries. So how can we continue to contribute to the education of surgeons in other countries when we can't travel? And so this, I think you guys may recognize as the coronavirus and it attacking the world, and I think we all feel that. And I think probably our colleagues in the low and middle income countries have felt it even more than us. And so your help is needed. So there's lots of opportunities and depending on your specialty, you may be able to connect to some of those opportunities. I've listed some of the groups here. Touching Hands is obviously our group through ASSH and Dr. Katarzyk is going to talk about, I mean, it's going to, has set up for everybody to list if you want to be a volunteer to go on those trips. Research, as Dr. Chang talked about. The American College of Surgeons has Operation Giving Back, and then the Pediatric Orthopedic Global Outreach Group. In addition to this, there's many others out there. But reach out to these organizations as a place to start if you don't know of a trip or somewhere to go and ask, how can I help? So let's talk about these opportunities and we're going to talk about a little of these as we go through. So first, curriculum building. This is the research curriculum and they have a lecture database so that you could potentially add a lecture of something that you're an expert on that could be done in a low and middle income country and help increase this database. This is just some examples of some of the talks that are out there. And I've listed some that are here in English, but they also offer these talks in other languages. So if you happen to speak another language, that's a huge add that can contribute to people's education across the world. Virtual lecture series. This is the one held by Touching Hands. You can see the dates here really throughout 2021 and 2022. They did webinar recordings and these were live webinars that then became recordings that people could watch, you know, in perpetuity. And this is the example from research of sort of the same thing. Live lectures. You may recognize some of the people in the audience here as the authors of these. And really a chance for people to interact. And then later on, it's saved and people can watch it on their own time or re-watch it even if they attended. Mentorship. This is super important. We are developing surgeons in other countries. Just as we develop surgeons here in the United States, our own fellows and residents, training doesn't stop the minute that they're qualified, right? We all have a difficult case. We have a problem we're not sure of the diagnosis or a complex case we're not sure which stages to attack it in. And so mentorship after these people are trained surgeons is really important. And so the research group has set up something called Pioneering Women in Reconstructive Surgery and that's really partnerships here of a mentor and a mentee throughout the world really helping further develop these mentorship pairs. And this started out with one-on-one lecture, I mean monthly lecture series, one-on-one teaching and then case reviews and then mentorship as needed. This is my mentee, Dr. Tinga Nyoni. She's in Zimbabwe and to this day, we still talk, meet, hopefully she's coming to a meeting here in the United States and we'll get to see each other. But she writes me if she has a tough case and we'll catch up over Zoom at an hour that works for both of us. And it's really a great opportunity for us to stay in contact and for her to know she has someone to ask questions to anytime. So how do you prepare for a trip? This is sort of the global preparing for a trip and I know some people are going to go into sort of the resource building a little bit more. But really you want, as Jim mentioned, to find someone who is interested in learning surgery. You really need that welcoming host in order for this to be a successful trip. So get on the phone with them, get on Zoom with them and talk about pre-visit expectations. And then when you get there, you're going to meet the other surgeons, the people that you're going to be training and working with. And then you're going to meet the patients. Figure out those cases that are yes, we can do this here and no, we cannot do this here. And then determine the needs and the resources. You may not be able to do everything on the first trip. You may need more resources. You may need other surgeons with other expertise. Your first trip is about figuring that out. And then you really want to start small. A couple of cases, teaching some key points. Find out what their experience with hand surgery is. Maybe they've never done any. Maybe they've done a substantial amount. And you're really trying to gauge that in your first visit. Lecture. They want to see your cases. They want to talk about them. They want to tell you what they know. They want to tell you what they don't know. And really spending a lot of time in the classroom is really important. And then obviously when you're in the OR, that's a constant opportunity to teach. And this is really that first trip we're assessing. This is a paper that's a great read if you are going on your first trip. This is how to build up that relationship. And we're in the assessment and engagement phase on your first trip. And then how do you really prepare? So if you're really going on your first trip, this is like the list of what do I do? How do I go? What do I bring? Loops, this is key. I actually didn't bring them on one trip. Luckily I had a very nice partner who loaned them to me for cases, but don't forget those. Find out what the local culture is. I have been to countries where you are wearing a dress as a female everywhere you go. And so if you don't know that, you may be offending the local culture. So please be aware of that. Good walking shoes, you're gonna be going everywhere. Some basic surgical instruments, as Jim said, we're not bringing a pelican case. A tiny set of surgical instruments is appropriate. Lots of lectures and presentations of cases, cases and more cases. Ask your colleagues, they don't all have to be your cases. Grab from your colleagues every old PowerPoint that they've given for pre-op conference in the past year. Just build up your library on your computer so that you can keep going and keep teaching. You will find their excitement for this is really great. So my take home messages are stay eager, keep looking for those opportunities just because the world shut down or maybe you have a life event and you can't travel. Don't give up on reaching out and outreach and all the exciting things that you can be part of. Teach virtually to increase your reach. Think about it, if I go to one country, I'm teaching three surgeons. If I'm lecturing online, sometimes there's 100 plus surgeons online with me. Assess the site and really build those relationships, go slow. It's the most important thing is that we're maintaining high quality care. We don't wanna go be the hero that does the toe to thumb that doesn't survive. And then operate within your skill set. This is not something that you do in your home country, even if it's a hand surgery. If you haven't taken a cleft hand down and changed it in your own country, I argue you shouldn't be doing a cleft hand in another country. These are all the people that I've worked with abroad and I wanna thank you. Thank you. Next up is Julie Katarinsic talking about what kinds of trips exist from missions to capacity building. Thank you, Lauren, for setting this up. You know, this is something that's obviously near and dear to my heart. This was my disclosure. I don't know if I should put this in. So Lauren asked me to kind of talk a little bit about different types of TRIPS, models of TRIPS. With that, I'm going to talk a little bit about the ASSH International Certificate so that we can try to find a better way to formalize knowledge to under-resourced countries, a little bit about sponsoring groups, and then just some general principles. Some of this is editorial, and also specifics about how you can get involved with Touch and Hands, which is what I'm most involved in right now. You know, this got a lot of press. I think Paul Farmer started this, the Lancet Commission, back in 2013. They understood the importance of global surgery, and then the HWHO, one year later, really recognized the worldwide burden and the need for surgery. Everyone knows Hurd, Scott Cosen, and this society started Touch and Hands that same year. And then if you haven't read it, the Lancet Commission in 2015 has this global surgery 2030. It's 56 pages. It's quite the read, but it's really well written about resources, education, and I recommend it to anyone with any interest in this. If you look at the peer-reviewed literature, you know, Jim's group, research, this is one of the first studies, which is really well done. A majority are craniofacial, because that's been around for the longest, similarly a plastic surgery article in 2012. And then actually Karen Chung in Journal of Hand Surgery in 2017 has one of the earliest in our journal about it. So all three of these are great reads. There's really four models of surgical outreach. One is the direct, supply, or vertical approach. Second is the transfer to the high-income country, or so-called even reverse fellowships. Then the horizontal approach, and then finally, which I think is last but not least and the best is this diagonal development. If you look at the direct, supply, vertical, that's kind of the original trip. You fly in, fly out, they're self-contained. The advantage of them is they can be small. You kind of know what you're getting yourself into. You can bring yourself in, out, and they tend to be short. So honestly, they don't disrupt our lives at home, which isn't a factor, but it has to be considered. The cons is what we've talked about. It's horrible, or how about no coordination with local facilities? You actually probably, you could inhibit the local infrastructure. You kind of go in, there's no communication ahead of time, and some of the surgeons are intimidated like you can't believe when you get there. So this is not going to help. And also, patients that will come, like Dr. Cheng said, the child that needs a thermal comes and doesn't get it. They'll never come back. They're embarrassed. They're horrified. So you can really alienate some of the local people. The reverse is the transfer to high-income country. This is often through institutional arrangements, the so-called reverse fellowship model. This may be appropriate for the more complex microsurgery procedures, brachial plexus, patients with a lot of medical comorbidities, that syndromic patient that Dr. Cheng was talking about. Patients that are going to need extensive post-op care that can't be provided. It does potentially give you the ability to teach procedures that they're not going to see, but on the flip side, do they have the resources to do these procedures? So it's a plus and minus on this with the potential brain drain. The horizontal approach. These are two of many countries that has this. Ethiopia, BFIRST is setting up in Malawi. There's a long-term infrastructure build, and this is probably a good thing, but this takes a long time and a lot of money. It does help to strengthen local healthcare systems, but again, long time. You do need local support. A lot of this is governmental, and those of us that have been there know how hard this is to draw up support for, and how do you measure success in these? Is it the number of patients? Is it the number of people, local surgeons you educate? It's hard to do, but this is one approach that once it gets set up is not bad, but kind of the mix of the first and second, I don't know where this came from. My kids put this, they're big Chris Kreider fans. This is like to liven it up at 7 o'clock in the morning. I'm a hockey mom. It's the so-called diagonal development. It really combines the vertical and horizontal. It's going to go the whole time, horizontal. The advantage of this is you kind of get there. Because you have some planning, you can really be effective from day one, which I think is very, because these trips are short, and the more you can do every day, the better. You really maximize local resources, and I think moving forward, again, as Jim mentioned, we're trying to utilize the local vendors. It's good for us. We don't have to take it. It's good for the local economy. It's good for the environment. So this is a goal. If we could get every, so this is an editorial, obviously. If we could get every piece of equipment, drug we need in the local country, it would be ideal, maybe one day. If you can set up multidisciplinary follow-up, and then the patient, the procedure selection, they're needs-driven. You have to get local information from the host. You need to see who you're working with, who your trainees are, because it's key to have trainees on these trips, and this really allows a two-way information exchange, and again, relationships, relationships are key. You can actually enhance the understanding of global health delivery, both to them and to the people you take with you. You can enhance surgical, clinical, academic skills, research skills that Paige talked about, and you really empower local professionals, and that's, I think, why we do all this, to provide better care with the resources that they have. Our resources aren't going to help them. They need to learn to work within their healthcare systems, and then hopefully teach other communities in need. Dawn's in the audience, just a little bit about this to people that do go on these trips. This is one way that the local physicians kind of get certified. I think it's 19. You go through it. You don't really get a certificate, but at least you can say, I went through this, and I covered basic knowledge. This is a very important thing. You can help us identify countries. We're trying to reach out a little bit, and these people can hopefully become the organized teachers' care providers. There's also a couple other ways, just if you want to know about it. There's the Cozen Fellowship, the Kleinert Fellowship through the Hand Society for people to come over, and also through the International Federation, there's the Kleinert Scholarship. There's multiple, so there's definitely ways. Another thing that the Hand Society is going to start in 2023, if you know anyone, we're going to try to bring 10 surgeons from outside countries to the U.S., so there's an application online. We can help expedite that, so please look at that. There's three ways, four ways in addition to the certificate to get, if you know any local surgeons that would be interested, please encourage them to get involved. Multiple, so moving on, there's multiple trips, or multiple groups. There's Touching Hands, HBOB versus the British Societies. There's research. There's millions. There's a lot of church faith-based. They tend to be more kind of primary care, but some of them are often looking for orthopedic surgeons, and they do a lot of community work. There's disaster relief, and there's military, so there's a whole variety of trips that you can be involved in. There's Hand Clinics in 2019, as the whole thing is on outreach, and I think if you want to flip through that, there's some good general principles most have been brought up. This is, Dr. Lever said, just talk, you know, local needs and available resources. I think that's key strategies for continuing patient care, reducing risk, like Jim Chang said. God forbid something goes wrong. I wouldn't be able to come home. I couldn't stand it. Reflection. I think you need to, at the end of the day, sit down, think about what you did, think about what you can do better. I think that's, in our busy days, it's really important to do that. Similarly, body count mentalities gone. Those fly in, fly out. I think that should, I don't even want to mention it, but I think it's important to mention it. You shouldn't mention it. And again, the long-term relationship. Dr. Bahar, about the QAMSI Ghana model, you know, share the knowledge and connect with surgeons and the therapist, I should have commented. Therapists are key, especially, you know, how often do you teach the family to be the therapist at the host facility to improve access? And work building systems of surgical care with training development. I mean, I think moving forward, all these are, is essential, probably more essential than providing patient care. And I'm going to end with Peter Stern in 2013. You can read this. This is his founder's lecture. And I feel strongly about this. It's the essence of clinical medicine. You truly make a difference in people's lives. So I think all this in context of what Lauren's trying to build is, the world would be a better place. So thank you. Thank you. One other thing, I'm going to say, sorry about this, I've got to say this. But the Hand Society, we had applications from 2014 for outreach. We got rid of them because a lot of those people have no interest anymore. So if you have interest, please go on and redo the applications very quick. All we really want to know is who you are, what you're interested in. You know, do you want to do brachial plexus, pediatrics, gist fractures, arthritis, very important. And we'll try to get you involved. But I do need everyone interested to redo their application quickly. So thank you. Can I ask you a quick question? Are the fellowship programs for trainees abroad or for attending surgeons abroad? Actually for both. The Kleiner is more for an attendee, but a lot of the smaller ones that we're sponsoring, they're for trainees. Okay. Thank you. All right. Next up, we're going to be talking about challenges and barriers and trying to ensure a trip success. Great. Thank you. Good morning. Okay. So I'm going to quickly talk about barriers and challenges and hopefully it's a helpful session. Here's some of my disclosures. So what are our goals? Really at the end of the talk would be things that you can think of that you can do to preempt barriers that you might overcome when going on a trip. How do you overcome challenges that pop up while you're on a trip? And then really the motto of prevention and preparation, which leads to success and ultimately your impact in being there or participating in global outreach. And that comes with, in my opinion, a lot of planning and preparation. So good communication and stewarding best practices when you're traveling. So some considerations when you go on a trip or when you start thinking about an organization that you're going to work with, one of the most important ones that probably doesn't get discussed is organizational culture. So the organization that you choose to work with, what is their mission? What is their purpose? How do they align all their activities around that mission and does that align with your interests in global outreach? What are their short and long-term goals? And these are very simple questions that are worth asking when you start talking to an administrator at a different organization to work with. What about the site that they go to and what's the local culture of that site? I think Jim and Julia oftentimes mentioned you can go and if you go there and do procedures and you are only just offsetting what local surgeons are trying to do themselves, you can alienate the local surgeon. You can be working against your purpose in terms of helping train and build up the capacity of a local site. So understanding the culture and the need of where an organization goes and how you fit in with helping support that local culture is pretty critical and, again, is worth just a simple discussion when you're starting to work with an organization to understand sort of what their purpose is. Having strong surgeon champions, both you as a champion and working with the champion on the local site is important just to navigate the system, understand some of the things that oftentimes aren't said directly but are understood by the local community. And then all of this is predicated on really strong communication and strong methods for communication, whether it's texting or e-mails or phone calls or Zooms. Just having some of that sort of set up and some cadence for that set up can be really helpful. And so all of this, you know, the culture of what you're trying to understand is the vision, the environment, and all the people and how those all interact. In terms of preparation, one of the ways in which you can divide things for preparation is what can you control and what can you not control. So things you can control. So the first is a needs assessment. And you can find different organizations use different ways of doing this. Oftentimes when I go on trips, one of the first things I try to figure out is what are the cases that the local site is setting up and what is it that aligns with what I can do and I feel comfortable doing and what are things that I kind of want to set the understanding that these are things that I don't do and we want to make sure that patients aren't traveling two days to come see you for a procedure that is something you don't do. And so really setting the stage and having some mutual understanding in terms of what your practice is and what are the things that is within the scope of your practice is important. And one way to start that conversation is the needs assessment in terms of what they have for facilities and resources, what they have for cases. And that, so this type of needs assessment informs your case prep and supplies and then sort of the obvious stuff that other people have also mentioned in terms of just logistical things to prepare for. This is an operational blueprint. It's just a very generic blueprint that I think can be useful for guiding how you prepare for a trip and how you make sure that you can overcome a barrier ahead of time or some challenge that pops up. So in the middle is ongoing processes. So we already talked about that coordination with host community, contextualization of activities is essentially making sure that what you're doing fits in with the local context. And that will change, I think Paige mentioned, even what you wear and things like that. It's important to be respectful of the local community. And the onus is on you and us to understand what the context is and what the local community culture is and for us to be respectful of that. On the top right is planning your program. So some of this is just sort of, again, operational things, but champions and stakeholders, needs assessment and then preparing your trip activities based on what's needed locally opposed to based on what you want to bring. And those may not always align. And it's important to understand that at the beginning. So you go on your trip or you begin your sort of relationship with the site on number two where you do outreach. And then number three, you analyze impact. So that's the data analysis and that varies based on organization, but it's important to have some structure to that. First do no harm and then second, see what the impact of you going was. We all, it's a big commitment for us to leave practice and go do this. And so you want to make sure that you're getting the most bang for your buck as well. So you want to make sure that you're being set up to help a local site and help make sure that your time is being used to be the most impactful. And then top left is refining the program. There's always an opportunity to improve in terms of how an organization is functioning, but you'll never get to understanding what those opportunities are if you're not measuring. And so that's really the principle of ongoing measurement. So some challenges in my experience, and I'm not the most experienced of the people on this panel, so certainly ask them questions as things come up and reach out. But these are just things I've gone through. So first is agreement with the host and the team on types of cases, number of cases, et cetera. This is the scope of practice or maintaining quality of care aspect of sort of making sure that there's a very clear level set as to what you do and what can be done on a trip. Safety first. I learned this, and research has a really good sort of objective way of doing this, which is when you have a trip planning meeting, for example, some of the first things you have to talk about is how does the team stay safe and how does the team get back safely. So that's first and foremost. So that is safety of the site. So you go through sort of like what's the evacuation plan if you got to go and get out of there? Do people have insurance and evacuation insurance and things like that? What's the exit strategy that you might need, et cetera? So the first topic oftentimes of those meetings is what are the steps we do to make sure we stay safe? Some trips or organizations have some buddy system because people get sick, and you want to kind of check in with people and make sure people can perform and make sure that they can be safe before they start taking care of patients. Knowing your limits, again, gets to scope of practice and anticipating complications and the management plans that pop up. It's not just the limits of what you can do, but it's the limits of the expected complications that can come up with the procedure and the local site having the infrastructure and support to manage those complications. And so just like here when you operate and you own the patient, as we all like to say, it's not dissimilar when you travel. When you operate or you operate with surgeons, you own them to some degree, and it's on us to make sure that they stay safe and their complications can be addressed. Partner with colleagues. I think team decisions is super critical and oftentimes may not get discussed, especially when you're starting out, and I consider myself still starting out with these, is I don't make big decisions about treatment plans and things like that without a team member. And maybe, as you get more senior, I think that's a lot easier to do by yourself. But when you leave your, I don't know how many people have worked in just different environments, but you leave your local environment, you don't have your own instruments, you don't have your own sort of workflows, and it's sort of like when you operate on somebody at your local place and you know how they kind of want some VIP treatment and they change things up and it kind of messes with your flow, and I tell people that's the worst thing you can do, just don't mess with my system and that's how you get the best care for me. So it's the same thing, you kind of want to try to recreate there, but the best way to do that, because it's tough, the environment's different, is to have a team member or a co-surgeon that you kind of talk through cases, make sure indications make sense, make sure the plans make sense, make sure the thoughtfulness for complications and how those get addressed make sense, and do that together. And I think that's a good way to at least to start as you're developing into this. And then just bring extras and some of that's understanding where you're going, headlamp, I've done cases where people have iPhone lights out because the power goes out and then the generator doesn't work and you're in the middle of a case and you need to have some sort of backup plan for that. So just walking through some of those situational analyses is really helpful as you prep for some of the challenges. So what was your impact? So there's a number of ways to measure the impact, right? You give up a lot of time and you want to make sure that patients are improving and you're helping in terms of bi-direction and working with surgeons. So quality of care for all patients, you focus on quality of care when you operate here, the focus should be no different when you operate in a different place or different country. You can assess different things like structures and processes of care. These are sort of standard by now, so the sterilization methods, timing out, sponge counts, antibiotics, those are things that are standard here, they should be standard when you travel. And then assessing outcomes, I think all organizations are learning better ways to do this, but to some degree I think historically it hasn't been a focus. Similarly, you know, in high income countries we're beginning to focus more and more on outcomes and using that to inform care decisions and similarly when you travel the same sort of processes should be implemented. However, more things on impact in terms of quality, the culture of measurement, improvement and equity in my opinion should be strong in the organization you choose to work with. So it's not just a number of cases or body count as Julie mentioned, but really more than that. Partnering with local surgeons in terms of helping elevate the local surgeon cohort opposed to displacing them and I think that requires understanding what the surgeons need and what the patients need and how you can help the local surgeons take care of the local burden of disease opposed to traveling in and displacing somebody that could easily do it themselves with the right type of training. Using technology to promote outcome assessment I think is getting more and more in the literature and I think through organizations and it starts very simply with things like WhatsApp and SMS and can get even more complex than that. And then lastly have fun and bring a friend and really having fun requires good planning so hopefully when you start going out and working with organizations they help you prepare for this. So good luck. Thanks. Thank you. Up next we have Dr. Castro Appiani talking about an international partner's perspective. He's a hand and upper extremity surgeon in Costa Rica. Hello. Good morning. I want to thank Dr. Laudin, Shafiro, and Dr. Rohin Kamal for this opportunity. With this speech I want to talk to you, I want to tell you a history. Since 2016 patients with brachial plexus in Costa Rica have low opportunities to improve his condition. I have some cases that I treat because they asked for an amputation a long time ago. Now I'm treating the neuromas of his stumps. The history starts with this guy, Dr. Mario Mendoza. We received this guy in 2016 in the National Meeting of Orthopedic Surgeons in Costa Rica. And I present him this case, it's a total, a complete brachial plexus lesion. I present with this guy and we make the surgery like seven months later. We make some fluoration and some nurse transfers to him. Then in 2017 I received another friend, a very good friend, Dr. Leonardo Lopez. And I present three cases to him. This first case is a 37-year-old guy with a brachial plexus injury one year ago. It's an upper trunk lesion and we made the surgery one year in July, one year later in July 2017. This is a very interesting case because he is a 32-years-old policeman. He suffered his brachial plexus injury on duty. He arrived to us two years later. With this case, I ask a few things, I realize a few things. The first thing is we don't have the conscience in our country to recognize this kind of lesions. We don't have the conscience that we have some things to do with this kind of patients. This is a very important case for me. For the time of evolution, we decided to make a free muscular flap, free functional muscular flap. The fourth case, the third case to present to Dr. Leonardo Lopez was a very sad case because he has an upper trunk extremity, upper trunk brachial plexus lesion. He said to me, I don't want the surgery because everybody tells me I will be worse with the surgery. I prefer to say it like that. He could improve, he could improve a lot of the mobility of his arm. After this visit, what else, what happened with this story? Well, I plan to start my training in brachial plexus injury. I travel to Torreón, it's a north city in Mexico, and I meet a lot of interesting people. I apply for the training I could get in, and I could meet different people of different places of Latin America. And during this training program, these three patients start improving. I continue the cases with these patients, and they start improving the movement of his arms. An important benefit when you make the match with the person that gave you a mission and you can receive the benefits of the training and the knowledge of this person, you have a lot of benefits more when you can meet other important people around the world. There is a very interesting group that we met in one of the meetings. We work a lot in this training program, and we enjoy a lot too. And finally, we were able to go to EAT. This is part of the group that made the training. And I guess the most important part, like you tell in the previous speeches, is to make the match between the person that gave you the mission, that gave you the knowledge, and obtain this knowledge for carrying to the country, and develop the skills that this person could give you, and reproduce in your country. The mission training benefits for my country was that between 2018 and 2021, we made 170 patients with treat, 170 patients with brachial plexus injuries, 70 patients with brachial plexus injury, 80 patients with peripheral nerve surgeries. I guess I could improve the knowledge of health personnel in my country to detect and refer, early refer to these patients to the hospital, and I could get an early treatment for these people. Okay? Other benefits that I could guess is improve the patient lives. Usually this patient had health of the families, of his families, I could improve the family's life too. I could improve the self-esteem of this person. And usually these patients have a low level of education, okay? Usually I talk with them and I ask about if they finish high school, okay? This is a long treatment, usually takes two to three years. I motivate them to use this time to finish and to improve his education. And some of these patients return to work. Well, and the stories could continue, will continue. In 2021, we received Laura Shafiro and Robin Kamal. We have the Gusto, okay, to create the Gusto Group. This is a group of cancer jurors in Costa Rica. And we have a lot of academic activities in Costa Rica, but we don't have the custom to write and make investigation in Costa Rica. And these two guys motivate us to make a group and start to write in Costa Rica. And this is our first paper, like a group. And then in 2022, we received a visit of a medical student. He is Samuel Castro. We share the same last name. We carry our research study to try to develop a suitable survey instrument for evaluation of patient with upper extremity lesion in Costa Rica. Right now, this work is going on. And I hope this history continue and I could give you some new histories in the future. Thank you. That was excellent. Thank you. Thanks, everyone, for coming. Does anybody have any questions? We have a couple of minutes for, yeah. Thank you. Is there an email address or how should they get in touch with you? Sounds good. I See some residents in the room and fellows in the room. Dr. Fox. I had a quick question for you As far as getting involved from kind of a resident fellow attending perspective What are your thoughts as a program director? on getting involved as a resident or how long you do that and when you do that and one of the best times to do that I Think that can be really hard. Unfortunately, the ACG me limits international travel except for to establish relationships for many Groups and plastic surgery and orthopedic surgery so it can be hard. You really do need a faculty champion That's going on a trip, but often you're required to take your vacation time To do that. So it is limited but I think certainly Reaching out and helping with develop as you know You've done and others have done developing some of these relationships and getting them set up Can help you to do that? And if you're really passionate about it, you know A Comboing it as a vacation and really spending that time, you know is a great opportunity But unfortunately, I think we are limited in the ability to go abroad for a month And that's really based on your GME and ACG me Thank you. Um, dr. Chang. I had a quick question for you as far as triaging cases and picking through kind of complex non complex cases How do you go about doing that either before a trip or at the beginning of a trip? Yeah, so Doing virtual stuff has really changed a paradigm for our trip. So a month before a designated trip We will have a few lectures a theme to the trip. Let's say syndactyly or congenital hand The hospital there will actually bring the patients in and we'll screen the patients virtually Which is an incredible thing for anesthesiologists and for the surgeon and then got you know It's amazing you show up and you actually know the cases you're going to do So it takes away the the fear for a lot of us to just kind of walk in on something and look through the textbook Quickly to do it. So half the cases are prepared that way and then you have other cases that come in you know off a Certain list somewhere else that you don't know you Operate on the cases you feel comfortable with The beautiful thing is we're gonna go back to that same place three months later and keep going back So if the child is sick, it's borderline. You don't have to rush into surgery so all of those critical issues the There's only one chance in this child's life to get surgery done. Those issues go away. Yeah. Thank you I don't know if there's any hands or a hand therapists in the room, but I guess dr. Kettering zeked under chain do you guys have any thoughts on how to get involved as a hand therapist and obviously that's a important part of hand surgical care I will tell you we if you're a hand therapist or anesthesiologist We would love to have you if you want to come you can actually apply. There's a formal application to the on the website One of and again, I think any of us can help connect you the I should know I don't know if there any therapists here if their association has an opportunity. I apologize I don't know that but if there's a therapist if you go on the touching a website, there's a specific therapy application excellent Does anybody else have any questions? All right, thank you for joining

global outreach

hand surgeons

access to surgical care

upper extremity injuries

capacity building

sustainable solutions

organizational culture

local surgeons

measuring impact