Humanitarian Missions

Heart Team Returns to Cambodia to Train Surgeons and Heal Children

Dr. Stephanie Levasseur examines a patient's echocardiogram

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. The trip undertaken by Dr. Chen's team of doctors and nurses from NewYork-Presbyterian Hospital/Columbia was part of a mission in which pediatric heart surgery teams from developed countries help build surgical expertise in Cambodia. The project is sponsored by Surgeons of Hope Foundation, Inc. and its partner, Gift of Life International.

After a grueling 30-hour trip, the team arrived at the Phnom Penh Heart Center (PPHC), a four-year-old cardiac hospital founded by the French foundation La Chaine de l'Espoir (the French organization that started Surgeons of Hope). 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 Kirkpatric, a pediatric ICU nurse; Dr. H. Michael Ushay, a pediatric intensivist, and Ellen Moquette, a pediatric catheterization nurse.

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.

Surgeons of Hope estimates that 100,000 children in Cambodia suffer from heart disease, and that one-tenth of those are in urgent need of cardiac surgery. Faced with this overwhelming demand and working on a very tight schedule, Dr. Chen and his colleagues immediately set about prioritizing cases. In addition to performing operations, the team also conducted catheterizations, a less-invasive technique that 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. The technique is also used to take pulmonary artery pressures to determine operability.

Team members Dr. Jonathan Chen, Dr. Johanna Schwarzenberger, and Kevin Charette with Phnom Penh Heart Center operating room staff

Upon their arrival, 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 Chen.

The team sent Dr. Torres and one of the nurses to nearby Calmette Hospital—a very under-equipped facility, according to 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," Chen says.

To make up for this lack of sophisticated imaging, "they did some wild things," 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," Chen says.

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 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 8 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 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 missions of Surgeon of Hope is to establish hospitals in less-developed countries and train local medical staff to provide the highest quality care. The organization's motto is Training To Cure. Alongside the New York physicians were a team from Cambodia, including three surgeons, none of whom spoke English well. 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 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 Chen: "He was surprised I asked him to do that."

Chen noted that one of the most important things the team could leave the Cambodian doctors and nurses were skills they could use. "It seems like that's what could make the biggest difference," he says. "It's never about the number of case you do."

The pediatric patients ranged in age from 2 years to 14 years. They came from all over Cambodia. Some were referred from smaller satellite clinics of PPHC where earlier diagnoses had been made. PPHC allows a family member to stay with the patient at no cost, and even makes provisions for the child to attend school in Phnom Penh, thanks to funding from paying adult patients and donors. The team plans to return in two years to see how the Cambodian physicians have progressed. Next year, they may visit a hospital in Mozambique.