Cover Story

Tenth Annual Medical Mission Trip to Nicaragua: A Bidirectionally Rewarding Voyage

Christian Machado, MD,1 Ilana Kutinsky, DO,2 Rodrigo Bolanos, MD,3 Jayanthi Koneru, MD,4 Sean Patrick Whalen, MD5

1Director of Cardiac Electrophysiology and Cardiac Rhythm Management Device Clinic at Providence Hospital, Novi, Michigan; 2Assistant Professor of Medicine at Oakland University School of Medicine, Michigan Heart Group, Troy, Michigan; 3Director of Electrophysiology Winter Haven Hospital, Winter Haven, Florida; 4Assistant Professor, VCU Medical Center, Richmond, Virginia; 5Director of Cardiac Electrophysiology, Associate Professor of Medicine, Wake Forest University, Winston-Salem, North Carolina

Christian Machado, MD,1 Ilana Kutinsky, DO,2 Rodrigo Bolanos, MD,3 Jayanthi Koneru, MD,4 Sean Patrick Whalen, MD5

1Director of Cardiac Electrophysiology and Cardiac Rhythm Management Device Clinic at Providence Hospital, Novi, Michigan; 2Assistant Professor of Medicine at Oakland University School of Medicine, Michigan Heart Group, Troy, Michigan; 3Director of Electrophysiology Winter Haven Hospital, Winter Haven, Florida; 4Assistant Professor, VCU Medical Center, Richmond, Virginia; 5Director of Cardiac Electrophysiology, Associate Professor of Medicine, Wake Forest University, Winston-Salem, North Carolina

Recently our team completed its tenth consecutive medical mission trip to Nicaragua. This is the largest country in Central America, with a population of 6 million people. It is one of the poorest countries in the Western Hemisphere, lagging behind other Central American countries on many socioeconomic indicators. Adult literacy is 68%. The per capita gross national income is US$2,720, and 48% of the population lives under the poverty line. The total expenditure on health per capita is US$335.

Cardiovascular disease is the number one cause of death, with a 30% contribution for all ages. 

The underlying common objective of these medical mission trips is to provide basic healthcare for the indigent. The mission trips require enormous behind the scenes preparatory work from the volunteers as well as the administrative and medical community of the indigenous populations. The volunteers are true “world citizens” and crusade for “basic” global healthcare as they embark on their own personal pilgrimage. As a tribute for those volunteers on both sides of the mission, we share this article with utter humility and aspire to articulate the collective experience.

When reflecting on this decade of doing yearly pro bono work in Nicaragua, many stories and experiences come to mind. Here we share details about this successful and rewarding program in order to:

  1. Acknowledge the work performed by an array of volunteers who have invested time, love, money, and sacrificed vacation time, in order to make these Nicaragua EP missions a reality. Each of the volunteers has selflessly given a piece of their heart to this tiny corner of the world and helped to make it a brighter place.
  2. Exemplify how people across many cultures and political affinities can unite for the common good. Many people work together as a team to serve the underprivileged with dedication. 
  3. Raise awareness about medical mission work and to inspire the hearts of readers who may quietly possess an interest in medical mission trips. The reason we go back year after year is because it is so gratifying to make a difference.

From the Beginning: With Dr. Machado

The story begins in 1999. I was returning to Nicaragua for the first time after having fled empty-handed, as many other political refugees did in 1979. I was determined that my return had to be different — a return for healing. The country was experiencing its own healing process, and was recovering from decades of civil war and unrest. Healthcare was one of the most adversely affected spheres during this time.

During this visit I toured one of the public hospitals in Managua, and after witnessing firsthand the desperate need for basic medical items and scant presence of cardiologists, I made a covenant with myself that I would give back to this country despite the circumstances under which my family was once forced to leave.

Each subsequent year, surplus supplies were delivered to many public hospitals, either through a personal visit or via FedEx from Providence Hospital in Michigan; my headquarters were fully supportive of this endeavor. It was in 2003 when a dear friend, Chilo Cuadra, who was the Vice Minister of Defense at the time and knew of my trips to Nicaragua, asked me to come to Managua and perform procedures at the Military Hospital. The result was the first ICD and CRT-D implants in the country. We then put together a team consisting of my lab leader, Art Mize, and my CRM rep, Tim McElroy (from Boston Scientific). Having developed a valued relationship with the local cardiologists, we agreed that we needed to up the ante. We wanted to assemble a functional EP lab in Managua. We brought one new item per year, frequently donated by my institution and industry. In 2009, all the pieces were finally in place for a functional EP lab. That is when I got a phone call from David Parr with St. Jude Medical and Daniel Holmes from Biosense Webster. At the time, they were assisting another mission (FOR Nicaraguan Health), doing implants at a different institution (Centro Nacional de Cardiología, or CNC). That team was led by Dr. Ilana Kutinsky and Dr. Rodrigo Bolanos. Dr. Bolanos is a native of Nicaragua who trained in the U.S., following in the footsteps of his late father.

Dr. Kutinsky had been going to Nicaragua for several years, implanting devices as part of FOR Nicaraguan Health. She recalls that upon her arrival in 2007, there were several young adults waiting for her in the hotel lobby. The majority of these kids had WPW and had been placed on amiodarone. They were not allowed to exercise and were in fear of the risk of sudden cardiac death. She attempted to obtain the necessary catheters and equipment to perform EP studies for these patients; however, it wasn’t possible. We were later able to bring these patients to Michigan for the procedures. On her next trip with our donated equipment and the help of some very dedicated people, they assembled a team of seasoned EP technicians, nurses, and professionals, and the first ablation procedure was performed at CNC. 

With perseverance and herculean efforts from the team members, the first ablation cases were also successfully performed in 2009 at the Military Hospital in Managua, with the generous support of the Military Hospital administration led by General René Darce. After this successful endeavor, we decided to unify all our efforts under one umbrella: FORNicaraguanHealth.org, founded and headed by Dr. Rudy Vargas. This organization was a well-oiled machine and already offered a variety of services that included pediatrics, orthopedics, GI, general medicine, and ophthalmology. A year-round, full-service primary care clinic was already in place in the city of Granada. The fusion of EP teams, we felt, would offer a stronger, cohesive, and more comprehensive service to the Nicaraguan people. 

About the EP Mission

The EP mission has evolved and grown since those early days, mostly due to the support and organizational skills of Dr. Rudy Vargas. Our team has been strengthened by the additions of Dr. Patrick Whalen and Dr. Jay Koneru. The EP trips to Managua have become enormously gratifying to the patients, their families, volunteering physicians, and locals. News of these successful efforts has spread both in the U.S. and in Nicaragua. 

Since 1999, we have done more than 200 implants including pacemakers and defibrillators, about 50% of which were recycled devices. (We published on the efficacy and safety of this strategy with long-term follow-up to encourage others to do the same.1) The average patient age (68 years) for device implants is very similar to the U.S. Most of the recipients of ICD therapy are non-ischemic cardiomyopathy patients, with Chagas disease being a frequent etiology. Ischemic cardiomyopathy has also become more prevalent over the past few years.

Patients are selected throughout the year on the basis of history, tracings, medical need, and lack of economic resources. The National Center of Cardiology, which is a government-based voluntary organization, chooses the patients on the basis of the above criteria. The second screening institution is the Military Hospital, which selects indigent patients and military family members with scant resources. The patients come from all walks of life and different parts of the country. 

We have performed more than 100 ablations, most of them SVTs, a few BBRVT, idiopathic VTs, and atrial flutters. The average age for SVT ablation patients is 22, with the range from 14 to 56. The most common SVTs that we have encountered are accessory pathway mediated. 

Preparation for the trip starts 4 months prior to arrival. It includes patient selection and communication between team members about equipment needs (diagnostic catheters, needles, sheaths, and ablation catheters) we prefer to bring according to the case. We make bundles for each patient, trying to predict what may be required for that particular arrhythmia. Invariably, we are surprised and have to improvise. All transseptal punctures are performed via fluoroscopy techniques since ICE is not available. Anesthesia is provided by our own volunteers and by Nicaraguan anesthesiologists.

We currently provide EP services at two hospital sites: Salud Integral Hospital and the Military Hospital. EP services include consultative services; pacemaker, ICD, and CRT-D implants; and SVT, right atrial CTI atrial flutter, and RVOT ventricular tachycardia ablations. The integral team was staffed by Dr. Patrick Whalen, Dr. Rodrigo Bolanos, Dan Holmes, and Dawn Sabin, RN and Mary Peters, CRNA (both from Vanderbilt University). The Military Hospital team consisted of Dr. Jay Koneru, myself, Jessica Ottino, NP, Jessica Wrobel (from St. Jude Medical), and Nicole Zakhem, NP. 

The volunteers from Nicaragua included Dr. Daniel Rivas, Colonel Dale Muller Foster, Dr. Rolando Jirón Toruño, Dr. Alvaro José Morales, Dr. Emilio Cisneros Jirón, Dr. Ariel Arguello Montealegre, Dr. Hermes Morales Molina, Dr. Nedar Sirias, Enf. Orlando Ortega Mayora, Bladimir González Osejo, Tec. Marvin Reyes Rosales, Yahaira Aranda, Dr. Carlos Duarte, Dr. Pablo Hurtado, and Myalis Parr. Drs. Chin Man and Joaquin Arciniegas were also instrumental in the earlier trips performing procedures at CNC. Special thanks to K.F.M. for her editorial assistance. There are several other people that are intricately involved with the mission that we cannot acknowledge due to space constraints.

Summary

The gratitude of the patients and their families wipes away all of the trials and tribulations of operating in testing circumstances. We are immensely grateful to have been given the opportunity to serve this community and be welcomed by them. We would like to encourage you to donate equipment, devices, catheters, or any other items that would otherwise go to waste in your institution. These supplies would be a treasured item in other parts of the world. As with all forms of public service, we set out to help those in need, and in that process, we have gained so much more than we have given. 

Reference

  1. Hasan R, Ghanbari H, Feldman D, et al. Safety, efficacy, and performance of implanted recycled cardiac rhythm management (CRM) devices in underprivileged patients. Pacing Clin Electrophysiol. 2011;34(6):653-658. Epub 2011 Mar 21.

To find out more information, please see the following links of these medical volunteering organizations:

http://www.worldmedicalrelief.org

http://www.fornicaraguanhealth.org 

http://hassanfoundationusa.org