Dr. Moeen Saleem is the Director of Cardiac Electrophysiology at the Advocate Heart Institute in Naperville, Illinois. In this article, he discusses his recent medical mission to Lebanon, working in collaboration with Northwestern Memorial Hospital and the Syrian American Medical Society, a global medical relief organization providing crisis relief in Syria.
How did this humanitarian mission come about?
This is my fourth medical mission. I went on a mission to Jordan in 2016, to Lebanon in 2017, to Bangladesh in February 2018 to treat Rohingya refugees, and back to Lebanon in 2018 with the team from Northwestern and Rush Presbyterian St. Lukes.
The mission was under the organization of the Syrian American Medical Society (SAMS), which allowed us to work through their NGO. I’m not Syrian, but I became involved with them back in 2016 on similar medical missions.
However, the story behind this year’s mission started in 2017 when I traveled to Lebanon. As an electrophysiologist, I was mainly doing clinical cardiology while there, but I saw many patients who needed EP procedures, diagnostic caths, and possible interventions. Unfortunately, we weren’t organized for that — we didn’t have contact with or access to a hospital. I was working in a clinic in a small town called Tripoli outside of Beirut, and as I was starting clinic for the day, a few men rushed in asking to borrow some diagnostic equipment. My translator, who was a Loyola medical student, told me they needed to borrow an EKG machine to determine if a child was alive or not. Before I even had a chance to register, I found myself running down the hall trying to see where these guys were going to see if I could help. I walked into a room where a toddler who was maybe 2 years or 18 months old laid on a hospital exam bed, completely lifeless and motionless, appearing dehydrated, with eyes sunken in, just skin and bones. Everyone was standing around. I didn’t know what transpired, so I started CPR. My translator then told me that all the people there had been trying to resuscitate the child for over a half hour — they wanted to know if there was anything left to be done, or if the child had passed. They wanted me to pronounce the child. The child was clearly not alive anymore, with no response, breath sounds, or heart sounds. In the corner of my eye, there was a gentleman standing next to me who I came to find out was the child’s father. The mother came in sobbing, and I stepped away to let them have a moment with the child. Everyone was very moved by what had happened, but because it was still the beginning of the workday, my translator and I had to fight back our tears to start our clinic day and see the rest of the 30 patients. I don’t know what got into me, but after witnessing that child, I promised every patient that I saw that day that I would come back if they needed a procedure done. Keep in mind that these people are refugees who have heard all kinds of empty promises — they were very gracious to me, but I could tell they didn’t believe what I was saying. I took down all of their names who I felt needed a procedure. I also wrote each of their cell phone numbers on a piece of paper; most refugees who have lost everything — their freedom, their homes, their dignity, their family members, and their basic rights — do fortunately have cell phones.
While in Lebanon, I was supposed to make contact with a local cardiologist/electrophysiologist named Marwan Refaat, but it didn’t work out. Dr. Refaat is with the American University of Beirut (AUB), one of the institutions that collaborated with us on the mission. So I emailed him when I returned home, because the following week was Heart Rhythm 2017 in Chicago. I asked if he was coming to the conference and if he would be interested in meeting for dinner. He replied, “Yes, I heard you were here! Sorry we didn’t get to meet then, but I would love to meet.” At dinner, I asked if he would be interested in collaborating with me to go back and take care of refugees or indigent people, if we were able to raise the necessary funds and also get donations from industry. He absolutely agreed. The following day at HRS, I ran into Rod Passman, who had trained me at Northwestern. He asked me how the trip was to Lebanon, and said that if I went back, he’d like to come with me. Later that day, Rod saw Brad Knight, who said, “If you’re going, you’re not going without me.”
When I later told Marwan that there were some other people from Northwestern interested in coming, I asked him if he would be interested in doing a combined humanitarian educational mission, having Northwestern faculty give lectures at his teaching institution. His eyes lit up. Marwan often saw refugees in his clinic, but couldn’t offer them anything because they couldn’t afford to pay. In fact, one of the patients that I had seen in clinic on a previous mission had also seen Marwan. Over the following 12 months, we gathered the names of these people that he would see in clinic, and we would make a list of cases that we would try to organize. Next, I applied for device donations from Medtronic, and we organized and acquired some catheters for mapping and ablation. Marwan then put together a symposium, inviting people from all throughout the Middle East to participate. Brad, Rod, Kousik [Krishnan], and I all gave lectures as well. About 2-3 months before we arrived for the medical mission, I asked Marwan to reach out to the list of patients that I had seen in 2017. I didn’t know if he would be able to get a hold of them because their lives and living circumstances could be unpredictable as refugees. He called me a few days later and said he had contacted almost everyone, and that they would come to the clinic. Therefore, we were able to set them up for procedures.
In the end, we had 9 cardiologists, 4 of them adult EP (myself, Kousik, Brad, and Rod). We had a pediatric EP and a heart failure specialist who did clinical work. We had 3 interventional cardiologists and a cardiologist advanced practice nurse. We had a rep from Medtronic for device implants, and a rep from Abbott come with us for our ablation cases.
The 2018 mission took place April 27th through May 5th. Overall, there were about 40 people that traveled to Lebanon as part of the medical mission. Approximately 67 cardiac cath procedures (including 55 interventions) were performed. We did 9 EP procedures in 3 days, put on an EP symposium, and Rod and I did a grand rounds at one of the teaching hospitals.
Where were the cases performed?
We were based out of Beirut, which is a beautiful city. Our hotel was located along the Mediterranean Sea. We would get up in the morning and look out to see people walking and jogging along the water. We did our complex EP procedures at AUB. In the 8 years of the Syrian crisis, never before had outside physicians been granted access to do procedures there, so this was huge. Again, friendly contact between Marwan and myself grew into this team of EP docs (Rod, Brad, Kousik, and myself) having access to AUB. We also did diagnostic caths, interventions, and some basic device implants at Rafik Hariri University Hospital, the largest public hospital in Lebanon. In addition, we performed diagnostic caths and interventions at a heart hospital in Tripoli, which is about a 2-hour drive outside of Beirut. Every morning the teams would divide up: two interventionalists would go to Tripoli, one interventionalist stayed at the hospital in Beirut, and others went to the Beqaa Valley to work in a clinic. Beirut was primarily where our procedures were done, and we would arrange for patients to transport to Beirut if necessary.
What would you say were some of the biggest challenges during this mission?
When organizing for a trip like this, there was no shortage of the humanitarian spirit and of people wanting to help. The biggest challenge was probably confirming access to the hospitals and negotiating the cost of procedures. The cost of a cardiac cath was anywhere from $500-1000, and that included the procedure. Boston Scientific and Medtronic donated stents, and that included an overnight stay at the hospital. The cost of EP procedures was roughly $1500-2500 per case, but that included us bringing devices, leads, patches for mapping, and diagnostic catheters. Rush University Medical Center donated all of our ablation equipment off the shelf.
In addition to organizing the funding, another challenge was coordinating the daily logistics and schedule. Once we got to Lebanon, we found that some of our catheter equipment was not compatible with the system and cable connections in place. Our Abbott rep talked with their local Abbott rep to see if we could either find a connector to fit our catheters, or swap out catheters. We were planning to do an ablation on a refugee patient using 4 or 5 catheters, but none of them were compatible. In this moment, we could either spend a lot of money, or we could be conscious of the cost and use one catheter. I joked that I would put my money on one catheter with four EP doctors, as opposed to four catheters with one EP doc. In a case with Brad Knight, Rod Passman, and Kousik Krishnan, we only need one catheter! We did a WPW ablation on a Syrian refugee with one catheter and NavX patches, and the case was done in an hour and a half. This was a displaced Syrian who had multiple emergency room visits for symptomatic WPW that had degenerated into atrial fibrillation, but the patient couldn’t afford an ablation.
In a separate case, we did an ablation on another displaced Syrian who had to cross the border from Syria to get to Beirut for the procedure. Normally, when we meet a patient on the day of a procedure, we ask how they are feeling, if they are experiencing any symptoms, if they have any questions, and when was the last time they had anything to eat or drink. However, with refugees, the conversation is very different: How are you feeling? Any symptoms? Any difficulty crossing the border? Any gunfire? Any bombs going off? Did you feel like your life was in danger this time crossing the border? What is most interesting is that the conversation is very casual and matter of fact.
What did you learn about the people and the culture, both in Beirut and with the Syrian refugees?
The mission of the Syrian American Medical Society and most NGOs is that while we help displaced Syrians, we will help anyone else too. We treated not only Syrians, but also Palestinian refugees and indigent Lebanese. I told Marwan that we would help any of his personal patients who couldn’t afford care. He said, “I have a young patient whose pacemaker is at end of life, they are pacemaker dependent, and cannot afford a new device. I told him, “No problem, we will bring a device and put them on the schedule.”
The Syrian crisis is now in its eighth year. There are approximately 1.5 million refugees in Lebanon, which accounts for 25% of the Lebanese population. I think that as a host country, Lebanon is doing the best they can with the resources they have. However, when refugees enter a country, it can have an effect on the local economy and resources. Refugees in general do not have access to public healthcare services or public schools. If you see a refugee child who appears to be 8-9 years of age, they are more likely to be 11-12 years old, which is a byproduct of malnutrition. The child whom I told you about earlier, who prompted this trip to Lebanon, was the second child in that family to be lost to malnutrition. These refugees are educated, they had jobs, they had lives, and they enjoyed all of the things we like to enjoy, but now all of a sudden they’re living in tents. Usually they would be organized in camps or there would be a cluster of them living on the land, where they would have to pay anywhere from $50-100 to a local landowner to squat and occupy a place on that land. These tents are also not guaranteed to have water or electricity. You might come across a tent that has some solar panels, and usually the people will work under the table or on the land to earn the money to stay and live there.
I’ll give you another anecdote. One day when Brad and I were in Beqaa Valley seeing patients, one of the last patients came in very quietly like he didn’t want anyone to know that he was coming in to see me. It turns out that this refugee was an ophthalmologist who actually worked in that clinic. He told me he had been having chest pains and that he had a history of coronary disease. He had classic angina and needed a cath. We set him up the next day to come to Beirut to be treated by Nouri Al-Khaled, an interventional cardiologist from Chicago. Nouri later found out that he and this patient had both attended the same medical school and knew all the same people. It was an emotional moment knowing that although they had gone to medical school together and knew the same people, their lives had gone in totally different directions.
We also had several interesting pediatric cases. Our first work day was on a Sunday, and with the interventionists at work in one hospital, we didn’t have access to do EP procedures. So I sent Rod out to a camp to see patients with his wife, Cybele, who is Lebanese. One of the patients she saw was a child who was brought to the camp for symptoms of asthma; as she listened to the child’s heart, she noted that the heart sounds were irregular. She called Rod over to listen to the child’s heart. Rod happened to have the AliveCor app on his phone, so they had the child’s mother hold the child’s thumbs down on the phone. Rod took a snapshot and sent it to me. The child had a heart rate of 30 and was in congestive heart failure.
Another child we saw had tetralogy of Fallot. There was also a child who was hypoxic when they came into the clinic because they had rheumatic fever and had developed endocarditis; the child had cardiomegaly and was also in congestive heart failure. The child with tetralogy of Fallot and the child with valvular disease from endocarditis both needed surgery, which made us very conscious of what we were spending, because we knew we had to save money for potential add-on cases like these. We took down their names, and when we got back to the states, we started reaching out to our contacts. My sister and another friend had worked with a pediatric NGO called the Palestine Children’s Relief Fund (PCRF), so I emailed them about taking on some charitable cases, including for a two and a half year old child with congenital heart block who was symptomatic. They agreed, and this particular child was arranged to be seen at AUB, but sadly, the family declined. The parents of the child with valvular heart disease were very apprehensive to go for care because their refugee papers had expired, and they were afraid they would be detained or imprisoned. It illustrates just how complex and tragic the refugee situation is.
While the mission trip may have ended on the calendar, the work hasn’t stopped. I give a lot of credit to the pediatric electrophysiologist who came with us — he stayed on and followed up with all of the contacts. Between the NGOs and his persistence, 2 out of the 3 children received the surgical care they needed. The child with tetralogy of Fallot did end up having surgery, and the child with endocarditis ultimately got a valve replacement and surgery.
Do you have plans to go back in 2019?
Yes — I’m obviously very passionate about this. The Syrian American Medical Society is a great organization. I’m also on the board of directors for another relatively new NGO called MedGlobal. I traveled with them in February to Bangladesh to help the Rohingya refugees. I definitely plan on going back with the Syrian American Medical Society and MedGlobal. Marwan and everyone at AUB were so accommodating and helpful in getting us access to the different hospitals. At the end of the mission in Lebanon, everybody was inspired to continue and come back. We learned so much about building relationships, working with local reps, and learning about catheter equipment compatibility.
From a personal standpoint, when I’m here in Chicago, I’m a board-certified electrophysiologist. However, when I go on medical missions, I start my day as an electrophysiologist or general cardiologist. By midday, I become a general internist, and by the end of the day, everyone there becomes a pediatrician because the clinics are so crowded. But ultimately, we are all global citizens, and we are there to bear witness and come back to tell their stories. I really struggled that day when I first saw that child. A close friend of mine who led my first mission is a pediatrician. I texted him that day, saying, “I don’t know what to do. This was a very difficult day. I’d like to put something about this on social media, but I don’t want to self promote.” He replied, “That child no longer has a voice. The world has forgotten, and now you are that child’s voice.” It’s important to share these stories about what’s happening in the world — telling their stories is what got other volunteers interested. I can’t thank Rod, Brad, and Kousik enough for wanting to be involved in this. They really added so much in terms of what we were able to bring to the table and organize, and the fact that they want to go back is very inspiring.
Is there anything you would like to add?
I believe this is the first time that cardiology was done at this level with this big of a group of cardiologists in Lebanon. I’d also like to thank Marwan, who volunteered his time to facilitate our trip. I’d also like to recognize the global health initiative / NGO affiliated with Northwestern, who made a sizable donation to help fund the trip.
Earlier this year, I was asked to present on this mission at Heart Rhythm 2018 during a session on global health. Considering that all of this got started at Heart Rhythm 2017, it was amazing to then be able to present our story the following year. Everything that we were able to accomplish with the team that we put together went beyond all expectations.
To view additional photos from the trip, please see the bonus video on our website!