ORANGE COUNTY, Calif.—A team of 32 doctors, nurses, and social workers returned to the US on May 23 after a two-week comprehensive, multidisciplinary medical mission to Yerevan. The group primarily was comprised of health care providers from Orange County’s Children’s Hospital (CHOC) and St. Joseph Hospital. There were four members of the delegation of Armenian descent, the rest were Americans with various backgrounds. The trip culminated months of preparation and was conducted under the auspices of Arpan Global Charities, a philanthropic medical organization which has conducted charity medical outreach in over fourteen countries.
“The purpose behind the mission was more than treating patients and delivering equipment” in Armenia, remarked Dr. Sudeep Kukreja the Director of Arpan Global Charities, and Neonatal Intensive Care Director at CHOC. The medical team’s goal was to establish long-term relationships and create programs such as sister hospital networks that would insure that medical advances be maintained by appropriately trained clinicians in Armenia. In the two weeks in Armenia, the medical team was organized into groups. Surgeons and anesthesia were divided into their subspecialties of pediatric, thoracic, and orthopedic surgery. The pediatric intensive care team of doctors and nurses visited intensive care units at two hospitals and also participated in general pediatric care. The internal care team of doctors and nurses visited outpatient clinics through Yerevan, including Nor Hajin, Nor Nork, Massis, Ashtarak, and Kharbert districts. They also worked two days in Gyumri and visited two orphanages. Dentist Vazrick Navasartian remarked that he had been overwhelmed by emotion since the team arrived and he was grateful that Arpan chose Armenia as its mission destination. The team also included a lactation specialist from CHOC and a social worker who focused on children’s issues and women’s issues including visiting a woman’s shelter.
Dr. Brian Palafox, St. Joseph Hospital Cardothoracic Surgeon, taught three procedures never before performed in Armenia. With Dr. Armen Chalian, also from St. Joseph hospital in Orange, supervising the anesthesia, Dr. Palafox showed how to perform lung surgery via tiny incisions and a camera (called VATS-video assisted thoracoscopic surgery) and how to provide high level of postoperative pain management via tiny catheters placed strategically and outfitted with continuous local anesthesia bulbs via the “OnQ” system which is widely used in the US. The video assisted thoracic surgery, was performed by the Armenian thoracic team at St. Krikor Lusavoritch Hospital in the Nor Nork region of Armenia. Dr. Palafox said ” I wanted their Armenian surgeons, who I might add are very bright and talented, to perform the surgery so that they could do it once we are gone.” Over 600 thoracic cases are performed a year at St Krikor Hospital mostly for lung cancer or complications of pneumonia. The humanitarian efforts were well received by the Director of Thoracic Surgery Dr. Hovannes Sarkavakyan and his team. At the same hospital in Nor Nork, Dr. Bedros Kojian, OB-GYN at St. Joseph Hospital in Orange, also performed and supervised a first for Armenia by showing techniques for urinary incontinence surgery with mesh implantation, as well as laparoscopic assisted vaginal hysterectomy. Dr. Kojian, no stranger to medical outreach in Armenia, commented that urinary incontinence, an often embarrassing yet common condition, is underreported by women because the “they (gynecologists in Armenia) don’t have the mesh implants that we do in the US” so surgical correction is not that often performed. The St. Krikor Lusavoritch Hospital Director , Dr. Minassian thanked the Arpan Global Charity physicians for their efforts, collaboration, and equipment donations.
Continuing with the precedent of performing procedures for the first time in Armenia, CHOC Director of Pediatric Surgery, Dr. Mustafa Kabeer, of Indian American descent, performed laparoscopic pediatric procedures for colorectal surgery at Arabkir Children’s Hospital in the Arabkir region of Yerevan. Dr. Kabeer worked in collaboration with pediatric surgeons at Arabkir Children’s Hospital in the Arabkir region of Yerevan. The welcoming arms and collegial spirit of the Arabkir surgeons overcame Dr. Kabeer. He remarked, ” we worked together as colleagues and the willingness to embrace my presence in their operating rooms was overwhelming. ” Arabkir Children’s Hospital Director Dr. Ara Babloyan presented his progressive vision for the implementation of evidence-based medicine on the first day the medical mission team arrived in Armenia. The next day, Dr. Babloyan, also an Armenian Parliament member, was named as the President of Parliament. Dr. Kabeer specifically thanked the surgeons he most closely collaborated with “like Drs. Sergei, Sahak, Boghos, and Shiraz.” By the end of the mission, Dr. Kabeer received many gifts from appreciative parents for his involvement.
In the field of Anesthesiology, Arabkir Children’s has “excellent systems and staff in place” said Dr. Chalian, President of Allied Anesthesia Medical Group in Orange, which provides exclusive anesthesia care for CHOC and St Joseph Hospitals. Armenian Hospitals have limited quantities of certain anesthetic agents like Sevoflurane and Nitrous Oxide, so there is widespread use of regional anesthesia like spinal, caudal, or epidural anesthesia to minimize the use and conserve the availability of inhalational general anesthetics. Dr. Chalian presented the US emphasis on preoperative preparation for children with parents present up to anesthesia induction and child life specialists in children’s hospitals using visual tools like iPad to ease anxiety. Also presented was the emphasis on postop pain management in the US for quicker discharges home. There are far less outpatient procedures done in Armenia. Most patients are admitted, often for days, compared to similar cases done as outpatients in the US. In that context, Dr. Chalian supervised the first ultrasound assisted postop pain management nerve block procedure performed by the Arabkir Armenian anesthesiology staff. The importance of these and other techniques done in the United States is to lessen the need for narcotics for pain control, decrease complications of pain medications, get children up sooner after surgery, and lessen the duration of hospital stays.
The Arabkir Children’s Hospital has a long time associate of Dr. Babloyan at the lead for anesthesia, Dr. Khatchik Kyurkchyan, who like the Hospital Director is very progressive, modern, and up to date with the latest anesthesia literature and evidence based care.
The Orthopedic team of physicians, Dr. Paul Beck and Dr. Phillip Krueger visited Izmirlyan Hospital in Yerevan. They mainly focused on joint replacement surgery, which is increasingly difficult due to the cost and lack of availability of implants.
While the surgical teams were active, the neonatologists and intensive care nurses were busy with critical care in the children’s intensive care units at Arabkir and Izmilyan Hospitals. Dr. Kukreja and his team included several CHOC residents who participated in the medical care. He stated “ starting philanthropic work early in one’s medical career provides a solid foundation for continuing charitable outreach in their future.” The mission team appeared on local TV in Yerevan and Gyumri, and was interviewed for Internet and print local news agencies. Days began with breakfast at the Hotel, then teams heading out to their respective destinations, and then returning nightly for debriefing meetings before heading out for late dinner in Yerevan.
By the end of the mission, six “firsts” (first time performed in Armenia) were recorded and steps created to continue these techniques by Armenian physicians. The care team saw 750 patients, performed 58 surgeries, visited several orphanages, and had very productive exchange of information between visiting team members and the medical faculty from Yerevan.
Assessing the overall state of healthcare in Armenia was of course limited by the short duration of the visit, however the following observations were identified. First, the quality of the physicians and their dedication and enthusiasm for advancement was felt to be superb. Problems identified included limited access to quality care, limited availability of equipment and medications, patient costs limiting treatment options in the absence of adequate insurance availability or government subsidy, overutilization of emergency rooms with nonurgent conditions (although also seen in the United States), insufficient experience obtained in residency training compared to US residency training, no incentive for clinical trials and academic research, absence of treatment protocols to insure uniformity in treatment and lead to earlier discharges, and a lack of consistency between healthcare outlets. With respect to public health, obesity is not observed like it is in the United States, and home grown “organic” fruits and vegetables are plentiful. There were no governmental agencies for children’s welfare or women’s protective services, and smoking is in overabundance with no evidence of education or advertising for it to decrease in the near future.
In the end, the entire visiting team from Arpan Charities in Orange County was overwhelmed by Armenian hospitality, which went above and beyond expectations. In the end, all of the doctors, nurses, and staff said they travelled to Armenia in the spirit of giving, yet they received so much in memories and satisfaction that cannot be measured. Especially for the mission team members of Armenian descent, leaving Armenia was tearful. Dr. Kamer Mgrdichian, Orange County Chiropractor, said that the trip has left a lasting impression and that it has changed him forever. He expects to return soon.