The heart of the matter
Dr. Jaime Gerber consults on a cardiac patient, in the hallway of City Hospital No. 3, St. Petersburg.
An estimated 1.3 million Russians die each year of cardiovascular disease. In St. Petersburg region alone, one out of every four citizens suffers from heart disease and its complications. The causes are legion: excessive alcohol consumption, smoking, unhealthy eating habits, insufficient education, socioeconomic factors, and of course genetics. Heart attacks, strokes and sudden death are commonplace; mortality rates are staggering - four times that of the U.S. These stark realities are what has brought a group of six cardiac specialists from Yale New Haven Hospital to St. Petersburg and Petrozavodsk as part of a longterm program for training and mentoring Russian cardiolo- gists. They are led by cardiac surgeon Michael Dewar, president, team manager and American coordinator of the Almazov Foundation of North America. Other team members include Timothy Dutton, perfusionist (heart-lung machine operator), diagnostic cardiologist Jaime Gerber,* critical care nurse Zuzana Svitek, interventional cardiologist Howard L. Haronian, and anesthesiologist Amar Lamba. Over the past five years, 28 select Russian physicians and surgeons have completed 4-5 week fellowships at Yale-New Haven's Heart and Vascular Center, working alongside cardiac specialists, learning about American medical practices. But the training does not stop there. Soon after the Russian fellows complete their U.S. training, their mentors travel to Russia to reinforce those skills, to complete the circle. On the Russian side, the program is stewarded by Dr. Maria Prokudina, a prominent cardiologist and director of The Healthy Heart Foundation (Russia), which partners with the Almazov Foundation and EurAsia Heart Foundation (Switzerland). Masha - as the group affectionately calls Prokudina - has a relentless vision, which she shares with every businessperson, state official and health official she meets: to establish an international cardiac center in St. Petersburg, where teams of Russian specialists collaborate to perform state-of-the-art care.
Patients wait to see physicians in the hallway of Republican Hospital, Petrozavodsk.
"Dobro pozhalovat!" Doctors Magomed Emin Askerov and 1lya Konstantinov - two of the most recent alumnae to participate in the Almazov Foundation program - greet the team as it arrives in Petrozavodsk, capital of the Karelian Republic.* Two months before, Askerov and Konstantinov worked side-by-side with their mentors in Connecticut: Askerov shadowed Doctor Dewar in the cardiac operating room; Konstantinov learned diagnostic skills from Doctor Gerber. At a morning meeting, the team assembles with key hospital personnel. 1ntroductions and pleasantries are exchanged. Then it is down to business. "It's an honor to have you in our clinic," Chief of Staff Alexander Shandalovich begins, with Prokudina translating. "1t is the first time we have hosted American colleagues here. Our idea is to enter into a conversation about taking care of patients. Together we will consult on complex cases, many with diabetes and all with three-vessel disease." He continues, his sen- tences filling with medical terms: "...Systemic embolism... frequent syncope... ultrasound images..." Handouts are distributed. "The first case. elderly male patient, surgeons Dewar and Askerov will perform the procedure. left atrial myxoma."
Suddenly, with that one word - "myxoma," the journalist silently embedded in this medical mission has been thrust into the story. I lean upon the windowsill. Twenty-five years ago, six weeks after my first child was born, a left atrial myxoma was surgically removed from my heart. The condi- tion is extremely rare, occurring in about five of every million persons. Yet these benign tumors can have serious, even fatal consequences if left undiagnosed. My personal surgery story was a tale fraught with drama and serendipity (second trimester diagnosis by cardiologist-husband; accidentally discovered by routine echo on newly leased equipment), modern medical advances and unwarranted complications (premature birth, emergency C-section, healthy/low-weight baby, top rated NYC cardiac surgeon, rapid recovery), mul- tiple emotional confluences and ultimately, a happy conclusion. The meeting drew to a close and I pled my case to Doctor Prokudina: it is very important that I interview "my" myxoma patient. "If he agrees," Masha says, patting my arm, "you will speak with him later."
For now, there is a schedule to keep, and little downtime. I'm tasked with following Konstantinov, Gerber and Prokudina on clini- cal rounds. We speed down the corridor, dash- ing up and down stairwells, ignoring the infrequent elevators. Physicians' cell phones ring constantly, yet the nurses' stations are strangely silent. There are no overhead pagers, beep- ing monitors, chugging generators, whirring computers, whooshing pumps, or the clanging metal furniture we have come to associate with stateside university hospitals. Smoking is pervasive, with visitors, patients, staff and doc- tors stepping outside for cigarette breaks. Walls are devoid of artwork, donor plaques, charts, nameplates, and hand sanitizer dispensers. An orderly drags a mop; another wheels uncovered food trays from room to room. "Who are these people?" I ask aloud, gesturing to a half-dozen men and women shuffling along behind us in an ever-growing queue. "They're the patients," my husband whispers. With no designated waiting area, they sit respectfully on hallway benches, waiting their turn to see the American doctor. Prodkudina details patients' case histories for the medical residents. Sporting a monogrammed lab coat, Gerber greets each patient in Russian as they enter the room. Konstantinov interprets their symptoms: high blood pressure, limited mobility, fatigue, shortness of breath, difficulty swallowing, and acute chest, back and neck pain. We hear from one middle-aged man, who despite a previous bypass surgery, still suffers from crippling angina. Wringing his hands, he tells the doctors, "I would like to have a better quality of life." Gerber recommends performing an immediate echo and angiogram to determine the course of treat- ment. Equipment and amenities are scarce in this echo lab. With neither paper hospital gowns nor private changing area, patients disrobe in full view of the doctors. More striking is the seamless interaction between Gerber and his protege. Born and educated in St. Petersburg, 28-year-old Doctor Ilya Konstantinov was also a guest in Petrozavodsk. He gently guides patients from table to treadmill, adjusting the ECG electrodes, his transition from student to role model well underway. "I have changed much of the way I manage patients," Konstantinov offers. "I now can open up and have a better dialogue." His exposure to what he labels "the gold standard of cardiac care" in New Haven has been "100% helpful" in shaping his diagnostic skills.
Handwritten alphabetical hospital files, Republican Hospital of Petrozavodsk
Konstantinov is the fourth young doc- tor Gerber has mentored in New Haven. "I show them American-style techniques and approaches, teach utilization of resources, and coordinate their hospital schedules," Gerber says. This, he explains, supplements their Russian medical training, "which allows recent graduates to enter the workforce." Gerber was pleased by the enthusiasm of the Petrozavodsk physicians. After delivering a standing-room only lecture (simulcast to four other medical centers) he remarks, "The seeds that are planted will take hold as these doctors become the leaders of the next generation." Dawn Ardito, an accomplished echocardiographer in the New Haven hospital, agrees. "The young Russian doctors have been wonderful," she said. "I spent a lot of time with 1lya, having known him from my visit to St. Petersburg in 2010. He impressed me with his eagerness to take everything in and adapt to new ideas. He was fascinated by the entire process and how it all came together at the end of the day." Educating advanced level medical professionals in underserved nations can backfire — often leading to the emigration of these same talented individuals to the West. Reversing this "brain drain" is a key component of the Almazov Foundation model. "This program was established with the intent of developing a long-term educational association between organizations in both countries," explains Timothy Dutton, a YNHH perfusionist who has been involved in the program since its inception. "The other aspect," Dutton said, "is a benefit of the longterm philosophy. As Russian specialists develop a relationship with the visiting teams, the hope is they [Russian MDs] will be inspired to train future practitioners." This reciprocal relationship sustains itself.
Surgeon Michael Dewar with Dr. Margarita Lesnykh, administrator at the Republican Hospital of Petrozavodsk, in the OR/recovery room.
To date, nine St. Petersburg area hospitals have been visited by two-dozen U.S. specialists. "The surgeons at the Federal 1nstitute are now busy, independent and learning to push back limitations on their own," said Almazov Foundation founder Michael Dewar. Since 1995, Dewar has performed more than 100 operations with Russian colleagues. "We have definitely seen positive effects of our mentoring when visiting with our 'graduates' in Russia," he said. "They have a certain confidence that is not seen in their colleagues. Several have been selected to work independently in newly estab- lished centers and proudly point to techniques or procedures that they are doing 'just like at YNHH.'"
Adjusting to the shifting macro obstacles takes perseverance. Dewar and his colleagues have had to navigate though what he terms "the institutional inertia — or, large underfunded hospitals with cadres of undertrained and underpaid nurses and physicians." Restrictive quotas on supplies and procedures contribute further to low morale. Despite three hugely successful visits of American pediatric cardiac surgeons in 2006, 2007 and 2009, Northwest Russia does not have, Dewar said, a single "fully trained, highly competent pediatric heart surgeon." Talented individuals are motivated to seek greener pastures. Doug 1srael, a YNHH doctor who has participated in five team visits to St. Petersburg, recounts how he brought suitcases full of supplemental medical items in the 1990s: drug samples, expired catheters and wires, and even an intra-aortic balloon pump. "Most obvious was the tremendous difference in the severity of disease in the patients," 1srael said. "People simply did not go to the doctor for preventive care, so the patients we saw had already had extensive heart damage." Such was the case of Ivan Emuranov, "my" myxoma patient. When I first meet him — an elderly, fine-featured gentleman seated on a hallway bench, words fail me. But after we exchange shy smiles, I relax, and (with Masha's assistance), convey my myxoma story. Ivan nods sympathetically. He is retired, 70 years old, and lives in Kostomuksha, in Northwestern Karelia. He has been undiagnosed since 1998. "That is when I began to feel some discomfort in my chest," he says. "I lived my life, trying to adjust to typical angina symptoms, but as the years went by, it got worse and worse." Walking just 300 meters would leave him gasping for breath. "A local doctor prescribed nitroglycerine tablets... and that did nothing," he shrugs. Finally, this year, he obtained a routine echo, and a diagnosis. "Is this surgery necessary?" He answers my question with one of his own. "I cannot say I am satisfied to have it. But now, I have a unique possibility to have this removed," he gestures to his heart, "and go on with my life. Tomorrow, hopefully all will go well. I'm happy for the opportunity to have this done with the support of American experts and the chance to build this friendship with the U.S. I feel very fortunate." He rises from the bench and I wish him luck. Mid-handshake, his cell phone rings.
Two simultaneous open heart procedures in the Republican Hospital OR.
Watching him chat breezily away, I marvel at his accepting demeanor. With only a few hours before his surgery, he demonstrates zero anxiety. Was this just his coping mechanism? I think back to the night before my procedure, when my stubborn refusal to take prescribed tranquilizers surprised the nurses. A chemically induced slumber held little appeal, so I opted for lucidity. Yes, I was nervous, but just for myself. My baby daughter was waiting for me at home, and she needed me. I wondered if Mr. Emuranov had someone waiting.
The next day, a local airplane crash of a RusAir flight from Moscow transforms Petrozavodsk Republican Hospital into an emergency rescue scene. The failed landing attempt claimed the life of 44 passengers and the few survivors are rushed into surgery. The mood is tense. Armed guards are stationed everywhere, camera crews emerge from vans and government officials confer with hospital administrators. Nevertheless, at exactly 8:15 A.M., Ivan Emuranov lies sedated on the operating table. Doctor Amar Lamba and a Russian colleague monitor anesthesia levels. Twenty-nine-year- old Magomed Askerov begins the cardiac surgery unassisted.
First, Askerov deftly harvests a vein, which is set aside for a potential bypass graft. Next, with a whir of the serrated saw, he cuts through the sternum. When the saw unexpectedly breaks, he swiftly resumes, using a wire. "In the USA, there would be a backup saw on hand," nurse Zuzana Svitek discreetly points out. There are other discrepancies: a shortage of disposable gloves; sterile solutions and instruments in repurposed food jars, a communal terrycloth towel in the scrub area, a relaxed dress code that allows open-toed shoes, and later that day, a second open heart surgery taking place simultaneously in the same operating suite.
The author with Ivan Emuranov, the day before before his myxoma surgery.
"They adapt and do a great job without modern techniques," Svitek remarks. For this, her second St. Petersburg mission trip, and her first to this hospital, Svitek came armed with nursing textbooks, handouts and a unique perspective. Prior to her Yale career, she accumulated five years of nursing expertise in her native Slovakia. "Growing up in a place with socialized healthcare helps me to identify with this situation,” she says. She has two goals for this trip: “Get the nurses to use flow sheets (for documentation), and influence a scheduling change away from their 24-hour shifts." When the Russian doctors came to observe at Yale, Svitek noticed they were, "truly amazed by our nurses' total involvement on the surgical team."
Cardiac nurses at the Republican Hospital of Petrozavodsk, on a break between surgical procedures.
Emuranov's surgery proceeds smoothly and without incident. Askerov patiently stands over the operating table for hours on end with unflinching concentration and an awe- inspiring self-confidence.
"Being in America for the first time... 1 liked it very much. 1t was very interesting and helpful for me," Askerov says between sips of tea. He is exhilarated and exhausted during his brief post-surgical break. Exceedingly polite, he volunteers that he is a married father of two young children, whose boyhood dreams of becoming a doctor while growing up in Dagestan are now fully realized. "Here, in the outlying cities, the care is not as good. The training is not the same," he says. Russian surgeons can work for decades as assistants, without any possibility of moving up the lad- der. Supplemental training in U.S. hospitals, he adds, "could bring changes in cardiac care to our region." Such changes were occurring in real time.
"Do you remember that patient seen this morning by Jaime [Gerber] with the crippling angina?" asked team interventionist, Howard Haronian. He reports that a "history making event" has just occurred in the catheterization lab. "For the first time here, with the assistance of my young Russian colleague, Doctor Michael Sareyev, 1 performed a high risk procedure - a special method to insert a stent in the heart - by shaping a catheter and inserting it through the patient's wrist to dilate a blocked artery," he explains.
This operation, rather routine in many U.S. hospitals, is rare in Russia. Due to a lack of apparatus or medicines, many Russian prac- titioners cannot attempt such risky, complex cases. Haronian said they had carried out two such procedures. "Success!" he exclaimed. "The young doctors were very grateful - stating that they would pursue this approach. They felt more confident."
Doctor Margarita Lesnykh, a Republican Hospital administrator who coordinated the visit, acknowledged her staff's educational needs. "Even me!" she says. "To have an opportunity to see how professionals work on the other side of the world, we can learn something new and exchange knowledge. That is always good."
Arriving by overnight train, the team splits up into small groups, each dispatched to different hospitals. The disparity among the facilities, whether due to variable standards inconsistent with Euro-American requirements, equipment, training, access to care and medical services, becomes evident when the team compares notes at the end of each day. The prestigious Postgraduate Medical Education Academy scored high marks on all counts, as did the Military Academy Hospital, where Doctors Dewar and Lamba completed a beating heart surgical procedure. "The Russian anesthesi- ologists 1 worked with were capable of tackling anything," Lamba says. "They provide good quality medicine to their patients."
Meanwhile, City Hospital Number 3 pre- sented a paradox. This 1150-bed behemoth of a hospital - the largest in the Northwest region, employs 400 doctors and 1000 nurses, who treat more than 86,000 patients a year. Many patients arrive by ambulance and stay for a week or more. The hospitals' departments have wideranging needs, not all of which are being properly met.
Doctor Gleb Sareyev, 33, proudly shows team members around his brand new, high- tech cardiac catheterization lab. After his 2010 training with Doctor Israel in New Haven, Sareyev was ready for greater challenges. "Before I went to Yale, I had little experience," he says. "I slowly gained confidence doing procedures." Within a year after returning to Russia, he was appointed director of this new department.
In another cardiology wing, five female patients are crammed into one room. Joining Doctors Prokudina, Konstantinov and Gerber on teaching rounds is 24-year-old Yegor Karev, who shadowed Gerber in New Haven just under a year previous. When Gerber sug gests a pacemaker to treat an elderly woman's arrhythmia, the discomfort is palpable. "We have exceeded our quota, and must wait for our next supply from Moscow," the attending physician reveals. Adding to the doctors' frus- tration was an absence of essential diagnostic tools: not a single treadmill or stress echo machine.
Dr. Maria Prokudina
"We need to improve cardiac management and education," says Karev, who is affiliated with Pavlov State Medical University. "Few hospitals in Russia possess modern equipment and trained specialists, particularly in compari- son with the level of care in the U.S. There are some tendencies of rejecting new ideas and methods. Russian doctors need more time for changing their points of view and therefore, their tactics towards world standards."
"Presently, we have free cardiac care for everybody, "says Doctor Boris Taits, chief of staff at City Hospital Number 3. "We are doing more, but not enough." In his large paneled office, Taits details the considerable challenges of juggling the needs of patients, facilities and staff. To oversee a facility that attracts top-notch physicians, he intends to modernize the physical plant and expand educational programs. "Every year brings another change," he says.
Surgeon Magomed Askerov
A WEEK LATER, the team is back in Connecticut. "I have learned patience, humility and to listen more, speak less and teach by example," Michael Dewar says.
One medical mission team visiting Russia for a week cannot change the system or the treatment culture, nor can it stamp out rampant coronary disease. But it can touch individual lives. Shortly after our return, I received an email from Doctor Magomed Askerov. "Do you remember the patient who removed his myxoma - Mr. Ivan Emuranov?" he writes. "He is very happy now. He had an interesting story."
Magomed tells me that Ivan's daughter had been in a difficult situation and was operated on just four days before Ivan had had his open heart surgery. "She was in very serious condition," Magomed said. "He cried and did not want to have surgery." He would not agree to the surgery until his daughter began to recover. She is now better and caring for him. Magomed ended the email with a simple request: "Thank the team of doctors." RL
Источник: Russian Life | January/February 2012