About

IN-STEP (American Indian Structural Heart Disease Partnership) is a new partnership between Cincinnati Children’s Hospital, Edwards Lifesciences Foundation and Whiteriver Service Unit in Arizona aimed at improving structural heart disease detection among Native American populations in the US. IN-STEP includes: (1) training local provider training in POCUS, (2) assessment of echocardiography integration into primary care clinics, and (3) assess structural and rheumatic heart disease through screening events.

For two months (Feb-March) 9 sonographer volunteers each spent a week scanning patients at the Whiteriver Indian Hospital. The sonographers were assisted by Ryan Close (site PI) and especially by LeCario Benashley, a young medical student who worked as a research assistant consenting patients and helping the volunteers navigate the hospital and the Whiteriver area.

About

I had an amazing team of 5 sonographers volunteer for this trip - Patrick, Alyce, Aliyah, Georgeanne and Cecilia. They spent a week at various District Hospitals continuing the echo education for the NCD nurses and physicians. As always their enthusiasm and expertise was appreciated by everyone involved.

I overlapped for a weekend with them as I was part of the surgical team working with Dr. Stephanie Saucier a cardiologist. She and I spent a few days screening for surgical patients in the Kigali area and then did the post-op studies as needed. The Team Heart surgical teams in 2022 and this year are much smaller than when we brought 40 people! This is due to the increase in knowledge of the Rwandan nurses, clinicians, support staff, etc. In fact the last day we were there Dr. Maurice did a case without any of the Team Heart volunteers in the room. This was the first instance of open heart surgery being performed by a Rwandan surgical team without the involvement of a visiting expatriate team!

In September I took a small team consisting of myself, Brittany, Silvia, Brigid and Dr. Gregg. Silvia is a sonographer from Milan who has volunteered in the past to Nepal, Sudan, India and this is her second Team Heart trip to Rwanda in 5 months! Dr. Gregg was with me a few years ago in the Philippines with the ASE/US Navy Pacific Partnership trip. Brigid has been to Rwanda before as well as Paraguay while Brittany is a peds sonographer, formerly at Duke who came to India with Silvia and I in 2019. We split up during the week to two Referral Hospitals working with the NCD nurses/physicians expanding their echo skills to include spectral Doppler in taking care of their patients.

Going to Rwanda again for the Team Heart 2019 surgical mission was a great success. Along with Marilyn Riley, the other cardiac sonographer we spent a week with the screening team traveling around to various District Hospitals selecting patients for surgical consideration. I was able to bring two people from Caption Health, the AI/Deep Learning startup from San Francisco I’ve been consulting with for 3 years. Ching is a graphics designer and Natalia an engineer have been working with others to develop software that will guide novice users to acquire diagnostic echo images. During the 2nd week we went around and showed a prototype system to some of the Rwandan physicians and NCD nurses I have been working with since 2014. All of them were in awe of the software and wanted us to leave it with them to help train others. For now that will be a future goal. Ching and Natalia were both able to get into the OR and watch a surgery which was an amazing opportunity for them.

Merry Camp is for kids with Congenital Heart Disease (CHD) located in the mountains outside of Portland Oregon. For the 2nd year in a row Brigid and I were privileged to be a part of the group of volunteers that include nurses, physicians and local friends/family. Brigid again was the official lifeguard and I was her helper which meant keeping leaves and bugs out of the pool and hosing off the deck an the end of each day. The campers had a great time as they always do including learning more about their heart diseases from Rob McDonald and other clinicians throughout the week.

It had been 5 years since I was in Bangalore at SSSIHMS with the ASE Foundation but they still remembered me! This trip was organized by Dr. Keshav Nayak and myself now that he has retired from the US Navy and is at Scripps in California. N. Srinivas, the Sr. Manager Department of Cardiology invited us and told me that the sonographers and physicians wanted to learn fetal and advanced CHD. I was able to invite some peds sonographers who made me proud as they jumped in with the hands on training and gave some lectures during a day long seminar Keshav and I organized.

This was my 3rd mission with Heart 2 Heart who have recently started coming to South America after more that 25 years of missions in Russia. My first time to Paraguay a beautiful country where one of my nephews spent 3 years as a Peace Corps volunteer. Brigid and I came along with cardiac surgeon Dr. Nilas Young, founder of Heart 2 Heart, Josie Everett, Ex-director, cardiologist Dr. Dali Fan and a small surgical team. We spent a week working with with the Paraguay echo team while Nilas worked with the surgeons doing cases each day. I was able to bring a Philips Lumify probe to show them how the images of these handheld devices have improved.

Going to Rwanda again for the Team Heart 2019 surgical mission was a great success. Along with Marilyn Riley, the other cardiac sonographer we spent a week with the screening team traveling around to various District Hospitals selecting patients for surgical consideration. I was able to bring two people from Caption Health, the AI/Deep Learning startup from San Francisco I’ve been consulting with for 3 years. Ching is a graphics designer and Natalia an engineer have been working with others to develop software that will guide novice users to acquire diagnostic echo images. During the 2nd week we went around and showed a prototype system to some of the Rwandan physicians and NCD nurses I have been working with since 2014. All of them were in awe of the software and wanted us to leave it with them to help train others. For now that will be a future goal. Ching and Natalia were both able to get into the OR and watch a surgery which was an amazing opportunity for them.

Dr. Craig Sable a peds cardiologist is one of the worlds experts on Rheumatic Heart Disease (RHD). He has worked for 20+ years in places like Uganda and Brazil collaborating with other experts. One of his research programs in Uganda is GOAL and the object to to identify kids with borderline RHD findings to see if penicillin prophylaxis works in slowing the progression of disease. Of course any child with definite RHD finds receives monthly penicillin. I was able to spend 2 weeks in Gulu Uganda screening up to 300 kids daily at schools around the city. GOAL has an amazing, well organized team of nurses and healthcare workers in order to make this happen.

Merry Camp is for kids with Congenital Heart Disease (CHD) located in the mountains outside of Portland Oregon. Started a few years ago by my friends Marty Rice, a peds cardiologist and her husband Rob McDonald, a peds cardiac sonographer. They retired from OHSU but wanted to do something for all the patients they have cared for over the past 30+years. Brigid and I were privileged to be a part of the group of volunteers that include nurses, physicians and local friends/family. Brigid was the official lifeguard and I was her helper which meant keeping leaves and bugs out of the pool and hosing off the deck an the end of each day. The campers had a great time and of course their favorite activity was with us at the pool where they didn’t have to be self-conscience about have a scar (s) on their chest because every one was the same.

In collaboration with the US Navy during Pacific Partnership 2018 (PP18). This was my 4th trip to Vietnam and the 3rd time I worked with the Navy cardiologists from the USNS Mercy, the hospital ship out of San Diego. This time CAPT Keshav brought another interventional cardiologist, an EP doc, a peds cardiologist and two Navy Hospital Corpsman. Spending time in the cath and echo labs was another amazing experience working with the Vietnamese physicians.

My 10th trip to Rwanda dovetailed with the 11th surgical mission of Team Heart. As usual Marilyn Riley and Jayne Cleve joined me as cardiac sonographers so that we could cover a week of screening patients pre-surgery, the week of surgery and doing all the post-op and pre-discharge echocardiograms. I spent a few days working with the NCD nurses and visiting friends like Ivan, Victoria and their baby girl Talia.

The Peds Cardiology group from OHSU in Portland OR have been going to American Samoa (AS) for years. Screening kids for CHD and RHD bringing some of them back to the States for life saving surgery. American Samoa has one of the highest prevalence of RHD in the world! I was asked by Ipu from the AS Dept of Health to come over and train people to screen all 16,000 kids on the island. Peg Knoll from UC Irving and I spent two weeks training 10 nurses, physicians and rad techs how to preform a limited echocardiogram.

Nepal is an amazing country at the top of the world. In collaboration with CardioStart through the work with Dr. Tom Hilton I kicked off a year long training project for 3 nurses to learn cardiac ultrasound. Like most countries around the world physicians do the echocardiograms. With a limited number of cardiologists having a cardiac sonographer perform the studies frees them up to do more patient care.

Through CardioStart we setup a training schedule where sonographers from around the world would spend two weeks each month coming to Nepal and working with the nurses. Didactic classes were held each morning and the afternoons were spent in scanning patients. It was amazing to me how enthusiastic the nurses were to learn. By the end of the year we had added a 4th nurses and all of them successfully passed the CCI Basic Echo Certification Exam!

The senior NCD nurses I had been training since 2014 from various District Hospitals around Rwanda received some Sonosite echo machines. I arranged for one-on-one training in their hospitals by bringing over two teams of sonographers from around the world and Dr. Neil Weissman. Each team spent a week working with the Rwandan nurses and physicians overlapping during the middle weekend when I took them all on Safari to Akagera National Park. The nurses really appreciated and learned from the experience. I had Jayne and Neil spend time at the medical school scanning and giving lectures. At the end Brigid, Marti, Barb and I went to see the mountain gorillas which even being my 3rd time was an amazing experience.

Four years ago my friend and colleague Mark Monaghan from Kings College Hospital in London started a RHD screening program called Echo in Africa with the assistance of the British Society of Echocardiography. I was lucky to spend two weeks scanning high school kids every morning and visiting winery’s for lunch in the afternoon. On Fridays any kids with positive findings were brought to the local medical center for a more comprehensive exam.

Led by the U.S. Navy, the Pacific Partnership is the largest annual multilateral humanitarian assistance and disaster relief preparedness mission and was launched in response to the environmental disasters in the Indo-Asia-Pacific region. In May 2017 I was lucky to again join with the Navy cardiologists as the team traveled to the Vietnamese coastal towns of Da Nang and Nha Trang – the eighth time in eleven years that the mission was based in Vietnam. Through my friendship with Luzvilla Anacta she arranged to have us use a GE Vivid iq and Vivid E95 to perform the first 3D TEE studies in the Da Nang cath lab.

Captain Keshav Nayak, interventional cardiologist and cath lab director at the San Diego Naval Hospital, has been traveling to Vietnam since 2010, developing a re-occuring ASD closure workshop for underserved Vietnamese patients along with his Vietnamese colleagues, Dr. Nguyen Ba Trieu and Dr. Han nguyen. Additionally, Hanoi structural expert Dr. Nguyen Lan Hieu and German ex-pat structural expert and philanthropist, Dr. Trong Phi-Le have joined CAPT Nayak on many occasions. “This project has been very satisfying for me in many ways. I am able to work alongside my wonderful Vietnamese colleagues in providing much needed structural heart interventions for poor Vietnamese patients. We have a great relationship now built over many years and many workshops ” said CAPT Nayak.

During the two-week trip, Nayak, Trieu, Han and Trong-Phi implanted 23 devices in children and adults to treat various heart defects. During this workshop, they performed ASD closures using 4D echo. This was the first ever 3D transesophageal echocardiogram performed at the Da Nang General Hospital with the Vivid E iq. “The Vietnamese team was very impressed with the image quality and 4D applications for ASD closure” said CAPT Nayak.

The US based combined Navy and echo team conducted a state of the art seminar reviewing  advanced echo techniques and applications for 3D Echo with Vietnamese cardiologists and sonographers from across the region. “The local team was incredibly impressed with the image quality of these ultrasound systems,” said Mr. Adams. “They crowded around in complete awe.”

Monday the 6th I flew from Atlanta to Rwanda via Amsterdam arriving Tuesday evening. I had missed the week of screening (thank you Marilyn and Ashlee) and the following week of surgery by the amazing Team Heart folks. This was our 10th year of life saving cardiac surgery for 16 patients. Jayne and Marilyn did most of the post-op echoes so I got to ease into African time by overlapping a few days with Jayne. It's great to see how quickly the patients recover - after just a couple of days they are smiling, walking and following the post care regiment. By Saturday the patients were all in the Step-down Ward and handed off to the Rwandan nurses / doctors as the Team Heart folks left for home - exhausted but happy.

The goal for my 2nd week in Rwanda was to work with the NCD (Non Communicable Disease - hypertension, stroke, diabetes, MI) nurses and physicians to increase their echo skills. With NCD's on the rise in Rwanda and many other developing countries there is a growing need for education and treatment. Here in Rwanda the Minister of Health has instituted a strong program using senior nurses from the 30 District Hospitals to be trained to run NCD clinics. In 2014 I brought over a team of 6 sonographers and we spent 2 weeks training 15 nurses. Being retired I can now spend an extra week after the Team Heart surgeries.

Working with Dr. Evarest Ntaganda who is in charge of training the nurses we came up with a plan that I would go to some of the District Hospitals up North and work with some of the nurses. That morphed quickly into 15 nurses and a few physicians traveling with me. It all worked out in the end. A day to give some lectures and then we saw patients at 3 hospitals, Ruhengeri, Butaro and Nemba. It helped that 3 of the nurses had been part of the 2014 group and were a great help in teaching each other. They have ordered 11 new echo machines and in Nov. I plan to return with a small team to do some follow up training.   

"A collaboration between the ASE Foundation (ASEF), the Philippine Society of Echocardiography (PSE), the Philippine Heart Association Bicol Chapter (PHA), and the U.S. Navy’s 2016 Pacific Partnership brought together a diverse team of clinicians for an education and training seminar in early July 2016. Our team met at the Bicol Regional Training and Teaching Hospital (BRTTH) in Legazpi City, Albay, Philippines for two days of didactic lectures, hands-on training of echo techniques, and assessment of patients to identify congenital and rheumatic heart disease. Our aim was to work together and learn from each other’s experience while providing education and training in an under served area of the world."

Led by Andrea Van Hoever, MSGH ASE/ASEF Deputy Director she helped organize all the activities such as scanning patients, the two day seminar with hands on but mostly kept us out of trouble and got us all home safely.

To learn more about this trip, see photos, and download lectures, visit http://www.asefoundation.org/philippines.

Rwanda, Land of a Thousand Hills
written by Amy Mott

Rwanda is a beautiful country of rolling hills, mountains and grassy lowlands. In French, it has been named ‘Pays des Mille Collines’ meaning ‘Country of a Thousand Hills’. It is also a Land of Plenty, of Beautiful People and of Struggle beyond what most of us can only imagine. While compared in size to that of Maryland, it is home to 12.5 million people in which the per capita income is less than $2 a day.

You cannot speak of Rwanda without remembering the Genocide. 1994 this country saw more than one million if its people murdered in just one hundred days. These killings were calculated and brutal, neighbors turning on neighbors, even priests turning on their own parishes. If you want your heart to break visit the Kigali Memorial Center built for the Rwandan people to grieve and remember and yet find peace.

While in Rwanda we were moved by the people of this land; their work ethic, compassion and hope. We saw farmers whose only tools were shovels to plant their families’ crops, ladies walking miles to the market balancing baskets of avocados on their heads, tiny children carrying water jugs larger than themselves back home from the river, women sweeping the dangerous, winding roads with only a small broom stick made of grass. But on all of these faces, were smiles and in their eyes, pride. If you come to this land, you will leave changed. It may not show on the outside but inside you know what you are now capable of doing. And you know that while you may have missed your Starbucks on the corner or shopping at Target, you cannot expect yourself to keep doing ordinary things. You realize that no matter where you go there are lives that depend on you being able to share your skills and your heart’s passion on their behalf. 

The Bach Mai Hospital is part of the National Heart Institute (NHI) in Hanoi and was one of the ASEF missions in 2015. I was lucky to go along with the team led by Drs. Jim Kirkpatrick and Jose Banchs and Andrea Van Hoever, MSGH ASE/ASEF Deputy Director. We spent a few days giving lectures and then trained a few nurses to perform limited echocardiograms. Like most countries in Asia echoes are done by cardiologists. We then spent one day in a remote village outside of Hanoi screening older patients. For me it was a surreal experience working on patients who 50 years ago might have been trying to kill American service men.

We got to spend a day cruising around Halong Bay a UNESCO World heritage Site which was a magical place. We also heard about all the devastation caused by what they call the American War. Working with the cardiologists at the NHI was amazing and we have continued to collaborate on projects. Mindray, one of the ultrasound companies donated a laptop machine so that they can continue to do outreach clinics.

My 2nd trip with Heart to Heart was back to Russia but this time to Chelyabinsk close to Siberia. Another sonographer, Elaine Shea came with us and she spent the week in the Adult Echo Lab while I was in the Peds Lab. 30-40 cardiologists from around the area were invited so we gave some talks as well as scanning some of their patients. While it had been 20+ years since I scanning complex congenital patients it all came back rather quickly which was good because the cardiologists were hanging on my every word.

For some of the more difficult I taught them the Buddy system that we use at Duke for AS patients in that every AS case has a 2nd sonographer try to get a higher gradient. Works for Fontan patients as well. We also got to see some of the countryside and spent an afternoon in a Russian sauna as a group! I was able to reconnect with Svetlana Kuzmina-Krutetskaya, an amazing peds cardiologist and her daughter Anastasia who is a cardiology fellow.

Another successful Team Heart surgical mission to Kigali. Marilyn, Jayne and I tag teamed the sonographer responsibilities for screening and post op echoes. I was able to work with some of the NCD nurses we had trained the year before which was exciting to see how their echo skills had progressed.

Jayne and I spent time to trek up and see the mountain gorillas which is always an awe inspiring experience. Almost as great as seeing the post op patients recovering so quickly with huge smiles on their faces.

I was asked by Dr. Abbas Ali, an Critical Care physician at Geisinger Medical Center to travel to Khartoum, Sudan as part of a WINFOCUS training mission. Never having been to Northern Africa I jumped at the chance. I arrived safely but my luggage did not so my Sudanese guide took me shopping. Abbas brought over two senior nurses as well and they spent the week doing an update on ICU nursing to 50 nurses and physicians. We had around 40 physicians and 5-6 nurses attending the echo workshop which included hands on training. Being originally from Sudan Dr. Ali is involved with SAMA (Sudanese American Medical Association) and I was lucky to meet some of his medical school classmates one night for dinner. Also got to sail on the Nile and eat fish from the Nile which means I’ll be back someday.

My third mission to India with the ASEF took us to Bangalore, the Silicon Valley of India. With Dr. Partho Sengupta and a group of amazing sonographers and cardiologists we spent a week at Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS). As you can see from the picture above SSSIHMS like a palace than a hospital but it was built to serve the poor so no bills are generated for the work they do. There are also schools for nursing and cardiac ultrasound within the Institute. During the week we worked with the sonographer students scanning hundreds of patients.

A few days before the ASEF mission I was invited to participate in the EchoNagpur conference by Dr. Shantanu Sengupta which was great fun and a very well run conference. Jayne and I then met some of the ASEF participants for a tour of the Taj Mahal in Agra before heading to Bangalore for the real reason we were in India.

In September I brought over a team of 6 sonographers to help train senior nurses to perform echocardiograms for 2 weeks. The nurses were from various District Hospitals around Rwanda participating in a 2 month Noncommunicable Disease (NCD) training program by the Rwandan RBC led by Dr, Evariste. With the rise of hypertension, diabetes, stroke and heart attacks in developing countries they would run NCD clinics in their remote locations.

Six echo machines were loaned to us by GE, Hitachi and Mindray. Every day I gave morning lectures on the basics of Echo and in the afternoon we set up scanning stations for them to practice hands-on technique. While at first they were shy to engage by the 2nd day the sonographers had won them over and they were very eager to learn. By the end of the 2 weeks we were sorry to leave. I took them all on safari one day and at the end of the 2 weeks we went to see the mountain gorillas!

February 2014 was my 2nd Team Heart surgical mission. I came over a week before the surgical team to screen patients with Marilyn and Drs. Pat Come (Boston) and Jeanne DeCara (Chicago). On selection Sunday we presented the top surgical candidates from the 100+ patients we screened. Very tough choices as there were only 16 slots (2 surgeries per day for 8 days) and many more patients needing life saving valve replacement surgery. Patients needed to be symptomatic but not too sick so that their post-op care would be too intensive.

In July I returned to Rwanda intending to work with the Rwandan cardiologists since they were receiving 2 Philips CX50 ultrasound machines. Since the machines were delayed in Customs I went to Plan B and hooked up with some of the PURE Emergency Medical physicians to help with the training program they were doing. It was very different from my usual echo focus during the Team Heart surgical or screening for RHD missions. They were teaching surgical and EM residents how to use ultrasound in the Emergency Department for FAST exam in acute or trauma situations as well as doing ultrasound guided biopsies.

Ceeya and Jabaris were also in Rwanda so I spent some time traveling around with them seeing patients and some of the more remote hospitals around Rwanda. Lucky for me I had brought a GE Vscan handheld echo device so we were able to use that where ever we went.

This was my first Team Heart surgical trip! What an amazing group of people! The first week I was with the small screening team of Marilyn, Jeanne, Julie and Pat where we traveled to various hospitals around Kigali to see the patients that the Rwandan cardiologists had selected for surgery. Seeing almost 100 patients in 5 days but only having 16 surgical slots made the selection process critical but very hard. We knew that many of the patients we did not select would not last another year.

Rwanda is a country of over 11 million people with only 5 cardiologists (2 are peds). They all are in Kigali the capital so the patients need to come to them which is a burden many can’t afford. One important question pre-op is can they get to a local District Hospital for monthly INR checks since Team Heart mostly implants mechanical heart valves since they last longer but require anti-coagulation medication.

The 2nd ASEF mission to India occurred in December when we returned in order to assist at a free cataract camp North of Delhi. This time we spent a few days training physicians with no echo experience via two methods. One group received traditional one-on-one hands on instructions while the other group were linked remotely with sonographers in the United States who could see their screen and direct image acquisition. At the end of the day both groups felt adequately prepared to perform a focused echo exam.

We traveled to the cataract camp where 5000 people were to have surgery over s 3 day period. Before the camp started we spent a day doing a focused echo on 1000+ people with suspected cardiac history to see if they could have cataract surgery at the camp or needed to go to a Delhi hospital for more surgical support. It was a great success as only a few patients were screened out of having eye surgery at the camp due to either significant RHD or a low EF.

My first trip to India was for the ASEF in early 2012. Led by Dr. Partho Sengupta we went North of Delhi and performed screening echocardiograms on a wide variety of people who had gathered for e religious celebration. During the final (long) day we set a Guinness Book of Records for the most Doppler studies done in 24 hrs - over 1000!

My first trip to Rwanda with Team Heart was for a 2 week RHD screening mission. Everyday we traveled to a different elementary school within 3 hours of Kigali. We setup two classrooms for screening boys and girls, lying foam mattresses across desks as beds. Sonosite donated the echo machines and every night Jennifer, our sonographer leader spent hours downloading the images and charging the machines. Most of the schools did not have electricity so we brought along a gas generator.

Heart to Heart invited me on a mission to Russia. Dr. Nilas Young, Chief Cardiac Surgeon at UC Davis, had been going over for years. One of my Duke sonographers had gone to St. Petersburg with the team 18 months prior and came back with amazing pictures and stories. While we also were able to tour the famous places in and around the city like the Summer Palace it was February which meant temps in the -20’s F!

Still the trip was an eyeopener for me and the start of many more that I would do in the years to come. In fact it feels boring to go on a “vacation” if it doesn’t involve doing something medical and giving back in some small way. I will be forever grateful to Nilas and Josie for starting me on what’s now a passionate path.