 Okay, so along the lines of outreach. I'm going to talk about my trip in December to Addis Ababa Ethiopia with Dr. Bernstein and we were working on improving the retinal care in that region So we'll just get right into it here I do have to put up this disclaimer all the residents have seen this every week every two weeks at floor scene These are my views only this does not represent Department of Defense or Department of the Navy policy or any opinion We'll go Navy So if anybody needs caffeine Now's the time all right Funny picture obviously We were this was after a long day on day 7 we had a pretty hectic schedule And we had flown out from a small airport at about I think about 7 a.m Gotten into the next airport at about 8 15 Picked up immediately driven right to hiking for probably No, I don't know four or five miles With lots of picture-taking and then this was the first chance to relax in quite a while And we were both just hanging out across from each other on this empty beer empty spot on a veranda and There was a low in the conversation, and then I looked up and Dr. Bernstein had just decided to slip off So if anybody needs one go get some caffeine here, and we'll just get going So Ethiopia this is obviously Ethiopia it is the large or the the second most populous Country in Africa, and it is the most populous landlocked country in the world So that I found interesting it wasn't always landlocked If you guys know much about the history of this area Eritrea used to be a part of Ethiopia Until the Italians came in the mid 1900s So obviously we were in Addis, which is in the center there That's the most recent capital for the last 70 so somewhat years and prior to that it was up north We spent most of our time in Addis, and then we spend a little bit of time in the north Seeing some sites, and I'll show you a few pictures of that too. So the demographics of the country again eighty seven point nine million people That's as of 2014, and it's growing at about a three to four percent annual clip Again interestingly, and they're very proud of this fact It's the only country never to have been conquered by European power in Africa And for that reason many of the African countries when they gained a dependence actually took The colors of the Ethiopian flag and use them on their flags. So that's why there's so much Green yellow and red in African flags And they've had this is the most recent flag, but they've had about 30 some odd flags in the last hundred years. They just keep changing it It's about twice the size of Texas, and there are four retina specialists So that demonstrates the need to be here And there are a few other ophthalmologists and some other all these four retina specialists are in Addis, and there are some comprehensive ophthalmologies who do limited retinal services such as lasers or scleral buckles but You can see that's a relatively low considering we have six retina specialists here and Salt Lake just in at the Moran not including all the Other folks so the state of medical care There's 13 medical schools in the country, but that's relatively recent As of about six or seven years ago The the country really up the number of medical schools and the number of applicants that they accepted to medical schools Because they had a lot of trouble with these quality physicians that they were training at the few medical schools all leaving the country Coming over to the states or to Europe and practicing and so no doctors were really staying there and because of that they they really up the number and the problem with that was that some of the trainees were of Lower quality or questionable quality most of the schools in the country The primary schools all teach in Amharic, which is the native language But then in the secondary schools that everything's taught in English However, even some of the residents that we were teaching new pretty minimal English Certainly weren't able to speak very well, which is is a challenge It's nice that they have the bodies that they need to start actually filling the ranks of the doctors But the level at which they're able to be trained is maybe somewhat questionable right now But that's the trade-off the government's making at this time Even despite that most of Ethiopians live without a doctor because they live in small rural villages and may never end up Leaving that village for their entire life the government hospitals are obviously notoriously low resource and They really do have a lack of quality training and part of that is because there's no incentive to be an academic clinician There's no incentive significant incentive to work at the government hospital and teach other than For the love of teaching so it's it's difficult to train and keep people The retinal care again for retinal specialists all of them are in Addis Two of them work at the mental to government hospital Which is where we spent a decent amount of our time and then there are two private clinics in in the city The doctor to Lixu he did is he's the longest Retina specialist there and he did his train hands-on training at or with Orbus And then he also did a observational fellowship here in 2016 and he did an observational fellowship as well at In California, so he's pretty well trained. He does full-scale retina service The second one that we worked with a lot was dr. Dereje who also works at at Menelik and he had some training in the Dominican Republic on laser and buckles And he's just started to have some Vectorectomy skills and those dr. To Lixu is pretty much teaching him How to how to do Vectorectomy and it was exciting we got to help him further his skills and then Dr. Alamou also did a year training at Tilganga and then did an observational fellowship out here to further refine his skills So he had his hands-on training out in Nepal And we'll talk about that later as in terms of the goals and things we want to accomplish Coming up. There's one other retina specialist that we don't have any contact with who works with dr Alamou that we kind of know nothing about So Menelik to they normally have rent a clinic two half days a week The residents pretty much only observe So that kind of makes it a little bit interesting you can see the photo there in the bottom that they have the two observer scopes and the The attending really never gets up from that chair and they just bring a patient in he takes a look He kind of describes things he tells them what they need and then they move on So they're able to be pretty efficient and they can see you know upwards of 50 patients in a half day without without a huge problem They don't have any OCT. They don't have any photo capabilities. They have no laser and they have no ultrasound So those are all major issues. It's really just Ophthalmoscopy that they're doing they also don't use the indirect ophthalmoscope unless they're laying the patient down so You know so pretty much that we said we did indirect on I think four patients that day and all of them We had to they bring them into another room. The residents lay them down. They get you they get on the indirect so We're gonna go also go into kind of teaching them that you can do indirect while someone's sitting up relatively quickly and easily And kind of help further some of the the skills there So They do surgery Written surgery two half days a week as well. They have an Ort leave atrectomy machine, which is a European company It's a pretty difficult interface. It's not you very user-friendly But the upside is is they do have many reusable pieces most of the tubing is reusable and they can they reuse the cutters and Most of the equipment is reusable so not much gets thrown away, which is really nice You can see the OR there in the lower right Me doing a buckle teaching one of the residents and then Dr. Tulik Sue and Bernstein and OR So what were our goals? Our goals were to train and improve the retina skills of the attendings currently there develop interest in the residents and teach the residents while we're there initiate a possible collaborative research project and Dr. Bernstein has been working with Dr. Tulik Sue and talking about AMD and the fact that they see a reasonable amount of AMD and Ethiopia more than kind of would be expected or certainly with the classic teaching of people of African descent Bring a bunch of much needed supplies for vitrectomy and buckles They were running very low on any buckles and they were pretty much using it Just one type of sponge is their only buckle that they had and then assess for ongoing needs and kind of create a plan to improve continue to improve things So day one we pretty much arrived. We brought tons of supplies. I think it was You know multiple thousands of dollars. I think in the twenty thousand dollar range in terms of PFO We brought a lot of reuse non reusable equipment in the US that they can reuse and sterilize forceps scissors Even entry systems that they will that they will reuse over and over again And then they also had a bunch of twenty three gauge vitrectomy probes that were stuck in customs for about They've been stuck for about two months because some paperwork didn't go through and that's one of the frustrating things about Ethiopia is that The paperwork is very very challenging and if it's not done Right the first time the government will just sit on it forever And it goes down into this oblivion. So we were lucky enough to stay with this nice gentleman Teclei and he is a pastor who is running an NGO for for young girls teaching basically rehabilitating them in the north and we met him through a Generous patient that dr. Bernstein and I had probably about a month before we left for Ethiopia We had a patient who needed a pneumatic retinopexy and he just so happened to work at an NGO in Ethiopia and knew this man and said hey Would you guys like to stay with a nice person? You've never met rather than stay at the hotel and Both of us jumped at the chance. So we were lucky enough to have a good guide and a very nice man Take care of us while we were there So day two we went over to Menelik To and dr. Bernstein talked about retinal degenerations with the residents for for an hour lecture in the morning And this was followed by a very busy clinic So about 35 patients in two hours with dr. Dureja And most of the patients in the clinic had bilateral advanced pathology You know total retinal detachment for multiple years in one eye and a total retinal detachment in the other eye So about three-quarters of them were led led into the room because they couldn't see the chair Or bilateral vitreous hemorrhages things of that nature And more diabetic retinopathy than I think Certainly than I expected to see there and you can see all the patients just waiting outside the clinic to come in and have their turn So day three We were back at Menelik and we did I did a one-hour diabetic Retinopathy talk because we've seen so much the previous day for the residents And then we did half a day retina clinic with teleksu and we saw 45 or so patients that day That's a picture of all the residents who were there for that For the lecture in the morning That's outside the the lecture hall and then the only eye bank of ethiopia was right there And it was a one room, but they did a pretty good job of obtaining tissue surprisingly so Um And then we went over to dr. Talix's private clinic and saw about 60 patients and looked at many patients with amd and uh, dr. Bernstein was looking at a lot of those patients seeing if there was a different phenotype or or anything that Could possibly be studied and trying to kind of assess for For future studies with some of these patients They do have an oct at that at at the private clinic as well as a laser and an or so It's uh, it's much better equipped and anybody who they see at the government hospital who requires oct or possible injections Amd patients, they all have to be sent out to the private clinic and and pay For that service. So hopefully we can we can change that in the future So day four we were in the or with dr. Dureja in the morning And uh, it's dr. Dureja doing a buckle here on the uh on the upper left and then me doing a vetrectomy for a total rd Um with dr. Dureja watching and then it was exciting. We got to have dr. Dureja peel his first epiretinal membrane um Under dr. Bernstein's and my watching eyes trying to help him learn that skill and uh, he did a great job It was a 2,200 membrane. So it was nice and thick and easy to to peel and get and uh We're hoping that he can come do an observorship in the future And then me doing a buckle teaching the residents and um, interestingly they do their buckles just under completely under direct indirect ophthalmoscope and um Also, uh, dr. Dureja his interesting technique for cryotherapy actually drains the sub-retinal fluid So the eye is really soft and pushes just looks without the indirect and pushes in until he sees the tear inside the pupil And then hits the cryo. So Interesting way to do it not the we we I we showed him the way that we did it and uh Hopefully he'll he'll decide to pick that up But that's how he was taught in the dominican how to do it and it worked really well He found the tear no problem Pushed it all the way into the center of the eye and hit the cryo and you could just watch it freeze Looking with your eyes. It was quite interesting. So And so uh on that day we did on that day again, we did dr. Rage's peel I did have a tractomy some retained pfo removal, which is pretty common Um, and then we also did an r. O. P examination on a baby who was transferred Um, who uh ended up not having any significant r. O. P. I think it was probably not where it's a patient that we would actually screen in this country They were just a little worried And so uh, so we took a look and luckily that baby was clear and then we did several detachment repairs with buckles So I got to learn how to do buckles with different equipment, which was good After in the afternoon, we spent a little time visiting the uh, the national museum with a couple of um Uh interested residents and we saw lucy And salam, which are the two oldest, uh, hominid skeletons in the world Three point two and three point three million years old So salam was a baby and um, and uh, his his remains were there So that was fun day five. We're back in the or uh working with the ortley and you can see dr Tolik sue there, uh with dr. Bernstein and then we second half we went to his private clinic We did a bunch of surgeries. We had some trouble with the ortley vatrector Um, it would not have any suction and we So we ended up having to abort a couple of cases because of that But we were still able to do a buckle of vatrectomy for a non clearing vitreous hemorrhage and uh a The failed uh pvr Complex rd that we weren't able to complete because of the vatrector breaking which was unfortunate Then we went to his private clinic and we did several other cases. Um and uh And uh, we did a pvr total uh rd We did a post trauma case that uh, dr. Tolik sue brought in specifically for us to help with. Um, and uh I was doing part of the case and so it was dr. Tolik sue and we just couldn't get a good view and Luckily dr. Bernstein was there to save the day and figure out how we could get a view and We were able to to save this kid's eye So that was exciting and then did a bunch of total rds and some some diabetic hemorrhages This was an interesting thing Uh, uh when we were at mental like two right at right but right about at lunch time They said hey come on in and they took me into a room literally adjacent to the operating room And they were roasting coffee over And an open charcoal flame So that's something that we might want to think about adding into our or spaces Um, and I guess it's it's uh kind of a tradition that when you roast and make the coffee that you're supposed to Lean in really close inhale the smoke and kind of waft it over your head So they wanted me to be the ceremonial person to do that since we were visiting to that day And then they made the coffee so And very good coffee So then we had some time to spend in the countryside and uh, we went to bahir dar Which is kind of like the ethiopian riviera, but there's actually a lot of history there So, uh, we went to several monasteries that are between fourth and sixth century Um, and then that's the view from the balcony of the place we were staying. It's on lake tana And uh, this is also the origin of the blue Nile. So it's the origin of half of the Nile river so Have a good time there Uh, that is an ancient bible in gegez, which is the Ethiopian Orthodox church language. It's very similar to um haraq. Actually, they use the exact same letters But apparently nobody can read it except the priests Because it has a completely different way that everything's arranged But that is a bible from about I think they said about sixth century And it's made on goat skin And that's the priest that that takes care of the one of the priests that takes care of the monastery You were nice enough to show us that and so the top picture is the monastery That's obviously been re-roofed. That's uh That's a very old monastery from I think 450 or so ad but It's been redone. These are the oldest pretty much the oldest monasteries in the country So very interesting and a lot of fun Day seven went to a place called lali bella, which is uh a In the north also in the north of the country and um, they basically Carved these churches out of solid rock and uh, you can see um, the bottom left picture is st. George's which is the most ornate and uh Deepest and the they actually dug down about 23 meters into solid rock Carved that out and then dug the inside out So it's actually from a single that single piece of stone And this king lali bella did 11 different churches So you can see the bottom left is the top where it's across and then you can see on the bottom right That's what the that's what the church looks like from a little down on another side And uh, again the the ceilings are Are 20 meters high And it's three feet of solid sorry three meters of solid stone on each wall So it's relatively small inside actually But and then some other churches that were slightly larger Again all monolithic meaning they were all carved out of out of the mountain Pretty pretty ornate And then that's the view the middle left is the view from the balcony where we were staying And that's uh, that's why we were enjoying Having a relaxing afternoon when dr. Bernstein fell asleep And then day eight and nine we spent an axon, which is uh the historical capital of ethiopia It's where the ax my empire was which was one of the largest empires in the world Around its time which is from about one 400 bc up until about ninth century ad And they Converted to christianity in about 300 bc And the ethi, or ethiopian orthodox church Believes that they have the original arc of the covenant that it was taken from And placed in ethiopia each of the churches has a um a copy that's put in the center of the church That's kind of their altar And uh, so that's how they say they kept it Hidden from anybody who wanted to take the arc of the covenant is there were so many they never Knew where it was in which church they say that in that middle picture there that very small cathedral is where the The true arc of the covenant is placed And uh, we were lucky enough to just be there on a day that top picture there is uh about probably what do you say dr. Bernstein about a thousand people 1500 Yeah, uh people gather at 430 And they parade a copy from that uh From that church around this the streets of the city and um And it was it was Quite interesting chanting and kind of parading it through the city about a mile or so the top left is the uh is from about 300 bc or excuse me 300 ad And it's uh similar to a rosetta stone It's got four sides and it's got four different languages on the side and it's a translation stone and they found that um, and uh have it erected in a in a small area and then the bottom left picture is uh The stelae which are basically gravestones grave markers, um, but massive And they used to put them up for when you died if you had enough money you would have your tomb underneath the ground and then you would have this marking the side of your tomb and They are the one that fell there apparently fell right upon erecting is what they think and it was 82 tons And they were putting these up in about the fourth to fifth century so Pretty interesting that uh, they were able to get those up, but apparently this one fell and I Felt like that was an engine engineering disaster They said it wasn't the foundation wasn't deep enough and so immediately when they put it up it fell down Which that would not be good. I would be unhappy Then the last day we just had about a half day. So, uh, we did a quick, uh, lecture with the residents and then we went out to the armor hansen research institute, which is the leading institute on tuberculosis and or excuse me leprosy in the world and they also do a lot of work on Mycobacterium tuberculosis and drug resistant tuberculosis met dr. Jonas there who is a medical researcher and and geneticist and worked on making sure they had adequate equipment to do DNA sequencing and Things of that nature for future research projects collaborating with them and then we said goodbye to autos so The outcome of our trip is that, you know, I think we made a good impact in terms of improving some of the skills of of the The the attendings there But they really need more retina specialists and they need more people giving retinal services even if they're not fully trained retina specialists Um, it would be great for dr. Derreggia to come over now that he's starting vitrectomy and he's learning some skills to to do an observational fellowship with us Or somewhere else in the states to get some further training Um, and then we definitely want to work with the alamu more on future trips We were unable to Other than meeting with him briefly one day. We were unable to spend much time with him And uh, actually nick batra who most of you know Worked with him a lot when he was here So we thought he would be an ideal candidate if he's interested to go out to spend some Uh one-on-one time with dr. Alamu and make sure he has what he needs and and help with further training They definitely need photography oct ultrasound FAA of possible capability certainly oct If if we're able to get it an ultrasound would be Would be very helpful for them and then they really need a better supply chain So they're not having to cancel a bunch of cases because they don't have attractors And working on projects. It sounds like maybe this coming fall winter They might start a genetics research project on amd with greg hageman, but They're working on that. They still have to we still have to get a bunch of approvals. So So questions How do you transport the pfo? Um that checked it wasn't really it wasn't a problem. Yeah, there's small there's small pfo is liquid though Yeah, okay, pfo is liquid and it's an they're individual containers So it's just like bringing your soap or shampoo, but there are in terms of actually gases. We've got them into Um Into butan Because there's a european version that's pre-filled syringes that are not under pressure And those you can do they're fairly expensive. They're 65 euros a piece So and interestingly they use almost exclusively silicone oil because it's so much cheaper there It's uh, it's about 40 dollars A you know a bottle for silicone oil whereas the gas canisters are several hundred Which is kind of just the opposite here or gas and gas is much cheaper than oil oils four to five hundred dollars and Here in the states because it's got to be FDA approved. So only alchemy can sell it Just a message for the residents and the fellows when you go to these countries Don't go with the approach we in the west you with the developing There are many little tips you can pick up from local surgeons remember they have to make do with little or nothing In all the years i've seen some amazing things that people are able to do in these countries Now Left over last year we take 45 minutes or so to do it carefully suture and i'm On your case when i'm teaching you about how to hold a needle and suture and so on And in the late 80s when i was operating not far from where you were with those coptic churches up north In Ethiopia they told me about this amazing plastic surgeon that i must go visit And so i did and he wasn't he wasn't an md qualified trade which is a local surgeon And he would do a medical capacity in about seven minutes And i thought that you threw up to see this and so i went and saw his technique which i described to you in a second And then he showed me supposed stop Patients and i thought that the house is as good a better than i can do And all he would do is he'd lie you down. There's no marking nothing It looks that you're sitting up and that is the thing that i always convey to my residents and fellows is Examining the patient sitting up Ideally joking with them and seeing how they move their faces. That's what he did He will simply lie you down and pick up your upper eyelid and go chop And then he took two stitches one two and said there you are on your bike And i thought that just can't give you a result and it's absolutely beautiful results He tried to publish this i encouraged him to publish this as his technique Of course, no western medical journal will accept it And me being the editor of a couple of lastings. I can't accept it because i'm the one encouraging him Ethically, so that never really got published. So we put it together as a little report for the world health organization putting it down as Old techniques that may still work type of stuff, but it doesn't give him the importance of it results And i saw a lot of patients of this Along the grounds of your retinal attachment the Honduras technique that you described In the late 80s About 88 89 In England, we do audits much more so than you do again And we compare results, you know whose retinal attachment rates are where and it's been It's been in in situ for all the since about the mid 60s In 1989 the person with the highest success rate for retinal attachment repair This is not using silicone oil, etc. One straightforward retinal attachments was Bill Douglas who trained in South Africa came to England to practice And he never used an indirect ophthalmoscope and he treated all these attachments with a direct ophthalmoscope Point of telling the story is don't lose the skill of examining retinas with a direct ophthalmoscope And i see a lot of you using 90 and 80 double lenses and 20 double lenses Use Use the direct ophthalmoscope to see if you missed or if you could have Got the skill of finding those peripheral Lackacity generation of detachment tears and set it up with the direct ophthalmoscope Because when i'm operating in the bush i have my direct ophthalmoscope And i use it constantly and i force myself to use it over here as much as i can So this gentleman, Dalglish, had something like a 97% success He would cry out like you would cry out Direct ophthalmoscope and he would cry out And his point was it's quicker, it's cheaper It takes care of you as a surgeon with skill not just as a technician to what we've all become Relying on all CTs and all the other stuff So i was really impressed by those numbers and i don't know if after his generation Anybody's carrying on doing this direct type of stuff But he used to teach generation after generation of african surgeons to do that So this is why you see these people still on the work doing this You know, we mustn't decry it. No, they get quite results And i learned a lot in terms of bottling and how to adjust the buckle from Dr. Derejia Because that's what they do, you know, we don't do as many straight buckles As they do, certainly because it's cheaper, faster, easier, and works great when you know how to do it So, um What do they use? Do they use silicon? What's that? Do they use silicon now? Do they use silicon now? Yeah, i don't know All right, so mostly they're still using sponges Okay, they do we do we brought them a bunch of silicone bands They try to reserve any encircling bands or anything for those cases that require 360 so a lot of times they're going to put on 180 degree sponge and then do a bit of track to me for For a complex case if they want to break that or something So there's a tree in northern Ethiopia which contains branches with bark which has a smooth oily layer That's what they used to use. That's why i'm asking you Yeah, they would just cut them No, we didn't say that. They use regular standard sponges and And silicon components I think the irony of all these is these great techniques that they successfully used for decades They're not they're not documented anywhere or It's disappearing So I just wanted to sum up how You know what a great job James did on this and it's really our fellowship here in retina and with the other fellowship Fellowships here are unique in that we really emphasize the international Division here when we're interviewing fellows that are blind here We're really the only program that does this that guarantees that every one of our retina fellows will have one to two weeks doing this in the Developing world and we're really trying to Get the fellows to be excited about this to continue doing this when they go on to their their future jobs And that's why You know nick Batra when he heard that we had been there and that we had met with halamu Really does want to go and as you know Has is going to go even though he's at a different university will be spot. Hopefully sponsored by us to go back Yeah, it's really it's really lucky that we get to do this because We're just we try to get other ones that are other fellows that are interested The hope would be is that if multiple people can go multiple different times you have Multiple training opportunities. You have somebody there every three or four months If you have three people rotating Going you get really good chance to work with these guys see what they need Assess them get them what they need in a quick time frame And you know further whatever education needs that they have to uh to really kind of build up Build up the skill set and the availability of services in the country So, you know, that would be the ideal is you have several people going Kind of on a rotating schedule to keep improving the skills and the equipment and what we have so