 Good morning. Thanks to Deb Adams for the invite. I love speaking here at THI, so it's nice to spend the weekend here in Houston. So no finished exposures. So today we're going to talk about the global needs of congenital heart disease surgery and profusion, as well as conflict and barriers to education that is required to get these professionals where they need to be to be able to operate on these children. And then finally, the educational endeavors of no the cardiac alliance and how we operate in conflict zones and So, no further ado, this is a slide from one of the articles and presentations my colleague and friend doctor Marcelo cartarelli authored in 2013 in the Journal of cardiothoracic surgery. This article I'd love to put in my presentation when speaking about pediatric cardiac surgery globally because it kind of shows you quickly abstractly the deficit of cardiac surgeons in continents around the world. As you can see, Asia, you know, almost 2000 short surgeons. And this is based upon the US ideal ratio of congenital heart surgery that takes place in the United States 140 kids per surgeon is available in the United States that was kind of set as the ideal ratio. So, as you can see in these other continents is the deficits of countries that fall below that ideal ratio of Joe heart disease surgical patients and active pediatric cardiac surgeons. So as we can kind of hypothesize a lack of cardiac surgeons in these continents probably also leads to a lack of other cardiac specialists such as pediatric profusionist pediatric cardiac anesthesiologist nursing and support staff. So you can really see the kind of need for global education to help reduce the amount of patients that need surgery and don't have access to surgeons in this. So we can break this down even further into kind of a map view or country view of that previous slide, and you can see there's a lot of yellow and red in Asia and Africa to two continents that had the highest deficit right. And the yellow and red both are showing the red being no surgeon in country and yellow being you know not enough surgeons in country to take care of the children that are presenting with general heart disease. So, with the red and the yellow country is not saying that cardiac surgery pediatric cardiac surgery is not happening in these countries this most certainly is, however, the population demands and the actual cases that are presenting aren't being taken care of by the amount of surgeons and specialists in country. Also there's very different geographical locations that a lot of surgery takes place in certain city centers but then as you move into the rural areas and outside is where we find these, you know, kind of deserts of no surgery taking place. And that's kind of where our charity as well as other charities are kind of going in and trying to help foster build capacity in these countries in these areas that have a population have a need and have people that want to learn just don't have the access to access education. So we're kind of going into these countries and trying to build that capacity. And we'll kind of go through some of the reasons and the barriers of why these countries are lacking pediatric cardiac surgery care. So I began traveling with cardiac reliance which was ICHF back in 2008. And it's incredible the amount of information that's been transcribed from the US, Australia, Europe into these countries. Lots of all textbooks have been pirated and PDF and photocopied and translated into languages all over the world which, you know, piracy is one thing but however open source journals and magazines. Really have allowed us to give this knowledge to so many different people. And, you know, as I travel to these far flung places, I noticed that I'm not only bringing knowledge to them but usually they already know this, and I'm just concreting that they've learned what they're, you know, and they're doing it correctly. So that's really nice to see that they're studying and then learning these things just not putting into practice and not having that person that has been educated formally to say yes you're doing this correctly and they feel much better. So, but there are barriers. And one of those barriers to this education and proliferation of cardiac surgery in children is conflict. Unfortunately we live in a world where conflict is occurring almost everywhere. It's a major obstacle. It makes scarce resources even scarcer. It's difficult for us to cross borders to ship in supplies to move equipment, even volunteers don't want to travel to some spots because it's dangerous. You know, general heart disease carries on children are born every day and needs to have surgery so we need to kind of figure out how to push aside these barriers and bring them this help. So this is a side I have another one that I used back in 2019 I'll show you as well. These are the top top 10 conflicts to watch in the world. And as you can see Ukraine's one Ethiopia's to their highlighted in red, because these are kind of the two places that cardiac alliance is focusing on this year. And I'll get into more about what we're doing in Ukraine, and then the future aspirations in Ethiopia. So in 2019, you can see Ukraine was on list but obviously rocketed to the first position due to the Russian invasion. Africa, as you can see in the previous slide is number 10 because there's so many problems in Africa that they had to combine into one conflict to make rooms or other conflicts because that's how many conflicts we have going on the world which is valuable. So, also, all these countries that have conflicts are also represented on the map as yellow and red that have no surgeon or limited search capability. So clearly, we're having issues training and maintaining staff and cardiac surgery in these countries due to, you know conflicts and issues are ongoing. And as you would guess, all the accredited schools or I'd say most of the accredited schools that exist in the, in this world are all in the green countries and if you remember the green countries, we're all United States, Australia, Europe, Canada. So these are the countries that have, you know, little conflict, or at least have a safe, you know, living environment and not being, you know, invaded and more torn. So, these accredited proficient schools in these countries that don't have conflicts us, you know, basically have boards that have government rules and regulations and are able to, you know, pass on the certifications to people and confirm their knowledge and training base from schools from places like THI to confer the degree and practice in the country. Most of these boards do have some ability, you know, Canadians can practice here we can practice in Canada that gets a little stickier in different countries where, you know, you might have to retest and stuff but overall these are kind of the boards that are currently available in these countries that are able to have these degrees. So what what sense what are we doing with profusion education so you know, we're basically an on the job model, we go into these countries we train profusionists side by side. We develop kind of a curriculum for each country based upon what they're doing and what level they are so you know when we first start these trips sometimes it's very simple cases. We progress as we go along. Deb can attest to this she's been in Iraq from the very beginning when we started working in Nasiriyah, and they progressed all the way through to having almost a self sustaining cardiac team. This right here is name he this is Benghazi Libya, where we also have set up programs. Again in a conflict zone, Libya, you know, obviously Benghazi was a hot zone for a while and still remains to be tamed. But they have a huge hospital, they only do like 15,000 line bursts that big guys medical center, there's tons of hearts of hearts are really needs to happen. So, training these profusionists with NCA has become, you know, a passion of mine and many others in this room they've traveled with us or other charitable charitable groups to kind of move this along. So, obviously the other country that we've been very heavily invested in as Ukraine. We started the Code Cardiac Alliance we started visiting Ukraine in 1994, and we've been three major programs which are a Karkov Odessa in Kiev. Karkov is where I've been the most Odessa was actually my first trip to Ukraine in 2010, and I've returned many times and Ukraine definitely holds a special place in my heart. Karkov is the first program that I was involved with that became completely self sufficient. So I train profusionists, the surgeon anesthesia nursing staff they're all been trained by us and went through all the steps and now they're so exemplary that they even travel with us now. So now they're profusionist travels with us to on our trips to other countries kind of pass along the knowledge, which is fantastic. So now Karkov is on the eastern side of Ukraine, and is being threatened with the war machine from Russia. So a lot of the people have been displaced from Eastern Ukraine into the West. So this is, you know, pre invasion, where we were in the country, and then basically almost. So the war started in February 24. We were in country just before that and I think December. We were in Lviv, we just started a program in Lviv. Beautiful Western town right on the border of Poland. We went there for a two week trip started the program we identified the surgeon young guy. His wife is a cardiologist, they have profusionist everything was in place. We did the trip. Everything was great and then the war broke out. Unfortunately, the everyone who fled Karkov in Kiev everyone was flowing into Lviv. Okay, all the refugees were pushing into Lviv and then trying to get across the border to Poland. We got notification from the surgeon that there was many children that were arriving that had newborns that had critical heart disease and needed operations. So we kind of went into hyperspeed and we put together a team real quick and we ended up flying into Lviv, or flying into crack out Poland in middle of March, and did a trip there. A one week trip across the border to 10 hour bus ride is pretty difficult to see all the refugees on the border to get into Lviv and do some operations. And to be in Lviv at the time, there was teams were arriving from all different hospitals, coming to Lviv to kind of set up other hospitals and just basically help that staff, because they had no place to operate in Kiev, and they all the teams basically moved to Lviv to kind of help out. So we were sharing our space with all these different people and operating at the same time and it was great to see. So, we're also in Africa. And the red is Ethiopia up there and just finished our first trip to Democratic Republic of Congo, Kinshasa, which is an awesome site, and they're super excited is great hospital. And we are going to Angola, and a few weeks in July. So, that's going to be kind of a new site for us so Africa is definitely on our map, and we're trying to build capacity there. We are looking for a perfusionist is a quick plug for fusions for the first week, or not the first week but one week in July, July 9th to 16th. We need a PD perfusionist to go to Addis Ababa in Ethiopia. So if you know anyone or anything. Let's go. The, and then, you know, talking about Iraq and NCA. We have a long history there. I'd be remiss to not talk about Bob groom, who is also in Africa and he's building capacity in Kenya at his hospital, they as a perfusion school now that he is teaching and graduating perfusionist and that's an awesome, awesome thing. And it's funny I've seen Bob in weird places all over the world was actually pumping in Tehran, Iran, and he kind of showed up in the OR one day and hey, and I couldn't not believe that Bob was in the OR and Tehran, while I was operating and he's like they're giving some speech speech at a conference you know so it was bizarre and I've seen. I can't remember where else I saw that I saw him somewhere. It was like an airport. I was in India. I forget where it was but I ran into it was bizarre. So. Yeah, so that's pretty much it I have you know, happy to be here. Dr Novik is traveling to leave right now. So I don't think he's going to be able to present I don't know if he got touched with anybody but I know he was in transit to leave so that's a difficult kind of flight, and to get over there, but I know Marcello or a senior surgeon and a research coordinator for the cardiac lines is going to talk next I believe and we look forward to having you guys on trips or getting involved anyway and we appreciate it and thank you.