DiDi Driver - Yunnan China

(DiDi bought Uber’s Service in China, and provide the same service as Uber)

I took a ride with Xiao Hou on my first day in LiJiang. We got along, so I asked him to take me around LiJiang the next day and listened to his story. After his permission, now I tell his story.

I was born in 1986 in a mountain village about 60 km from LiJiang. Our village had about 27 families. We lived apart, each with a big yard. All families raised chickens and pigs in their yard.

We had a primary school in the village from grade one to four with a dozen students and one teacher. The teacher graduated from high school. After grade four, I went to the county school about five kilometers away.

Like most other students came from villages around the county, I lived on campus for the county school. Every Monday we carried food and fire woods from home for the week. The school had about 200 students. We used our own little stove to prepare meals each day. There were more than 100 little stoves. Mealtime, the smoke was everywhere. By Tuesday, we all looked dark from making meals.

I graduated after grade nine. I did not continue to high school as my grades were poor. There was an opportunity to work in a shipyard in Anhui Wuhu, which was 2,500 kilometers away. It was the first time in our village for someone to go so away. I joined 19 others and left the village in 2001.

As an apprentice, we made about 30 Yuan per day (about four dollars) in the shipyard. The work was hard, and life was lonely. After six months, only six of us stayed. The shipyard was not doing well. After about a year, we went with our mentor to a shipyard in Shanghai. Other new jobs also took us to ZheJiang and Nanjing. We stayed in Nanjing the longest for about three years. Life was better when I made about 100 Yuan per day.

I saved about 20,000 Yuan each year. I went home each year for the Chinese New Year and spent half of the saving for transportation and gifts for everyone. Many young people returned for the new year. We organized a couple of basketball games and there were dancing parties in the evening.

I met my wife at the dancing party. She was from a neighboring village. We didn’t know each other before. She felt I was different from others who stayed in the village with my time in big cities. We kept in touch for a month after I returned to Nanjing, then I asked her to marry me on the phone. She said yes and came to Nanjing. After about a year, we decided to move back to the village. We wanted to have a baby. It was expensive to live in Nanjing and raise a child.

LiJiang was a poor place for a long time. After the earthquake in 1996, the World Bank provided a no-interest loan to develop tourism.

After returning to the village, we worked on our farm and had two boys. We came to LiJiang about a year ago. I learned driving and my wife worked in a hotel in LiJiang oldtown.

Our two boys are not 5 and 7 years old, and they live on the campus of their daycare and primary school. I go back to the village every Friday to pick them up for the weekend and drive them back on Monday. Both daycare and primary school have a cafeteria. They don’t need to prepare their own meals now.

My families have lived in our village through generations. I am the first one left the village. The time has been good for us. If my boys have good grades, I will send them to college.

头一天来丽江，坐小候师傅的车，谈得来。第二天又让他带我去丽江周围玩，听他的故事。小候师傅同意后，我来讲他的故事。

我86年出生。我们村在山里，叫大东乡东江村，有27户人家。每家都隔了几十米，有自己的院子，人畜分开。村里有个小学，一年级到四年级一共十几个学生，有一个老师，是个高中毕业生。小学五年级到初三去乡里的完小。

完小在四五公裡外，要住校。每週一從家裡背一周的糧食和柴火。每天要給自己燒飯。學校里有兩百多個學生，有一百多個小灶。煙薰火燎的，到週二衣服就全黑了。

初三毕业，我是村里第一批出去的；工业局联系，我们19个去了芜湖造船厂。学徒每天挣30元六个月月后只剩下了六个人。造船厂不景气，我们和师傅去了上海，然后又去了浙江和南京。在南京呆的最长，三年。每天能挣100元。每年攒了两万块钱，年底回家要花到一半。几个村年底要打几场篮球，晚上还有舞会。我就在舞会上认识了我老婆。她大概看我比较时尚。我回南京了，又在电话上联系了一个月，我就问她愿意吗，她就答应了， 来了南京。住了一年后我们还是回乡了。城里的房子太贵，我们也想要个孩子。

丽江一直是个很穷的地方。96年地震后，靠着世界银行的无息贷款，旅游业发展起来了。

回家后，在家种地。丽江旅游发展起来，我和老婆一起来了。她在一个客栈打工，我学会了开车。我们两个孩子一个五岁，一个七岁，都在乡里幼儿园和小学里寄宿。我每周日把他们送去，周五接回山里的家里。他们可以在学校食堂吃饭了。

我们家祖辈在山里种地，没想到在我这一代走出了山里。碰上了好时候，家里日子好了。我们的两个孩子，要是学习好，我就送他们上大学。

I had a fungal lung infection

I knew I was in trouble on August 21, 2018, when I was on a business trip. Lying in a hotel bed, I felt my body boiling hot. I had felt a chest pain a day earlier and just began a mild cough. When I got home the next day in the late afternoon, my temperature was 102. All symptoms suggested pneumonia.

I didn’t want to go to an emergency service in the evening. I made an immediate appointment on Doctor on Demand, a telemedicine service. A doctor went through all my symptoms through a video call and shared her diagnosis of pneumonia. She prescribed azithromycin, a common frontline antibiotic treatment for pneumonia. My wife rushed to a pharmacy to get the prescription right before it was closed for the evening.

The antibiotic dropped my temperature to 100. After the 5-day course of azithromycin, I went to see my family doctor. He took a chest x-ray, which showed a 3 by 6 centimeters mass in my left lung. The family doctor put me on another antibiotic, levofloxacin, and told me it would cover a broader spectrum of bacteria.

My fever lingered between 100 and 101 through these days. I started to lose appetite and weight. Fever should be gone already under a right antibiotic. Felt I needed a second opinion, I started to look for an appointment with a pulmonary doctor or lung specialist. I didn’t expect this to be a challenging endeavor. I had not used the healthcare systems for a long time beyond occasional visits with my family doctor. When I called for an appointment, Mayo clinic would see a new patient in November and the University of Minnesota Fairview Hospital told me to wait till October. Eventually, I got an appointment on Sep 5 with a pulmonary doctor at the St. John’s, a hospital in a neighboring suburb.

The pulmonary doctor felt the levofloxacin should have the infection under control, and she was puzzled by the lingering fevers. She ordered a CT scan on the same day to get more information. I got a call from the doctor on the same evening and was not prepared for what I heard.

She told me that the CT exam found a 7 by 7 by 5 centimeters mass along with several small masses in my left lung that were suspected for malignancy, or lung cancer. This would not exclude the possibility of lung infection, but the malignancy was the main concern. She suggested a CT-guided needle biopsy for a more definitive diagnosis.

This news was not easy to digest. The pulmonary doctor stayed late and sent me a copy of the CT report. I shared it with a few close doctor friends and my sister. The implication was serious. My sister, working for a large pharmaceutical company in New York, started to look for connections with the best cancer institutes in New York City. One doctor friend advised me to focus on getting a right diagnosis first and not worrying about the possible outcome. My wife and I hugged and reminded each other not to worry about the lung cancer just yet.

One problem we faced was where to get care. I might need care from oncologist, interventional pulmonologist and infectious disease specialists. I needed to go to a hospital, where all cares could be coordinated. The doctor at St. John’s was nice and responsible, but her hospital was small and unknown to us. Finally, we decided to go to the Abbott Northwest Hospital. It’s a larger hospital. A close friend worked there. She helped get an appointment on Sep 11 with a thoracic surgeon, who specialized in lung cancer.

A second problem was more complex. Lung cancer was serious, but the chance I had it was also small. I did not have its major risk factor of being a primary smoker or exposure to second-hand smoke. In addition, the mass grew from 3 by 6 centimeters to a much larger size from Aug 29 to Sep 5 – too fast for a tumor to grow. The needle biopsy recommended by the pulmonary doctor had a 20% chance to collapse the lung, or pneumothorax, which would require hospitalization. The problem was how to minimize the complication rate while getting a right diagnosis.

The fever still lingered around 100 to 101. After the 10-day course of levofloxacin, I went back to the family doctor. This time, he prescribed another antibiotic called doxycycline. This became an empirical approach of trying different antibiotics and hoping to catch the bug.

The thoracic surgeon ordered a PET scan before my appointment to get more information. The PET scan confirmed the findings on the CT report. The thoracic surgeon recommended a biopsy procedure via bronchoscopy, a procedure that causes less complication rate than a needle biopsy and has the flexibility to get more samples. The biopsy was scheduled on Sep 17.

After seeing the thoracic surgeon, I saw an infectious disease doctor at the same hospital, who prescribed another antibiotic, amoxicillin. It covered a different spectrum of bacteria. I was happy to try it after the doctor suggested that I might feel much better after 2 to 3 days. We scheduled another appointment following the biopsy. The relief, however, didn’t come after three days.

An interventional pulmonologist conducted the biopsy under general anesthesia on Sep 17. After asking the nurse to adjust my pillow in the OR, the next thing I remembered was waking up in the recovery room with my wife on my side.

The biopsy report came the next day. If the CT report on Sep 5 was “life threatening”, this report was indeed “life giving”. It confirmed that there was no malignancy in the biopsy sample. Instead, the doctor found large yeast forms with the shape of blastomycoses. In another word, I had a fungal lung infection. This explained why all those antibiotics had not worked – I did not have bacterial pneumonia.

I was feeling good about finally getting a right diagnosis until I started to read about fungal lung infection and blastomycosis. Fungal lung infection was a rare condition and misdiagnosis was common. In a report from Southern Saskatchewan Canada between 2000 – 2015, a total of 15 cases of blastomycosis were confirmed by lab report. Initial misdiagnosis occurred in nine cases and six of them died. The main cause of death was acute respiratory distress syndrome (ARDS) after the majority of lung infiltrated by the fungal infection.

The infectious disease doctor put me at ease after reading my biopsy report. There was an effective antifungal treatment for blastomycosis, which he started it with me right away on Sep 20. He also told me although my lung function was compromised, it was still in good shape with little risk for ARDS.  

After three days of antifungal treatment, my fever receded for the first time after a whole month. It was such a relief. Finally, I had the right diagnosis and treatment. It took a whole month, but it was not too late.

Throughout my career, I worked with doctors on new treatments for patients.  This was a humble experience navigating the healthcare system that I had thought I knew well but really didn’t as a patient. I was lucky to have close doctor friends, who kept me on the right track and avoided additional delays. My family, friends, and colleagues kept me focused on my health. They reminded me that I was in their thoughts and prayers when I faced uncertainties. I was happy to tell them finally I was on the mend.

I had an excellent insurance plan provided by my employer. It provided my access to specialists, diagnoses, and treatments with little out of pocket costs. I was grateful for getting all the care I needed for granted and recognized it as a privilege.  

Finally, I was wondering where on earth I got the fungal infection?

The Great Lakes is an endemic area for blastomycosis. The infectious disease doctor asked me about everything happening on my two trips in the boundary waters areas in the early summer this year, such as whether I broke any beaver dam. The last case that he diagnosed came from a group of four guys took woods from a beaver dam and burned them while camping and canoeing in the boundary waters. All four contracted fungal lung infection.

I became nervous with the line of questioning, worrying about not going to the boundary waters ever again. After thinking about the trips for a few days, I remembered one event. The blastomycosis lives in moist soil, decomposing wood, and leaves. When we were in boundary waters in June this year, we were mostly fishing and canoeing in its beautiful lakes. On one day, after a light rain, my friend and I grated the gravel and dirt road leading to his cabin. We had a lot of fun of dragging a scraper blade up and down the road a dozen time. This would have the best chance to expose me to the fungus than anything else we did during the trip.

It was a relief to know, after surviving this fungal lung infection, I could still enjoy the boundary waters, fishing, and canoeing. We just need to leave the gravel road, beaver dam and its fungus alone.

Postscript
The Minnesota Department of Health contacted me in December to collect information on my exposure to blastomycosis. They have a good summary of on the overall exposure information in the state of Minnesota: http://www.health.state.mn.us/divs/idepc/diseases/blastomycosis/statistics.html

Mending Hearts in Yunnan

Xiao Hua (“Little Flower”) was brought in by her parents to the First Affiliated Hospital of the Kunming Medical University in Yunnan (called “Yunda Hospital”). Her parents were migrant workers from Guizhou, a neighboring province.  They came with a hope that doctors here can “fix” their little girl who is now 5-month old. 

After a pre-birth echo exam, the doctor told Xiao Hua’s parents that there was a small hole between upper two chambers (called “ASD”) and a big one between lower two chambers (called “VSD”) in Xiao Hua’s heart. With these two openings, Xiao Hua’s heart mixed oxygen-rich blood from the lung with oxygen-poor blood circulating back from the body. Without repairing, Xia Hua would not grow properly because the defects would put more burden on the heart and lung and eventually damage their functions permanently.  

Xiao Hua’s case caught the attention of a team of doctors and nurses visiting from America. They are medical volunteers for Children’s HeartLink, an international non-profit group that works on improving treatment of congenital heart diseases in underserved parts of the world. Congenital heart diseases affect one in every 120 new births, and are the most common birth defects. There is a large disparity of CHD care around the world. Newborns in western countries are routinely screened for critical CHDs, and typically treated in their first year of life. Ninety percent of children with CHD were born in places that do not have adequate care for CHD. For example, Minnesota, a state in the US with four million population, has about 65,000 new births each year. The three pediatric heart centers operate on approximately 500 CHDs each year. In the province of Yunnan China, the population is about 40 million with 500,000 babies born each year. There were two hospitals that operate on 2,000 CHD cases a year, which serve half of the babies who might need surgeries. The partnership of YunDa with Children’s HeartLink aimed to improve capacity and quality of CHD care and serve Yunnan and neighboring provinces and countries such as Myanmar, Laos and Vietnam.

The American team was led by Children’s HeartLink’s Andreas Tsakistos and Dr. St. Louis, a pediatric heart surgeon from Children’s Mercy Hospital in Kansas City. The team has been working with the Yunda Hospital in the last four years to help them improve the overall quality to treat complex heart conditions. Xiao Hua’s procedure would not be complex for older children, but her young age and 6-kg body weight would push the limit of the local team to secure a safe and successful outcome.

Dr. Lee Pyles, a pediatric cardiologist from West Virginia University, examined Xiao Hua before the surgery with Dr. Wang Yu, the local echo doctor. They gave the go-ahead of the surgery with their confirmation of the diagnosis indicating the ASD was 5 mm and VSD of 10 mm, which are big holes for a small heart. Dr. Tao Jie led the surgery with his local team of heart surgeons and OR team with assistance from Dr. St. Louis and the perfusionist, Mr. Doug Zavidil from Children’s Mercy Hospital.

Pediatric heart surgery is the ultimate team sport in modern medicine. For Xiao Hua’s surgery, an anesthesia doctor put her to a deep sleep during the procedure. A team of perfusionists took over the function of the heart and the lung using a machine to maintain blood circulation in the body, letting the heart rest for the operation (called “bypass procedure”). The smaller the body is, the harder the procedure is for perfusionists to manage the margins of errors. For example, the blood volume for a 60-kg adult (132 lbs) is around 4,500 ml; for a 6-kg baby (13 lbs) is 450 ml. A small error of the bypass machine running at a wrong speed would have a 10 times impact in a Xiao Hua than in an adult. Mr. Doug Zavidil worked with the four-member local team on how Dr. St. Louis would typically choose instruments that specialized for small babies. During the procedure, they discussed constantly how to control the blood flow, temperature and medication to maximize the condition for the surgeons to operate.

Drs. Tao and St. Louis operated as if they had been partners for years. They communicated through an interpreter, although each seemed to know exactly what would be a next step. The surgical techniques for Xia Hua’s procedure are almost identical everywhere following standardized protocols and medical guidelines of international professional societies. The exchanges between Dr. Tao and Dr. St. Louis were more on their personal experience as cardiac surgeons. Dr. St. Louis routinely operates on small babies a few months of age with complex conditions. He is also among a few pediatric surgeons in America who specialize on pediatric heart transplant. Dr. Tao operates both on adults and children. He wants to take his team to operate on smaller babies like Xia Hua, and make it a routine procedure.

Xiao Hua was on the bypass machine for nearly an hour. The two openings inside her heart were patched by the two surgeons using the sack (called pericardium) that surrounds the heart. The perfusionists slowly waned Xia Hua off the bypass machine and let her heart take over. The electricity in the heart started first, each heart beat followed by a stronger pump of blood back into her tiny body. After the confirmation of all positive indications of the heart, the surgeons closed Xia Hua’s chest.  Xiao Hua is now a zipper baby, a term pediatric doctors like to call babies with a mended but healthy heart.

The ICU team took over after the surgery. The post-surgery care for Xia Hua was as important as the surgery itself. The heart was on medication to help maintain its function. Her breathing was assisted by a ventilator while the lung regained its function. The Children’s HeartLink team included Dr. Arif Somani from University of Minnesota, ICU nurse Karin Mayo from Children’s Healthcare of Atlanta, Nurse Beth Lang and Respiratory Therapist Kimi Lucas from Children’s Mercy Hospital. They worked with the local team led by Dr. He and head nurse Yang from transferring Xia Hua from the OR to the ICU. The two teams had many exchanges on how to manage Xia Hua on and off the ventilator and how to manage post-op pain. There are differences in routine practices between the two healthcare systems, changing minds can be as hard as changing hearts. Children’s HeartLink has been successful in establishing partnership during its training visits between medical volunteers and local teams based on building trust, on-site collaboration and communicating on common goals on quality improvement.

During the week of Children’s HeartLink visit, the two teams operated together on five children for heart surgery. Dr. Edgard Bendaly, a pediatric interventional cardiologist from Sanford Hospital in South Dakota worked with the local interventional team on a dozen more children’s whose heart defects could be repaired through minimally invasive procedures using catheters and closing devices.

Xia Hua’s parents met Dr. St. Louis outside the ICU. They wished to get a photo of Xia Hua with the entire HeartLink team. However, many team members were gone to different places during the one-week visit. Xia Hua was safely transferred from the ICU to a regular unit and discharged from the hospital after 10 days. Perhaps her parents wish could be met when the team returns to Yunnan next year. Their wish reminded a quote from Dr. Kumar, a pediatric cardiologist who works with HeartLink in India, “Parents everywhere want the same for their children: a relief from suffering and a promise of a long and healthy life.”

Dr. Tao Jie and Dr. St. Louis operated together during the Children’s HeartLink visit in YunDa Hospital in Nov 2017

 Mr. Doug Zavadil assisted the YunDa perfusionist team operated the bypass machine during surgeries.

Dr. Pyles examined Xia Hua after her heart surgery.

My experience as a Chinese American working in the medical device industry

My friend asked me to participate in a career development panel at first annual conference of the Minnesota Chinese Association for Science and Technology (mncast.org). It’s an honor and a good opportunity for self-reflection.

I thought about lessons I learned from my mentors, colleagues and my working experience after I came to the US in 1991, and starting my first job in the medical device industry in 2000.

Thirty years ago I entered college, majoring biomedical engineering. This is a field of improving our health through medical technologies. My training in math, engineering and physiology took me to my first job with the Guidant Corporation. I worked on cardiac pacemakers and ICDs, implantable devices that mitigate health issues of the heart. I joined Inspire Medical Systems in 2008, a twin cities-based startup company. We’ve developed the first FDA approved implantable device for treating obstructive sleep apnea, a chronic condition that affects 18 million Americans. Sleep apnea has been found to cause daytime sleepiness, cardiovascular functions, and neurocognitive disorders. Now the Inspire device has been implanted in more than 2,000 patients.

My reflection today is more related to being a Chinese American working in the Medical Device Industry

Think Independently (独立思考)

To solve a new medical problem is like coming to a new country, we encounter challenges that we have never faced in our lives before. We try to follow paths that have been shown to be successful. There are times, however, we need to make decisions on our own. The ability, skill, and recognition to think independently helped me to make the decision to leave a multi-national corporation for a small start-up of three people at the time. It has been a rewarding journey in the last 9 years.

Take Initiatives (迈一步)

It is hard to take initiatives when we worry about others may not understand you. It is easier and safer to stay in our comfort zone. Take initiatives helped me to expand my career path from being a good scientist to leading a team for bigger challenges. It’s a step I am glad that I took early in my career.

Pursue Your Passions (追求梦想)

I want to share two personal passions today. I play table tennis at the Shoreview Table Tennis Club (see svtt.info, we need new members) every Wednesday. Every Tuesday night, I dreamed about beating my friend FL the next day. FL just retired this year. He has been mercilessly beating me for the last 13 years. This reminds me a definition for passion, which is the pursuit of happiness through suffering. I think this year may be the year, as FL is slowing down in his forehand attack.

The second passion for me these days is to improve early diagnosis of congenital heart diseases in rural China. When diagnosed early, kids with a congenital heart defect can live a normal life after a surgery. Late diagnosis can miss the treatment window or leave poor outcome even with the best surgeon. Delayed diagnosis of congenital heart disease is still common in rural China and other parts of the world that lack of access to good healthcare. We have started a nonprofit organization this year that dedicate to this cause. Our name is One Heart Health (onehearthealth.org). I hope you will go to our website and support us when you can. 

A Pediatric Cardiologist from West Virginia Practices Rural Medicine in China

I first met Dr. Lee Pyles on the airplane on our trip from Minneapolis to Lanzhou, China in 2008. Lee carried a giant suitcase, a roller bag and a big backpack. Lee grew up in West Virginia, and just moved back there recently after 15 years working with the University of Minnesota. In the nine years after that initial trip, Lee and I have traveled together to Lanzhou, Huining and Linxie in Gansu, Kunming and Xixuanbanna China.

Dr. Pyles is a pediatric cardiologist. During the training visits, Dr. Pyles performed echocardiograms (or “echo” for short) to verify diagnostics and confirm the plan for each surgery that the Children’s HeartLink team would work on with the local team. These patient exams were like a live classroom. Lee loved to teach. No detail was too small where it was critical.

It is a constant challenge for an echo doctor in China to see up to 100 patients a day, which is easily five times the volume in the US. It is a balance of serving a high volume of patients and maintaining the quality of diagnosis for each. Lee taught from his experience of understanding physiology to help the local team improve efficiency and quality.

On the first day of each training visit, members of both teams gather for a case conference to review all candidates for surgeries during the visit. Lee and I noticed the high percentage of pulmonary hypertension among children that were initially selected by the local team. Pulmonary hypertension in children with congenital heart disease (CHD) is caused by the high-pressured blood from the left ventricle of the heart that flows through an opening that called ventricular septal defect, to the right ventricle then into the lung. A prolonged high pressure can cause irreversible damage to the lung and the heart. When diagnosed early, closing the ventricular septal defect can avoid the permanent damage to the heart and lung with a curable outcome. When not diagnosed in time, pulmonary hypertension associated with the damaged heart and lung function increases the risk during surgery and recovery and may mean the patient has missed the window for treatment altogether.

It is rare to see pulmonary hypertension among children with CHD in the U.S. and other developed countries these days. The murmurs generated by the heart defect are recognized by trained pediatricians during early childhood checkups. In a place like Gansu and Yunnan province in China, however, many children from rural areas may not see a doctor for years after birth. Lee and I have visited several rural counties in Gansu and Yunnan working with local doctors to find these children and help improve the diagnosis of CHD in rural communities. We have developed a telemedicine system for a health workers to record and transmit heart murmurs via smartphone for review and consultation by a heart specialist in another location.

Many of the children Lee and I met in China had not seen a U.S. doctor before in their lives. Doing echo exams with their cooperation was no small feat. The young ones might bite their tongue, staring at Lee’s big nose. The infants and toddlers could cause riots. Lee could always see the trouble ahead and went to his big suitcases to fetch a toy. These made-in-China toys were big hits with the babies. Their moms were also impressed when they heard the toys were all the way from America.  Lee still travels with all his suitcases whenever we go to China.

Note: Thank you, Ryn W, for helping with the editing. 

On Inspire 10th Anniversary

The Inspire team celebrated our 10th anniversary this year. My reflection with a few quotes heard during this journey:

"It will get complicated very quickly." - Kingman Strohl, our trusted advisor since the first study planning meeting in May 2008.

"Always remember to put the patient first; rest will be easy." - Glen Nelson, Inspire first board chairman, who was an inspiration for the team.

"That is a cardinal grade of a palate." - Jerry Griffin after seeing the first CT scan of feasibility study patient.

"So you think there is a chance." - Ed Schuck, our beloved board member, who had always believed in us.

"The only thing we don't do is the ordinary." - Paul van de Heyning, the surgeon performed the first hypoglossal nerve stimulation implant with Medtronic in the 90s then with Inspire on Feb 20, 2009.

"It is always possible, Quan." - Marc Willems, sleep lab manager at University Hospital Antwerp, helped us titrate therapy.

“You get my best work on the July 4^th weekend.” – Pat Strollo after finishing the first STAR trial manuscript later published on New Engl J Med in 2014.

"We not only do good clinical practice, we do great clinical practice." - Saf Badr after hearing our requirement of GCP in clinical trials.

“It is white on rice.” – Tim liked to say when the going gets tough and used many times during the first 10 years of Inspire.

"It worked!" - Mark after trying the cuff electrode and an external stimulation on the deer hunting opener in 2008.

"We are not out of the woods yet." - Darrell used many times during late night sleep studies.

"Do or do not, there is no try." - John quoted from the Star War.

"I got a letter from the FDA." - Joel received the FDA approval letter on April 30, 2014.

"Presence, action, and belief." - Randy on the art of selling.

"Know who is who in the zoo." - Ivan on the practice of selling.

"All night, every night." - Luke on keeping the Inspire therapy on.

"Sleep Well, Have a Better Tomorrow."

A Perfusionist Who Cannot Carry His Bag

"Passion is a Pursuit of Happiness through Suffering". When I read this interpretation of passion as a pursuit of happiness through suffering, I remembered a few medical volunteers of Children’s HeartLink during our trips to China over the past 13 years.

A Perfusionist Who Cannot Carry His Bag

Kris Nielsen is a perfusionist from the Twin Cities. His job in the OR is to keep the patient alive on a heart-and-lung machine while the surgeon operates on the stopped heart. His work is nothing short of magic.

During our first trip together to Lanzhou, China in 2010, Kris explained that the protocol for heart-and-lung bypass was largely standardized, so he was pleased to see a familiar set up in the OR where we would work the next day at the First Affiliate Hospital of Lanzhou University. The first day of surgery was a success. The medical team from the University of Minnesota and the local team bonded quickly. Kris observed closely, kept his surgeon informed, and shared his observations with his counterpart from Lanzhou. After discussing some ideas with his new partner, Kris helped implement a few changes during the next day of surgeries. It was amazing to see them chit-chat with only one or two words in English and a lot of nodding.

At first, Kris dealt with his jet-leg with an early morning run to the Yellow River. He was full of energy. Kris and Raj, the anesthesiologist on the team, spent a lot of time together. Naturally, they joked with each other inside and outside the OR all the time. Kris teased Raj mercilessly after Raj had been schooled on how to gracefully put a needle in the tiny vein of a Chinese baby by the local staff on the first day.

But on the third day of the trip, Kris became quiet in the OR. He asked for a blanket and wrapped it around himself. His responses to the surgeon were down to one or two words. By the late afternoon, I found him lying down to rest in the break room. It looked like the jet-leg had finally taken a toll. Kris missed our group dinner, and then he missed our breakfast, too.

It was the Montezuma’s revenge that punishes travelers in the middle kingdom just as in the Aztec empire, regardless of the purpose of the mission. Kris had struggled for two days without telling most of the team. It pained Kris so immensely that Raj had to carry Kris’ backpack as they walked together from the hotel to the hospital the next morning. Raj had his revenge as well.

I shared Kris’ story a few times with other volunteers on their first trips to China, and I no longer laugh some of them favor KFC over the handmade noodles or other street food that I couldn’t resist on the streets of Lanzhou.  

Kris Nielsen and his fellow perfusionist from Lanzhou First Affiliate Hospital, 2010.

Note: Thank you Ryn W for the editing. 

A Journey of a Biomedical Engineer

I was excited to prepare for a seminar at the Biological Engineering Department at the University of Minnesota. It has been 30 years since I began my journey in the field of biomedical engineering when I enrolled in Shanghai Jiaotong University in 1987.

At that time, I did not know any other biomedical engineer in my life. I was attracted by the description of “biomedical engineering”. Solving medical problems with the knowledge of biology and tools of engineering appealed to me as a promising field. Biomedical Engineering was a newly created department at Chinese Universities. We went to many other departments on-campus or off-campus for classes. We rubbed shoulders with other students in electrical engineering and mechanical engineering classes. We rode bikes to anatomy and physiology classes at a nearby medical college. Our own professors taught us computer programming, ultrasound and medical instrumentation.

By the end of the four-year college in 1991, most of us got jobs in the instrumentation department at a hospital or at a few medical companies in China which manufactured x-rays and other medical equipment. Many graduates of my college had left China to study abroad. The opportunities for admission to a US university and obtaining a student visa were rare in the early 90s in China. For many, it was a path to a bright future.

I was admitted to the University of California, San Diego. The Bioengineering program at UCSD was founded by Professor YC Fung, and chaired by Shu Chien at the time. Professor Fung initiated the field of research on biomechanics, which studies tissue properties of muscles and circulation. In an outing with new students, Professor Fung recalled how he got his start in biomedical engineering. He had been an aeronautics professor at Caltech. When he found that his mother was developing an acute glaucoma, he began to immerse himself in the medical literature to learn about it, and sent his notes to his mom’s physician in China. The intense learning led him to a close collaboration with a medical doctor, and later, with many other physicians in areas of heart and lung mechanics.  Professor Fung no longer taught classes in the department, but told me the first real-life story of a biomedical engineer.

Dr. Chien took me into his laboratory research in cell mechanics. I studied the aggregation of red blood cells, a phenomenon that occurs in life but with little understanding of why and how. I spent countless hours in a dark room with a powerful electron microscope, but was unable to find what bound these cells together. To this day, I still remember what Dr. Chien said, “You are going to be a scientist. You want to learn everything there is to learn on your project.”

My learning continued at the University of Utah, where I decided to pursue a PhD in its Bioengineering Department. My growing interests in the electrical system of the heart found a home with two mentors at the Cardiovascular Research and Training Institute. Bruno Taccardi was studying how heart muscles affected electrical wave propagation in each heartbeat. He devised systems with hundreds of electrodes that placed directly in a beating heart to measure electrical field during propagation. Rob MacLeod, my PhD advisor, had developed computer programs for visualization and simulation of these complex systems based on some of Bruno’s measurements.

Bruno was in his late 60s at the time. He “retired” from his institute in Parma Italy, where he was the director, and came to Utah to continue his research. Bruno wanted to know everything about electrical propagation in the heart.  He only wrote a few papers in his career, but one of them was read by nearly every researcher in the field. Rob MacLeod was a young faculty member and I was lucky to be his first student. I could not have asked for a better mentor. Rob recognized my challenges with scientific writing. He gave me a list of classic papers on cardiac electrophysiology, and critiqued my review summary of each paper. The exercise went on for a few years, and ended with our first paper together on interpolation of electrical potentials in the heart.  After six years, I finished my PhD in biomedical engineering. I was ready and anxious to solve problems in the real-world.

It was an exciting time in implanted device industry with recent introduction of cardiac resynchronization therapy, a new therapy for patients with heart failure due to an electrical conduction problem in the heart. I was impressed by the enthusiasm of scientists I met during the interview with Guidant Corporation, one of the three companies that manufactured cardiac pacemakers and defibrillators. I decided to join them after the interview and hoped one day to work on a new therapy myself.

I was open to work on any problems. The first problem I worked on was a condition called chronotropic incompetence. With aging, many of us lose the ability to regulate heart rate with increasing metabolic demand, for example, during exercise. In traditional cardiac pacemakers, an algorithm increased heart rate based on body motion detected by an accelerometer sensor. This had limitations, for example, an accelerometer would not determine the different metabolic demand between climb upstairs versus downstairs. I started with a project to measure respiration using an implanted respiration sensor in a cardiac pacemaker. This was a new feature in the pacemaker to provide heart rate support during patients’ exercise. The pacemaker can sense the increase of respiration with an impedance sensor and changes of motion with an accelerometer. The combined information would improve the algorithm to regulate heart rate with the metabolic demand during the exercise.

The ability to monitor respiration in an implanted device soon led me to a discovery that many cardiac pacemaker patients stopped breathing frequently during sleep, a disorder called obstructive sleep apnea. In a collaborative study with a cardiac electrophysiologist doctor and a pulmonary doctor in Pittsburgh, we found nearly half of his VA pacemaker patients had undiagnosed sleep apnea. We formed a new team in 2001, the apnea team, which included original team members of Kent Lee, Jess Hartley and Jeff Stahmann. Our goal was to detect and monitor sleep apnea with a cardiac pacemaker and explore new treatment options. Boston Scientific, which bought Guidant, now produces pacemakers that can monitor sleep apnea status every night for this chronic condition based on our original work.

Once diagnosed, sleep apnea treatment is another major clinical challenge. The standard of care is positive airway pressure delivered by a mask placed over the nose and mouth during sleep. I made a good effort trying the treatment myself for two weeks and I had a very hard time to get to sleep. So it was not a surprise that nearly half of the patients with sleep apnea do not use any treatment.

My opportunity to work on a solution for sleep apnea treatment came in 2008. Tim Herbert, Mark Christopherson and others had worked on an implanted neuromodulation approach for treating sleep apnea while at Medtronic in the 1990’s. The idea was based on the finding that tongue relaxation during sleep was causing airway obstruction, and the tongue could be controlled via the hypoglossal nerve. The Medtronic team developed an implanted device to stimulate this nerve, and demonstrated in a small study that hypoglossal nerve stimulation would stiffen and move the tongue forward and could resolve upper airway obstruction. Medtronic did not continue this project, as it was not in their core therapy areas. In 2007, as a true entrepreneur, Tim quit his job in Medtronic, licensed the technology from them, and recruited Mark to join him to start Inspire Medical Systems, whose singular goal would be to develop and commercialize a neurostimulation therapy for obstructive sleep apnea. During one of our conversations before joining them, I asked Tim what made him believe they could accomplish what Medtronic could not in developing this new therapy. Tim put a children’s book in front of me, and asked if I remembered reading A Little Engine that Could. I told Tim that I grew up in China and had not heard of the book. After finding the book at a bookstore, I liked the attitude of “I think I can”.

In April 2008, I left my job at Boston Scientific and joined the Inspire team and began the next chapter of my journey as a biomedical engineer in finding a solution to help people sleep better.

Letter to Congressman Paulsen on Immigration

Dear Congressman Paulsen

You visited us when we were a company of 10 people in a small office in Brooklyn Park, Minnesota. Inspire Medical Systems was just spun out of Medtronic in our mission to develop a new treatment for sleep apnea. You asked us why we felt we could accomplish what Medtronic had given up. I jumped on like a good student who felt I had the best answer. That was the same question that I asked our CEO, Tim Herbert, during the job interview a few months earlier. Tim pulled out a little book with the title of “The Little Engine that Could”, and asked me if I knew the book. I told him that I grew up in China, and had not read children’s books for some time. The story of “I think I can” from the book impressed me so much, I signed on shortly after. So I responded to you, “Congressman, have you ever read a book called The Little Engine that Could?”  

“I think I can” is my story as an immigrant American. I left China in 1991 right after finishing college with the fresh memory of the student movement in 1989. My search for a better life was blessed by an opportunity to study in America, and the help from a caring sister, who was studying in California. My mentors in graduate schools shaped my skills as a biomedical engineer. They also formed my desire to improve lives. My job in the medical device industry is fulfilling as reflected in one of my employers’ motto “When you have the power to save lives, share it”. After eight years in America, I received one of the most treasured privileges in my life, a green card, the right to live in America permanently. I became a US citizen after 18 years in this country. I was attracted by our democracy and kindness and fairness of our people. I wanted to participate as a citizen.  

Our recent immigration policy changes related to travel ban make me think about my fellow immigrant Americans. I think about my friend from Egypt. He is a VA doctor, who received the Chief of Staff Clinical Excellence award last year. I think about a collaborator in Detroit, who grew up in Syria and trained in the US. He is one of the most respected doctors in sleep medicine today. I think about a young surgeon, who was born in Iran. He lost his Dad last year, who worked until his last day in Minnesota, as a family doctor. I hear the story of a fellow engineer, who grew up in Ethiopia, and came to America when he was young. He tells me the fear of watching what happens after the recent policy and wondering his belonging.

The task of fighting terrorists is as hard as fighting other violent crimes. We need to be resolute and be determined. We cannot, however, harm innocent people in our response. Over the last two hundred years, people came to this country to search for better lives. It was not an easy journey for most of us, including the separation from the home country often with families behind. We travel back when there is a parent who needs care, or when there is a niece who gets married. The travel ban harms immigrants from the seven countries included. It also affected me because of the concern of our policy maker's willingness to overlook the harm for fellow immigrants. We cannot have policies that erode the principle of our country of immigrants.

When I am reflecting today on who we are, and what I want to be, I am reminded by a former coworker who told me to choose work that is life giving. I am reminded by my CEO, and his mentor, the late Dr. Glen Nelson, who told us to put patient first. I am reminded by our celebration of 1,200 treated lives at the recent holiday party of our company now of 80 employees, where Dr. Nelson’s widow, Marilyn Carlson Nelson told us to do work that is good and to help people. I am reminded by what my Dad taught us at his 80th birthday, to be kind, be sincere, be informed and think independently.

Congressman Paulsen, you have a great responsibility representing Minnesotans in Washington. There are complex issues about which you will make decisions that will impact lives in the coming days, months and years. I hope you will represent us with kindness to others, support work that to be life giving, be informed and think independently.

Quan Ni

An Immigrant American

"You are not perfect, you have flaws."

I found out from Gale today that my first dental cleaning from her was 16 years ago. 

I marveled, "Your kids were babies then". Gale became a grandma last year. 

"They are still babies."

I chuckled after a few seconds. Gale was not happy with my response. 

"It took you that long!"

Gale and I have bonded over the last 16 years in keeping my teeth. I have a unique set of teeth from the overuse of tetracycline and the lack of dental care growing up. Back in the 70s’ China, tetracycline was a go-to antibiotic for every bacterial infection including common cold, gonorrhea, which I had plenty. The “tetracycline teeth” kids, as many of us being called while growing up, would not like to show the jarring teeth in dark and brown color when take selfies today.

Gale was protective of the bond, after my initial dental exam. She always apologized after the first exam of each new dentist in the office we broke in together over the years.

“I am sorry you have to go through that, Quan, but you are unique.”

After examining the dental x-rays today, Gale was seemly satisfied. Then she added,

"But you are not perfect, you have flaws,".

Feeling my dental homework un-appreciated, I responded, 

"I do floss." 

Nashville and the New Year Resolution

On my way to Nashville, I recalled a passenger I met a few years ago on a long haul flight to Shanghai. He grew up a surf boy in San Diego, and later found home in Nashville. He owned a company making hunting gears. Using his product catalog, he proudly showed me hundreds of different shooting targets that he designed. He was fit, even though he seemed to be chewing tobacco during the entire trip. After several hours of friendly conversations, he told me to stay away from the dessert. “No sugar, my friend”. Finally, I decided to put less sugar on the resolution for the new year.   

The Uber driver who picked me up in the Nashville airport was also from California. He followed his children and their mom here after the divorce. After learning this was my first trip to Nashville, he got excited. “Are you ready for some honky-tonk, my friend?”. Honky-tonk? I had to google it quickly, and was excited too. New adventure and new learning every day, that is the second resolution on the new year list. 

My colleague told me he would have a surprise for me in Nashville. After searching what was around the hotel that he recommended in the Gulch neighborhood, I found that the Station Inn seemed to be the place to be for live Bluegrass music. I felt sorry that I apparently ruined his surprise. The Bluegrass musicians played in the Station Inn were surprisingly good. The Tuesday night band was a collection of professional and amateur musicians. The two guitar players took turn at the mic. One of the young guitar player looked like about 15. Later on, he had to leave early for school tomorrow. We sit close to the fiddle player. He just kept blown us away. The bass player was the proprietor of the place in the last four decades. Then there were mandolin, banjo, and Dobro.

Dobro is a guitar with a metal plate which creates amazing resonant sound. I found more about it on youtube by Jerry Douglas, the best Dobro player according to my friend.

The players took turns for a half step up to do their highlight of a song. The rest of the band would look him on, nodding in support. They were having a good time. We were having a good time. It was a harmony of collaboration, inclusion, appreciation, patience and calm. Those, of course, are the rest of the new year resolution for 2017.

Relection after the Election

Disbelief, sadness, escape and reflection.

Those are my reaction since Donald Trump winning the 2016 presidential election on November 8th.

When the network TVs called Florida for Donald Trump, who had already won most of the mid-western states, I turned off the TV and went to bed. It was hard to fall asleep. The victory of Hillary Clinton had been imminent right before the election day as predicted by various national polls. My own vote for Hillary was full of confidence.

The wave of sadness flushed in the next morning on Wednesday. The result was final. The social media around me were filled with raw emotions. I had to go to work.

Work was the best way to escape. Our colleagues mostly leaned towards republican as others who work in the medical device industry. I felt relieved and respected during the morning staff meeting when everyone clearly felt the gravity of loss on my face and several others. In the next few days, I finished everything on my to-do list, talked to family and friends, and played table tennis like every other week, trying to escape from the sense of loss.

Family and friends are much more important than politics.

It is time to reflect on what I saw and what I missed in this election.

My voting came from my belief in collaboration over competition. I saw that with Hillary a continuation of policies to help those in needs, to collaborate to achieve peace and to slow down climate change. In contrast, I saw Donald Trump a bully who put himself above everyone else, and who could ignore anything to advance his own agenda.

But I must have also ignored much what 60,072,551 American have voted for Donald Trump.

Americans wanted a change agent during recent elections. The choices of Bush over Gore in 2000, Obama over McCain in 2008, and now Trump over Clinton in 2016 all found someone brought fresh perspectives and agenda for change. The directions for change were not the same in each election, but the idea of we can do better was the same motivation in the past, was probably the same for 2016.

There were also 60,467,601 American have voted for Hillary Clinton. This election result could not reflect what is right or wrong. Like a lyric from one of my favorite song writers “what you say right now is just your courage at this moment”, this election reflected the current sentiment of the country.

Nobody should leave America, because this is our country.

Our beautiful democracy has protected us from chaos or wars that would have occurred in many other places after a divisive election like this one. I want to give change a chance. The republican party has an amazing chance to get something done in the next few years. It would be a big beautiful thing if politicians spend more time with their constituents than with lobbyists and donors.

I don’t think Donald Trump will be able to mess up too badly.  I believe there are more Americans will stand up to bigotry towards women and prejudice against minorities. The next election cycle is in two years.

We will look back this election in 2034 and remember the Supermoon this weekend. The moon is the closest full moon to Earth since 1948. I will go out into the dark night and enjoy the brightness of being.

My Vote as an Immigrant American

In the early days after arriving in the US, I was often asked when I would go back. Not all of the inquiries were unwelcoming, but I understood that not everyone would like to have immigrants in their country.

It was not easy to stay in America. After graduation, it is difficult for a foreign student to work in the US legally unless you can find an employer that sponsors the H-1 visa. I was very fortunate to receive the permanent residency, a green card, through the national interest waiver program because of my research work and gracious support from many colleagues. The road to citizenship took seven years after I received the green card.

I have chosen to stay because I love America. I left China after the 1989 student movement. I saw on TV how a government sent tanks to crush peaceful student protests. I realized how important that people should have voices in deciding their leaders. It was here that I cast my first vote as a citizen in the general election in 2012. My own vote, which I do not take for granted, is the most important right that I treasure as being an American.

I love American workplace. After finishing school, I found a scientist position with a medical device company. Before long, I started to work on a product that can help millions of people with sleep apnea, a chronic condition that affects sleep and causes heart problems. America has the most competitive medical device companies in the world. I am always proud to tell people here and abroad about my work because we have the most innovative products to help improve and extend lives around the world.

I love America because of its generosity. My graduate education and research were funded by government grants. I am happy to see taxes I pay and so do many others make possible these federal programs, such as the national institutes of health and national science foundation. I appreciate my local city and state governments are obsessive about keeping the roads free of pot holes after each long winter of Minnesota. 

When I cast my vote this time, I reflected on my journey as a Chinese American. I benefited from an immigration policy that allowed me to use my talent to work on medical devices that can help millions. I understand the struggle of immigrants, and their desire to improve the life of their families. I love the non-profit organization Children's HeartLink, which I volunteer my time. Its mission to improve access to congenital heart disease care helps countless families and fosters friendships in partner sites in China, India, Brazil and Vietnam. What I have learned from the experience is that it is richly rewarding from collaboration and help others. I appreciate my teachers, neighbors, and friends who showed me how to value diversity, respect the environment and treasure our independence. These are the values that I have based on to cast my vote this year. And this is why I am proud to vote for Hillary Clinton.

Indian Leadership in American Business

A friend shared several articles on the rise of Indian in large US companies on Wechat, a popular social media in China. Sundar Pichai at Google and Satya Nadella at Microsoft are impressive successes of Indian immigrants in America. The rising wave also includes the recent appointed dean of Harvard Business School (Nitin Nohria), University of Chicago Booth School of Business (Sunil Kumar), and several other large US corporations and institution.

These articles from the Chinese media consider the following factors:

1. Strong network within the community: many Indians help each other in the workplace, such as job interviews, promotions etc.
2. Focused on relationship in leadership: the tradition of apprenticeship makes Indian leaders more likely to participate and build strong relationship and loyalty with subordinates.
   
3. Others: IIT as the ultimate elite school has produced half of the top Indian leadership; strong language skills; and early exposure to the American culture.

Some of these summaries came from the vantage point of comparing with the experience with recent Chinese immigrants in America. Indeed, the background of these Indian leaders are very similar to mine, and many of the technical immigrants from China in their mid-career. We grew up in places were poorly developed, went to good universities, came to the US to pursue postgraduate education, and stayed.

The focus on relationship in their leadership was an interesting observation, but makes sense after thinking about my own experience with friends and coworkers from India. My own observation to add:

1. Continue to pursue the next career goal: I know more Indian co workers than Chinese who completed an MBA in early career. I attribute this to the Chinese philosophy of “Zhi Zhu Chang Lie”, knowing having enough makes one happy. Many Chinese become technical expert and stop. My Indian friends more often have eyes on the top spot of the company
   
2. Strong family and community: this observation is very superficial, but it is often breathtaking to participate in the Indian family and friend gathering, weddings and other ceremonies. Community is a salient part of the Indian culture. My most awe experience is the best table tennis club in the US is not by Chinese, who dominate the sport, but hosted by the Indian Community Center in the bay area (http://www.indiacc.org/tabletennis). These communities can often serve as the backbone for strong leadership. The individual pursuit of excellence or happiness is different from taking everyone with you to pursue a common goal.
   

Alas, I congratulate my Indian friends for their rise in American Businesses, the diversity will be good for all.

A Mobile Health Case Study - Shruti Program

The Shruti Program is a good case study of a low-cost solution for early detection of ear infection to prevent hearing loss using mobile health technology.

It is a partnership among Medtronic, ClickMedix, international partnership for innovative healthcare delivery and partner sites in India.

The key components of this program include:

1. Addresses a clearly defined unmet need of early detection of ear infection in areas that are lack of direct access to diagnostic facilities
2. Provides a cost-effective technical solution with a cellphone-based otoscope that enable local screening by trained health workers and remote consultation by specialists
3. Builds an eco-system of community-based screening clinic, standardized screening, and patient care coordination after screening.

This model can work for many other prevalent conditions such as congenital heart diseases, retinopathy, and obstructive sleep apnea.

It is always important for these models that aimed for providing community-based screening to examine its validity for both sensitivity and impact of false positives in the early stage of development.

They are the solutions to serve the bottom of pyramid.