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. 

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.