My recent monitoring adventure began when I received an inquiry as to whether or not I would like to accompany Drs. Mardjetko and Sanchez as a part of the Scoliosis Research Society’s, SRS, mission to Bulgaria. I was honored to be asked and immediately replied that I would accept this amazing offer. Within the next few days, I gathered GPO supplies from Dana and packed my bags for what would turn out to be one of the most rewarding, marvelous experiences of my life.
This was the first time this mission would occur in Bulgaria. I learned about similar missions in Columbia, Barbados and Ghana from other colleagues and was very willing to learn from the advice they had about these trips. Seeing photos from these trips, as well as the Discovery Channel’s FOCOS special, led to an increased desire to participate and help these children.
Ten days later, I met Dr. Mardjetko, from Advocate Lutheran General and Chicago Shriner’s Hospital, at Chicago’s O’Hare International Airport. We had a pleasant flight to Rome, Italy. From Rome, we departed to Bulgaria. Bulgaria is an 8 hour time difference from Chicago, and approximately an eleven hour flight from Chicago, so this was quite the plane ride! After our final arrival in Sofia, Bulgaria, we were greeted by Dr. Stefan Georgiev, the Medical Director of Surgical Recovery Services from Osteotech and Dr. Roman Hitchev, the President and CEO of Osteotech. From the airport, we went to our hotel in Sofia, where we rested.
The first day of the mission led us to the orthopedic and traumatology section of Tokuda hospital where we met Dr. Vasko Yablanski, a Bulgarian orthopedic surgeon. Drs. Mardjetko and Yablanski held clinic where we met three wonderful children and their families. Each child’s history was collected and a physical examination was completed. X-Rays and MRIs were also examined and each curve was measured. It was really interesting to learn what happens before a patient is considered for surgery. Dr. Mardjetko explained everything to both the families, and to me, and why he was asking the questions he was asking. It was wonderful to see the positive, interactive relationship that Dr. Mardjetko had with each child. Each family was very grateful to have an experienced team that would be taking care of their children and their complex deformities. Being part of this team was a very gratifying feeling.
On the second day, we met with the same children, as well as one more. Dr. Sanchez joined us from Madrid, Spain. Both surgeons examined the hardware for the surgeries and began planning out the surgeries. 3 children were initially selected for surgery on the next two days. I also met with a neurologist and explained spinal cord monitoring to her. She was familiar with the concept of monitoring which she had observed in Japan, however, currently in Bulgaria, she explained that neuromonitoring is not performed in an intraoperative setting. I explained the different kinds of cases that we do monitoring for and showed her examples of cases in which there were changes. I explained that changes may arise from technical, physiological, surgical and/or positional causes. After an intervention, in these cases, responses returned. She acknowledged that this was a very helpful tool in the OR, however at this time; this would not be possible for several reasons, in Bulgaria. The neurologist stated that they currently perform clinical EEG and EMG and that she had recently performed 2 trials of VEPs, although they were very difficult to obtain. She also showed me their setup that they use. She stated she would be interested in observing me in the OR but was unable to attend.
On the third day, the first operation was performed on a 15 year old female with chromosome 8q syndrome and neuromuscular scoliosis with progressive collapsing kyphoscoliosis and 80 degree scoliosis, and 80 degree kyphosis. My preliminary discussion with anesthesia was very interesting. This is when I learned that shaking your head vertically means no and side-to-side means yes. So, when I asked if any neuromuscular block had been administered, the answer was really yes, but I thought no! They also did not understand the concept of a MAC value and preferred to assess the patient’s depth by BIS monitoring alone and stated that BIS monitoring is considered 21st century technology. The chief of anesthesia, Dr. Georgi Simeonov, was very interested in monitoring and how it can be very helpful to everyone participating in the case. I was able to provide him with literature about the types of monitoring we perform as well as the anesthetic requirements for these types of monitoring. My training at Biotronic prepared me to answer all of their questions in detail and I felt like I provided them with helpful information. I thoroughly enjoy teaching so being able to explain these concepts as well as having a welcome recipient who was willing to learn, was very rewarding. It was quite an awesome feeling to realize that I was the first one to ever perform intraoperative monitoring in the country of Bulgaria! I am very hopeful to continue with the Biotronic tradition of academic excellence and philanthropy and provide these physicians with the fundamentals they will need to continue with reliable intraoperative monitoring in the future. I am very grateful for the education I received at Biotronic so that I could use it to help in these areas where monitoring is not protocol. Screw testing was also performed. Overall the staff was amazed to see the immediate data that monitoring was able to provide. The surgery concluded without any complications, including monitoring, and the patient woke up without any deficits. It was determined that the second procedure would have to wait until another day.
On the fourth day, the second and final operation was performed on a 10 year old female with congenital hemivertebra T9 and 68 degree progressive right thoracic curve. This procedure went quite well however some positional changes occurred in sensory signals as well as a possible physiologic/anesthetic change in LE TcMEPs. This was an excellent opportunity for the Bulgarian staff to realize the importance of monitoring and how there are several factors that affect the patient’s outcome. Thankfully, the patient woke up without deficits.
After this surgery was complete, I changed into my street clothes to join the surgeons for a press conference. As I left the changing room, I saw the father of the girl that just had surgery. As soon as the father saw me, he burst into tears and hugged me. This was one of the most positively overwhelming, extraordinary; words cannot describe how I felt moments of my life. This father was so grateful for my contribution to his daughter’s well-being; he could no longer express it with words. That hug transferred raw human emotion and it will be remembered forever. I walked in awe and in sheer bliss to the press conference with Dr. Stefan Georgiev and the parents of that child.
The press conference was also a very unique experience. Drs Mardjetko, Sanchez, Yablanski, and I joined Dr. Roman Hitchev and Dr. Stefan Georgiev as well a Bulgarian interpreter. The local press was invited as well as the former prime minister of Bulgaria who was now a hospital administrator. The SRS mission was explained, as were the surgeries that were performed and the neuromonitoring that was provided. There was much excitement about the level of care that was provided for these children for their complex spinal deformities. At this point I also learned more about the Bulgarian health care system, and local medical politics. Bulgaria has a socialized health care program in which the government provides support. Private hospitals also exist however; patients need to pay for their own care. In addition, surgeons are not trained for these complex cases. Simple scoliosis corrections are performed in which locally produced Harrington Rods are placed. Neuromonitoring simply does not exist for lack of funding and education/knowledge. At the end of the press conference, the mother of the first child that was operated on greeted me in the same fashion as the father of the second child. After receiving these powerful emotions, I understood the need for help in these countries, for these families and most importantly for these children. I was honored that I was able to be a part of this experience.
That evening, before our long journey home, we all went to a local, Bulgarian restaurant, Chevermeto, where we sampled traditional local cuisine and were pleasantly surprised by both dancing and singing entertainment. The entertainment represented different regions of Bulgaria and reminded me of Greek, Russian and Turkish influences. The food was delicious and so fresh! They are known for their goat cheeses and locally grown wine.
As I reflected on our trip home, I was very grateful for the things I would be returning home to. I was also very grateful for the things I had left behind. This was by far, one of the most amazing experiences of my life and I can only hope to contribute more. I am grateful to Biotronic for allowing me this wonderful opportunity to help these children and provide them with excellent monitoring and hopefully help establish a monitoring program in Bulgaria. I look forward to future missions with SRS.