Welcome to ASG Global Spotlight, a webinar series created with our global audience in mind at a different time from my usual offerings to make sure that you all have a chance to join live. These webinars will feature global experts in their field, and I'm very excited for today's presentation. Our attendees are joining us from all over the world today, and the American Society for Gastrointestinal Endoscopy appreciates your participation. Today's event is entitled Global Health Endoscopic Care in Resource-Limited Healthcare Settings, Our Experience in Guatemala. My name is Reddy Akova, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. There will be a question and answer at the close of the presentation. If you have any questions during the presentation, you may submit them at any time online by clicking the Q&A feature on the bottom of your screen. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now, it is my pleasure to introduce our two panelists for today. Dr. Brian Sauer is an Associate Professor of Medicine, Division of Gastroenterology and Hepatology at the University of Virginia Healthcare System. Dr. Sauer's research interests are in Barrett's esophagus, quality and efficiency in endoscopy, and pancreas cyst neoplasms. In 2016, Dr. Sauer founded the UVA Multidisciplinary Eosinophilic Esophagitis Program, or EOE, which is a co-operation of physicians from the Division of Gastroenterology and Hepatology and the Division of Asthma, Allergy, and Immunology at UVA. Dr. Sauer is a fellow of ASGE and has received numerous leadership and excellence awards in teaching and critical care. And we are very fortunate and honored to have Dr. Sauer with us today. Our other panelist is Dr. Michael Daugherty, who is part of the team at the Rex Digestive Healthcare. Dr. Daugherty is also an Adjunct Professor of Medicine, Division of Gastroenterology and Hepatology at the University of North Carolina. Dr. Daugherty's research interests are aimed at an end goal of extending access to GI services to all populations in a rational and responsible manner. He has a particular interest in luminal cancer prevention, specifically for gastric and colorectal cancer, as well as esophageal disease. Dr. Daugherty also collaborates with researchers and clinicians from other institutions on investigation and endoscopic procedure outreach in Central America. Dr. Sauer and Dr. Daugherty will share their experience with us today on global healthcare and endoscopic care in resource-limited healthcare settings in Guatemala. We are, again, very fortunate and honored to have them both here with us today, and I will now hand the presentation over to them. Thank you so much for that kind introduction, Reddy, and thank you to all who are participating today or who are viewing this video at a later date. So today, Dr. Daugherty and I have the honor of talking to you about global health and specifically the endoscopic care and resource-limited healthcare settings, our experience in Guatemala. The photo that you see there, that is the first endoscopy case that we did in Santiago, Atitlán, Guatemala several years back in 2019, and it was really the culmination of a lot of efforts from numerous people, and we were delighted to be doing that and continue to the program today. So these are our objectives. I am not going to go through these in detail. They were on when you signed up for the webinar, but we're going to do some definitions and then kind of share our experience and tell some stories along the way. So first, I think we have to define what really global health is. It was originally derived from public health and international health, and I'm old enough to be in an era where international health was originally labeled tropical medicine. Thankfully, they've changed that to international health. And it's really great, I think, because it embraces both prevention in populations and clinical care in individuals, and that's really what we all do as gastroenterologists all the time, right? Much of our weekly time is spent doing preventive care and screening colonoscopies or endoscopies, and a lot of it's spent in clinical care for folks with symptoms. The other aspect, though, about global health is that it really hopes to establish some health equity among nations and for all people as a major objective. And so the definition here, global health, is an area of study, research, and practice that places a priority on improving health and achieving equity for all people worldwide. So it really resonates well with me because that's a goal of a lot of what we do. So there's a lot of examples of global health initiatives. Most of them are in communicable diseases, i.e. those infectious diseases. We all know that in today's era with coronavirus, but that's been really the focus on a lot of different initiatives over the many years. This is why a lot of times infectious disease experts are kind of leading the charge for global health initiatives. There's also been a huge emphasis on maternal and fetal health over the years. But today and as we go forward, I think there's going to be more of an emphasis on these noncommunicable diseases that are becoming an important part of morbidity and mortality worldwide. So these are things like cardiovascular disease, cancers, diabetes, all those things, and it really accounts for a lot of deaths worldwide. Many of these deaths, 25% or 9 million, occur before age 60. And so I think in today's era, we would call that somewhat premature death. And many of these occur in the low and middle income countries. And so many of these are preventable. Obviously, there's a lot of factors involved there, health choices, lifestyles, access to medical care is huge as well. You can see here cancer is really the second leading cause of death globally, and many of those do occur in those low and middle income countries. You can see here that both colon and stomach are the second and third leading causes of deaths worldwide. And so both those are GI issues. So I think we in the gastroenterology community have a huge opportunity here to address some of these non-communicable diseases globally. Now, there's a lot of barriers, though, for gastroenterology and global health. Obviously, the cost and size and availability of equipment, much of what we do is to perform endoscopy procedures, to diagnose cancers, to prevent them with removing precursor lesions. And there's a huge, though, cost to that. These towers are large pieces of equipment. They're very expensive. It's not something that we can travel with. We can't put these in a suitcase and go somewhere. And then there's this need for adequate facilities to process and clean the scopes and be able to perform the procedural complexities such as sedation and some of these interventions. And so that's not available all over as well. It's not something we can set up quickly and take down quickly. So in my experience, a lot of hospitals all over the world that I have visited will have kind of the surgical equipment to perform many operations. But very few of them have working endoscopy towers. And then, of course, global experience in training and practice is limited. And there's always logistical barriers like travel and funding. So this is a really interesting survey of fellows and program directors in the United States. And most faculty and fellows really believe that global health would strengthen their fellowship education. But really, very few actually had any type of program offered for global health education. And these are the barriers that they mentioned in the survey, obviously funding and scheduling of that. Lack of standardized objectives, insufficient data on the impact, and then some folks that are not as interested in this. But I really do believe that this could be a key component to training worldwide. And I think for the fellows that are listening, if this is something that you want, I think it is something that we can overcome a lot of these barriers. We do have a lot of good examples in gastroenterology of global health initiatives. MGH and Mayo, Dartmouth, and Yale have partnered with several places in Africa where they're dealing mostly with esophageal cancer. And they've really done a great job using esophageal stents as therapy for that and really benefiting a lot of folks who have been able to undergo that. There's also a high amount of liver disease and esophageal varices there. And they've been doing this for many years. They've talked about some of their general liable lessons here. And really, it's support from the political, academic, and financial entities really in both countries that have made this work. And then the efforts put forth by those folks involved in these programs to have planning these trips, maintaining the equipment, doing research, and figuring out best ways to help the patient populations in those specific areas as each are unique, and then educating folks in that area. Doug Morgan has worked extensively in Central America where gastric cancer rates are fairly high. He published this study of 741 cases with gastric cancer. And it was quite interesting. A small percentage of folks underwent treatment, only 25%. Individuals with extreme poverty, age over 55, and then folks that live far away from these regional treatment centers were less likely to undergo treatment. These are a lot of barriers folks have for cost and travel, and certainly with age as well. So just a brief story about my interest in global health. I did not travel much growing up, and first went to do some international travel when I went to India after my undergraduate training. And that really sparked an interest and opened my eyes to some of my interest in global health. I worked with a surgeon in India for a couple of summers, and it was a great experience both personally and professionally. And I've continued that relationship and made numerous trips there to assist in the endoscopy care there and GI care. And then I went, traveled in Belize during medical school in a program that we had there. And then more recently in Honduras and Guatemala setting up some endoscopy equipment and units. So we'll talk, you know, the biggest kind of program that we've set up here is Guatemala, so we'll talk more about that as you know. So here are some ways that I went through kind of as we were kind of talking and considering this steps to establish really a program. Number one, it's all about relationships. And so it was identifying relationships and exploring those interests of centers that wanted to expand in gastroenterology. And so the second step was kind of to develop a plan of how we're going to do that. What is the need in that patient population in that location? And then we had to identify an infrastructure. Is there, how are we going to get the GI care, especially when it deals with endoscopy, which has, you know, certain needs that we already talked about for equipment and facility needs. And then, you know, another way that is another important aspect is to plan regular visits and frequent visits to be able to be there for, to provide these services. And then finally, really establishing some type of research with a purpose so that you can understand the patient population, the location better and do a better job in providing the resources that are necessary. So that is what we did in Guatemala. You know, the first, you know, back several years into my probably five or six years ago now when I started, when I had an interest in global health and didn't have anything that I was doing at that time, besides my kind of longstanding experience in India. So I decided I was going to try to figure out a way to do some global health in Central America or South America and sent some kind of basically cold call emails to folks to see if there was an interest in gastroenterology. I didn't get too much of a response, as you can imagine, since there wasn't a relationship there. And then thankfully I met, I met Michael when he was interviewing at the University of Virginia for a GI fellowship. I was assigned to interview him and we sat down and I realized from the CV that he had been doing some work in Guatemala at a hospital after his residency had completed. So I was really interested in that. It turned out that was one of the hospitals that I had contacted and not heard back from. And so we kind of talked about whether there was a need or desire for gastroenterology services there for much of that. Shortly thereafter in 2016, I made a trip down to Guatemala. Michael was there at the time working as an internist and I had a lot of questions there that I needed to be answered if we were going to set up some program. You know, number one, did that hospital want or think that they needed GI care? And that was pretty evident that that was in fact the case. Number two, was it safe? You know, did I feel like I could bring a team of medical volunteers down there to be able to provide the services? Another huge aspect was, was there appropriate patient care and follow-up? You know, I didn't want to come down there for a short period of time and then have these patients not have doctors that they could see on follow-up. The hospital we are at does have a robust outpatient center. So that was really great to see. And then really, are there the facilities to perform endoscopy like I talked about before? Is there that infrastructure? Is there a room for that? Are there the set up to clean and reprocess scopes or can we adapt what's there to be able to do that? And so that site visit was really hugely important if I was going to go forward and ask for donations or figure out how to get the equipment down there. That met all the needs that I felt were necessary. We did do somewhat of an informal endoscopy needs assessment in 2017 and 2018 with one of the internal medicine residents, was in this region of Guatemala and did some interviews with providers asking them about the need for endoscopy and the services. And it was really pretty clear from that that there weren't a lot of endoscopy services in that region that were reliable. And also that there was a need from the provider standpoint of needing these kind of services. So in 2016, kind of in 17, 18, that was kind of starting my goal to kind of get the endoscopy equipment. And after three years of effort, really in December of 2018, I made a trip down to Santiago Atitlan to help set up the endoscopy equipment with David in this picture, who is a representative from Olympus. Now, you know, a lot of folks, this slide makes success look like that arrow on the left-hand side. Really it was more like the arrow on the right-hand side of how success happened in this regard. You know, I went and asked people or talked to people. A lot of people said this wasn't possible. And I got the answer no from several folks at a time, several times. I actually went back to Olympus after being told no several times, and they had just reopened up a donation program. And so we were thankfully the first one to go through that program to get some endoscopy equipment. So this was great to kind of set up all this in Hospitalito Atitlan in Santiago and really was a dream realized after a lot of efforts from myself and many other people. So I'm going to hand over the discussion now to Dr. Daugherty here, as he's going to go through kind of what we've done in Guatemala. Thanks, Brian, and ready for the invitation. So yeah, and I would highlight Dr. Sauer's extensive work here. It was a lot of persistence. I was kind of watching, hopefully on the sidelines, through those couple years that he kept trying to get equipment donated and finally got it down there. So I was just going to talk a little bit about more of the specifics of what we do down there and then start by just talking a little bit of background about the setting. So Guatemala, a large economy in Central America. It's part of the Central America Four. So these are generally the poorest countries in the region, Nicaragua, Honduras, Guatemala, and El Salvador. And Guatemala is somewhat unique in that they're quite diverse, even within the country. Spanish is the official language and spoken at least at a conversational level by most, but is actually only the first language of a little over half the population. There's a large number of many indigenous people groups of Mayan descent, and there's actually 25 recognized languages in Guatemala. And then there's Garifuna culture on the Caribbean coast. So this is a lot of racial and ethnic diversity, also contributes to some health disparities that are magnified given the overall economic deprivation. So as you can expect with a poor country, the health system is also quite resource limited. And these show up in outcomes. Guatemala specifically has one of the highest infant mortality rates in Latin America, certainly the lower end of life expectancy, a very low doctor to population ratio. And this 0.4 doctors per thousand people really is probably more exaggerated. The WHO recommends about one to one thousand. The U.S. for perspective has 2.6 for one thousand and some countries in Europe over four. But in Guatemala, especially, you know, where there's also no recognized advanced practice providers or physician extenders, these are really the only providers. There are there's a lot of medical care is delivered by by nurses, pharmacists. But 70 to 80 percent of the MDs are actually concentrated in the capital. That's where a lot of the paying patients are. That's where most of the medical facilities are, the more technologically advanced ones. So this is where we were working. And the Guatemala is also known as the land of volcanoes. So this is Lake Atitlán. It's a very beautiful region. And Atitlán or Santiago Atitlán is the little metropolis there, about 50000 people. And this is some other pictures of traditional dress. This is actually very common, probably the most frequent type of dress that you will see and women in the region. And it's a very. Fun place to visit, but as far as where that puts it in the context of the country for endoscopy access, looking at where Lake Atitlán, this is small, but it's just this lake with the one red circle. And then most of the endoscopy services are concentrated in the capital with the other red circle. And you may look at these and think they look pretty close together. But this is actually about a four hour car ride. There's some windy mountain roads or another route along the coast that's a little bit circuitous. And so you combine this with the fact that most of the people coming from the lake and and a lot of other regions in Guatemala are more indigenous background. They may not speak Spanish well. They may and for that reason have to take multiple family members for interpretation, just for helping navigate the the capital city. There's a lot of financial toxicity from all that taking off of work. And there is some discrimination because of the indigenous heritage. My experience when I was down there and I think this was corroborated with our needs assessment is that when folks are referred for endoscopy, but the minority of them ever get to it. So they just they usually just don't go or maybe they go and try and it's too difficult. And so there there really is little endoscopic services within three or four hours of where we are working. And then that raises a valid question. You know, do is this really the clinical priority for this patient population? You know, is the endoscopy the thing we should be working on? But I agree. I think that's that's valid. We're not talking about bringing endoscopes down rafts and rivers to jungles where there's not electricity or anything like that, but developing health systems, developing economies need to prioritize primary care, vaccines, nutrition, prevention, acute illness and a few higher yield subspecialties. So general surgery, orthopedics for trauma will be guide for for deliveries and prenatal care. But then once you start getting kind of a basic level of of health care in these transitioning economies, it will start living longer and you do start needing other subspecialties. And this has been our experience that people do get referred for endoscopy. The medical community knows that endoscopy exists and and and feels like it's needed for several patients. They just can't get it. And when you if you can run a laparoscope, you can run an endoscope. Generally, you know, you have monitors and you have the equipment to perform that. So that's where we fit in the the hospital. And we were fortunate enough to get for Brian to get the donation from Olympus. So then then you have to think about setting up the endoscopy unit where endoscopy has never been done before. And I will qualify this is that I don't know if there will ever be people who listen, listen to this from, you know, truly more resource constrained. This is certainly resource limited, but I wouldn't say it's austere in environment. The facilities are are quite nice. There are two functioning ORs. The hospital has purified water through the whole hospital. They're familiar with a certain level of surgical equipment, have methods for sterilization, reprocessing that. So there are other places that that are in the developing world that, you know, re-sterilize biopsy forceps, a lot of different ways to kind of make the procedural unit function in very financially constrained circumstances. And we fortunately have plenty of donated equipment so far to provide excellent care, I think. But you do have to think about what's going to be unique about each of these steps along the way with a new environment. For instance, the consent process, there was one that existed, obviously, for procedural consents, but it was a little bit different. You actually have the family member has to sign the form. It's kind of a form of witnessing the consents. But there was a protocol involved, so you just kind of learn that and adapt to it. Scope reprocessing, Brian has alluded to already, but that was a big component we had to figure out. And actually, one of the biggest costs to the facility, so obviously, all of our team's manpower is donated free. The hospital does contribute a few staff to help with pre-op. They supply, obviously, IVs, CO2, the space. But the high-level disinfectant is actually about almost $100 a gallon, and you need three to four to adequately submerge the endoscopes. And so that was kind of a big cost for them for these procedural weeks. You have to figure out how you're going to store the equipment and keep it running. That's a big problem with nice equipment donated in more resource-limited settings. There is definitely medical equipment theft in this area and all over the world, so figure out a way to keep that secure. Patient selection, I'll go into a little bit more in the next slide, but how are you going to get the patients? How are you going to make sure they're appropriate? Because you're not there all year long seeing patients in clinic. It's not just not your own clinic that you're referring from. Figure out how pathology works. We send pathology to the capital, to a lab, and it takes several weeks for turnaround. So how are you going to follow up on that? We've established a system where we're kind of available via some telemedicine or basically internet feedback if one of the primary providers has a question. But most of the time it's straightforward and they can handle it. You have to give people reports. So we have a color printer that prints out a procedure report in Spanish with nice pictures because there's no EMR that links all of this health system. The patients may drive from two or three hours away and then they'll go back to their provider and have no record except for what they bring with them of what happened. So how do we get the patients? This is pretty much all open access referrals. Initially, we thought it was the best use of our time to maximize the amount of procedures that we could do. As more docs actually from other institutions have been interested, we have had pretty sufficient manpower and are probably going to introduce more of a consultative role. There are, and the hospital has expressed a lot of interest in the value of that also to their patient population. A lot of procedural trips have this model already. The surgical trips that go down, we'll see patients for a day or two in clinic before and identify all of the cases and then do more of the procedures towards the end of the week. But we gather patients by these type of publicity announcements on the fronts of churches, of local clinics, and then local primary care provider general practitioners identify patients that they think would benefit from an escopic procedure and refer them to the hospital. Most patients have never had an endoscopy. And then you have the follow up in place when they leave after their procedure, they're given a follow up visit to come to review any path or results of the procedure. Considerations for the team when you're starting one of these programs. I think it can probably just be boiled down to be flexible, adaptable, humble, and as prepared as possible and leave enough time for all those things. You want to acquaint yourself with what equipment and other ancillary services you have at the hospital. Introduce yourself to everybody you're going to be working with. Try to learn from them. Figure out the local processes. You don't want to mislabel specimens and have path not get sent for that. There actually was a learning curve for figuring out how to document in this setting. It's a little bit different. A lot of paper, a lot of different documentation norms that especially the nurses had to get used to. And then just to be flexible. And if there's something that you would have normally done a different a different way as part of the fun of this experience, I think getting to figure out different ways to achieve the same outcome. As far as the ongoing process through the trips and multiple trips, it's important to have a lot of reflection and frequent re-evaluation. We usually don't book our procedural days completely full really any day, but especially the first day, because there is inevitable, although unforeseen obstacles that will come up and it takes a lot of planning. Make sure you have the reprocessing supplies, the appropriate drugs. But there's always going to be something that you need to troubleshoot. And it's nice when there's time to do that and people are not feeling stressed, but be willing to adapt midway. So are just a little bit about our experience, the kind of cases we see and have done. Had three trips so far since 2019. We had hoped to have maybe over double that. We've gotten to cancel it actually within like a week of of traveling due to COVID both in March 2020 and last month from the most recent surge. But on the three trips that we've been able to to carry out, we've done 100 procedures, about 30 something cases per week, mostly endoscopies, colonoscopies. Still, the medical community is not quite as familiar with it because they haven't had access to it as much. And traditionally, gastric cancer, H. pylori, has been a bigger issue. There's but that's that's developing. We have one endoscopy tower. We use one of two operating rooms. We leave the other operating room open for other surgical cases that may come in. And then there's there's three gastroscopes, a peds colonoscope. And on all the trips so far, we've had three endoscopists, including the GI fellow, which is myself at the start. And then we bring three either endoscopy nurses or maybe a tech and then our own nurse anesthetist. So our endoscopy team is pretty complete. There is some of the hospital staff rotating or circulating in the room, occasionally handling path and then assist with pre-op, generally, especially translation between an indigenous language and Spanish. So in in Santiago, the primary people group is the Souto Gil. And then there's some Cachiquel, Kiche as well that are, you know, I don't I don't speak those languages. So we need interpretation and then a help with IVs and pre-op and then some scope scope cleaning as well. And so the type of cases that we do again, we've tried to have a fairly, I guess. Low, low tolerance for procedural risk. I think that's been important in this this endeavor that the hospital has worked a lot over over many years to gain the trust and some rapport in the community. And if we were to, you know, accumulate complications that would be quite damaging to that. And so there are considerations. There's not as many resources from the rest of the health care system that we may be accustomed to. There's no immediate surgical backup all the time. There's certainly not always. There's rarely an MD anesthesiologist, an ENT. There's no IR. There's no blood bank. So you have to be a little bit prudent with with selecting the the procedural risk you're willing to accept. But the types of indications are somewhat similar to pretty similar to what we what we see here, at least for the upper endoscopies, mostly just Pepsi and reflux. And then there are certain red flag alarm symptoms that are you would expect end up do reflecting pathology. So we've found a couple of gastric cancers that were highly suspicious even before going into the procedure. Colonoscopy, again, we're still getting a hold on that. There's not as many people as I would have expected presenting for diarrhea. A lot of people are presenting for being sent for constipation and or abdominal pain. The interesting thing is that we are finding some polyps. And I think our end is too small to say whether that's actually a similar proportion to what we would otherwise see in the US. But it's not rare. And it's almost always unrelated to the reason the person presented. So it is kind of interesting to consider whether with the transitioning of economies, more westernization of lifestyle, processed foods, more sedentariness in a lot of the population, we may start seeing more Western disease. We definitely see that in the metabolic disease. And now maybe we'll see that in colorectal cancer as well. But there's also just not very good epidemiology. So it's not it's not not clear to me exactly what the instance of colorectal cancer is currently. Just going through the types of cases we see, obviously, even if folks have H. pylori or some other pathology or dyspepsia seems to be a very prevalent symptom. But a lot of the endoscopies we do are just like this that you guys probably see all day, every day. It's pretty normal. You see a good bit of gastritis. This person had H. pylori. Other curiosities, pancreatic rests, some stigmata of reflux. And then, like I mentioned, you do see polyps, a couple of larger pedunculated polyps here that probably would have caused the person problems at some point. And we found a whipworm, which you will, I'm sure, see at some point if you do enough cases, even in the U.S., folks who have immigrated from different regions. But it's always pretty interesting. I think we I think I think this is a whipworm, but it could be adult pinworm as well. This is in the cecum. We gave this person albendazole. They had some irregular bowel habits and abdominal pain. Not sure if it was related, possible. And then this is one of the gastric cancers. This was from the dacardia to the incisura. Again, pretty alarming features to start with, weight loss and dysphagia for several years in an older gentleman. And I don't I think this the follow up from this, he didn't actually the family didn't actually elect to pursue cancer directed care in the capital, even though they were referred and which is is reasonable. But I think this procedure was still valuable because it gives a lot of closure to the patient. They had a two year functional decline and really knew there was something wrong, but they couldn't figure out what. And now they have the answer and at least can can plan around that. This is the other gastric cancer, gastric outlet obstruction. And so and this was also quite concerning, initially 50 pound weight loss. So future directions for the the trips, our goal is to have three, maybe four trips per year, 40 something procedures per trip, ideally expand maybe the their research enterprise there. I think the you have to do that delicately there. The hospital just has been very interested in expanding their research enterprise, but there isn't really anything going on now. And there is some appropriate apprehension in the community towards these type of efforts. So I think you have to always keep the where we will have to keep the local community's interests paramount. And any research should probably be benefiting to to them and their community. But I think even basic epidemiology would be helpful because we know there's gastric cancer. We don't really know how much colorectal neoplasia there is and what other types of pathology is specific to that region. We would and probably with the research enterprise or maybe more other other public health and prevention initiatives, we could involve more trainees, which would be useful for for us and them. We would love to extend our network locally. So we have, I think, a great relationship with this one institution, but we'd like to partner with more institutions or a larger referral base. And also local endoscopy providers. So this is a common theme that comes up with global health emissions, I guess. There's this this question of sustainability and partnership. And I think some of the most successful and and laudable programs have really focused a lot on training local providers to basically make the gringos or Americans obsolete. And we would be be fine with that. I don't I don't think we are supplanting any or filling any sort of gap that would otherwise been filled by by a national provider. I don't think there is there are a lot of challenges to this. So I think the specific site we're at, the volume is probably not high enough to support endoscopies all day, every day. And so then you run into an issue of the again, the high level disinfectant. If you're only going to do one or two cases a day, is that really worth spending three or four hundred dollars for for Cydex? But those things can be navigated and we'll look forward to seeing what kind of collaborations we can develop in the future. Just some concluding thoughts and pictures. The experience has been really rewarding. I think I worked as an internist before even training in gastroenterology at this site in Guatemala. And to now be able to to also bring back what I felt was one of the large needs for the community in our specialty is really rewarding. And I know everybody who's been on the trips has always really enjoyed and felt like they were doing something to make a difference there. And the task ahead is to figure out how to sustain that and and make the most of the future. We'd like to acknowledge everybody who's made this possible. Brian already mentioned Olympus and AmeriCares, which help us transport a lot of the supplies and also provide a lot of propofol frequently for us to be able to perform the procedures. The Central America Outreach and Endoscopy is a nonprofit that we've set up. If you want to get involved, these are all the individuals who've been on trips and then also Hospitalito personnel. Nick Nickel is the other gastroenterologist who's participated so far. And there's other individuals from other institutions that are planning on coming on future trips. But I think now we'll probably take some time for questions. I'll just highlight. Thanks, Dr. Gordy. Great job and explain all that. I'll just highlight that, you know, I think for the participants in this trip, it's been really an honor to go and to serve others in this capacity. It's very rewarding. We understand that the patients oftentimes aren't able to get endoscopy unless this program was developed and persists. So they have all been very gracious and thankful to the medical teams that have have come down and volunteered our time and expertise to. So it's been really rewarding for everybody. We work hard and it is fun as well. So it's been great. And I really encourage anybody listening or maybe looking at listening to the video later on that if this is an interest you have, I think there is a way to figure out how to do this anywhere in the world. And it's it's really going through some of the process that we talked about. You can see an example here. I think one of the things that that Michael and I struggled with was there weren't a lot of examples that we had to kind of go off of. So we were doing a lot of this stuff de novo, so to speak. And, you know, I think having examples where you can rely on folks or if you need some thoughts or or advice, you know, we'd be happy to to to answer any emails or talk over the phone, even if you have interest or have interest in setting up something like this somewhere else around the world, because I think there's a lot of opportunities. I'm looking at the the Q&A, I guess we can start running through these, I think. Biggest barrier that there's I'm not sure what the specifics of what kind of barrier this is referenced to, but there's there's several barriers. There's the barrier of us being able to go. There's time and funds. So we generally go, I mean, take some academic time, but I've taken vacation time. The we're fortunate enough to have mostly most of the team coming from UVA or another institution that is supportive of their their involvement. I think Brian can speak more about the specifics of that, but there's some funding issues there. And then barrier once you get there is, I think, figuring out. What is. Sifting through indications for procedures, making sure they're appropriate with a limited time beforehand. There is some incidents of folks, you know, having already had an endoscopy recently that was reassuring and just wanting to to come because the Americans are here and it's available. And that may not be the wisest use to reduce your resources. It's infrequent, but occurs. And and just making sure that we're doing the right thing for everybody. But that's my thoughts. Brian, you have any other thoughts? Yeah, I think I mean, honestly, the the initial largest barrier is getting the equipment. That's a large amount of equipment that, you know, is somewhere around the two hundred and fifty thousand dollar amount. And so, you know, so I think one huge barrier is the equipment. You know, the other thing, the other big barriers are, you know. Finding a suitable location that needs endoscopy. So, you know, when you find it, you know, that's those are kind of the two biggest barriers when we were kind of going about some of the global health initiative is where is there a site that needs endoscopy that wants endoscopy that we can establish a relationship with that's longstanding? And then, you know, how do we get that equipment there? And then Michael talked about, you know, since we've moved beyond that, obviously there's barriers for for each trip, whether it's getting the funding for it, getting you know, this is we've always used Propofol for our endoscopies in this setting. We felt that was the safest, safest way. And being able to to provide that or purchase that from from the local exchange in Guatemala, you know, has been a barrier as well. So but I think, again, like Michael said, that's part of the the fun, so to speak, of this of the process. Right. Is is, you know, getting a having a goal and working hard to get that. So I'll answer the second question here is how do you select the team to travel to Guatemala? It's not a really formal process at this point. This is kind of, you know, a grassroots effort at this point, still from the from the get go, really. You know, there's a lot of folks that are interested or express interest. Usually I talk to the, you know, nurses, nurse anesthetist and techs that have an interest in this and and ask, you know, kind of why they're interested in what their their hopes are. And and really I've chosen some folks that have just, you know, expressed an interest to go and who have done well in endoscopy nursing. And, you know, they are going to be in a different setting. And so I think having, you know, nurses that have experience is really key. And that's who we we've been able to bring bring down. Interestingly, on our first trip, I didn't realize this, but all three nurses that that came with us, none of them had really traveled much out of the United States. And so this was their first kind of experience internet with international travel outside of kind of resort resorts or vacation travel. So and that they, you know, did well and had a great experience as well. So. See, there's one other question, how can ASGE members get get involved with this program? You know, I think I think contacting Michael or myself, if you're interested, is certainly, you know, we'd welcome that. You know, I think if we're happy to be help you in any way, if this is if you have a mindset of establishing a similar type program in another part of the world, I think that would be fabulous. You know, certainly I would we'd love to see the ASGE sponsor some of the of the trips or educational programs that as as this kind of expands, that would be a great way for the ASGE to be involved moving forward as well. So, you know, I think that the ASGE has had great partnerships with a lot of international centers and programs, both educationally and to teach endoscopy through their ambassadors program and through some of their educational programs in different languages now. And so they've been a huge help just in the in the global health initiative for gastroenterology worldwide. And so I think that's been that's been great. Obviously, membership in the ASGE, there's a there's a ton of international members. And so that's been that's been beneficial. It's no longer it's kind of an international organization at this point. So I think that leveraging kind of all the folks internationally is huge. We'd love to partner with folks locally in Guatemala as well as part of the ASGE if folks are interested as well and just be a service to those folks in any way we can. And even in other parts of Central America, too, if you have research interests or something like that, that we can develop, I mean, that's kind of I think the next one of the future areas that we're trying to move into. So it'd be great to collaborate. Thank you. Thank you so much, Dr. Sauer and Dr. Doherty for this very informative presentation and for sharing your experience in Guatemala with us today. We definitely as Dr. Sauer mentioned, we definitely will try to bring back some of the programs. I know you mentioned the Ambassador Program and we're trying to bring back a version of it. So hopefully we can we can help where we can with programs like this. But this is this is amazing. You've done both an amazing job, you and your team in Guatemala. So thank you. Thank you for being here with us today. Before we close out, just a reminder to the audience to please check the ASGE's calendar of events as we'll continue to feature relevant sessions to our global spotlight series. Another event that I would like to highlight is scheduled for Friday, December 3rd at 8 a.m. Central Standard Time and it will go until 145 p.m. This virtual event will feature live endoscopy cases from state of the art centers around the world. So registration is now open and feel free to visit the ASGE website to register for it. In closing, again, thank you so much, Dr. Sauer and Dr. Doherty for this excellent presentation. And thank you to our audience for making this session interactive. We hope this information has been useful to you and your practice. With this, we'll conclude our presentation. Thank you again. Thanks. Thank you.

Global Health

Endoscopic Care

Resource-Limited Healthcare Settings

Guatemala

ASG Global Spotlight

Dr. Brian Sauer

Dr. Michael Daugherty

Challenges

Barriers