¿Vale la pena? YES!
Written by Lindsay Doucette, Program Director
“Is our being here worth all of the time and effort that it takes to prepare for our visit? ¿Vale la pena?” This was the question posed by one of our US team members to our Paraguayan host, Dr. Jose Kuzli, when he picked us up from the airport on Monday.
Today is our third day at the Hospital Nacional de Itauguá, our second day of surgery. As we gathered in the faculty lounge, the surgeons seemed somewhat anxious. Yesterday’s surgery was successful, but today’s case will be much more difficult. They are treating a large and complicated Arteriovenous Malformation (AVM). The complexity of AVMs is ranked based on size, depth, location, and other factors. This week our bi-lateral team is taking on the more complex, grade III or IV AVMS. These patients have waited a long time for care, as there are no neurosurgeons in Paraguay, either in public or private hospitals, who feel prepared to operate these cases. AVMs are rare, affecting approximately 1 in 100,000 people per year. Dr Kuzli estimates that he encounters around two per year. And while he does treat the more superficial grade I and II AVMs, he didn’t have enough experience in the more complex cases to feel confident operating them on his own.
That was the motivation to invite Dr. Nirav Patel, a neurosurgeon from Brigham and Women’s Hospital in Boston, to join our team. Dr. Patel is passionate about AVM surgery, and his enthusiasm is palpable. His expertise in this particular type of surgery has taken him all over the world, and now to Asunción, Paraguay.
Dr. Patel, Dr. Kuzli, and Dr. Silvia Vaca are sitting with me in the lounge while the anesthesiologist and surgical technician prepare the patient. They are discussing the previous day’s surgery for a 22-year-old woman named Dora. Her surgery went very well, and she should be released from the hospital by the end of the week. As we wait, Dr. Patel asks Dr. Kuzli, “Do you think you could do this surgery on your own after we leave?”
Dr. Kuzli replies, “Yes, I think I’ve learned the secret. The difference is in the pre-operative planning.” Dr. Kuzli notes that, by observing Dr. Patel, he learned the importance of thoroughly studying the brain images until you have in your mind a three-dimensional map and a clear plan for how to access the AVM. “No one taught me that before,” Dr. Kuzli shares. “My way has been to open the head and find my way. I see now how important pre-operative planning is. It’s small things like this that make an enormous impact.”
Dr. Kuzli goes on to share how, when he picked the team up from the airport, someone asked what he thought was a silly question: Is our being here worth all of the time and effort that it takes to prepare for our visit? Vale la pena? Remembering our question from the airport, “Is it worth it?” Dr. Kuzli exclaimed, “Of course it’s worth it! All we need is a little push.” Through peer-to-peer accompaniment and first-hand instruction, Dr. Kuzli was able to reinforce his knowledge and enhance his skills sufficiently to expand access to complex AVM treatment for patients from across Paraguay. The lives of patients and their families will be changed for the better for years to come.
The team poured over images of the patient’s brain to map their approach.
Dr. Kuzli reflected on how every visit from an NNI team has made a significant impact because of how it has inspired his team. In 2018, the Solidarity Bridge Neurosurgery Program offered a course in Paraguay on transnasal surgery for skull-based tumors. It was that short course that inspired Paraguayan neurosurgeon Dr. Diego Servian to pursue more training in the area. Now, four years later, he is recognized as a specialist in transnasal pituitary surgery.
US anesthesiologist Dr. Deepak Sharma's visit in April of this year also “lit a fire,” as Dr. Kuzli put it, under anesthesiology residents at the hospital. They deepened their understanding of the role that anesthesia plays in cerebral vascular surgery, and the impact it can have when it’s done well. And they felt valued as important members of the surgical team. Dr. Kuzli observed that he is already seeing growth in the work of the residents, and he senses their motivation and hunger to learn more. This partnership with neuro-anesthesia continues this week with the presence of US anesthesiologist Dr. Grace Kim, who demonstrated how to remain calm during a delicate moment in the first case. When other team members can stay composed at critical moments, it helps the surgeon remain focused as well, which can have a significant impact on the patient’s outcome.
The team with Dora before her surgery. She is recovering well and expects to go home shortly.
While it’s always important to carefully consider the burden versus benefit of our surgical mission trips, this week the benefit is evident. I’ve noticed a sense of symbiosis and pride in the neurosurgical professionals here. It’s clear that spaces for community, accompaniment, and ongoing mentorship in this field are critical for supporting these professionals and improving the care of their patients. Dr. Patel received excellent mentorship from NNI colleagues Dr. Bermans Iskandar and Dr. Robert Dempsey during his residency at the University of Wisconsin. And Dr. Kuzli is clearly providing great leadership and mentoring for residents here at the Hospital Nacional de Itauguá. Such comradery and shared passion for the work contributes significantly to overcoming the many challenges and setbacks that exist in our healthcare systems, both here in Paraguay and in the U.S.
And so, is it worth it? ¿Vale la pena? The answer is a resounding, YES! It’s more than worth it.
Through partnerships and collaborative actions that are measurable and sustainable, the Neurosurgery and Neurology Institute works to build capacity and expertise in Bolivia and Paraguay in order to increase access to safe, affordable and timely health care.
We are committed to alleviating the suffering, death and disability from neurological disorders and injuries that disproportionately impact patients in the countries where we serve.