E13 Emilie Joos On Global Surgery

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Chad Ball 00:15
Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons, we hope you enjoy it.

Ameer Farooq 00:41
Hello everyone. In this episode, you had the opportunity to talk to Dr. Emily Joos. Dr. Joos is a trauma surgeon at the Vancouver General Hospital and has been doing some amazing work in the field of global surgery. She talked to us about what it was like to be deployed in Haiti to some of the ethical challenges related to global surgery, and gave some really sound advice for trainees looking to do global surgery as part of their academic career. We hope you enjoy it.

Chad Ball 01:21
First of all, thank you very much for meeting with us on Cold Steel. Emily, it’s an absolute pleasure to have you. I know how busy you are in your personal and professional life. So, it’s a real privilege. You know, to those of us that know you, reasonably well, there’s clearly two really strong professional passion that we see you engage in. One is obviously injury and trauma. And the other is certainly international and humanitarian type surgical care. We’re curious if you could tell listeners, how you developed a passion for each of these maybe people along the way that ignited your interest in them, and just sort of how you became such a leader in this area.

Emily Joos 02:03
And that’s great thank you both for inviting me on this podcast. I think that’s a super great initiative and very modern. So that’s a great question. And actually, when I decided I wanted to be a surgeon, I wanted to be able to do it all basically. What I mean by do it all, is be able to tackle a lot of different problems. And there’s a lot of different body cavities and not specialize in just one system. And I also wanted to help people. And initially, my path was infectious diseases, I thought I would do something in HIV. And because I thought that wasn’t one of the world’s greatest problems. And then looking into surgery, I realized that you could do a lot of good there too. And there was a huge gap in terms of delivery of surgical care. So that led me to mostly trauma, because as I said, I wanted to do different things and be able to tackle problems everywhere. And I really liked that specialty because you just basically could operate on any area of the body and be able to stop the bleeding and really save patients who are in Extremis. But also on the global scale, it made sense, because so many patients now die from bleeding and flow of control problems, basically surgical disease, and that’s pretty easy to address and very teachable. So, I thought that would be really a great combination for me to do trauma to be able to tackle that problem globally.

Chad Ball 03:30
It makes so much sense.

Ameer Farooq 03:33
Absolutely. And one of my favorite articles you wrote was actually published in Roscoe and talking about these two passions. And you talk in that article, along with your colleagues at the VGH about what it takes to deploy a surgical team in a crisis situation. Can you talk about what goes into planning a surgical humanitarian mission?

Chad Ball 06:58
It’s such a good comment, Emily, and it’s such a helpful thing, as you see firsthand, and many of us know, to organize that internationally. I mean, two really great Canadian, you and I know well, really just got on planes showed up in Haiti and said, we’re here to operate Well, how can we help? And the driver of course for that is always good, but really, they were in the way and that people have to look after them. And eventually we’re in bed with the Israeli group there, but it was a real problem. When I went to Haiti, it was much, much later. And it was more of a reconstructive effort. And it was with a reasonably well-known group run out of Canada. But one of the things that I was concerned about with Haiti in particular was that there seemed to be no local legacy. So we would show up do these operations there was for example, lots of trauma orthopedics going on around us that the local surgeons, the Local trainees really had no footprint. And, although I certainly don’t personally work at the level that you do internationally, it was very different from other experiences I had had in Honduras, and through Africa, where the local groups were very involved in the residents and the trainings were very involved with us. And you felt like you were leaving a helpful, somewhat helpful legacy going forward with regard to training and so on. Can you comment on that? What are your thoughts.

Emily Joos 10:29
Now, and that’s really great. And I’ve always struggled with that exact example. And to me, I’ve only been to Haiti once to do a mission that was, I think, not very sustainable and would probably not do it again. But I had the same feeling that local healthcare providers were not fully engaged, and I couldn’t really put my finger on it, because I’ve been deployed to Africa and it was completely different. I could feel that, local providers were proud to work there. And even if they had low resources, they can actually do stuff with it. And they were so excited to receive training and to think that they could actually provide quality of care even when their humanitarian organization would leave. But in Haiti, it feels like what it felt to me, and I’m hoping I’m wrong, but what it felt to me is that the population and including the health care providers were so used to having their health care system completely supported by foreign organizations and NGOs, that they just really put that all this responsibility in their hands. And we’re just going with the flow. And that created kind of a sense of entitlement. Like when I was over there, in this hospital that was built by two Belgian surgeons, it was frustrating to see the patients demanded CT scans and high levels of care that while they didn’t even have the basics there, and really not an understanding of what was feasible and always possible to build locally in terms of capacity building for the country. So I’m not sure if it’s because the country has always been very weak. It’s a fragile state when you think about it that way. And that they were never able to build a full, long healthcare system. But it probably is also the fault of a lot of humanitarian agencies and organizations that have just been country forever. And I’ve just not allowed the system to build itself. But I can’t put my finger on it. I wish I had the right answer, because I feel like there’s so much good to be done there. But it’s been difficult.

Chad Ball 12:25
It’s so interesting, right? Because both of those examples, whether it’s Haiti at a structural level, or the outlook level, or whether it’s our Canadian friends showing up in a crisis ready to help, it really does underscore the importance of knowing what you’re walking into and getting educated before your leads. And in hooking in with the right groups and talking to people like you before you ever consider something like that.

Emily Joos 12:50
I know that even NSF struggles, NSF is an organization does, really trying to be where it matters the most and in a really timely fashion. And I respect them a lot for that. And they’ve had an in-country presence in Haiti forever, I think, for at least 40 years. And we’re never able to close any of their projects. Because they can’t leave anything sustainable behind it can’t hand over these activities to the local healthcare system. But what it struggles with too is they’ve been really, really trying to engage their local physicians to actually stay and build with hospitals and keep the services running. But what they faced is when those local providers were kind of like put on that spot and asked if they wanted to keep going or engaged in those activities, they would actually prefer to work in private hospitals and do kind of a half and half type of practice where it became very unsustainable to actually support the NSF hospitals with only local providers. And I really don’t know if it’s the systemic issue, because like I said, the weak government but and then being used to not having any public services. So turning to the private workforce, that could just be it. But I know that even NSF has had a really hard time and they employ 90% of local staff. They do very rarely deploy expatriates, if they don’t have to, they’ll just employ local staff.

Ameer Farooq 14:22
So I guess one of the things that I struggle with and we’ve sort of been talking about this at different angles, what do you think is the way forward then for those of us who want to be interested, and be involved in global humanitarian surgery, in terms of establishing a real system, like do you think the way forward is really to focus on education and training local providers? Is it collaborative type approaches? Like what are your thoughts on how you navigate this type of ethical, kind of real ethical challenge?

Emily Joos 14:57
Yes, for sure, and I’ve really scratched my head with it. Because, to be honest, the really cool thing to do in that type of work is to do the deployment. And I think all of us will say, and I’m sure Chad will agree that it’s very exciting to go and deploy into difficult settings into disaster settings where you can actually provide help and you feel useful, and you feel like you’re using your training to provide the care for most people, and that that’s really fun. But at the same time, it’s not sustainable and you’re not building capacity. So, it’s frustrating at the same time. So that’s a great question. I think there’s multiple ways to approach this, I think you can take like a big picture approach and think about capacity building in terms of systems. And then you’re thinking about working with like big agencies like you WHO, building on the end SOP. So, these are national surgical and anesthesia programs that have been launched in Sub Saharan Africa to actually try to build that capacity. And that goes through like local governments. And it’s a pretty heavy and long process. But I think that’s what’s going to build capacity and long term. And people who are super involved with that are the McGill group, Center for Global surgery at McGill. And they do a lot of that work. Another approach, which is not opposed to that is building capacity to training. And that’s the one I’m interested in taking. Because working with NSF, I see tons of opportunity to actually train local providers because NSF will offer infrastructure they’ll build. They’ll use local hospitals; they will build capacity in terms of like setting up an operating room with very high standards. And that’d be tried to be basically similar to a European North American standards, good instruments, good equipment, training of nurse anesthetist, the trainings of OR tech, sterilization, everything is included. It’s a package deal, basically of surgical care. But what’s not included is the actual surgical provider person doing surgery. And what I’ve noticed, I’ve done two deployments, one in Congo, and one in Central African Republic. And in those two places, we had zero local surgeons. And as I said before, NSF always recruits local surgeons, they really try to avoid hiring people from abroad and bringing expat over, especially when it’s unstable environments. But we had to in those two projects, because there was really no one there. But what there was, were a lot of general practitioners, so clinical officers, medical officers who some of them were super keen on learning surgical skills and had good hands and could actually do procedures but with no opportunity for real training. There was no structure behind it. And NSF has always been reluctant to do this type of training for physicians, because they’re not a training agency. Of course, they’re not an academic organization. They’re really a home humanitarian organization, they’re not supposed to the development, but at some point, it becomes kind of a necessary endeavor, if you want to leave something behind the build capacity and close projects, without thinking that you’re going to end all the activities. So, what we’re trying to launch now is a task sharing project. So that’s basically teaching surgical skills to non-surgeon providers. So that could be clinical officers and medical officers to basically build knowledge and skills essential surgical skill to basically lifesaving surgical procedures, and very low resource settings in NSF project. So, we’re using the NSF instructor infrastructure, the NSF tools, NSF guidelines, the NSF protocols, everything that’s already in place, and adding a training component to it through UBC, basically, trying to see if we can actually build capacity in that way, by training a local providers who will hopefully stay in country stay in those settings, and provide basic lifesaving surgical care to their patients.

Chad Ball 18:55
That’s amazing. Wow. How long has that taken Emily?

Emily Joos 19:00
It’s been the first mission; I’ve actually wanted to do that. And I’ve pitched the idea to NSF multiple times. They’ve closed the doors 100% of the time. So, I put this on ice a little bit. Also, because I had two babies in a row, and didn’t really have time to think about it but they actually reached out to me last year, a year ago, and he said we’re ready to try this. They have never tried it before. There are tasks during projects all over Sub Saharan Africa. This is not novel. I think this we actually have one in Canada, the ESL program out of Saskatchewan, but NSF had never done something like that. And they had always opposed it like very vehemently boasted, because they say that these are not real surgeons, and they’re not. They shouldn’t allow an untrained surgeon, unlicensed surgeon to perform surgical procedures and they always were very firm about that. So, this was a huge change of heart from them. And so, I said okay, I would help because that was really something I wanted. to them. And it’s taking a whole year to actually, first of all, build a partnership, pick the project or implement the actual training program. So, like the candidates, the training the trainees, and then start building this curriculum. So, what I did is I’m doing a modular online curriculum, they have access, they do have Wi Fi there. And it’s an easy way to actually transmit that knowledge. And surgical skills part has to be taught in the field by the NFS deployment surgeon, which is the piece that’s little bit hard to control, because these settings are not extremely safe. And so, it would not be really, I don’t think he’d be a good idea to deploy Canadian surgeons, every couple of months actually performed the training, and it wouldn’t be good continuous care. So, we chose to deploy an NSF surgeon to that project for a year to perform the in the field training to the skills training part, and the trainees are being evaluated using the new CBD model from the Royal College, basically to EPA. So hopefully, that works. So, the training is in South Sudan, it’s in Aweil, South Sudan. And I’m really hoping this will go somewhere I’m hopeful, it will not be perfect, because I’m sure there’s going to be a lot of room for improvement. But the trainees are there to actually doing surgeries and doing the modules. And I’m actually going to go evaluate that project in two weeks. And that’s it, and so we can give you more updates.

Chad Ball 21:34
Wow, that’s unbelievable. It’s such a legacy project. And you should be so proud of that, in our community, not only in trauma, but in general surgery across the country should be proud of you for doing that. It’s interesting to think about the Canadian, just listening to you, because the reality is we sort of do that in Canada, anyway. We train GP surgeons, and we certified GP surgeons that are in rural or extremely remote areas of Canada, it makes so much sense to us. So, it’s really interesting that the NFS has had such a hardline stance for so long. so incredible.

Emily Joos 22:09
It’s only in Australia and Canada, it’s very recognized type of training, if you look, we have actually done a little bit of an environmental scan in terms of what type of tests have been tested and projects were available in the world. And apart from Australia and Canada, there is not much in Sub Saharan Africa, but none of them are really mature instructor programs. They’re just basically doing it on the job. It’s on the job training, which is great, too. And I think it needs to be done. But in terms of like high income countries and high resource settings, only these two countries are actually doing this type of training. And that’s the angle I use to convince NSF said, you know, if we’re doing this and approving this in our country, and basically validating those GP surgeons to perform those surgeries, I don’t see why we can export that concept to the player in Africa.

Chad Ball 22:58
Unbelievable. That’s amazing. If we shift gears for a second, Emily, can you tell us? You know, certainly listeners who may not know you yet, super well, where did you grow up? Where do you get your training? Maybe who influenced you along the way? And how did you end up in Vancouver?

Emily Joos 23:16
So, I’m from Montreal, I’m French Canadian. And I did grow up there and I did my medical school at McGill, then went to Quebec City for general surgery residency, and did my trauma critical care fellowship to LA County and LA. And then from there, I actually initially want to go back to Montreal, because it’s where I grew up and as I said, you have a very mature global surgery program there and excellent trauma program as well. But there was no position there when I finished my fellowship. And they had a local opening in Vancouver and that’s what brought me here and I never left. I’m really glad I’m still here. In terms of influences, when I decided I really wanted to do surgery, as I said, I really wanted to do surgery that was useful for the most people. So, I started looking early into global surgery and NSF and read tons of book about this organization, what they were doing and who was doing humanitarian work and where, and I came across one of the first female general surgeons whose name is Lucille Teasdale, who actually give her whole life to building a hospital in Uganda. That hospital is called St. Mary’s Hospital-Lacor in northern Uganda and she built it with her husband, the pediatrician, Piero Corti. They actually, amazingly bill something that’s still standing right now. And not only is it still standing, it’s actually providing training, including surgical training for Ugandan medical students and residents in all specialties. This hospital initially was just funded from their own organization they got funding also from the Italian government, from her husband and from the Kenyan government from her and he got full buy-in from the Ministry of Health in Uganda. Now I think it’s funded 50/50 by Uganda and by their foundation. So, it’s still running, it’s going strong. And I was really lucky to be able to go there for a month as a medical student, just for an observership, which ended up being kind of a, like a mini residence, because they let me do a lot of things, which was really great. But it was awesome to see that this was still working. It really gave me hope that there were things that we could do in those settings, even if we keep saying that nothing works in Africa is not true. Because this is extremely positive in terms of an example of a local hospital that delivers high quality care. And like I said, in a lot of different domains and specialties, and is still going strong, and is now providing training. So, she was one of my first models actually died of HIV from exposure and during her work over there. But yes, I feel like this is the kind of model that I want to follow. I think she did a lot of sacrifice for her to do all this. And I don’t think I want to follow that exact route. But definitely believing that you can build something locally is something that remain really alive in me.

Chad Ball 26:25
There’s so many of us that have been so deeply and profoundly lucky to either spend part of our training or have these really enriched experiences on a global basis. For me, as you know, it’s been South Africa over and over and over again. And it’s important that I think we get out the narrative and that we restate that some of these places and some of these countries are doing unbelievable work. I mean, the randomized controlled trial that we did with South African group and riskier Hospital in Cape Town about draining, you know, stabbed hearts and positive cardio windows versus not. I mean, that work couldn’t get done anywhere else in the world. And I often feel really almost every day such gratitude towards all those folks that helped train me and really pushed me forward in huge leaps, quite honestly. And there’s so much to be gained. But I’m also very leery following your narrative, but we also have to be sure that we leave like that we are not just taking and doing a performance surgical tourism, that we’re helping them in some way that we can be of benefit to them as well.

Emily Joos 27:36
Absolutely. And that paper is one of my favorite ones, by the way. And my fellows absolutely have noted by heart when they finish your fellowship. Thank you for doing that.

Ameer Farooq 27:46
I feel similarly inspired listening to you talk about this. As someone who was very interested in doing global surgery, I hung out with the guys in Boston as well, and really was inspired by them. But listening to you talk about Dr. Tisdale and the work that you’re doing is super inspiring. But it’s often hard to think about, how do we balance a busy clinical career domestically, as well as all the personal responsibilities? I know you have little babies at home. How do you reconcile those competing interests? And how do you balance those competing priorities?

Emily Joos 28:31
I’m not sure the word balance is the right word. And I’m sure you’ve heard that before. But I think you really have to go with things that make you feel alive. I think that’s really important in your life, that you lose focus that you really think hard about things that matter the most to you, because we have one life to live and it’s very easy to become scattered. And that’s one of the I would say the risks of academic medicine in general is to get pulled in a million directions into a million things that seem very interesting, but not exactly your passion. And this is also why people burn out I think, but to answer your question, like I do, like family to me, as I was extremely important, I really wanted to have kids and then like, I love them to death. And they and I probably don’t spend enough time with them. But that was something that was going to be a priority for me. But I also in my work want to do the type of work, in terms of capacity, building global surgery. I would be very disappointed if I wouldn’t be able to build that into my career long term because it’s really why I went into surgery. And so trying to, like you say balance all those different expectations of myself. Basically, I tried to integrate that global social work into my daily academic work. So, I think being a trauma surgeon makes it really great because it’s something that we do every day. We do build capacity. We do try to build a trauma system wherever we are so that everybody’s empowered to take care of trauma patients so there’s not really a disconnect between a building that in South Sudan versus building it in rural BC, in Paris or in like, smaller towns in northern Canada. I think there was a lot of parallel that I use every day basically. I tried to do a lot of work locally as well, because I feel like there’s a lot of connections there. But I also try to protect my time. And so I mostly do calls like, the way we work here is that we do full weeks of calls, like we do weeks of acute care surgery a week of trauma, when I’m not on service. It’s basically my protected zone to do that type of work. And I’m very fortunate that my colleagues all support me, and if I have to deploy, they’ll cover my week service and I can actually do those things, but also to be able to focus on the training, for example and write about that, I think that’s really important. But you really have to make a deliberate effort to build into your schedule.

Ameer Farooq 31:00
It’s funny that we hear this phrase, this sentiment with many of our guests that there isn’t really such a thing as balance. But it’s more about doing what makes you fulfilled and makes you feel alive.

Chad Ball 31:15
Let me ask you one specific question and maybe to end would be what advice, specific advice, would you give to a general surgery trainee in 2020? Moving through their residency in terms of engaging this? Would you tell them to do it early, would you tell them to do it late? Who should they contact? How should they move forward?

Emily Joos 31:36
That’s a good question. And we often get that question. Especially for example, in info sessions for Red Cross MSS. But what I would tell general surgery trainees, I think the number one thing they should focus on is: be excellent surgeons. And that’s, I can’t say that enough. And I try to tell all my trainees that every day. That at the end of the day, what you want to do is do a really good job at what you do, and be excellent at what you do, no matter how you’re going to turn this around. Like, it doesn’t matter where you work, or how many people you’re going to touch or how many papers you publish, you really have to be good at what you do, and otherwise you will not have a good impact. So, I think surgical training is extremely difficult. It’s not that long, when you think about it is only 5 years. So, you really tell them to try to really focus on that aspect of it and make sure that when they finish, they can actually be the best that they can be. And of course you grow, you keep learning, you’re learning every day. But I think this is a privileged moment for you to develop those skills, while being supervised by excellent surgeons. And that’s a huge opportunity not to be wasted on being distracted with other things. So that being said, I think it’s also important to try to learn about global surgery, in general, and mostly global health and how that world works. And to me, that was very difficult, because I did it later. I did a master’s after I finished my training and to learn about the intricacies of global health, which is still very complex to me. But I think trying to get a sense of like, what’s out there, how humanitarian work, functions, who and all those UN organizations, I think is important because if you’re going to do meaningful work in that domain, you need to understand the intricacies of that completely different world that weren’t ever exposed to in terms of deployments, during residency. I did nothing, I just really focus on my training 100%. As I said, I really just wanted to be a good surgeon. So, I didn’t go anywhere. And I wouldn’t think it’s that important nor very useful to actually deploy when you’re a resident because you’re not the best surgeon that you can be at that point. So, I think you really have to focus primarily on that. But getting to know things about global health, like I said, and like just trying to build up on your knowledge of network, I think would be really important.

Ameer Farooq 34:12

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