Medical Mission to Cambodia: Interview with Sri Sundaram, MD, FHRS

Tell us about Jeremiah’s Hope and how you got involved with this Christian medical ministry. Where are cases performed?

Jeremiah’s Hope is a nonprofit charitable organization that was founded in 2000 by Dr. Mark Sheehan, one of my general cardiology partners. He founded it along with Dr. Daniel Smith, a cardiothoracic surgeon that works in our hospital. They started going to Cambodia in 2000, and by 2006, they had established a relationship with Calmette Hôpital in Phnom Penh. Calmette Hôpital was founded by the French, and its mission is that 50 percent of all its patients have to be indigent. As part of our ongoing mission’s relationship with Calmette Hôpital, a different medical specialty group (e.g., cardiology team, OB/GYN team, ENT team, etc.) travels to Cambodia every other month. The cardiology/EP team goes every February, and stays for 10 days. I’ve been on 5 trips so far. 

We have now sent over 100 teams. We essentially have our own hospital there, including an outpatient clinic with about 10-15 beds, 2 operating rooms, and a fully functioning office where we see patients on a regular basis. So this mission, which started with only two doctors, has now grown considerably! 

Are a certain number of days on the trip dedicated to cases? Also, how did your involvement with the Cambodian-American Cardiology conference come about? 

It was 2012 when we first began bringing over EP equipment to Cambodia, and we now have a fully functioning EP lab. Since then, we’ve performed the first of everything EP related in Cambodia — the first biventricular ICD implant, the first ablation, the first atrial fibrillation ablation, etc. We also trained Dr. Mam Chandara, the first electrophysiologist in Cambodia. It was during this time that we realized that in a country with 10 million people, there was only one electrophysiologist, and that we really needed to start educating others in EP. So we started offering education, doing three hours of cardiology lectures every day at the one medical school in Cambodia. Dr. Mel Scheinman became involved as well, doing afternoon EKG sessions. We also realized that we couldn’t just offer education to those in the capital of Phnom Penh — we needed to bring cardiology education to the rest of the country as well. Therefore, we started advertising a Cambodian-American cardiology conference. My main focus when I’m in Cambodia is to run this conference. When we created it 5 years ago, we had less than 100 people attend. This year, we had 533 attendees! It is now the largest medical conference in the country. We provide CME credit, and have speakers from five countries. We’re transitioning to try and get more Cambodian speakers and female Cambodian speakers to present at conferences. The conference is entirely free to attendees, and it’s become a bigger success every year. 

What members of the team travel with you? What other doctors or nurses were involved in this year’s trip? 

This year’s cardiology team consisted of 25 members. My partner Dr. William Choe and I lead the EP team together every year. We have echo techs, device reps, a cardiothoracic surgeon, and a number of EPs that go with us. This year’s team included Dr. Scheinman, Dr. Jonathan Lipton (an electrophysiologist from Tasmania), Dr. Daniel Noonan (an electrophysiologist from Boise, Idaho), and Dr. Ryan Aleong (an electrophysiologist from the University of Colorado). Drs. T. Jared Bunch (from Murray, Utah) and Young-Hoon Kim (from Korea) have also gone with us several times. Everyone pays their own way there. 

What kind of equipment is available?

Most of the hospital equipment is donated, either from France or from here in Colorado. Whenever our EP lab upgrades their equipment, they know to give it to me. We have a Bloom stimulator, Prucka recording system, Stockert generator, and a fluoroscopy system, so that’s how we make it work. 

Approximately how many and what types of cases did you perform during this trip? 

We did about 20 cases, including device implants and ablations. Our main goal is no longer volume, it’s education ­— we want to teach the Cambodians what we’re doing. We’re not trying to crank out cases — we used to do that, and we realized we could make a bigger impact if we taught the local staff what we were doing. We let the advanced cardiology fellows perform the pacemaker implants, so the cases sometimes take a little longer, but then they learn how to do it. 

Are cases also performed when you’re not there?

Yes, some cases are done. However, with only one electrophysiologist in the country, he is pretty busy and does as many cases as he can do. When we’re not there, patients have to pay — we take care of the indigent only. These are the ones who cannot pay and do not have an opportunity to be taken care of. In clinic, we generally see about 200 patients during the 10 days that we are there. 

Do you know what types of cases you will be working on before you arrive?

We generally know which patients we’ll be treating — we occasionally get the ECGs ahead of time. However, we’re still not quite sure how they know when the Americans are coming — there is always a line of patients out the door waiting for us when we arrive! This year, we treated a 13-year-old boy with multiple WPW pathways, and an ejection fraction (EF) of about 10% because of his tachycardia. We knew we were going to be seeing him, but because his heart failure was so bad, we could not do an ablation on this trip. We optimized him with heart failure medication, and then one of the EPs went back last month and successfully ablated him. 

What would you say are the biggest challenges faced during these missions?

The biggest challenge we faced initially was that no one knew what EP was, so we weren’t getting any patients in the beginning. There we were, bringing a world-class EP team and state-of-the-art equipment, but unless you were in the capital, most of the people had no idea what EP actually did. So education and showing what electrophysiologists can do was our first challenge. Our biggest challenge now is deciding which patients can get the pacemaker implants or the ablations. When we come with 10 different pacemakers, we can only only implant 10, so we have to be careful deciding which patients get those devices.

What have been some of your more memorable patients?

Almost all of my most memorable patients are the younger ones, because I feel that without us, they wouldn’t have ever had this opportunity again to get healthy. For example, there was a 13-year-old boy with general heart block. He had a heart rate of 20, so he would pass out every time he stood. He was essentially bedridden. This was the most difficult pacemaker implantation I’ve ever done in my life. Dr. Bunch and I implanted the pacemaker, which took almost 3 hours, but in the end, we were successful. The next day, the boy stood for the first time, and he was able to walk out of the hospital three days later. His dad started crying when he saw this, because he said it was the first time his child had been able to walk in a number of years. Later, during a routine pacemaker follow-up, the boy came into the clinic, had his pacemaker checked, and walked out — with barely any idea who I was. He was now just an ordinary kid, and I will always remember that. There was also a similar story with a 19-year-old girl with WPW in 3 different pathways, an EF of 10%, and liver and renal failure. It took us 1 year to get half of her pathways ablated and a second year to get the rest, but she now has an ordinary life — she is married, has children, and is doing absolutely great.  

What have you learned about the people and the culture?

The Cambodian people are incredibly grateful for the work that we’ve done to help them out. The medical students and residents are truly eager for more knowledge. In the U.S., when the bell rings or when rotation is done, the medical students are generally gone. However, every time we’re in Cambodia, the students will stay for hours beyond the end of the lectures, asking questions and just wanting more information. The culture is very vibrant and young, and the country is growing. They want to help themselves, and we want to help them help themselves. 

Will there be another medical mission trip in 2019? How can others get involved?

Yes. People can contact me directly or go through the Jeremiah’s Hope website (https://cmmcjh.com/). I’ve actually had a few people contact me from the pictures I posted on Twitter — there are quite a few EPs that want to go next year. 

Does a different team of people travel every year?

It’s usually myself and Dr. Choe. But there is generally a different team every year — whoever can make it. Not everyone can come every year, so we’ll take anybody’s help for as long as they want to come and whenever they want to come. 

Is there anything else you’d like to add?

Social media has been very helpful. The Cambodian residents and cardiology residents send me ECGs through Facebook and instant messaging at least once a week, asking clinical questions about how I would treat a certain case. I think it’s fantastic — you know, we’re still making a difference in our day-to-day patient care even though we’re not there. 

Seeing the impact that social media has had in the EP field has been incredible.

I think there are a lot of EPs that want to do something like this, so social media has been really helpful in facilitating this. There are obviously many other groups that go to different parts of the world, such as Haiti or Central America. If doctors knew more about these groups and how to get in touch with them, I think there would be more volunteers throughout. We’re just a group of ordinary electrophysiologists in Denver that one day said, “let’s do this”, and made it happen. Everyone can do it.

For more information, please contact: 

Dr. Sundaram @srissundaram and Jeremiah’s Hope @JHMedMinistry