Okay everyone, we're going to go ahead and get started. First off, thank you so much for joining us for this evening's National Grand Rounds event titled Global Medicine, Rehabilitating Hope Through Volunteerism and Relief Efforts. So this evening, we're very excited to welcome our faculty. We have Dr. John Alm with us, as well as Dr. Danielle Melton and Dr. Hee Kyung Kim, and our moderator this evening will be Dr. Teresa Gillis. And we're going to run through just a few housekeeping slides before we get started here. So first foremost, this activity is being recorded and we will have it made available on the Academy's online learning portal. For the best attendee experience during this activity, please use the microphone when you're not speaking. You are invited and encouraged to keep your camera on and to also select hide non-video participants. So this will ensure that the speakers are prominent on your screen. In addition to that, if you're interested in asking a question, we definitely do encourage participation. So please feel free to use the raise your hand feature and you're also welcome to unmute yourself to ask the question or using the chat feature that we will be kind of moderating. Just please take note that time may not permit us to panel every single question, but we will do our best to get to every question. And then just a bit about some of our Zoom features here. So we have the start video and mute and unmute buttons, our participation and participant list and chat. That's where you can pop any questions in. Any reactions, feel free to use those. And then just another place to unmute and start your video. And this is where you can select hide non-video participants as well. Okay, and so for tonight's agenda, we'll start off with just these introductions and then we're going to move on to our presentations. We have a great panel set up this evening and then we'll move on to some panel questions. And we will save some time at the end for your questions as well. And from here, I will pass it off to Dr. Gillis. Hi, good evening everybody and welcome to our National Grand Rounds. I'm very pleased to be able to introduce our speakers tonight. Dr. John Ulm is our first speaker and he graduated medical school from A.T. Still University and completed his residency in physical medicine and rehabilitation at the University of Missouri. He's completed a fellowship in interventional spine and musculoskeletal medicine from the University of Kansas Health System, as well as a postdoctorate diploma in sports medicine from the International Olympic Committee. He has served as an IOC physician for prior Olympic Games and currently serves as a team physician for Team USA Swimming. Dr. Ulm serves on several committees for the American Academy of Physical Medicine and Rehabilitation, as well as the Academy's representative to the American Society of Anesthesiologists. He has authored several book chapters, journal articles, and serves as a reviewer for the American College of Sports Medicine's official journal, Current Sports Medicine Reports. Dr. Ulm is the Chairman and Residency Program Director for the Department of Physical Medicine and Rehabilitation at West Virginia University. Additionally, he serves on the Regional Contractor Advisory Committee for the Centers of Medicare and Medicaid Services, the Board of Governors for Encompass Hospital in Morgantown, West Virginia, and on the Advisory Board for the Ryan Shazier Fund for Spinal Rehabilitation. With that, welcome Dr. Ulm. Thank you so much, and thank you everybody for joining us tonight. You know, I'm one of three presenters tonight, and we're all going to bring a little bit different perspective. The joys of global medicine is that it's very unique, a lot of times, to not only the country that you may be going to, but also the individuals that are providing care and the needs of that regional community. So again, we're all going to present a different take on it. You know, I think the goal is for everybody to kind of hear what options are available, and if you have interest in it, to kind of seek out those opportunities. I think as physiatrists, we definitely have a unique perspective where we have a lot of tools in our kit bag, and so there's a lot of patients around the world that we can help. So to start with, I myself will be talking about two separate locations, completely different. Antigua City, Guatemala will be the first one, and the second one, oddly enough, will be Dublin in the Republic of Ireland. So first of all, it's Hermano San Pedro Hospital. I guess I left an O out there, or the autocorrect got me. Antigua City, Guatemala is a beautiful city. It's a UNESCO World Heritage Site. One of the unique aspects of this city is that this hospital in itself, it is manned by foreign physicians each week of the year. There's a different specialty that comes to the hospital, and it serves as very much of a hub for subspecialized care throughout Central America, even northern parts of South America. So people will travel far distances just to come here to get some input on how to help them. The challenges though, and this goes a little bit beyond just Antigua, but how does it start? With many people who are looking at global medicine is, you know, where do you begin? How do you get things going? That was myself getting this rolling off the ground, is how to get a project and to deliver care to a country and to help people as much as you can started. In particular, this one, I took the approach of riding the coattails of others. I had some friends who were in other surgical specialties that were going there, essentially going off of the foundation, which they do, Medical Mission Foundation, riding off their back, and they provide a lot of the logistical administrative support for the mission itself. The challenges of doing any type of international medicine, especially when you're delivering care, is going to be that you have to bring supplies, you have to bring personnel, you need to have credentialing to go to the country. And so how do you accomplish all that? And a lot of times we as physicians, you know, this getting outside of our wheelhouse, unless we have some type of administrative role where we're at, but even that may not suffice because doing things on an international level is a whole different world. So again, I was able to find a group that I was able to bring physiatric care to and ride on their coattails going forward. It's been a great partnership for people who've been doing it for decades now. And so being able to go off of what they do, the contacts they have in the country, how they go across customs with medications, different drugs, different types of medical tools that we bring. I mean, just bringing a lithium-ion battery from AED across at an airport can be an ordeal. So when you're talking about bringing more than even simple stethoscope, there's got to be some logistical work that's done way ahead of time. And so again, if you're looking at getting something started, look at those opportunities where maybe something exists already. Starting off though, we're taking very much of an approach of delivering care, which is great. It's very rewarding. The problem with it is, and this is why I call it a beginning is, we're there and those who do interventions realize, for example, I'll do epidurals and the benefits of that epidural will last about three to five months. And if we're going annually, what is this patient going to do in the meantime? So again, as nice as it is to provide care, the bigger goal is how to enable the local medical practitioners to deliver that care or come up with a plan to sustain the benefits of what you're doing. Because flying in once a year, trying to be a hero for the week just isn't going to do it when you're really trying to help a community and a group of people. So the next step when we're getting into the challenges is how to address that. A lot of that is going into education. And so that's where we're trying to evolve it going forward is getting out to the regional hospitals. So more than just the location we're at, really trying to do teaching with those that we're working with on a regular day basis. And this case is a lot of who we're dealing with, there's therapists. And my short-term to long-term goals for going to Guatemala City or Guatemala is really being able to help the therapists there identify problems, try to treat them as much as they can, try to lay out different medications. And again, knowing what regionally within the country they have available to them to look at how those patients can receive care in the meantime. So that when we do come, it's more of a patients that really are outside of the scope of those that are in country at that location who need that next level care is what we're trying to do. But ultimately, my goal is that these become less and less. And then it more comes back where we're just doing a lot of education, collegial activities to empower the people at the hospitals that we're visiting at. So that's going through. And so there we go through from a third world country and delivering some care. Again, challenges of doing that are going to be that how we give that care, how we bring it by doing it just once a year. So again, now you need logistical support if you're going to do it more often, as well as deal with customs, so medications and equipment to now the second country that we're doing care in is Republic of Ireland. For me, it started, I took a trip to Ireland a few years ago and fell in love with the country and felt like I needed to go back. Interestingly enough, as a first world nation is they don't have physiatry. So I took this as a challenge. As far as I could understand, there's I think eight physiatrists in the country of Ireland. All of them are foreign trained. And so they don't have a way to really bring that generation of physiatry forward because they don't have training programs. And this aspect working from a global medicine aspect point of view is not necessarily delivery of care, but how can we bring physiatry to another country? So in this aspect, reached out to the Royal College of Surgeons in Ireland, a very open, very welcoming and a wonderful institution to collaborate with, and really trying to start it from the ground up of getting interest in their medical students to recognize a field such as PM&R, where we hit that crossroads of both surgical, medical, and then the rehabilitation aspect, and what we do for our patients and how we support the other specialties around in our healthcare community. So there's a lot of reaching out. The picture on the right is we had to meet and greet with the AMSA students. They do have an AMSA group. And so we met with them, gave them a talk. Also going around and giving grand rounds at the different hospitals within Dublin. And so this gave us an opportunity to really expand upon what physiatry can do as an add-on addition to an already existing healthcare system. And so this is where the educational component goes. And again, we're not treating patients at all when we take this trip. So again, a lot of meetings, a lot of education. There's a lot of collaboration that we're trying to build. So this is still in the early stages. One of the big areas they had a lot of interest in was cancer rehabilitation. So the picture on the top left, that's my cancer rehab physiatrist that came with, but it was also pediatric physiatry. They really, that is very much outside of their comfort zone. So the bottom left, the individual on the far left, Dr. Stephanie Farmer, she was our pediatric rehabilitation physiatrist. And so again, trying to lay down some groundwork of how they can deliver that care to these kids. And so they've got the same issues obviously that we do here in the United States, but by not having the outset or the onset of World War II and how physiatry built up since that time and then addressing the needs of kids, this is where they really had an interest. And so again, bringing these two subspecialties has really been, I think, an eye-opening experience for them, but also for us to see what it looks like in an atmosphere where we don't have physiatry to support these medical services. So, but again, it should always be about learning from one another. One of the interesting things that they have is they do have a national rehabilitation hospital, which is primarily, I think, where all our physiatrists are working at in the country of Ireland. But the uniqueness and the difference that we see there is how they take care of their patients. We are governed by third-party payer systems. And unfortunately, we all know that that limits how much time we have patients in our care versus, it reminds me of probably when I first started in physiatry years ago, but we would have patients, you know, in our unit for three months, sometimes longer, that's where they're at. And so they're able to follow the outcomes from the initial neurologic injury or whatever the injury is and carry that through for about a quarter of a year. Some of the things going in hindsight though, too, it allows us to look back and this is where that collaboration learning from each other goes is, you know, can we look at outcome measures? This has become more and more of an issue here in the past five to ten years, but, you know, now we've gotten past that stage where we're lucky to get 14 days inpatient stay for our patients is, how do we look in, how do we demonstrate positive outcome measures when we have such a short snapshot? And so what we're looking at is collaborating with some research projects with the NRH in Ireland and what that looks like. Also, where we bring it back to them as well is because of the way their healthcare system is, they don't get a lot of ambulatory clinics. So that's one of the reasons where they keep their patients so long is they don't have the outpatient clinics that we do. And so they do keep them for extended periods of time, but once they leave, that's where they run into problems. So it's allowing a very good collegial atmosphere where we look at both aspects of that and then compare that and then hopefully develop ways to look at outcome measures from a research aspect. But again, with anything, always enjoy it, and they were smart enough to invite us over during St. Patrick's Day, and so it was a wonderful weekend. We finished off our trip in Dublin, Ireland over St. Patrick's, and they had the Six Nations Rugby Tournament, which Ireland won, so we got to go to that. Again, really trying to take in every aspect of it, but trying to enjoy it as much as possible. So those are my two experiences, and I will hand it off to one of my colleagues here. I think we will take questions at the end of the sessions. So it's my pleasure to introduce our next speaker, Dr. Danielle Melton. Dr. Melton is on the faculty at the University of Colorado School of Medicine with the Osseointegration Bone Anchored Limb and Limb Restoration Program, where she serves as the Director of Amputation Medicine and Rehabilitation Program. She is board-certified in Physical Medicine and Rehabilitation with appointments in both PM&R and orthopedic departments. Dr. Melton serves as the Science Chair of the Advisory Panel for the NIH and the DoD-funded Limb Loss and Preservation Registry and on the Board of Directors for the Amputee Coalition. Her clinical care and research involves best clinical practices for limb loss and limb preservation. Dr. Melton served as the Amputee Director of the Rehabilitation Services Volunteer Project, RSVP, while in Houston, Texas, where she volunteered to provide rehabilitation and prosthetic services to patients with limited resources. She also participated in a sponsored orthopedic mission with the University of Texas Houston Health Science Center and TIER, where she managed more than 75 amputees that resulted from the Haiti earthquake in 2009, raising funds to create a prosthetic facility to provide ongoing care. Last year, she was invited to be the keynote speaker at the International Range of Motion Project, ROMP, conference in Guatemala. Due to a political coup, this was postponed to this October, where she will work with local Guatemalan hospitals to train and educate clinicians and residents on best practices in caring for amputees and community outreach programs. Welcome, Dr. Melton. Thank you. Thanks, Teresa, and thanks everyone for being here. Yeah, I'll just kind of walk through some of the how I got involved with this. Actually, I looked up the date. It's actually January 12, 2010, so it was the earthquake in Haiti, and that was about two months into that. Our group, our orthopedic group in Texas, put together about 30 of us went down there on a mission. And, you know, from various disciplines, we had, I think, 11 physicians, two of which were rehab docs, nine of which were orthopedic surgeons, and it was coming from a level one trauma center, so they had lots of experience. We were lots of therapists and nursing, and we really, I don't think, had any idea what we were getting into when we went down there. You know, it was disaster relief by every stretch. You know, I was looking up some of the statistics. More than 200,000 people died in that earthquake, and there were estimated across the country 6,000 amputees. A quarter of a million homes were lost or destroyed, and I thought this was interesting. 13 of 15 government buildings collapsed, and that's a real important point because, you know, part of the problem, well, the U.S. Embassy was actually unscathed, and part of the issue is that they had very poor or almost no building codes, and that's why all the buildings collapsed, and that's why there was so much devastation during the earthquake. Lots of relief efforts, you know, from all over the world, really. A lot of NGOs, non-government organizations, provided relief efforts. We had an opportunity to partner with the hospital Sacro Corps in Crudom. It's near Millau, and I think we flew into Cap-Haitien, and so overnight, and this hospital at the time was one of the most advanced hospitals in the country, but, you know, before the earthquake, it was able to house about 73 beds, I think. Overnight, they had to take care of hundreds and hundreds of patients, and they had to find, you know, what, how did they handle this? It was more than 400 patients were in kind of makeshift buildings. They had to put up multiple tents to house these patients. You can imagine the just sort of the infrastructure was really difficult to deal with. Initially, they started with two ORs, and they had to increase that to five, but the conditions of those ORs were really not ideal. When we were down there, we had an opportunity to take care of more than 400 patients. More than 150 of them were severe orthopedic injuries. More than 75 amputations that I had an opportunity to see every day. Talk about, you know, really gained a lot of experience in, you know, that patient population. While we were down there, we were, we had performed more than 100 surgeries, and a lot of it kind of lessons learned. A lot of the groups that had gone before were putting in and doing kind of maybe complex surgeries that we really probably didn't have the infrastructure. And so I just want you to take a look at some of these photos. I know there's a lot of photos on here, and they're, they may be small to see, but these were the conditions that the surgeons were operating in. You know, far from sanitary, far from, you know, I mean, we were lucky to have running water. And so we really, you know, as a group had to really think, you know, you want to do the right thing for these patients, but really is performing a surgery the right thing if we don't have the right supplies to do that? You know, very primitive facilities, poor sanitation, really outdated supplies, the antibiotics were outdated, even the stuff that we brought down. You know, John mentioned, you know, some of the challenges of just getting some of the supplies down there. You know, the stuff that was already down there was, it was, wasn't labeled. You had pills and things you didn't even know what, it was really, I had to take a step back. And so, you know, it was, it was an experience. You had surgeons, what's the last time you saw a surgeon bringing their patient to the OR on a stretcher? These are the guys I worked with, and, you know, everybody was just wonderful. I'm trying to advance this. But the spirit of the people that were down there, just, I mean, I hadn't looked at these slides in 14 years and preparing for this, I did, and it just still brought back such emotion for me. This was a little girl in the center who lost her arm and perfect rehab candidate. She picked up the marker in her left hand and started learning how to write her name and actually copy anything that I put down on that dry erase board. She just couldn't get enough of it. So it was just really, probably one of the most emotional things you can experience, just the devastation, the life devastation, and then just what they are willing to allow you to help them do and just how appreciative they are. There's a couple of pictures on here. You can see the supplies that we were able to bring down. They didn't have like crutches. They certainly didn't have, you know, the ability to have prosthetic devices. So we brought walkers and crutches and you can see, you know, a P-PAM. And really one of the biggest things that we took home from that, we were there for a week and then, you know, it was hard to leave because, you know, there was just so much more that needed to be done. So we, some of the relief efforts that we were able to raise, the funds that we were able to raise was to create a prosthetic lab that we, you know, shipped down there. Now, if any of you know anything about Haiti, it's very, it's notoriously politically corrupt. And so trying to get that through customs and through there to where it needed to go was really challenging, took months to do. But ultimately we did set up a prosthetic lab. I keep hitting the wrong button to advance the slide. And so this is just, you know, one of the other lessons learned that I will just comment on, it's what is, how do you sustain what you do in a kind of a disaster relief mission type setting like that? And what you really want to do, and John touched on this too, but you really have to be able to train the local people there to then carry on what you're, you know, you're trying to do. So trying to fund training for nursing, trying to identify prosthetic technicians who could then provide ongoing maintenance of the prosthesis that we set up, you know, the lab that we set up and delivering of prosthetic devices, you know, it was over a year long process that we were able to make sure that that came to fruition. So I want to switch gears here. So that was like sort of my first foray into that. The other thing that I've been really involved with is this rehabilitation services volunteer project. And, you know, interestingly, I've had an opportunity in Houston and now in Colorado and Denver to see that because Dr. Jeff Berliner, actually, when he came to Colorado, he took and he started it here, it's my understanding, you know, probably a decade ago. And really what this allows us to do is to provide some of these access to care issues that we have even within our borders, much less on a global basis, but that there's a real need there. And so I just want to encourage any of you that if you're interested in getting involved, there is a way if your city doesn't have something like this, there are certainly, you know, organizations like RSVP that can provide a roadmap for you to do that in your own home community. And it is really such a really cool thing to be a part of. And then lastly, you know, we mentioned the ROMP program. I'm really excited. I was really upset that I couldn't actually make it to down there last October. Apparently things politically have really calmed down. So I'm excited. We just last week scheduled the next trip to go down there. So I will be doing that again this October. So happy to answer any questions, but I'll turn it over to Dr. Kim. Oh, sorry, just before I didn't realize it was gonna come up like that. You know, the thing that ROMP does really well is again in Guatemala and Ecuador and some other places is actually to be able to provide prosthetic devices. And ROMP, you know, we mentioned earlier outcome measures, but they've really kind of taken sort of the model system of how we should be doing and caring for these patients within the United States and really try to implement a lot of the same thought process and going into community outreach and making sure you're engaging these folks. And so I really commend that group. I'm really impressed with what I've seen so far. So if you're interested, please again, reach out. I'm happy to connect you with the right people. Great. Thanks, Dr. Melton. It's my pleasure to introduce Dr. Hee Kyung Kim. Dr. Kim serves as Professor and Chair of Physical Medicine and Rehabilitation and the Kimberly Clark Distinguished Chair in Mobility Research at the University of Texas Southwestern Medical Center in Dallas, Texas. Dr. Kim joined UT Southwest in, I think if I have this right, Dr. Kim, in 2023? 22. 22. She's board certified in the United States and South Korea and holds subspecialty boards in Pediatric Rehabilitation Medicine and Brain Injury Medicine. She's nationally and internationally regarded as an expert in Pediatric Rehabilitation Medicine, especially the care for people with cerebral palsy, including pain and spasticity management and utilizing botulinum toxin injections to the salivary glands. She's also a renowned sonographer from Muscles and Nerves, specializes in single event multi-level chemoneurolysis with botulinum toxin and phenol alcohol injections, botulinum toxin injections to the salivary glands and sexuality and pain management in children and adults with cerebral palsy. Her research interests focus on people with CP, especially spasticity and drooling management with botulinum toxin, robotic therapy and exercise for spastic muscles in children with cerebral palsy and also lifespan care for people with cerebral palsy, including sexuality. She's a member of a WHO development group, preparing a package of rehabilitation interventions for people with CP. She's been selected as chair of Global Academic Physiatry Subcommittee of the Association of Academic Physiatrists since 2023 to address the global needs of physiatry training, especially with respect to developing nations. So welcome Dr. Kim and thank you. Thank you. Thanks for very nice introduction, but I don't have that much to say because the previous two speakers shared all the information with you guys but I always keep thinking what they want to learn from this one. Maybe you guys want to learn how I can get there, right? Who is inviting you? How I'm going to find out this, all the things. So I'm going to share my own journey for this one. So this is my disclosure. So for you to do involve the global health, I think there's some essential component, secure some funding, identify host countries, forge a partnership with the local entities and build a diverse, because PM&I is all about team approach. Physiatrists cannot be the only team members. So you have to build your own team and then you have to tailor the plans to host country needs and implement robust monitoring and evaluation and facilitate continuous follow-up and adaptation. And I think that's what Dr. Melton and Dr. Arm is doing it at this time. So initially this is very, I took out one picture because it was a little too much, but anyway, so as a pediatric physiatrist, this is my second year and then my managers in cerebral palsy clinic, he liked me a lot. He said, Dr. Kim, you want to do some voluntary work? So of course I want to do this. So he brought this lady who is the Variety Children's Lifeline Executive Director. So Variety Children's Lifeline is actually funding for the congenital heart disorder. So I met her, then I explained about all the pediatric PM&R and she said, oh, you're not treating congenital heart disorder, so we cannot support you. I said, after you guys treat the congenital heart disorder, all the people who has a stroke from the cardiac surgery and debility, we are the one who take care of them. So how are we going to handle it without us? She still didn't help me out. So I flew to San Diego to visit the president of this organization. So he is originally Egyptian. I'm originally Korean. We have a beautiful, strong accent each other. And then this executive director was a translator, or interpreter in between. And he said, what do you do? I said, I'm pediatric rehab doctor. And he said, oh, you do diabetes? My grandchild has diabetes. I said, I do pediatric rehab. Oh, I forgot my hearing aids. But anyway, that's the way we started. And he said, I like you a lot. So I fund you $50,000 per mission. I said, God bless me. Okay, I told him that I have my job, I have to do work. But anyway, that's the starting point. Then my host country, I chose Chile, because I had a patient who was treated by me. I made him walk from not walking to walk. All the Chilean children wants to come to me. So several patients flew to Philadelphia at that time. But after then, I cannot do anything because they have no fund. So I convinced my patient father, who is rich, to start some organization. So I have a fund now, so I flew to Chile to exploratory visit with whom I'm gonna work with to disseminate pediatric rehabilitation. And then the top picture, she's my patient mother, the lady. They are very important to some university hospital trauma team. They're looking for the money. So I said, no, thank you. I came out. And then she said, oh, why don't, Dr. Kim, why don't we go to the place where my son gets treatment? That was Telethon. Just like America, we have Telethon. This is a nationwide rehabilitation service. I said, this is it. If I can train people through Telethon, I can train whole Chilean people. So I formed my team, and I set this three-year project. So I have money, right, I have money. That is very important. So the first year, just like what everybody did, we are heavily focusing on directing. Each discipline is teaching each discipline work together. We put in one room, and the afternoon we go to the each discipline place, and we've trained them. We work together. So that was a three-year work. And then our first year, so we did a lot of teaching, teaching. And second year, we go to the lab. So we are doing action, teaching the real skillset and techniques. And then we teach them how to diagnose the disorder disabilities. So this is, my team members were 11. So myself, pediatrician, but sedation, because I had a lot of procedures. So I want them to learn how to do conscious sedation. So I brought pediatrician with other conscious sedation. I brought developmental pediatrician. Orthopedic surgeon, PT, OT, speech-language pathologist, social worker, because it's team approach I have to teach. Nurses and resident. I brought 11 people with me at that time. And I contacted the botulinum toxin company to donate the money, $20,000. Actually, they brought 40 bottles of botulinum toxin from Brazil to Chile to support my mission. So anyway, third phase, now we simulate the cerebral palsy clinic, just like America. And I put all the staff and team members in each room, and we are seeing the patient. We watch them, how they do. And then we did a follow-up visit in following years. So that's the Chile. And then the Italy is fun part, because Italy, I didn't do anything, but I was presenting at ISPRM. And then here's Dr. Forti, who is the chair at that time. He liked my poster very much. I was presenting permanent rehabilitation, non-invasive permanent care. He said, Italy, we need this. I said, okay, send your fellows. And he started, he was my first one. I don't know if you can see in the bottom middle, bold. His name is Massimiliano. He was my first fellow came. And after then, every year they bring, she's the second fellow. Now I went back. I was their visiting professor seven years. Every year I'm getting the trainees, but they all want to do pediatric rehabilitation. But in Italy, they didn't have a pediatric rehab. Last year, July, I went back and then they are formally, officially, now they have a pediatric rehab medicine. All my fellows are teachers for them. So they flew back to Rome to see me and we went out to drink. So this is another way. Admission doesn't, or global health doesn't mean that we have to go to poor country, right? Poor country with knowledge and skill. That's the country we are heading. So they can really providing, they can provide pediatric rehab medicine in Italy at this time. The other one is the Middle East. I was a consultant for Dubai for 20 years. How they started? Because I was very nice doctor. So one of the Middle Eastern doctors saw me and she said, Dr. Kim, you're such a nice doctor. I'm going to do something for you. So what are you going to do? She said, you're going to go to UAE. At that time we had the 9-11. So all my colleagues said, you're going to die. You're never going to come back. I said, I die only one time. I go, because I didn't know what is UAE. So I flew there. I was treated like the president of America. And then I proposed that they want me to come every three months. So I proposed that you fund me. I'm going to bring all my team twice a year. I'm going to train everybody here. So your program or pediatric rehab can be sustainable. So they say it's too expensive. I say, you send your children to all Europe and then each year children spend $100,000 they're using it. So they listened to me. So I was there and then we built the orthotic labs. And then I converted this one, two of the pediatricians, the pediatric rehab doctor. So they opened the pediatric rehab center in Dubai. And then Dr. Majid on the right side, he is the one who is running the show at this time. He become very rich because he is running the rehabilitation center. But I did provide the service in this country as I planned. So the pediatric rehab program at least is sustainable. One of American graduate works in Dubai at this time. So we, afterwards we get together on Zoom. We are providing service. We do Zoom follow-up. This is my original team members. You can see we have Hannah everywhere. Hannah or Hannah. So we had a fun. And then now Nepal. Nepal is the first country I wanted to go but they didn't fund me. So I just packed my bag and with my European friend who is Nepali originally, she and I spent about $2,000 each other. We paid it by ourself because we really want to do. So when we arrived in Nepal in 2002, they admitted all the healthy CP children in the hospital. So I said, why they are in the hospital? Because they never got treated. So they don't know what's going to happen. So we started to actually pheno injection. I was teaching five orthopedic surgeon how to do phenol nerve blocks in OR. That was 2002. 2018, I went back to follow. And then I gave all the formula how to make the 5% phenol because one of orthopedic surgeon's wife was a pharmacist. So they start to treat all CP children in Nepal. And when I went back, they are doing research with that all the cerebral palsy children get treated. The Dr. Rahul Raju, who is sitting in the middle now, he is the fellow at AAP, the GAPS. He is the first board certified PMNR doc in Nepal. And Indiana University goes there and help. And he's in charge for the spinal cord injury institution. But we are merging with kind of helping him how to build PMNR residency program so they can have future plan for the patient who needs PMNR service. So that's why we are working on it. So that you can see, I'm wearing AAPMNR shirts. I'm a little fat, but I'm walking. So you can see the t-shirts, right? That was me. That's the way they, they must have a lot of patients for John. Neck pain, back pain. Look at this ladies, you know? And then the other one. So China, I have been going to China 13 years and this is exactly the same way I do. I bring whole team, PTO, DCPH, all kinds of pediatrician. Together we are helping them to build a sustainable pediatric rehab program. In China, most of the patient with the disability stays in orphan, orphanage. So our 10 years work was happened in, at the orphanage but they have doctors and we are training doctors and therapists. And at the end we do conference together to double check. And we give even test and we have evaluation period and we have them teach. So we are teaching the, we are training the trainers. So we have, we switch the role. So we have them teach us and we can double check how much they understood. So that's the one. In Japan, Japan has been, so this is another very interesting. We are thinking Japan must be so developed, right? But the care for the children with the disability is not advanced. They can feed them very well. They can clean them very well but the early detection, early intervention concept is not there at all. So one of our researcher at Columbia University was a Japanese and she saw how I'm treating the patient. So she went back to her country and her father wrote the grant. And we have a grant from Japanese government. So you can see orthopedic surgeon, researcher, therapist. We go to Japan once a year. We finally formed the Cerebral Palsy, Japanese Cerebral Palsy Congress. We encouraged them to form the Japanese CP Congress and they were teaching orthopedic surgeon because their care, I never ever seen very severe scoliosis which I saw in Japan because they don't really treat them. So we are treating every different disciplines and the last visit was December last year. And I think now they are using the ultrasound with the guided injection. They start the spine surgery for children with the CP. So, and therapist is working with all the comprehensive care so that's very successful. I think, let's see what time is almost done. So, Tanzania is the last one. Tanzania, I started because I working at Columbia Cornell opened my eyes to Africa. So I was a chaperone for my resident who they rotate through Tanzania. They are there six weeks for just regular rotation for them to learn. And then when I followed them, I realized that nobody's actually doing anything for children or patients with disabilities. There's no PMR docs. The therapists are there, but therapists are doing tenotomy. They put the patient in the gym and they cut the tendon with the local anesthesia. So I was looking for the fund. So the funding source was the organization where I got the support for the China mission. So I convinced them to go to Africa. So I brought the executive team to Africa with the surgeon, myself, pediatrician to explore how we can work together. But when we visited a large hospital, they were looking for really more financial funds. So we didn't like it. So we gave up. And meanwhile, we found the RN who is a nurse in the States. She was doing missionary work over there with her family. So we started to plan again. We finally went back this year, a couple of weeks ago. Actually, that's why I was keep yawning. And then this lady at the bottom, she's the nurse from States. And we were also evaluating and treating patients. And this is a maid in Tanzania wheelchair. With the wheelchair frame, they put the plastic chair over there. But they are really healthy. All the children are very healthy. This is actually, we went to school and we went to specialty hospital. But this is because they're all waiting for us. They're cleaning the room. They're running around. Very, very healthy. But the problem is that I don't have a counterpart, which means that I don't have a partner to teach. Therapists are very few therapists, no doctors. So we diagnosed a lot of children. Actually, they don't have a diagnosis, therefore they don't have a treatment. So we are seeing a lot of patient and treating the patient. The recommendation was happened, but we don't know what to do. So we're going to have a meeting again, how we're going to continue this work or not. And if we have to make the decision. But I experienced all kinds of different difficulties from different partners. But I think the resident or all PMNR wants to do this kind of work because we are very warm person. And we chose PMNR to do this kind of work. So I just want to share my experience, how I got there, how I got the fund, how I got the sponsors. I think that's the most important. But if you have a heart and you will get support, you will find that most countries. So just check the list one more time. This is what I explained to you already. So I think we have 10 minutes. So we're going to start to take the questions. Great. Thank you, Dr. Kim. And thanks to Dr. Alm and Dr. Melton. We had some questions to sort of start things off, but we don't have to necessarily stick to that. I do think very briefly, if you could kind of maybe mention if there was a particular mentor or someone who really opened your eyes to participation in such activities around the world or in your in your own town. Well, I did not have any mentor, actually. But I was always thinking about that. So I could have my own mentor. That's kind of the same way. I knew it was something I wanted and just kind of fell into it and carved my own path. Yeah, I would ditto that. I mean, you know, I think I think it probably is more that you see a need and you figure out how and then and then contact the right people who you think can help you get there. So I really appreciated Dr. Kim's comments about just her path, because I think everybody's going to have a different one. But but identifying people, I know I've had an opportunity within our own residency program for people to who are interested. Dr. Yepsen's actually on here and she's she's got a real desire to do this and she's seeking it out. And that's what I would encourage all of you to do, find the right people. And this is a great group to start with. I'm sure all of us would be happy to to kind of help with that. And one of the questions that came in the chat was to ask for a suggestion of maybe three top three specific trainings that you feel are very applicable in low resource countries, like very sustainable or or achievable in a low resource country. Do you have any thoughts on that? Yeah, I know I'll start it off and I'm sure some comments, too. But, you know, I read that, Dr. Williamson, and I think that, you know, obviously my passion is O&P. So I'm going to look at it through that lens. But I think the other thing that that I noticed, maybe it was just where I was doing the work, but I think wound care is another big one that I think that if you've got some training in that, you could probably make a difference. And of course, that's with disaster relief, I think maybe more so than than others. What I found is that, you know, the sustainability is a real issue because, you know, you can you can send components down there. You can send even initial prosthesis. But if they don't have a way to to maintain it, it's it's problematic. And so the point I made earlier, and I'll just reiterate it, is you have to engage the local people and train them. And I think most of us made that comment today, but really partnering with them. So, you know, the three specific trainings, obviously, I think it depends on what your passion is, but or what you're going down there to do. But that's what I would I would say in ensuring that that from a sustainability standpoint, that you're partnering with the right institutions, because we saw a lot of sort of fraud and abuse, at least we did in Haiti. And so you'd want to make sure that what your dollars are going down there to do or your time or effort that you're going down there to do is is with the right setup so that, so that, you know, it's actually going to make a big impact. I would say from an interaction standpoint, I actually don't even necessarily think it's medical specialties. I think some of the greatest areas where you have sustainability is going to be with the local therapists. That was definitely the case in Guatemala leading up to it in the year planning that trip. You know, had a lot of virtual meetings with them on the ground. There were more therapists than there are physicians. And and somewhat similar to the experience in when we went to Ireland is the physiotherapist there. They they, I think, see the potential of what the field of PM&R can do. And so they they've already thought of the things that they would want to do to help these patients. And so I think we are able to bring in the medical component of how to make that better for them. You know, but PM&R, I think, is kind of like a Swiss Army knife. We can do a lot of things. But if you don't know what the what we're capable of, it's hard to really wrap your head around it. And so, again, I think it's, you know, partnering up with those that are going to be there with the patients that would probably benefit the most. And from my perspective, I felt like a lot of that was the therapist. Thank you. Are there questions from the audience that folks would either like to speak up or put their question in the chat? Please feel free. I think another question is, you know, and I think Dr. Almey really pointed it out that your local source, your local partner can really help identify what's most what's most needed and what's what's available or what what's available, but also what can help sustain, sustain the learnings and the teachings. I think Dr. Kim also touched on, you know, financing these and some novel approaches, either through grateful donors, grateful patients, maybe some formal and informal connections as well. I see Matthew has a question. Go ahead, Matthew. I just like to know I'm going to be in attending very soon, and I'm curious if most of these ventures are sort of independent of where the physicians are and the staff are working, or if most of them that you see are in partnership with whichever institution or group that person is with. Meaning, would you speak to your staff about like, you know, can we can we coordinate this together to get time off? Can I go into through the organization to look for other people to recruit to bring with me? Or is it more of like I'm going to take time off so that I can do this? And then in the background, you're working to gather your team. So I can answer for that. If you work in the academic setting and some institution gives some about one week every other year or every year to do some voluntary work. So it depends on the institution. Initially, I used my vacation time. And then once you build and then once your level goes up and then you have more flexible times, like John and myself, you know, we have a way to get around all the things. But you have to work really, really hard to do those kind of work because you cannot miss your clinical work, right? So instead of seeing two patients, I see four patients before I leave this kind of work. So my productivity never goes down. So then you can appeal to your boss that, you know, I don't compromise my work, but this is what I like to do. And also, when you negotiate, you can talk with your boss that this is what I'm requesting. Can you accept? So you can negotiate those things. That was my negotiation when I moved from Philadelphia to New York. I talked to my boss that you can tell me whatever, but this is what I want to do. So if you say yes, I will move to New York. So ever since then, he never talked to me anything about that. Is that answer to your question? Yeah, it does. Thanks, Dr. Kim. And it's very true. It is very, it's very important. You know, starting off, it's a lot of it is vacation time, personal time to do these things, you know, and some of it too. And like Dr. Kim is saying is, you know, if these are important areas for you, especially while you're going to become a new attending, you know, when you have a chair that's interviewing you for a job and they say, do you have any questions? I mean, those are the questions that you want to ask it. Will I have support to do this? And they'll tell you that the ins and outs because, you know, we have to make sure financially our departments are sustainable. But at the same time, you know, if you've got a leader of your department that's supportive of it, they're going to find ways to help support you do that as well. There are some good questions in the chat. One question is, do you need malpractice insurance for each country? How do you deal with that? Oh, I can. My part is I usually try not to touch the patient if I don't have a license to go to China. You need a license. So we have a partner in local hospital. So they work for us. So we get the license. So we really can treat the patients. But some countries, they don't care. They just want us to treat the patient. Like when I went to Tanzania while I was in New York City, they asked me to treat the patient. So I was teaching the neurologist how to do phenol, Nervobla, botulinum toxin injections. And I didn't need to have a license. So it depends on the country. But what I'm saying is, but you don't want to take too much responsibility in case something happens. So I always stand by them. But I try not to put my fingertips to the patient. I show to them, you can put the needle here. You can approach it like this. If they're wrong, I hold their arm, not fingers. So that's another trick to teach them. And that is part of the education component to it as well. A lot of it, there are times, depending on the country, like Guatemala, for example, we're doing the treatment. But we'll be going back, hopefully on an annual basis to Ireland. But when we go there, because of a lot of the rules and regulations from the European Union, I mean, we're going to go as consultants. So we may round with the team, but we won't put any orders in. We're not going to touch the patient, just as Dr. Kim is saying. And we're really going there as consultant role to kind of share our knowledge. Because again, the goal is that then physiatry begins in Ireland or whatever country you're working in and that you bring in your skill level so they can be self-sufficient at some point. Another question is about, you know, were your local universities that have public health or global health programs, were they able to offer assistance in navigating some of the more challenging health systems or countries? You know, I'll make a comment on that. I think ROMP, you know, they're bringing, you know, me down with, I think, some other volunteers down during that time. And I think it's supported by the public health system. And they're primarily to actually provide education to the trainees down there. So the residents and therapists and going to the different hospitals. Now, I think we are also doing some home visits and going to clinic. But I don't, it's a good question I'll have to ask. I don't think that I'll actually be, you know, directly hands-on. And I'm not doing injections like Dr. Kim. But, you know, I think providing some guidance and education is really where we can help and make a difference. And another question is, are there opportunities for medical students and residents to get involved in these mission efforts and global health initiatives? I think it depends on the fund who is funding us. I am really hoping that each university has that kind of fund, which is not easy nowadays, right? But in my case, I tried a lot to bring the residents. Initially, I was. Recently, I couldn't because of the funding source. So yes, yes, they can follow. It depends on how we allocate the fund for the student and resident. There are questions about, you know, that there's requests from physiatrists abroad to come to the United States and spend time learning at the United States while they work to develop systems in their home country. From the group's experience, do you think that's a that's a really beneficial or meaningful activity? Yes, I can answer for that. I forgot to mention that one, but we do the organization who is supporting us to go to China and Africa. Actually, we our mission is education rather than treating the patients, right? So to help them to be sustainable. So after we teach them, we identify the person who we can, we want to do further training. So we bring them to the States. It doesn't need to be a doctor. So if physician, each discipline should choose one person. So PT, OT, physiatrist, if they don't have a neurologist, orthopedic surgeon, we bring them to the States and we train them one month and they go back. Actually, in China, they will become real trainers. They don't need us that much. That's why I convinced them to move to Africa from China because they are able to do most of the surgery and rehabilitation therapy. We trained them over each city. We went to three cities over 10 years. Each city we do four years or a little more and overlap. And while we are there, we flew back to the previous city and we double check how they are doing it. And I think that's going to be key for it. I mean, that's some of the steps actually just had our institution or my university here signed an official agreement with the Royal College of Surgeons for that reason to basically send faculty back and forth across the Atlantic because you can go there. But the next step really is going to be, I think, seeing kind of how we do it. But again, the challenges of that are going to be the difference of the health care environment itself. But yeah, I think it's going to be very key for those abroad. If they haven't seen something, if you see something yourself versus you just hear about it, having that experience of seeing what an acute inpatient rehabilitation hospital looks like, I think will help a country develop their own program as well. My experience with that, I'll just add that I had a couple of people reach out and I ended up having a fellow from Jordan one year and his government actually funded his fellowship. So that may be an option if you're talking to folks over there or abroad, just wherever. That may be an opportunity for them, hospital system or the government to get the right training. Haley, do you have a question? I did on Dr. Melton's just comment about the fellow from Jordan. Was that like a true fellowship that they applied through like ACGME and then matched to or was that a fellowship on top of the fellowship that like your program normally already was running? Does that question make sense? Totally. Yeah, it was not an ACGME because that would have been super challenging. I mean, there's a lot more hoops to jump through for that. The way we ended up making it happen was through a research fellowship. There was a little bit more leeway to make it happen and to make it happen relatively quickly. So yeah, I think there's probably some avenues. And of course, that was just when I was at UT. But I think every institution is probably a little different. You just have to do some research where you are on what's available out there. There was also a question or comment in the chat about Doctors Without Borders. Do you have any knowledge of rehabilitation efforts with Doctors Without Borders? I have heard of a couple, but it's not a bad way to go. And so that's kind of how we started with the Guatemala issue is piggybacking off of another program. You learn from it a lot. And so whether that's finding an opportunity to go, I think it will open your eyes to some of the challenges that you'll need to overcome because there are a ton of logistics that go into it. I think when we get to it, it's the fun pictures and everything. But the first time going to Guatemala, it was 12 months of planning just to get through and medications and seeing what we could bring across the border and what we have to work with local hospitals. So again, I think if you really are interested in it and those opportunities are there, just grab onto anything, do it, see what you think about it. Some of it too is if you're developing your own in the future, you can see what you like and what you don't like from that existing program. But it's also making the points of contact because you may meet somebody and say, you know, Doctors Without Borders and go, hey, you know, I would love to collaborate with you doing this while we talk offline. And so there's relationships built by doing it. And so I would say when it comes to some global medicine, a lot of things, maybe it's my personality. I think just dive in, try and learn as much as you can, gain the experience. Don't wait for the perfect scenario to develop because otherwise you'll just be sitting on the sidelines. Yeah, there are some additional comments about faith-based organizations doing clinical work globally. And someone mentions Cure International. That is a pediatric focus. And I think, you know, this has, we've run over by a few minutes, and I think that's reflecting everyone's enthusiasm for this topic and the great nature of our speakers tonight. I will draw to a close unless there are last comments from our speakers to share. I mean, for me, I think if you dream it, you will get it. So if you really, really want to do it, you can use your money to start sometimes. But I think firstly, you have to be really, be a good doctor first before you move on. And then your opportunity is always there. And then we can support each other too. Thanks, Dr. Kim. Thanks, Dr. Ohm and Dr. Melton as well. Thank you for joining us this evening. And reach out if, you know, we'll try to have resources for you if you do reach out. Thank you so much. Bye, guys. Thank you.

global health initiatives

partnering with local institutions

healthcare providers

education and training

empowering healthcare professionals

financing initiatives

securing funding

medical students

residents

fellows