The provision of surgical services in underserved and disaster-stricken areas of the world is becoming an issue of increased interest. At the same time—and most experts on the subject would agree—although traditional medical missions have had positive short-term benefits for patients, training native physicians to deliver the type of care available in economically strong countries has a greater long-term and sustainable impact. As this trend of training local physicians in resource-poor regions continues to evolve, I thought it would be useful to describe how a team of U.S. health care providers responded in the aftermath of an earthquake that struck Armenia in 1988, registering 7.0 on the Richter scale. Indeed, the lessons learned from that event are as meaningful today as they were nearly 28 years ago.
The earthquake hits
It was a typically cold morning on December 7, 1988, for Artashes Aznauryan, MD, the Minister of Health for the Soviet Republic of Armenia—a country of approximately 3.5 million people at that time. Dr. Aznauryan was in his office in Yerevan, the nation’s capital, reviewing reports from his section managers, when he felt a rumbling under his feet and noticed that the tea in the glass resting on his desk was shaking.
Less than 30 minutes later, one of his assistants informed him that they seemed to have lost telephone contact with the hospital in Spitak, located 74 miles northwest of Yerevan. At the time, Spitak was a city of young, educated, middle-class families with new schools, new factories, and a new hospital. The republic was proud of this modern city and was hopeful for its future.
Dr. Aznauryan told his assistant to check with the telephone company to see if there were any disruptions to the transmission lines. The assistant reported that there was complete disruption of telephone communications with Spitak. He had called the police headquarters in Yerevan and been informed that wireless communications with the city had yielded no response. The police were sending a helicopter to assess the situation.
Sensing a potential tragedy, Dr. Aznauryan immediately dispatched his deputy and several physicians to Spitak. They soon reported that a major earthquake had hit; all the buildings were either collapsed or damaged severely.
Dr. Aznauryan had a serious situation at hand. The physicians and nurses in Yerevan worked in shifts, and the day shift personnel had already gone home, leaving the smaller afternoon shift in the capital’s hospitals to provide care to the victims of the earthquake. He rushed to the state television station to announce the catastrophe and to ask that physicians and nurses return to their hospital posts. Every single physician and nurse immediately reported back to work.
Dr. Aznauryan assembled his division managers to mobilize a communications post and sent all available ambulances with as many physicians and nurses as could fit in the vehicles to the scene. The drive to Spitak was slow because of road damage from the earthquake, and by the time the first teams arrived, the sun had already set. Working by the headlights of the ambulances, first responders began rescuing the victims buried beneath the rubble. Physicians later described the scene, where they found some victims who were alive but pinned under structural collapse. To free these patients, amputations of arms or legs often were performed using local anesthesia and with the aid of flashlights.
The next several days confirmed the republic leaders’ worst fears: approximately 25,000 men, women, and children had died, and an estimated 130,000—nearly 80 percent of Spitak’s population—had experienced traumatic injuries. In no more than 20 seconds, the earthquake had essentially destroyed the city.*
Responding to the request for help
At the time of the earthquake, I was professor of surgery and chief of plastic surgery at Yale University School of Medicine, New Haven, CT. On the morning of December 8, my administrative assistant informed me that there had been a telephone call earlier from the Soviet Union Embassy in Washington, DC. We returned the call to the First Secretary of the Soviet Embassy, who informed me of the catastrophic earthquake and asked if I would be willing to go to Armenia to offer my professional assistance.
Since that time, it has been suggested that whereas the then-Soviet leader Mikhail Gorbachev had been trying to reform the Soviet system with his policy of Perestroika (a political movement for reformation within the Communist Party of the Soviet Union during the 1980s) this earthquake actually may have played a role in improving relations between the Soviets and the West. Mr. Gorbachev happened to be in the U.S. on an official state visit at the time of the earthquake and cut the trip short to return to Armenia and evaluate the magnitude of this disaster. He then formally reached out to the West and requested humanitarian aid—the first such request from the USSR since World War II.
During our telephone conversation, I explained to the Secretary that while some of the rescued citizens would die in spite of all efforts, it was possible for others to receive adequate care from their own physicians. The bulk of the survivors had experienced severe injuries and would need subsequent reconstructive surgery. I informed the Secretary that I would form a surgical team as soon as possible, but, in the meantime, they should bring in dialysis machines to care for the many patients who would sustain renal shutdown from their crush injuries and the resultant myoglobinuria. That aid was quickly provided by a team from the University of California, Los Angeles.
AmeriCares, a not-for-profit relief organization headquartered in Stamford, CT, was one of the first U.S. agencies to arrive in Armenia and evacuate patients to the U.S. One of the first U.S. facilities to treat victims of the disaster was Yale-New Haven Hospital, CT, which accepted two patients.
I went to Yerevan with Jeffrey Heinrich, PA-C, EdD, a physician assistant (PA) in my plastic surgery section, to assess the medical needs of the earthquake victims. We met with Dr. Aznauryan, who briefed us on recent developments and progress, and deputies of the Ministry of Health, who described the infrastructure and levels of training of physicians and nurses in Armenia. We were able to visit several hospitals and evaluate the seriously injured patients and the many more who had less severe injuries but would still need reconstructive surgery.
Some physicians spoke English, but most did not, and virtually all of the nurses spoke only Armenian and Russian. Specialty surgeons were largely trained in Armenia, but many competed for these training positions in Moscow before returning to their homeland. Many surgeons said they had trained in the subspecialties of plastic surgery (such as burns, hand surgery, microsurgery, facial fracture surgery, facial cleft surgery, reconstructive surgery, and cosmetic surgery), but we were unable to identify any plastic surgeons who had trained in the provision of the full scope of plastic surgery services as we know them in the U.S.
Anesthesia was administered by physicians trained in that specialty, but many procedures we witnessed were performed under general mask anesthesia; few patients who were under general anesthesia were intubated, even patients who were undergoing surgery in the prone position. Regional block anesthesia was nowhere to be found.
Nursing education was under the direction of a physician in the Ministry of Health, and nursing care appeared to be at a level not seen in the U.S. since the early 20th century. Nurses were given no clinical responsibilities and served simply as caretakers. They had no role in the dressing of wounds or monitoring of vital signs. Indeed, patient families were encouraged and expected to attend to the patients’ nursing and feeding needs.
It was apparent that U.S. surgeons who would travel to Armenia to volunteer their services would be unable to communicate in a common language with their colleagues regarding day-to-day patient management. Teams of surgeons, anesthesiologists, and nurses would have to be formed to be effective providers.
Alternatively, patients could be flown to a western country for reconstructive surgery. Unfortunately, to be suitable for this option, patients would have to be strong enough to sit in an airplane seat for many hours of flight, making it an impractical solution for those patients who most needed our care.
On our return to the U.S., the leadership of the Armenian General Benevolent Union (AGBU)—a not-for-profit organization established in 1906 to care for Armenians in the diaspora—asked for my assessment of the situation. It was my belief that the only meaningful long-term solution for the many patients who could not travel would be to train a team of Armenian physicians and nurses in the Western team approach in the U.S. and return them to their country to treat those patients. We could subsequently assist in training additional teams to sustain this work, but this approach would require a serious commitment of time and money.
To my surprise, the AGBU, under the leadership of president Louise Manoogian Simone (1989–2002), accepted this challenge and quickly raised $500,000 from private donors. Shortly thereafter, AGBU leadership arranged for me to meet with Leila Karagheusian, the 91-year-old surviving daughter of Mihran Karagheusian, a New York, NY, rug manufacturer and philanthropist who started the Karagheusian Foundation in 1921. After asking many thoughtful and incisive questions, Ms. Karagheusian wrote a check for $1 million. Eventually, the U.S. Agency for International Development (USAID) provided a matching grant, resulting in $3 million in funding for this AGBU project.
With funding in hand, we contacted Dr. Aznauryan to explain the two proposed projects. The Minister of Health chose the offer of a long-term commitment to education and training to upgrade the Armenian health care system. He assigned Sevak Avakian, MD, Deputy Minister of Health for Foreign Affairs in Armernia, to this effort.
Assembling and training the team
The next step was to select the team of physicians and nurses from Armenia for training in the U.S.
We had the full support of Yale School of Medicine and Yale-New Haven Hospital. Paul Barash, MD, chairman, department of anesthesia, and Karen Camp, RN, deputy director of nursing, surgical services, joined the team. We had several meetings to plan the selection process and training curriculum for the Armenian team. The planning group included the Yale team, Dr. Avakian, and Regina Ohanyan of the AGBU, who served as administrative coordinator.
We determined that we would need to train two surgeons in plastic surgery; two anesthesiologists in modern anesthesia technology; and 12 nurses in intraoperative, recovery room, intensive care, and floor nursing care methods. Most importantly, we needed to train these health care providers in the team approach in which nurses are accepted partners in patient care from admission to discharge.
We then concluded that each of the physicians would need direct, hands-on clinical training; observation alone would be insufficient. Dr. Barash and I proceeded to apply for formal approval from the Accreditation Council for Graduate Medical Education for training of the two surgeons in plastic surgery, and the two anesthesiologists through our two respective residency review committees (RRCs). The RRC for plastic surgery, under the chairmanship of Leonard T. Furlow, Jr., MD, FACS, concluded that we had enough cases to warrant the addition of two residents to our program, as did the RRC for anesthesia.
For these four physicians to have hands-on clinical training, they would first need to pass the Educational Commission for Foreign Medical Graduates (ECFMG) examination as required under federal law. Any infraction of this requirement would result in immediate loss of all federal research grants to Yale University. However, we realized that we would not have time to teach them enough English language to pass the exam before their arrival in the U.S.
Our other option was to get Yale University to apply to the ECFMG for an institutional exemption. I contacted the ECFMG to get instructions on how to apply for the exemption and in the course of these discussions the ECFMG’s leadership decided to become a sponsoring institution of the program, thereby eliminating the need for Yale to apply for such an exemption (see Figure 1).
We then traveled to Yerevan to discuss this program with the Ministry of Health. We asked the Ministry of Health to select 18 surgeons and 18 anesthesiologists from whom we would select two candidates from each specialty. We also asked the ministry to select 48 to 50 nurses from whom we would select 12 participants. I also felt it was most important to select individuals who would be committed to returning to and remaining in Armenia to ensure the sustainability of our efforts.
We spoke with all the candidates and explained that they would need to devote many hours of training in preparation for their trip, be willing to leave their families for one year, and undergo long and arduous training in the U.S. After a week in Armenia, we selected the 16 members and added one pharmacist to the team. One surgeon, Gagik Stamboltsyan, MD, was trained as a microsurgeon, and the other, Garegin Babloyan, MD, was a vascular surgeon; both trained in Moscow and had returned to work in Armenia. The anesthesiologists, Armenuhi Kharatian, MD, and Garen Manvelyan, MD, both trained in Armenia. The entire team began a comprehensive course in English under the supervision of teachers selected by the AGBU. This group of physicians and nurses arrived in the U.S. in September 1990 to begin 12 months of intensive, comprehensive plastic surgery training.
Our intention was for all of these health care providers to work at our hospital as a team: the two surgeons operating under our supervision would each work with one of the Armenian anesthesiologists in training and with assistance from one Armenian scrub nurse who was, in turn, trained by one of our nurse instructors. The patient would then be cared for in the recovery room by another Armenian nurse who was being trained in postoperative care. Once the patient returned to the floor, another Armenian nurse being trained by another nurse instructor would provide floor care.
Ms. Camp, with the help of the operating room (OR) supervisor, Luba Dowling, RN, selected which Armenian nurses would be trained in intensive care, including advanced monitoring, respiratory care, and electrocardiogram interpretation. If a patient needed care in the surgical intensive care unit (SICU), one of the Armenian nurses in training would be assigned to that patient. In this manner, the physicians and nurses were fully immersed in the management of patients as a team. In fact, we housed them all in groups in several apartments on the same floor of a building one block from the hospital to encourage their daily integration as a team.
Their intensive training continued for the full year, with periodic reviews of their progress and development. In the meantime, the AGBU formed a consortium with the Armenian Relief Society and USAID to develop five additional programs in Armenia to prepare for the returning medical team, including the commencement of their care of the patients, as well as their continued training (see Table 1, below). The consortium’s plan was to establish (1) a plastic and reconstructive surgery center (PRSC) in Yerevan; (2) an Armenian nurse/physician exchange program (NPEP); and (3) additional programs to provide support and training in mental health and psychiatric outreach, pharmacy, and biomedical engineering. I will limit my discussion to the first two programs, as they are specifically relevant to surgery.
Table 1. Consortium
|AGBU • Armenian Relief Society • USAID
Plastic and reconstructive surgery center
Nurse/physician exchange program
The PRSC was established through the efforts of the AGBU to provide a fully equipped state-of-the-art OR and SICU, as well as support for equipment, medical supplies, and pharmaceuticals in preparation for the team returning to Armenia. Another goal of this program was to establish a U.S.-standard academic section of plastic surgery at the Yerevan Medical Institute to train additional plastic surgeons.
The NPEP was established to provide ongoing training for the team of physicians and nurses returning to Armenia. The goal of this program was to send U.S. nurse managers to Armenia to continue the nurses’ training, to help them develop their management skills, and to establish programs for the Armenian nurses to train additional nurses. Arrangements also were made for various plastic surgeons to travel from U.S. academic programs to help establish training programs for the Armenian surgeons.
A new era
Meanwhile, the Armenian team completed their prescribed training in September 1991 with a commencement exercise attended by the leadership of the Yale School of Medicine, the Yale-New Haven Hospital, and the AGBU (see photos above). We selected Dr. Stamboltsyan to serve as chief of this plastic surgery team and to head the program in Armenia. The team returned to Armenia and began their work at the new PRSC in Yerevan.
The Soviet Union was experiencing a complete transformation in the same time frame, resulting in the dissolution of the USSR and the establishment of independent republics, including the Republic of Armenia in 1991. Planning and negotiations for implementation of these various programs commenced with Dr. Aznauryan and was completed by Mihran Nazaretian, MD, the Minister of Health of the new Republic of Armenia. Armenia’s independence made for more seamless progress and development of the original plan.
The AGBU continued its support, adding three American members to the PRSC: a unit administrator, a head nurse for the OR, and a head nurse for the SICU. The ORs and SICU were equipped with the latest anesthesia machines, physiological monitors, and ventilators. A medical library was established with the donation of English language textbooks and subscriptions to various medical journals. Mary H. McGrath, MD, MPH, FACS, a Past-Regent and Past First Vice-President of the American College of Surgeons (ACS), was instrumental in securing approval from the Plastic Surgery Educational Foundation for the use of the handbook, Plastic Surgery Essentials for Students.
Plastic surgeons from several American academic programs, many of whom are members of the ACS, the American Association of Plastic Surgeons (AAPS), and the American Council of Academic Plastic Surgeons (ACAPS), traveled to Armenia to participate in this program, including (all MD, FACS) Gregory Borah, Julia Terzis, Mimis Cohen, Theodore Chaglassian, and Lloyd Gayle.
This program proved to be timely—as the various Soviet states became independent republics, tensions mounted and borders were closed. Soon thereafter, fighting broke out between Russia and Georgia over North Ossetia in Russia and South Ossetia in Georgia. This conflict led to numerous casualties.† When the fighting ended, the President of the Republic of Georgia, Zviad Gamsakhurdia, contacted the U.S. State Department to inquire about sending some of the seriously injured patients to the U.S. for reconstructive surgery. The U.S. State Department informed him that this course of action was possible but suggested, instead, that the casualties be treated in the neighboring Republic of Armenia, which already had an American-trained plastic surgical team in place. The transfer of these patients to Armenia was arranged, and many civilian casualties were treated by the Armenian team.
In subsequent years, the team developed an academic training program in plastic surgery at the Yerevan Medical Institute. The training program was established by Dr. Stamboltsyan and two additional surgeons—Armen Hovhannesyan, MD, who trained in Moscow, and Artavadz Sahakian, MD, who trained in France. These three surgeons trained three more plastic surgeons between 1994 and 1997. One of these surgeons, Gevorg Yaghjyan, MD, came to Yale for a year of research in plastic surgery. Dr. Yaghjyan returned to join the faculty at the Yerevan Medical Institute and established an academic foundation for the residency program in plastic surgery; he later became deputy dean of the medical school.
The team has trained 46 plastic surgeons as of December 2015 and now has a certifying examination issued by the Armenian Board of Plastic Surgery.
Dr. Stamboltsyan became Minister of Health (1997–1998) and then returned once more to lead the PRSC. He was elected to Parliament in 2003 and became Chairman of the Committee for Health.
In 2005, Dr. Stamboltsyan and four of his colleagues (Drs. Hovhannesyan, Leon Torosian, Karen Danielyan, and Yaghjyan), formed the Armenian Association of Plastic, Reconstructive and Aesthetic Surgeons. In 2007, together with their colleagues from the Republic of Georgia, this association hosted the First International Congress of the Armenian Association of Plastic, Reconstructive, and Aesthetic Surgeons.
I attended the 4th International Congress in Yerevan in November 2013 (see photo above). It was the eve of the 25th anniversary of the earthquake in Spitak, and the meeting took place in the Madetaran amphitheater, a library of historical documents dating back two millennia. Papers were presented over three days by plastic surgeons from Armenia, Georgia, Russia, the U.S., Austria, Poland, Germany, Spain, and Japan.
We learned quite a bit from this experience, including the following lessons:
- Don’t be afraid to aim high.
- If an opportunity arises, from a tragedy or a necessity, be aware that powerful allies are willing to help.
- Governments are more than willing to take chances on unique programs if they have the potential to benefit many of their citizens.
- Many sources of financial support—from individual donations to foundations to governmental agencies—are available.
- Regulatory agencies are more than willing to offer guidance and identify unique mechanisms of certification.
- Many resources are available in our own institutions that are willing to contribute to the success of the endeavor.
- We can rely on the assistance of many individual supporters.
The accomplishments of this team of professionals have proven to be extraordinary, thanks in large part to the help of our colleagues in New Haven and across America. This team of health care professionals from Armenia, who sacrificed so much, has remained together and has worked to further the training of countless others in their home country. Above all else, their success can be attributed to their choosing empowerment over charity.
This article is based on Dr. Ariyan’s presidential address at the annual meeting of the American Association of Plastic Surgeons, April 12, 2015, Scottsdale, AZ.
*Barringer F. The Gorbachev visit; Thousands feared dead in Soviet caucasus quake. New York Times. December 8, 1988. Available at: www.nytimes.com/1988/12/08/world/the-gorbachev-visit-thousands-feared-dead-in-soviet-caucasus-quake.html. Accessed December 7, 2015.
†Brooke J. As centralized rule wanes, ethnic tension rises anew in Soviet Georgia. New York Times. October 2, 1991. Available at: www.nytimes.com/1991/10/02/world/as-centralized-rule-wanes-ethnic-tension-rises-anew-in-soviet-georgia.html?pagewanted=all. Accessed December 7, 2015.