December 21, 2020
Remote teaching of flexible endoscopy from New York to Kyabirwa, Uganda – a report from Jerome D. Waye, MD, Professor Emeritus at the Icahn School of Medicine at Mount Sinai, New York, USA.
A few years ago, the chief of surgery at Mount Sinai Hospital in New York, where I have been on the staff for 62 years, asked me to go to Uganda to teach a course in endoscopy. This year, I retired as of January 1, and was scheduled to go to Ethiopia where the World Endoscopy Organization has been developing an endoscopy training center at St. Paul’s Millennium Hospital and Medical School. I informed Dr. Michael Marin, the director of surgery for the entire Mount Sinai Medical System that I would visit his unit in Uganda, following my Ethiopian teaching session, during the second week of February, 2020 as a continuation of the WEO program for teaching in underserved areas of the world.
Arrival in Uganda was followed by a 4-hour drive with the last hour on a dirt road. I was awed when I saw the Kyabirwa Surgical Facility built by Dr. Marin. It is a free-standing multiroom fully self-contained one-storey building. It has two fully equipped operating rooms and intake areas, assessment rooms, and teaching and conference rooms, and has a recovery room to rival any in the US. Power is supplied by solar panels, there is a purification system for well water, and the waste disposal system is highly advanced.
The chief surgeon, Dr. Joseph Damoi, greeted me along with six other Ugandan surgeons who had traveled from various parts of the country to attend “Endoscopy Camp.” None had any prior experience in endoscopy and all wanted to learn some basic techniques which they may use to further develop some skills in endoscopy if and when their hospitals should acquire endoscopic equipment. The first day was spent in orientation to flexible endoscopy and my demonstration of both upper and lower procedures in one of the air-conditioned operating rooms. I had previously requested an Olympus demo tower and scopes. This equipment almost did not materialize because of customs difficulties, but Mr. Hugo Craven (Olympus Dubai) fixed the problem and sent a very knowledgeable technician from Nigeria to assist in the setup. This was invaluable as the technician took great care to demonstrate safe handling and disinfection of the equipment and monitored several of the staff through the cleaning process. The rest of the week was devoted to one-on-one teaching, with rotation between upper and lower procedures using the two scopes provided. Everyone had at the opportunity for hands-on practice. Safety was stressed in the operating room as well as in my slide lectures and videos which started off each day.
Dr. Marin traveled to Uganda with me, and I met with all 26 of the staff members, including doctors, nurses, technicians, clerks, maintenance people and administrators. All of the staff were hired from the surrounding community, which had previously had no access to surgical care before Dr. Marin had the vision to build the Facility. International surgical development has always been a part of Dr. Marin’s vision: all of his Mount Sinai surgical residents rotate through a hospital in Honduras, and he also organized a full surgical team to travel to Haiti following a devastating hurricane.
As I left Kyabirwa, Dr. Marin asked if I could continue to train Dr. Damoi in endoscopy when I returned to New York. However, I was skeptical about the safety and practicality of long-distance endoscopic teaching, and also because of having to travel to the Mount Sinai Hospital to access the direct line to Kyabirwa. One of the design prerequisites of the Surgical Facility was the ability to transmit televised procedures between Uganda and Mount Sinai. Thus, when the Facility was being built, Dr. Marin had a 20-mile trench dug (by hand) from Jinja, the nearest city, in order to install a high speed fiberoptic internet cable. In fact, I could access the signal from this on my home computer.
I was concerned about the time lag between what Dr. Damoi would do and what I instructed him to do, but my concerns disappeared with the first encounter: I logged in from home and found that the speed of transmission was instantaneous. I was able to view a split screen with Dr. Damoi’s hands on one view and a simultaneous scope view from a camera aimed at the monitor screen atop the Olympus tower. Our two-way conversation and the absence of any lag between what he was doing and what I was seeing gave me the feeling that I was right beside him, coaching his every move, just as if I were in the endoscopy suite at Mount Sinai teaching a procedure. We both saw the same screen and I had a view of his hands. If I said, “push the forceps in a little bit further,” he immediately did so. The only difference was that I could not tap him on the shoulder if he used the up control when I said, “tip down.”
Over the past several weeks, we have seen esophageal carcinoma, gastric atrophy, duodenal ulcer, colon tumor, and diverticular disease, and have changed a diagnosis from dysphagia related to achalasia to food getting stuck at a Schatzki ring. Dr. Damoi has reached the ileocecal valve during every colonoscopy that we have done together and is becoming much more comfortable with flexible endoscopic procedures, providing a service to the community that had not been possible before.
Remote teaching of flexible endoscopy is possible and feasible. In these days where travel is difficult and the internet is becoming an increasing part of everybody’s lives because of the COVID virus, we can still reach out and teach in areas where the usual teaching techniques are not currently possible, and do it safely and well. Other students as well as multiple teachers can participate during these sessions via one of several internet programs. We currently use the Zoom platform. The internet provides a great capability to reach out and teach what we usually do in a one-to-one apprentice fashion: eye–hand coordination based on simultaneous intralumenal visualization with continuous verbal coaching.
For the technical aspects, the key seems to be that the internet bandwidth need not be more than 15 Mbps upload and download, but that a part of the bandwidth (perhaps 10 Mbps) is dedicated and reserved for remote teaching purposes. Our system is a fiberoptic feed (although a dedicated cellular line could be used) where the transmitting computers are wired directly to a local area network (LAN), not connected through wifi.
Author: Jerome D. Waye, MD, Professor Emeritus Icahn School of Medicine at Mount Sinai