In this conversation, Kai and I discuss what drew him to a career in healthcare, specifically cardiothoracic surgery.  We also discuss his passion for international health and how that led him to create MYHEARTUS.  We then discuss the “Golden Hour Mandate” and the impacts of that mandate on practitioners of healthcare. Enjoy the conversation.

Todd Schlosser: Thank you so much for joining us here on Scrubbing In. Today my guest is Dr. Kai Engstad who is a cardiothoracic surgeon. I’d like to start off every episode with this Dr. Engstad, and that is a simple question about what got you in or interested in healthcare. What was it that happened that made you want to go into surgery as a field?

Dr. Kai Engstad: I come from a nonmedical family, so I didn’t have the usual family influence that many physicians have. I was always as a kid growing up always interested in science and somehow just developed an interest in medicine early on and kind of decided that healthcare was where I wanted to go and really just never stopped.

Todd Schlosser: It sounds like there wasn’t any influence in your family because it sounds like you were sort of the first person in your family to do medicine as a career. Were there other people outside of your familial circle that you might consider an influence or a mentor that got you into it or was it just a general interest in science that sort of got you into it?

Dr. Kai Engstad: I always kind of leaned towards medicine because it was kind of the combination of science but also kind of the human aspect. I’d been an athlete in high school and ended up having a need for multiple orthopedic surgeries and kind of became somewhat friendly with my orthopedic surgeon. During college, I traveled to Uganda in Africa where he was doing some work and kind of joined him. Certainly that nudged me towards medicine and surgery in particular.

Todd Schlosser: Awesome. And traveling. which is something that you do quite a bit of, we’ll talk about here in a little bit. The general interest in medicine kind of got you into medical school. You went to St. Georgia’s University School of Medicine, correct?

Dr. Kai Engstad: I did.

Todd Schlosser: What is it that got you to that school specifically? That’s in Grenada, correct?

Dr. Kai Engstad: Yeah. I was always really interested in international healthcare and medicine. To me that was kind of a perfect mix of medical education that was going to suit me well for practice in North America but also getting the opportunity to spend a couple of years living abroad and having a little bit of a different perspective on medicine.

Todd Schlosser: Does the medical training that happens in a school outside the US, like an international school, does it differ drastically from a traditional sort of domestic schooling that you would get for medicine?

Dr. Kai Engstad: Other than the setting, no. The school is pretty much set up to prepare people for practice in North America. The curriculum is designed to provide people with the knowledge they need to kind of come back and practice in the states.

Todd Schlosser: It still does have a Western medicine approach to health?

Dr. Kai Engstad:  Yeah, absolutely.

Todd Schlosser: Okay. Speaking of that, you did come back to the states after you graduated from the St. George’s University School of Medicine, and then I believe you went to New Jersey and did a residency at… Was it Saint Barnabus Medical Center?

Dr. Kai Engstad: Yeah. I did my general surgery training and finished up at Saint Barnabus.

Todd Schlosser: You eventually ended up at Oregon Health, and that’s where you did a fellowship for cardiothoracic surgery?

Dr. Kai Engstad: Yeah, exactly. I finished up general surgery in New Jersey and then moved out to Oregon at the Oregon Health Sciences University and completed my fellowship in CT surgery.

Todd Schlosser: And Oregon is where you call home now, correct?

Dr. Kai Engstad: Yeah. It’s a pretty nice place to live, so I didn’t have much desire to leave once I got here.

Todd Schlosser: Fair enough. I will say this. You do leave quite a bit, you just come back because it seems like you travel quite a bit for what you do now, and it seems like you’ve incorporated your passion for sort of international health and travel and medicine. I’d like to speak a little bit about MYHEARTUS where you’re supporting the development of cardiac surgery in Myanmar. Is that correct?

Dr. Kai Engstad: Yeah, absolutely.

Todd Schlosser: Is that something that you started or something that you joined?

Dr. Kai Engstad: I started MYHEARTUS as kind of a nonprofit to help support some of the work that we’re doing over there. Originally I’d gone to Myanmar with another organization, which does a really good job. They’re called CardioStart International. I just really hit it off with the surgeons there, and we kind of formed a nice relationship. They asked me to be kind of their surgical mentor. For the last four years I’ve been going there, three or four times a year for a week at a time mentoring them and helping them develop their surgical skills and independent cardiac practice.

Todd Schlosser: Can I ask a few questions around that specifically?

Dr. Kai Engstad: Absolutely.

Todd Schlosser: While you’re there during your week of mentorship, are you there with a team actually doing surgeries?

Dr. Kai Engstad: One of the things that really kind of attracted me to Myanmar and that group in particular is that they have a full operative team of locals, and they are slowly developing their skillset. When we go over, they decide what they want to work on, and then they select usually somewhere between eight and ten patients, and we talk about… We review what we’re going to do and then we generally do two operations a day for five days and then kind of debrief everything. They get kind of a concentrated experience into these various techniques that they want to work on.

Todd Schlosser: They sort of have their own setup. They have a perfusionist. They have an anesthesiologist. They have everything you need to be able to walk into the OR and sort of do and also teach how to do certain techniques and certain surgeries. Is that correct?

Dr. Kai Engstad: Yeah. They function independently, so they have their own anesthesiologists and perfusionists and surgeons, but they’re all relatively early on their learning curve and certainly there’s plenty of opportunity for education and increasing their skillset.

Todd Schlosser: You, in fact, just got back from Myanmar yesterday. You were there for a week teaching them. Is it a certain surgical technique, and you just do two surgeries a day for five days for just one certain surgery or is it a plethora of surgeries that they want to witness?

Dr. Kai Engstad: It’s a little bit variable. This last trip they had a specific interest in aortic surgery, so we did some kind of complex aortic surgery and used hypothermic circulatory arrest, which is something they haven’t had a lot of experience with, so that was a steep learning curve for both the surgeons and the perfusionists and the anesthesiologists. They’re all really quick studies and picked up on things right away and really did a fantastic job with good outcomes, which is always important.

Todd Schlosser: Let’s say you’re back home in Oregon now, and something comes up with your partners in Myanmar, I imagine the communication is still ongoing even though you’re in Portland. You may not be able to be there and show them on site how to do something, but I’d imagine they still reach out to you for mentorship but also guidance in surgical techniques and practices they should do. Is that sort of how that relationship works?

Dr. Kai Engstad: Yeah. That’s exactly right. Technology has been such an enabler at communicating with FaceTime and WhatsApp, and email allows us to review cases and answer questions that they have about cases that they’re going to do. And then we also are constantly working on didactic education, so I’m sending them articles to read and we discuss them. There’s really just a… It’s kind of a continuous ongoing project based mostly around what they’re working on at any given time. But, absolutely, we have a really close relationship and really we’ve become somewhat like a family.

Todd Schlosser: The work that you’re doing in Myanmar is that scalable to much more than just Myanmar through technology? Let me give you an example. I’d imagine you have a home hospital there in Oregon, is that correct?

Dr. Kai Engstad: Absolutely.

Todd Schlosser: If you were doing a surgery there, I know that cameras are nothing new in the operating room, so is there a way that they could sort of tie into the feed of cameras that you have there and witness you do a surgery even though they’re in Myanmar or wherever and you’re at your home hospital there in Oregon?

Dr. Kai Engstad:  Yeah. I mean certainly, the kind of concept of live broadcast surgery has been around for a while as well as recording operations or portions of operations that you can review and discuss. Certainly that’s one teaching tool that I think is quite invaluable. It’s always nice to be able to see something before you do it for the first time.

Todd Schlosser: Yeah, I mean that goes for anything, but I’d imagine doubly so in surgery.

Dr. Kai Engstad: In fact, I think that many surgeons for their own education now you can review on a variety of different sources, various videos of surgical techniques that allow you to improve your practice and develop your skillset without having to jump on a plane and go anywhere.

Todd Schlosser:  I also wanted to talk to you because I saw an article you wrote about the golden hour mandate, and I’ll just briefly paraphrase what that is for people who don’t know because I didn’t know until I read this article. Again, if I mess this up on any level, please correct my assumption. It’s the mandate that if you’re injured in a war zone you need to be treated by a hospital within 60 minutes of when you receive that injury. Is that the golden hour mandate?

Dr. Kai Engstad: Yeah. There’s kind of the concept of the golden hour, which has been around for a long time, which is achieving definitive care for severely injured patients within an hour. Certainly in combat the earlier you get to patients, the better that they do. During the global war on terror, the military had adopted and, in fact, mandated this kind of premise that injured soldiers should receive definitive surgical care within an hour. Obviously, that requires not only a tremendous amount of logistics in order to get medical care close to where people are being injured but also making sure that the people that are staffing those facilities are well trained, competent and able to provide the care.

Todd Schlosser: Before we dive into sort of someone with those logistical challenges, and I guess sort of what that clause is, I’d like to ask sort of what got you interested in that specific topic, the golden hour mandate, but really just healthcare on the front, if you will?

Dr. Kai Engstad: Sure. Well, apart from doing cardiac surgery in Myanmar, I’ve had an interest in humanitarian surgery and surgery in conflict zones. So I spent time in Northern Iraq and Kurdistan. Certainly in that environment, there’s the combination of military injuries as well as civilians being injured in combat zones. I’ve kind of developed an interest in that. I’m actually working on a master’s degree right now related to that, and I’ve just become aware of a variety of issues including the fact that the military struggles sometimes to provide care within that golden hour. That was what kind of led me to write that article.

Todd Schlosser: In the article, you do mention a lot of senior surgeons are sort of leaving the military, I believe it was the Army specifically in large numbers even because you just reach retirement, which I believe is 20 years or they’re just not re-upping. Is that directly related to the golden hour mandate, do you think?

Dr. Kai Engstad: Yeah, I think it’s multifactorial. I think that you have people that just for a variety of reasons are leaving whether that’s through planned retirement or deciding to leave, but also when there’s active combat unfortunately that’s when people gain a lot of experience in a short period of time. As the tempo of war slows down, the kind of knowledge skill, just like anything in life, if you’re not doing it on a regular basis, you tend not to be as good at it. All of those things coming together have created this kind of perceived crisis that a lot of people are talking about.

Todd Schlosser: Can you go into a little bit specifics about what that perceived crisis is?

Dr. Kai Engstad: It’s really a matter of two things. One is our current military surgeons having enough surgical volume to maintain their skillset, so that’s one component of it, especially as more senior surgeons are leaving the military. The second is that when you have a large number of troops in the field you have the infrastructure to support them. You have field hospitals. You have logistic support. You have medical evacuation capabilities, and that was fairly well developed both in Iraq and in Afghanistan as the nature of conflict changes and people are moving into Africa and other areas where you don’t have that same level of logistic support and medical support, and that tends to change a little bit.

Dr. Kai Engstad: Whether or not it’s actually feasible to have definitive surgery within an hour or for some combat operations is something I think the military is struggling with a little bit right now.

Todd Schlosser: What do you think are some possible solutions to that perceived crisis as you put it?

Dr. Kai Engstad: I think it’s training. It’s certainly from the military side they’re looking at skilled transfer from physicians to medics who are practicing at a fairly advanced level, so they’re able to push forward some of the care that would’ve traditionally been provided by physicians into medics that are closer to the action so to speak. It’s also perhaps accepting that sometimes care won’t be able to be provided within the golden hour so to speak and just making sure that everybody understands that war is a difficult thing and you can’t always have that backup. But I think it’s important both for the public as well as the solider in the field to understand that and make sure that not everybody has an honest expectation.

Todd Schlosser: If you had advice to give surgeons who are sort of in the same place of their career that you are, what might that advice be?

Dr. Kai Engstad: One of the things that I’ve just found tremendously satisfying is being able to share the knowledge that I’ve gained in cardiac surgery with my colleagues abroad. There’s just an absolutely tremendous need for cardiac surgery training around the world and people are really hungry for it, and it’s extremely satisfying. We all get burdened a little bit with politics and hospitals and rules and regulations and paperwork and the electronic medical record. Doing international work is really, I find, tremendously refreshing and you come back pretty recharged. I’d really encourage people to get involved in whatever way they can because we’re all extremely lucky to be cardiothoracic surgeons in the US. We’re just extremely privileged and it’s nice to be able to share a little bit of our privilege with others.

Todd Schlosser: Well, Dr. Engstad, that is all the questions that I have for you. Thank you so much for joining us here on Scrubbing In. I appreciate your time.

Dr. Kai Engstad: Very much appreciate it. Thank you.