Episode 21

Technology Disruptors in Rural Medicine with Dan Leman - Part 1

Episode Transcript

Dr. Randy Lehman: [00:00:11] Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision.

Dr. Randy Lehman: [00:00:47] Welcome back, listener, to the Rural American Surgeon podcast. I have a very special episode for you guys today, something that I thought was a very interesting and compelling story. It has very, very much to do with rural medicine. And I welcome my friend and not relative, Dan Leman, spelled differently, to the show. Dan is a PA and he was involved with an interesting tech startup that had implications for treating people that are underserved in rural Colorado and other places. And so, Dan, thank you very much for agreeing to come on the show. I really appreciate it. To be here, thank you. So tell me a little bit more about yourself, your PA training, what you've done throughout your life, and what you're doing for a career now.

Dan Leman: [00:01:32] Yeah, no, thanks. So I started in medicine as an EMT on an ambulance here in Colorado and worked in the ER for a while and decided that I didn't want to be a doctor because who would want to spend that much time in school? And I was also married and had children at that point in time, too. And so with that, went to PA school and did that when I was 25 and came out working in urgent care and got bored.

And so pretty quickly, in maybe two years into being a PA in an urgent care, a friend of mine said, "Hey, you remember that old ER doc that used to work for? He started a telehealth business and he's looking for a PA. Why don't you check it out?" And so I called him up and said, "Hey, I hear you're looking for a PA to do telehealth. I don't really know what it's about." You know, this is 2018, so pre-Covid. And so we met in a coffee shop and it was just him starting a telehealth business.

And really his vision at the time was Colorado, and specifically Colorado Medicaid will reimburse for telehealth. And there's a real need in rural Colorado for that modality to actually bring care to patients. And so early on, he said, "That's what I want to do, I want to be able to bring care to where it's not through technology." Then became my partner was he had developed his own software, he was an ER doc by training and had done that for 20 years, but decided that that was where he wanted to go.

And so I worked for him for a while doing telehealth and we can get more into that over time. But we developed not just the telehealth platform, but through Covid, did some special projects, ended up developing some of our own hardware and getting to a spot where we were working both in Colorado and even in other spots around the world with our hardware. And it was going okay. And there was a lot of potential there. But for a variety of reasons, I transitioned out of that business and moved into a kind of a career pivot to work for a nonprofit organization with a mission focused and specifically involving Haiti.

And so you've been involved in Haiti as well and you've worked at the same hospital? Actually, I had done some training at Bonefin Hospital when in PA school and some ties down there with my wife's family. And so I ended up working for now for the last almost three years for this nonprofit out of medicine almost entirely. But there is a hospital that is underneath that management now and several other different ministries that we operate in the country of Haiti.

Dr. Randy Lehman: [00:03:59] Yeah. So to be specific, our church is involved in international missions in multiple ways. Haiti was we've been in Haiti since the 70s and we have several different things. Child sponsorship, some construction things, some orphanage interests and hospital interests. Not maybe all under the same umbrella. Very good.

And that is, you know, there's rural surgery in America, which is really what this podcast is about. But I also do some international missions myself and I think that there's an extension. I know there are a lot of people that are developing rural surgery tracks in the United States and some of the people that are interested in developing those tracks to better serve the needs of rural America are also interested in international missions.

And certainly if you're going to be a surgeon and you're going to go to Africa or you're going to go to any other developing country and volunteer. If you go and have the ability to do a C-section, it might save a life or some of these other subspecialty things that are outside of maybe traditional general surgery. And then also just being able to be flexible. I mean, I that's the first I'd heard of rebar for external fixation, but I do know that they've used mosquito netting for hernia repair in Africa.

Certain things. You're not going to have the full tray of things that you normally have at your hospital back in the United States. So for the How I do it section of this podcast, I want to talk about what exactly you guys did with this telehealth. What was the software, what was the hardware? How did it go both in the US and abroad, and then where is it now and everything and why. So let's start with first off, what was it?

Dan Leman: [00:05:49] Yeah, so it started with just software and the development there was kind of the early stages of a waiting room software where people could come in electronically, be in a waiting room and get pulled out for to different docs. And so it had the capacity to be able to connect different patients to different specialties. And there's a lot of pieces there.

And so that part was developed before I came on board. And I think maybe one of the lessons from that is one, software development is super expensive, especially then maybe AI is changing that and the use cases are ever changing. And so to jump into the software game takes a lot of capital, but it was worth it at the time.

And so we used that for a while. And then through Covid, the state was asking for some help with their jails to be able to do telehealth in the jails and connect better their patients, both for behavioral health and for medicine. And so we got into starting to provide some products.

And with that, there was our desire, as we provided urgent care around the state, was how do we get the data that we need so that we're not just making educated guesses, but we don't really need to be there for a lot of these things. How can we connect in patients? We started bringing together technologies and ended up developing what ended up being essentially a briefcase that with a trained person, had heart and lung sounds via a stethoscope, an EKG, ear, nose and throat skin camera, all with a battery pack contained, and then cameras and screens that the operator, the doctor, could operate from afar so they could move things around. All of that was in one briefcase. 

And then with that, we would train individuals to be able to carry that and be the hands basically of the doc to be able to get a good exam. So that developed with a with another partnership with the Colorado Coalition for the Homeless, where we did a street outreach program with them, where we actually developed backpacks. So we could take those briefcases on somebody's back, we'd have legs pop out of the backpack and they could just set up shop right on the street. We would see patients right like that with a nurse who would go out with that and then connect. And in that case, and in rural Colorado, we would see patients often who would say, "I would not have come in to get seen if this technology didn't exist because I couldn't. I can't drive an hour and a half to go see somebody." And that's how far it would be. But I have an EMT in my own hometown who can connect me in to be able to do this.

Dr. Randy Lehman: [00:08:22] Were you in any other states?

Dan Leman: [00:08:26] We did not. We just operated because we were probably one of the only telehealth programs to use PAs. And so we elected to keep our licensure just within Colorado. And so we did see all corners of the state, but we just stayed in Colorado.

Dr. Randy Lehman: [00:08:40] Okay, and then in Bolivia you said, right? What did it actually get used? Patients actually got seen there?

Dan Leman: [00:08:50] Yeah. So our patients... There's the two sides. We had the healthcare provision side that we saw patients, I was just in Colorado. And then our hardware and the briefcase and all of that, we worked with a lot of different programs. So we worked with a program out of Miami that was working for homeless. We worked with a program in Bolivia where this was a cardiology-specific program with Chagas disease. We partnered with a local public health organization and they had patients six, eight hours away from any cardiologist.

And so we went and trained a local health professional. So I went down there and trained them and had cases there and they're still using them, is my understanding, connecting those patients back to cardiologists to treat their Chagas disease so that they don't have to commute.

Dr. Randy Lehman: [00:09:39] That eight hours and they can do a tele-EKG.

Dan Leman: [00:09:42] Tele-EKG is live. And then the stethoscope is better than you would have around. Like you can use the stethoscope as a regular stethoscope, but then that transmits through to several cameras so that you can get a full exam on the patient. And so you can't do procedures necessarily that way. But for somebody who's getting just medication treatment, it was excellent. And we could do in their house. So we... We also set up a satellite and phone.

Dr. Randy Lehman: [00:10:07] And so last question on that. Are they still doing it in Colorado?

Dan Leman: [00:10:13] So the company is still seeing patients in Colorado. We closed down the hardware side of it. Why? A few pieces. So we really wanted to leverage the hardware with trained in Colorado, especially in EMT. We actually did a grant program where we developed a camper van with similar equipment. And that was going to go out, but the reimbursement model for it just wasn't there. There was a, I don't know if you're familiar with the ET3 program that was out for a little while that Medicare put out where they would reimburse for emergency calls to go to non-emergency room locations.

And so instead of forcing every patient, every ambulance to take a patient to get paid to an ER, they could use telehealth as an example. It never went through. Most insurances didn't really want to come the same amount for a telehealth visit. And so you're trying to pay for your doc, you're trying to pay for your EMT and your equipment, all of it. And you just... The reimbursement model wasn't there at that point in time.

And especially with the state, our big push there was with the state Medicaid population and the state really wasn't interested in enabling it to really do well. And so at that point in time, my partner's interest, the one who started it, was much more interested in the software and the telehealth side without the hardware. That was his skill set. My skill set moved more into the hardware side. And so when I moved on, it was better to shut down hardware. The other piece there... Sorry, I'm getting long-winded.

Dr. Randy Lehman: [00:11:45] Okay, we'll just cut it off.

Dan Leman: [00:11:46] Yeah, two-second sound bites, that's all you need. Iteration is hard. I mean, I think that's the other piece of it. It takes a lot of money to continue to build software and hardware and from a small business standpoint to get the capital and, and all of the different pieces in. We were talking about building, you know, batteries and bringing in components from China and you know, you're laser cutting some different things and assembling and like I was building these things in my garage for a while and that sounds cool if you're Bill Gates and you've made billions. But when you're not Bill Gates and you haven't made billions yet, it takes a lot. And it just wasn't, it wasn't worth the resources.

Dr. Randy Lehman: [00:12:27] Love it. So that brings us to the next segment of our show, which is a financial corner. And I had a thought about this. So I remember hearing about, or reading, I can't remember a New York Times article where they went around and interviewed people on the street. What is the most likely way that you're going to get rich? And when I heard the results: Number one was inherited, number two was win the lottery and number three was sue somebody.

Dan Leman: [00:13:06] Interesting.

Dr. Randy Lehman: [00:13:07] I was very disappointed when I heard the results.

Dan Leman: [00:13:10] You haven't tried any of those, have you yet?

Dr. Randy Lehman: [00:13:11] None. Yes, exactly. Not counting on them. My three at the time I thought about it, I think I heard about this maybe five years ago or so was, you know, step one, hard work would be the most likely, most reliable. Step two, investing. Step three was maybe invent something. And so that's where it ties into what you're talking about. Because if you can change just kind how something is fundamentally done, you can, you can and should be compensated well for that, my opinion.

And if people put more creative energy into maybe that, I mean I think there's a lot of creative energy that is being put into that. And I think that America has just been a breeding ground for all of this amazing technology and advancements. Just overall, the light bulb, the fact that we're recording this at night on, you know, Riverside and it's going to be podcast to everybody. It's, it's ho-hum at this point it's just unreal. You know, airplanes, combustion engine, jet engine, it's just amazing. And, and not that doesn't even mention all of medicine.

Dan Leman: [00:14:24] Right.

Dr. Randy Lehman: [00:14:25] Most of which the biggest breakthroughs were by accident. But that's all right.

Dan Leman: [00:14:29] Yeah.

Dr. Randy Lehman: [00:14:31] Still there's, there's a, there's enough energy being put in that. But if people would put that much energy as they would trying to sue somebody for some money, maybe just into some of those other things, definitely world would be a better place. I don't know where we would be exactly at, but I want to ask from a financial corner perspective for you to, to share some of the, as much as you can or know or feel comfortable, the financial aspect of inventing this software and it. Would you tell somebody else to try and do something like that? And what lessons did you learn?

Dan Leman: [00:15:05] Can I speak on the hardware side instead of the software?

Because that's more my skill set, the hardware side. So we went all the way with that backpack and the legs and all that. We wrote two or three—I wrote two or three provisional patents. And so we went down that road of thinking, you know, "Oh, we can be that Shark Tank inventor who's just going to get millions." And we were in that world to some degree as well, just floating around with other companies, talking to some VCs and deciding whether to go there or not.

I think there's a few things that I learned from it. One is—sorry, anybody who's involved with venture capital—but it's not a great environment. And for both my partner and I, the hype and the sleaze were not worth it. And so we made a conscious decision to not go that route, to not seek money, because we didn't want to try and oversell something.

I think the second piece was, when's the last time you've heard of an invention in the last 20 years that was just a single person who didn't just build it up? Everything with technology the way it is today takes a ton of capital and other pieces that come together to be able to invent that. So I don't mean to be a Debbie Downer—like I think there's a lot of potential there, but the percentage likelihood is low. Even some of the cool things that we were seeing with some of our others that we worked with in different startups, the ability for them to take the biggest step forward was less on the technology-specific side and more on a business model side that was innovative. And so I think that's like Uber, who took taxis and said, "All right, how can we use technology to disrupt this?" That to me is sort of the 20th, the current century invention is the disruption of the old into something new.

Dr. Randy Lehman: [00:16:50] Yeah, through software, which was not the... and the hardware piece kind of like came and... Yeah. So I... that's great insight and it's kind of what I expected you to say, actually, but... All right, great. Let's move on to the next segment of the show that's called the Rural Classic Rural Surgery Stories. These are the stories that your counterparts in the urban environment would never believe. And I actually had a story for this since...

Dan Leman: [00:17:17] Yeah, I'm not a surgeon.

Dr. Randy Lehman: [00:17:19] You're not a surgeon, and I happen to be. And we have this connection with the hospital in Haiti. I had a story from there. So it doesn't get much more rural than Bonne Fin, Haiti, literally.

Dan Leman: [00:17:32] Can I describe it?

Dr. Randy Lehman: [00:17:33] Yes, please.

Dan Leman: [00:17:34] So I think it's worth noting that the hospital there is—I mean the town itself is 400 people, if you can call it a town. It's a 120-bed hospital, four ORs. So the hospital compared to town size is just ridiculous. The road to get there from the main highway, which is paved, is, I heard this week, 9.7 miles. It's unpaved and it takes probably an hour. And in the last three years, the rains have made it a lot worse. So the degree a four-wheel drive vehicle will make it and a motorcycle will make it. That's about it. Like, yeah, your Honda Accord is not going to make it up there.

Dr. Randy Lehman: [00:18:10] You need a mule.

Dan Leman: [00:18:11] You need a mule.

Dr. Randy Lehman: [00:18:12] And so, yeah, 9.7 miles an hour is your... If I'm doing the math correct.

Dan Leman: [00:18:16] You're doing the math correctly. Yeah.

Dr. Randy Lehman: [00:18:18] What made elevation?

Dan Leman: [00:18:19] It's like 2,300 feet.

Dr. Randy Lehman: [00:18:22] Best part about Bonne Fin, it's not so many bugs and it's cooler. The heat isn't so bad.

Dan Leman: [00:18:26] Yeah. On a motorcycle, I made it in like 23 minutes.

Dr. Randy Lehman: [00:18:29] Yeah, that's not too bad. 23 miles an hour average.

Dan Leman: [00:18:32] I'm sorry. No, that was from the main town.

Dr. Randy Lehman: [00:18:34] I got to do my math.

Dan Leman: [00:18:35] That was so just the dirt section. It was probably only like 12.

Dr. Randy Lehman: [00:18:38] Oh, okay.

Dan Leman: [00:18:39] That was a long time ago. Anyways, that's the setting for the hospital.

Dr. Randy Lehman: [00:18:42] Yeah. And you're an aggressive motorcycle driver, so.

Dan Leman: [00:18:45] You've never ridden that thing.

Dr. Randy Lehman: [00:18:47] So my story in Bonne Fin happened when I was a fourth-year medical student and I went to Bonne... When was that, Fin? It was in '15.

Dan Leman: [00:18:56] Oh, I was there just before you. I did my two months. I finished December of '14.

Dr. Randy Lehman: [00:19:03] Yes. So I came literally the next month and I was there for a month. And because you were baking cookies for all the staff, that's why they didn't like me as much.

Dan Leman: [00:19:12] Yeah.

Dr. Randy Lehman: [00:19:12] So this happens to me everywhere I go. So basically, the team had an orthopedic surgery team coming for one week. I was there as a one-month med student elective rotation, basically in Global Health. And I spent time in the ER, but obviously spent as much time as I could in the operating room, operated with some of the Haitian doctors, the Haitian OBGYN in particular.

That first week was by far the most impactful, but in a negative way. And what it gave me is, you know, we learn from our mistakes and mistakes of others. And that's one of the things that I hope to do with this podcast is share, you know, as much as is appropriate, lessons learned. And one lesson that I learned from this particular experience was that I had a... We had a patient that was a, you know, a young man, a healthy father of five, and he had a motorcycle accident and he's laid up in traction for a couple months waiting for an orthopedic team to arrive at this hospital.

Motorcycle accidents are pretty common down there. His... He is alive. Right. But he ended up having a hip fracture, a femur fracture, and a tib-fib fracture. And we had... Here we are an orthopedic team so the patient was listed for surgery, went for a repair of all of his fractures in one big whack. Well, monitoring intraoperative labs, you know, things like this, it's... It's not the same in that environment. And the patient really was actually fairly stable through the operation, but the operation took a long time and not necessarily longer than normal. It's just that there were three separate pieces to the operation.

And after the surgery, we took the patient to the hallway and then he coded and just went unresponsive and no pulse brought him back in. We resuscitated him and got labs and things. And it turns out, you know, what we didn't really notice—in the United States, maybe, you know, we would have more of a robust monitoring system intraoperatively, and there would be also all sorts of resources available to us, such as transfusion. But there was a lot of blood in the sponges and two full suction canisters essentially of blood just from sucking throughout the case. While, you know, the operating surgeon's so focused on... on the task at hand.

The patient's hemoglobin ended up being three when we drew it while we were doing the resuscitation. So after we found the patient's hemoglobin was 3, we had to weigh our options and we had no blood available. Now they, because of this experience, they've actually created more of a walking blood bank from my understanding at Bonne Fin. You aware of this? I think there is, or there was at least talk of developing…

Dan Leman: [00:22:34] They're connected with the blood bank down in Les Cayes in town. And so there's some of that, but I don't know if they carry, I should know that, but I don't know if they carry like, oh, blood there.

Dr. Randy Lehman: [00:22:42] Or anything like just having a listed group of people that they know what their blood types are that they could call them. That's why I made my walking blood bank and come in and donate now.

Dan Leman: [00:22:51] Yeah, or maybe they do.

Dr. Randy Lehman: [00:22:52] I think that they do.

Dan Leman: [00:22:53] Yeah.

Dr. Randy Lehman: [00:22:55] Well, long story short, we didn't have any of that set up at that time. And we didn't have an ICU. We just had a hospital floor. We had the operating room, you know, at. And there the team was, you know, a very limited team of people.

And if I had it to, you know, if it was a year or two later and I'd done my ICU rotation, you know, I was at that time not really much of a meaningful contributor as a fourth year medical student. But basically we, our only option was we transfer the patient back to the floor and give him fluids because he was no longer bleeding. It's just, you know, sustaining that.

So we resuscitated him, but we had to send him back to the floor and then he ended up dying that night. And effectively, you know, any good that we did from that whole trip in terms of a utilitarian aspect is totally undone by the, you know, five orphan children that are, you know, orphaned, but, you know, they're left with a single parent and just makes you feel terrible.

And there has to be a lesson that has to be learned. And I think that people need to hear this, especially you're considering international missions. You have to be first, do no harm. And it's not that we are trying, obviously we're trying to do our best, but then the outcome is just so miserable. So that's the rural surgery story, that it's really an international surgery story. It's still relevant, I think, to rural America, because, you know, when you're in a hospital that has no ICU, doesn't have cardiology, doesn't have dialysis, that we're all practicing in these critical access environments, then you have to consider, you know, should I take this patient?

And then there's elective versus emergent patients that present to you. And I'm living the same conundrum that you all are on each individual, you know, given patient. And it also depends whether you're in rural America in a place where you're six hours by fixed wing aircraft to a referral center, or if you're like where I am in Indiana and you've got ICU capabilities 45 minutes away by ambulance or two hours to Indy or Chicago.

Dan Leman: [00:25:09] So can I poke you on that story just a little bit?

Dr. Randy Lehman: [00:25:12] Sure.

Dan Leman: [00:25:12] So two things that I think about. One is not related to missions in general. How does you operating in different settings? Because you operate in three different hospitals, right?

Dr. Randy Lehman: [00:25:23] Yeah.

Dan Leman: [00:25:24] Four. And so I think about like this team coming in and I've been on a bunch of different medical teams in different places around the world. I shouldn't say around the world, Mexico, Haiti and the mindset, it's when you're outside of your normal routine, it's easy to compromise something that you forgot that you took for granted.

And so would that kind of a surgery have... Even if they had elected to do all three repairs or whatever they did, what would have been different in the US when you think about just that some of the different pieces that are there, that even the surgeon coming into a new setting just took for granted and didn't think about. And what's the lesson like as you see yourself in different settings? How do you apply that today to make sure you're not... When something outside of the norm comes? What do you do differently when you have, you know, like I think we talked earlier, like a family member coming in. You don't have to share that story, but just that was outside of the norm. And all of a sudden normal things that you have in place are took for granted. How do you reconcile that or what lessons have you learned from that? How do you make sure that you don't miss something?

Dr. Randy Lehman: [00:26:29] Well, if you're a surgeon that is thinking about doing international missions, on the first time that I would go on an international mission, I would make your sphere of what you do tighter and make it more towards the middle, if...

Dan Leman: [00:26:48] Possible, have more precaution than you would...

Dr. Randy Lehman: [00:26:50] Yeah.

Dan Leman: [00:26:51] At home.

Dr. Randy Lehman: [00:26:51] Because there's these unforeseen things that could come up and make things harder at the time. Again, I was a med student, so I... I don't think... And I'm not an orthopedic surgeon, so the nuance of the repair and the choice of incisions and all this, I'm... I really don't know. But I assume the patient could have just stayed in traction. We fixed one fracture, go back to the operating or go back to the operating room another day after he's stabilized. And in retrospect, that would be the thing to do, the obvious thing to do, but they were only there.

Dan Leman: [00:27:23] I'm sure there's some thinking which I've seen a lot of, like, we're only here for a week. Like, if we don't do it now, this guy's gonna be in traction for three more months on this other whatever. And like, well, let's just compromise and get it done.

Dr. Randy Lehman: [00:27:35] Yeah. And so that's the question. And probably the surgeon now being a surgeon, I can just imagine. And doing international missions, the focus on doing the operation well. And the missing of the big picture was probably the down... The... One of the big downfalls there.

So that's the other thing you want to do is what's the perception of the community or the family on this scenario? If... If he walks with a limp... Okay. Not as big of a deal as the worst possible outcome. So you have to really protect your downside risk for those worst possible outcomes and really be aware of it. Now there's... There's things that can happen. And I always say like this, the patient takes the risk, not the surgeon. And you know, you have, you have to focus on that, especially in those settings.

Dan Leman: [00:28:32] There's no liability in a sense for those, for those physicians. Yeah, I think that is something to keep in mind too of just... And you probably see it in the US as well in some of the more health illiterate population where it's so easy to come in and just be like, this is what we're going to do, this is what's best. And you know, to a Haitian, you're just like, wow, like an American surgeon is going to work on me, like it'll be perfect. Yeah, that's just the mindset that's there. And I think we can take for granted that doctor patient relationship gets diminished in those settings. People are excited like, oh for Jesus, we're going to come and do these things. It's like, well, but did you value that person enough? Like you would value your, you know, your wealthy patient back home or not to use wealth as a...

Dr. Randy Lehman: [00:29:16] There's so many lessons that the surgeon learns from the international missions. I would strongly encourage someone, I don't want to scare anyone away from doing international missions. There's so much, it's so refreshing. It can combat burnout. You don't have to wrestle with the computer.

Your patients generally are much more grateful you're performing a surgery that truly in the United States, if I didn't exist, most of the same operations are still going to happen. I'm providing certain things, I'm enhancing the quality of life in my county. There's things definitely doing that if I didn't, nobody else would. But not so much the actual surgery that you, you see when you go internationally. So please go. But you, you need to just go with an open mind, be thoughtful and then allow that experience to impact you just as much as you, you're impacting the people there.

Dan Leman: [00:30:08] Yeah, no, I agree. And I do think there's one other piece to that, which is going with or to a place that you, you fit into a system. Whether it's because of follow-up care or whether it's because you know, if there, if there is a local surgeon and then you show up, well, of course everybody's going to want to go to you. Like you're, you're Randy Lehman.

Dr. Randy Lehman: [00:30:29] Yeah, you don't want to hurt.

Dan Leman: [00:30:30] Right. You don't want to hurt that. But, but then also you do have things that you can leverage for that local surgeon. And so I think doing it within that environment, that's going to be best. As you already said, short term and long term.

Dr. Randy Lehman: [00:30:41] Yeah.

Dan Leman: [00:30:42] For the community that's there.

Dr. Randy Lehman: [00:30:44] I've never been with PACS, but I know a lot of several surgeons that have been with PACS. PACS is focused on training surgeons in Africa. Maybe we can throw a link through the show notes and in for that. We can also potentially link our organization as well.

Dan Leman: [00:30:58] Yeah, we're not sending medical teams right now. Haiti's in not a great spot so yeah, we can't really travel there. Although most of what we have been doing is teaching teams.

Dr. Randy Lehman: [00:31:06] Yeah.

Dan Leman: [00:31:07] At this point.

Dr. Randy Lehman: [00:31:07] So you'd like to do that. The book like "When Helping Hurts" - you know, these are all things that you need to think about. But for an individual that has no experience, I think going and doing and seeing is a good start. And then some people are going to really be, you know, called to that line of work and, and go on to do the things that really need to be done.

And people that are moving - have a good friend that's moving down to Honduras semi-permanently basically and in some ways probably giving up a practice in the United States permanently because it might be hard with that gap to come back. Many practices won't hire you back and there's lots of things.

So you know, for me now I have a trip that I go with BMDMI to Honduras now basically annually. I usually bring several people of my own team with. They have it all set up. They have pre-selected. It's run by a pharmacist and her husband, and she has a really good understanding of those types of risks. So the patients show up on the clinic day at the beginning with their EKG, their chest X-ray, their labs, all their imaging, their gallbladder ultrasound printout. They show me it's just, you know, choleolithiasis and they've been pre-selected for comorbidities.

So most of the people that show up and they get surgery but they see me and then they go see anesthesia afterwards and everybody has to agree and it's based on their experience that they've been able to kind of build this. So then we have much less in terms of follow-up mess that we, that we leave, you know, behind. But that's, you know, one big issue is who's taking care of the patient after you leave. That's always a question. So you just have to talk to the organization that you end up, you know, thinking about going with and, and trying to make sure that you leave things better than you found it. Just like you know, we do with everything right.