Global Engagement Spotlight: Dr. Lawrence Cai

By Mohammed Al Kadhim

Dr Lawrence Cai is a 4th year plastic surgery resident and is the Donald Laub International Fellow for 2021-2022. He is engaged in global work through ReSurge International, an international non-profit organization that focuses on improving reconstructive surgery practices and patient care outcomes in all over the world.

He first started working with ReSurge International while in medical school at Stanford through a program called Design for Extreme Affordability. Extreme creates small groups from about 40 students hailing from across the University, putting them into teams of four to do projects in partnership with non-profits working in low- and middle-income communities and countries. His group was tasked to work with ReSurge International “How to improve burn care in acute setting (patients in the hospital or the operating room).” His team ended up created infrastructure for a skin-bank.

Burns are a major burden of harm in many developing countries due to open fire cooking practices and other socioeconomic differences. In the US, the treatment of burn care can include the temporary grafting of cadaveric skin to cover the wound as temporary measure until it is ready for grafting with the patient’s own skin. But in Nepal, where the team was assigned to work, there was no system nor the infrastructure for this approach. Even the concept of skin and organ donation was un-common, in part due to the Hindu culture and prevailing beliefs of the population. The team started by creating a public awareness campaign to encourage Nepalis to help other people by signing up to donate their skin after death. This work ended up lasted for about three years during which he travelled several times to Nepal.

Dr. Cai has been proud of the progress of these efforts. After a couple years of hard work to establish the foundation for a skin bank, the local hospital in Katmandu continued to obtain skin donations from locals and use them to treat burn patients. Some of the biggest challenges to overcome were the beliefs and culture norms that were major barriers to donation, yet the program was successful even without further intervention from ReSurge International.

In addition to the skin back work, he is involved in two other projects; the first is to quantify the impact of surgical training both in the US and in the international setting. He elaborated by stating, “Here at Stanford we have 40-50 attendings to teach us while, for example, in Zimbabwe there’s a total of 3 plastic surgeons in the whole country. So, the question is how to quantify the impact you [as a teach] have directly and how that impact propagates as a multiplier effect to future generations.”

The second project he is working on is helping ReSurge International design an online plastic surgery curriculum with The College of Surgeons of East Central & Southern Africa (COSECSA) so trainees learn to become plastic surgeons. Surgeons from the US design and record lectures for specific teaching modules and surgeons in COSECSA submit cases illustrating teaching points and demonstrating techniques and approaches. He went to Zimbabwe over Thanksgiving to introduce some of the curricular content and solicit feedback on how to craft material that meets trainee needs.

We asked him about some of the differences he observed in work and resources between the US and some of the settings he worked in. Dr. Cai said that the comparison is astonishing and even hard to

imagine. He gave examples of electricity cutting out while in the OR performing a skin surgery, and staff pulling out their cellphones for light and continuing the job. In addition, with the frequent electricity breaks there is insufficient refrigeration for skin banking.

He learned a lot from the people he worked with, simple things like how they use their instruments or the kind of sutures they use. They are very creative in their work, and he saw how necessity creates innovation. He observed how truly creative they were in finding solutions with very limited resources, and he felt it made him with more flexible in situations he might be unfamiliar with.

Dr. Cai noted that it is crucial to spend the first period of time just observing and listening: “We cannot implement the solutions we created theoretically without knowing what the actual need is, how the whole system functions and whether our ideas are even possible to execute.” He added, “We cannot make one step forward based on what we think is best, we have to know what adaptations would work and what adaptations need to be changed or amended if possible.”

He stressed the importance of strengthening local capacities rather than implementing projects that will vanish after one leaves. “In the past, the trend was that a group of surgeons and nurses visit a country, teach on specific topics, operate on a number of cases, then leave. But ReSurge International has a different vision now and it is to provide what is actually needed and could be a sustainable resource to the local system.”

We asked Dr. Cai about what essential components are required to establish or engage in a global training activity. “You will need to identify strong and committed international partners first, you can’t help people who don’t really want your help or are not interested or engaged in working with you. There should be an equal mutual desire to develop something that would last even when you are not there.” He noted that non-profit organizations like ReSurge International help identify partners due to their experience in various regions and connections they have built through the years.

He noted that having leaders like Dr. James Chang and Dr. Tom Weiser is important, as they have the expertise and passion and can provide guidance in one’s approach. Dr. Chang was a huge inspiration to Dr. Cai, whom he met him after he had done his work with Extreme and a few ReSurge trips. Dr. Chang is the Consulting Medical Officer for ReSurge International and encouraged him to do a full year of research, allowing him to follow his passion and pursue the work that he loved.

“It is incredibly rewarding to see the impact you have both as an individual and as an institution. I want to continue doing global surgery in the future and I would strongly encourage interested residents to do such work. The earlier the better, that way you won’t have a lot of preconceived notions about how surgery is supposed to be done in an ideal setting, that way you can design programs based on what you have seen and what you believe is applicable in LMIC settings.”

We ended our conversation by asking Dr. Cai about any special memories he had. He smiled for a second then said: “While in the hospital, working with Dr. Shankar Rai was so special, he is full of energy and kindness. He has the passion and desire to do the best for his people and his hospital and his enthusiasm makes you want to do more and more. I think that Nepal is the spiritual home of my global surgery work. I’ve been there six times. In one of my visits, I had extra time, so I did a 12-day trip to an Everest Base Camp with a friend I met in Katmandu. We have some amazing mountains in California but being at

the Himalayas has a magical impact on you, waking every morning watching the sunrise, going on hikes at 15,000 feet and more is truly incredible, it’s such a peaceful feeling. Another time we went together with our colleague Mohan Dangol, a physiotherapist in Nepal, who took us to do karaoke at their home, dinners with the team and so many other memories I will cherish for the rest of my life.”

Dr. Cai brought a huge painting of Mount Everest that he placed on his wall at home. He looks at it from time to time and thinks of all the people that received better care because of the efforts that he was and will always be part of.