OMSNIC interview featuring Dr. Ratner
Dr. Ratner’s medical mission work began in 1999 with a trip to the Philippines to treat a boy from Nepal, and now extends to Vietnam, Nepal, Fiji and Indonesia. In 2007, he and Dr. Christopher Nguyen created the Open Heart Project with the goal of providing surgical and orthodontic support to children with facial deformities in Vietnam and Nepal. A key part of their humanitarian mission is teaching local surgeons and improving medical education and training systems at hospitals in those regions.
Described by colleagues as “a surgeon’s surgeon” for his skill at managing complex cases, Dr. Ratner has a full scope practice in Santa Ana and Orange and holds staff positions at UCLA School of Dentistry and St. Joseph’s Hospital in Orange.
OMSNIC: Tell us how your mission work began with that first trip to the Philippines.
Dr. Ratner: I got a call one day from an anesthesiologist in Manila. He asked if I would come to Manila to treat a nine year old boy from Nepal who had been unable to open his mouth since age two. An Australian dentist volunteering in Nepal had found him. They got him to Manila for care, but when he arrived, they didn’t have a surgeon who could operate the case. He had ankylosis of his temporomandibular joint, a very fixable thing, so I packed up my instruments and flew to Manila the next week. I reconstructed his joint, and while there, I also did a few orthognathic cases, and presented a full day seminar in temporomandibular joint surgery.
OMSNIC: Did that Manila surgery trip provide the connection to Nepal?
Dr. Ratner: Yes, that’s how it all started. In Manila, I met a Nepalese surgeon who had come to watch me do that surgery. In 2002 I went to Nepal to operate with him. We went out to the village to see the boy I had treated. He’s 26 now, and doing well. I have been to Kathmandu three times since then.
OMSNIC: How did you meet Dr. Chris Nguyen, your Vietnam mission partner?
Dr. Ratner: An orthodontist in our area referred Chris to me for evaluation. I did his jaw surgery in 1988. He was 22 years old, an undergraduate at Chapman University, and very interested in dentistry. From that point forward, he set his goal to be an orthodontist. He went to Boston University for dental school and orthodontic residency. When he finished, he came to see me and we’ve been fast friends ever since. In 2004, we were both invited to Vietnam with a group called Project Vietnam.
OMSNIC: What brought about that invitation?
Dr. Ratner: They invited me specifically to do bone grafting for their cleft patients. They had three plastic surgeons who were experienced in cleft lips and palates, but were unable to perform alveolar bone grafts. When we arrived in Lan Son, James Norris, the lead surgeon, informed me: “You’re an oral surgeon, not a plastic surgeon, so the only thing I’m going to let you do is bone grafting.” I replied, “Sure, whatever you want.” But as our days grew long, he asked me if I’d like to learn to do lips. My immediate response was “Absolutely!” We ended up doing about 40 lips together on that trip.
OMSNIC: Why did you and Dr. Nguyen create the Open Heart Project in 2007?
Dr. Ratner: Chris wanted to form a group to work with and train Vietnamese surgeons. I was all for that. With Project Vietnam, we had been operating on patients in small hospitals near villages in North and Vietnam. I told Chris that I wanted to operate in a major hospital where we could also share ideas with the local doctors. We interviewed at the Odonto-Maxillo-Facial Hospital in Saigon. After our discussions with the Chief of Staff and Chairman of Oral Surgery, they allowed us to perform triage on the patients who had come for our help. Although they were skeptical, once they observed us operating, the doctors were excited to scrub with us. It ended up being a wonderful experience for everybody, and we’ve been going back every year since.
OMSNIC: How do you typically work with local surgeons on an Open Heart trip?
Dr. Ratner: I usually bring one of my UCLA residents with me, and we always have at least one Vietnamese surgeon operating with us. We’ll do half a surgery and they’ll do half of the surgery. As we move along through the week, they end up doing more, and we watch and assist them. We also try to present a seminar to the local doctors on a subject of their choice.
OMSNIC: Tell us how your work in Vietnam expanded to include Hanoi.
Dr. Ratner: In 2009, about two years into our missions, the chief surgeon from Vin Duc Hospital in Hanoi contacted Chris. He said, “I’ve heard about your work in Saigon. Would you consider coming to Hanoi?” So we went to the North specifically to do craniofacial surgery. We spent all day in Triage, and ended up performing reconstruction on a couple of hemifacial microsomia cases and as well as osteotomies on a few cleft patients. Dr. Ha and his staff were very inviting and willing to let us be part of their educational system. Now we go every year or two. I’ve now been to Hanoi about eight times.
OMSNIC: How do you choose the patients for care?
Dr. Ratner: We basically operate on children, but a few adult tumor patients seem to get into our surgical line-up. They patients show up from remote areas of Vietnam to stay at orphanages until we arrive. First we do a day of triage to determine which patients are within our means to treat, and healthy enough for surgery. We typically see 80 patients, and out of those, we’ll operate on 60 of them.
OMSNIC: What’s your surgical schedule like with so many patients?
Dr. Ratner: Each surgeon will typically operate 5-7 cases a day. We start operating after rounds at 8 am. With three operating tables we can usually finish our cases by 7 pm. At least once or twice during each mission we will work until 11 or 12 pm.
OMSNIC: After surgery, how do you follow up with all of them?
Dr. Ratner: We keep all of our patients in the hospital until we leave. So we see every patient every day while we’re there. By the end of the week, we have 60 patients in the hospital. Rounds are always with the local hospital staff and includes a modicum of teaching. We address post operative management of our patients at that time. We see all of them post operatively on Saturday morning before we go home. The local surgeons often email me pictures and x-rays of our cases, and ask for advice when needed.
OMSNIC: Has working with Vietnamese surgeons influenced your practice at all?
Dr. Ratner: Yes, these surgeons very good at soft tissue work. Since so many teams travel to Vietnam, we see variable results in their work. The Vietnamese cleft lip revisions are superb. I have learned some great techniques from them.
OMSNIC: Have you seen an improvement in their education and surgical skills over the years?
Dr. Ratner: Yes, every time we go, the surgeons are better. Although they don’t receive a lot of didactics, their clinical training is intense. Almost everything is learned by doing. Due to expense restrictions, they don’t have access to our journals, and their instrumentation is extremely limited. So we bring books and instruments for them. They’re very capable and they are like sponges, soaking up as much knowledge as we can supply. It’s a joy to operate with them.
OMSNIC: Is limited instrumentation a problem in many of the regions you visit?
Dr. Ratner: Yes, there’s very little power instrumentation – electrically powered drills and saws are too expensive. What they have has mostly been donated. The equipment is old with a tendency to fail right when you need it most. So we bring as much as we can. Their resources are so limited. The first year I went to Fiji, I really couldn’t do any surgery because I had no power tools. One time in the Philippines I used a drummel drill I bought at a hardware store to reduce an ankylosis.
OMSNIC: What brought you to Fiji?
Dr. Ratner: You meet people as you travel. In 2012, a group of surgeons invited me to do cleft surgery on Taveuni, an island in Fiji. While I was there, they decided I would be more useful working in one of the major hospitals. Having so little experience in Maxillo-facial trauma there was a real need for didactic and clinical training. I gave a full day seminar on facial anatomy, surgical approaches, fracture reduction and fixation at Labasa Hospital. I’ve now been operating at that hospital for the past three years.
OMSNIC: Indonesia is your most recent endeavor. How did that begin?
Dr. Ratner: An orthodontic educational group here in California asked if we’d like to go to Sumatra. An Indonesian family has set up medical and dental schools at the Royal Prima Hospital in Medan. One brother is a doctor and the head of the medical school. A sister is a dentist and the head of the dental school. Another brother is a contractor and built the hospital. It’s awesome.
OMSNIC: What specifically will your role be?
Dr. Ratner: They want our help setting up a craniofacial team. We said we’d love to do it as long as we can involve the local surgeons in the process.
OMSNIC: What would you like to see the next generation of OMS do to improve the practice of oral and maxillofacial surgery around the world?
Dr. Ratner: I’d like to see OMS education become more global with greater access. Knowledge has become such an expensive commodity and it’s unavailable to many surgeons in poorer countries. Sharing ideas and techniques should be seamless, and travel should be in both directions: doctors going back and forth between underdeveloped countries and places with access to newer techniques and equipment. I would love to see that.