Snapshots from Vietnam

My first day as a volunteer doctor is spent at the Buddhist Pagoda in Hoi An. Karen and Nam, the head nun, have organised a list of patients. First is 4 year old Hien, who was left at the front door of the pagoda 4 weeks ago. Her mother may have AIDS or be too poor to care for her.

Hien looks unwell and has a swollen, discharging left eye. I think it could be periorbital cellulitis and start her on antibiotics.

Minh has dyspepsia. This is a common symptom here and I suspect helicobacter pylori is endemic. Eradication pack samples would be handy.

Dai Ngo, 67, has a cough. And no wonder, as she holds up her chest XRay and there’s a 20 cent sized piece of shrapnel in her right lung…a legacy from the war.

Cue Ng, 40, has hepatitis C. There is little intravenous drug use here in Hoi An, but plenty in Saigon and Hanoi. I’m told the HIV rate may be as high as 70%. A methadone/antiviral medication clinic is to start in Saigon…a first for the country.

Tuyet, 72, has claudication, which comes on after she has walked more than 2 kilometres... She is reassured.

Thao, 25, has obvious thyrotoxicosis with exophthalmos, tremor and tachycardia. She had a thyroidectomy in 2002, but has an enlarged right lobe easily visible.

I call it quits after seeing 35 patients.

Day 2: I travel by motorbike to the neighbouring province of Dien Ban, accompanied by Dr Josh Solomon, an American intensivist who volunteers in Vietnam for 9 months each year, and our interpreters, Anh and Vu. Each province has a dozen or so medical health centres staffed by nurses and medical assistants. Doctors do some of the sessions and the clinics provide immunisations, dressings and triage for the local hospital.

Many patients are rice farmers in their fifties with back and right shoulder pain. This is caused by degenerative disease from using the scythe in the fields. Paracetamol is dispensed.

One fellow is different as he has left shoulder pain….sure enough, he’s left handed!

Co Truong has a BCC on her neck, the first one Josh has seen in 8 years.

We finish with a home visit to 13 year old Thanh. He has AIDS and his parents have already died from this. He is cared for by his grandmother. Josh has treated him for 5 years, flying him to Saigon each month for antivirals, but he became resistant to the drugs. He has had a zero T-cell count for 2 years! There is a 10 cm ulcer on his right knee, the base is black and we suspect pseudomonas. Josh supplies ciprofloxacin but I can see he is very concerned.

I call in to see Hien back at the Buddhist pagoda. Her eye is now fine but she’s scratching at night. She has some bites on the palms and behind the ears…scabies.

Day 3. Home visits with Karen and Carmel, a volunteer nurse from Victoria.

Le, 37, has asthma. I give her a salbutamol spray and the “Josh spacer”.[an adapted plastic water bottle]

The next house is a hygiene nightmare. Son, 3, and his sister, Van, 9, have infected eczema, mainly on their faces and scalp. Carmel will do daily visits, washing the affected areas with sterile water and applying cortisone creams. She will give them their morning antibiotic dose and Dao,10, their elder sister, will do the other doses. Karen will tackle the hygiene problems.

We visit Nguyen, a 30 year old man bedridden for 12 years after encephalitis. Karen has had a carer for him 6 days per week. He was in a bad way a few months ago but now he has gained weight, he’s smiling, clean, has no bed sores and is much more alert. The carer, Lien, washes him, feeds him, exercises his limbs, reads to him and sits him up for short periods. There are no chains on his bed as there were before.

We visit Karen’s school. There are afternoon and evening English classes for disadvantaged children and teenagers and jobs can be found for them in hospitality once they have the language skills.

Each afternoon the disabled women’s group do craft work. Sherry, an American artist volunteer, has the group making decorative objects to sell on the internet.

Another woman, Nguyen, aged 22, has an inoperable VSD. She has an oxygen saturation of 78. She is on home oxygen but the sound of the machine has been keeping her awake at night. I brought some top quality ear plugs for her!

Day 4: I do a clinic at CHIA.[“Children’s Hopes in Action”] providing services for those with congenital abnormalities and chronic illnesses.

Vu Tran, 8, has epilepsy. He has 3 fits a week and the local school will not take him. He is on an intermittent sub-therapeutic dose of 50mg phenobarbitone. This is a typical treatment regime but for his weight he should be on 175 mg. Phenytoin is also available but seizure treatment has a long way to go here.

Trung, 14, is hearing impaired. He has classic serous otitis media. An audiogram can be done in Da Nang for a few dollars and ventilation tubes are available.

Josh and I visit a different province, Duy Xuyen, and I see the hypertensive patients. There seem to be only two systolic readings here, either 100, or 200 plus. Several people have already had CVAs. Treatment is often stopped or is inadequate. Josh trains the staff using a treatment algorithm, but patients are scared of using two types of medication, let alone three. Nifedipine, thiazides, amlodipine and captopril are available.

Dieu, 83, has distressing Parkinson’s disease. The only treatments available are anti-histamines and I prescribe chlorpheniramine.

Day 5: Back to the Pagoda. Dao, 65, has been itching for 12 months, especially at night. She has tried western and chinese medicines to no avail. There are bites under breasts and on her buttocks…Scabies again.

Day 6: Free time and we head for the beach on the South China Sea. There are deck chairs, umbrellas and Saigon Beer served with ice blocks.

The menu includes “Grabs, Clamps, Pisches and Shop Chewy”. The fishermen are out in their round bamboo boats, called Thung. They propel by using an oar in a “figure of 8” manner. Any other way and the boat just spins. They stand to cast their nets, which must be like playing golf standing in a hammock.

Day 7: Back to Dien Ban. This is a different clinic and 200 patients are waiting!

Trang Vo, 42, has had a CVA. Examination reveals atrial fibrillation and a loud mitral regurgitation murmur. She had rheumatic fever then atrial dilatation, disruption to the sino-atrial node, AF, clot, then a CVA. We order an ECG and ECHO and she will require surgery.

Day 8: I’m asked to see an 18 year old girl at the Pagoda. Her name is Tam. She is short and prepubertal and has blocked ears.

When I pull back her hair to check her ear I notice a webbed neck. From some ancient paddock in the back of my brain, out it pops---Turner’s Syndrome. Later I hit the internet for more information and see that hormones are indicated and screening for hypothyroidism and cardio-vascular malformations suggested.

Day 9: We run a clinic at Josh’s home. Josh wants my opinion about Tu, 47. She has had 6 months of intermittent fevers, headaches, weakness, aches and pains and insomnia. I’m at a loss. But not so our nurse Carmel, who asks her when she had her last period. Six months ago! Josh points out that he is excused, as you don’t see too many cases of menopause in ICU.

Cham Pham, 59, has renal failure. She needs dialysis soon but each time it’s 500,000 Dong [$US 30], way beyond their means.

I leave Hoi An for a few days in Sapa, a town in the mountainous north. There are dozens of Black Hmong women in the town, selling their wares. I am asked to do a “market” visit and Ti,14, is my interpreter. The patient is an elderly woman, of the Red Zoa people. She has an infected laceration of her ring finger with marked cellulitis and pain. I give her Keflex and Fucidin ointment.

Two days later it’s much better, with less swelling, some movement and no pain. I get Ti to explain to her that she must finish the medicine. Ti says the woman wants to know how much I will pay her to finish taking the medicine! I ask Ti to tell her in Viet style, ”She’s dreaming.”

Next day we trek 12 kilometres to Ti’s Hmong village. Ti and her mother cook food we have brought in. The house has a low ceiling and is the size of a single car garage. There is an open cooking fire, no chimney. The meal is delicious. Ti left school at the end of primary school,aged 10. Secondary schools charge fees which they could not afford.

It’s my last night and I decide to lash out and dine at the upmarket Victoria hotel. I order Aussie leg of lamb, done medium. I get raw buffalo-Ah, Vietnam!

Viet Nam Experience
David Cooke

Five am. The loudspeakers on telegraph poles blare out scratchy music to wake the populace and induce them to start their day's work. I wonder why they couldn't wait another hour or so to let me sleep till a reasonable time. Later in the day the tourists will be entertained with Vivaldi broadcast from those same speakers.
Already the day is heating to its 35 degree and 98% humidity, and the hazy sun beats down on the ever busy roads. Motorbikes and pushbikes stream in a procession past the hotel in a seemingly chaotic traffic system that strangely appears to work. It is not unusual for a bike to accommodate four people weaving like fighter pilots with incessant tooting of horns.
At 7.30am my nurse Judy Avenell and I are picked up by two young interpreters, An and Nguyet, and, hanging on we enter the traffic for a clinic out of the town of Hoi An. After twenty minutes we are still alive and Judy has managed to open her eyes for the last two kilometres.
We enter the clinic building which is proudly shown to us by the local “EC”, a man trained somewhere between a nurse and a doctor.
A fan is fetched and Judy begins to screen the patients for diabetes and blood pressure before handing them on to myself and Mai, an Australian nurse who manages the Hoi An Foundation and has been here for many years. American doctor, Joshua Solomon started the organisation some years ago and spends many months of each year in Viet Nam.
The people are gentle and appreciative but suffer from these two diseases due to the high salt and sugar content of their diet.
“Are you taking the tablets?” the interpreter asks on my behalf.
“No, I felt better,” is a common answer and indicative of the amount of education these patients need about their treatment.
I sigh and the interpreter explains that the blood pressure is 200/100 and that this fifty year old is at risk of stroke. We give advice and prescribe the available medications some of which we stopped using in Australia twenty years ago. One such is Cozaar I note, stopped in a hurry in the western world because of serious side effects, and so I take people off this treatment. I wonder why we are doing this work when there are locally trained doctors until I learn that they have no continuing medical education, never meet for discussions and are reluctant to share any medical information.
With vast amounts of bottled water to counteract the enervating heat, we wade through the day seeing more heart murmurs in my three weeks in Viet Nam that I have seen in forty years of Australian practice. It is largely rheumatic disease with a smattering of Fallot's tetralogy and septal defects. These go unrepaired in the majority of cases due to the cost ($US5000) of surgery for people whose annual income may be around $US600. These people would be lucky to reach twenty years of age.
I see wounds from the “American War” and there seems no resentment by these ex Viet Cong men and women. “That was then,” they say, “this is now.”
The pathology is gross and plentiful - hydrocephalus, Marfan's syndrome, cerebral palsy, marked clubbing and of course the horrific effects of Agent Orange.
The people seem happy and accepting of their situation, and, as doctor is spelt “GOD”, I seem to have more success in getting patients to stop smoking than in Australia.
Today we see about seventy patients although each day is totally different. Some days we travel far out into the countryside while others involve loading the bike on a ferry and working across the river on one of the many islands.
What a momentous experience. What a learning curve! My wife and I live in a comfortable hotel for $US25 a day including breakfast and it is possible to eat for $US7 - 8 per day.
Would I go again? Ask me in a year's time when I've got over the exhaustion, but probably Yes.
The two Vietnamese girls, Nguyet and An are stimulating, energetic and full of knowledge, (as well as being clever on a bike) and Mai and Carol, two Aussie nurses who run the Hoi An foundation are truly inspirational, dedicated and selfless.
Three weeks of this experience and I return to my Lighthouse Beach Surgery. The rooms are airconditioned, there are no frogs jumping across the floor and the computer generated scripts for modern medicines are paid for by the government. A man needs heart surgery and is taken by air ambulance to Sydney where a surgeon will perform the operation at no cost to the patient.
I muse on the difference and I shall never be the same again.

Reflections

This is my fourth trip to Vietnam and I always have a range of emotions on my visits. The country is very beautiful, the people are friendly to visitors and the food is tasty and interesting. On the other side of my emotions, I am dismayed by the hard life most people live here and their lack of access to medical treatment. I don’t believe that many people in the western industrialized world realize what daily life is like here – work hard, very little chance for advancement and minimal health care.

That is why the efforts being made to improve the daily lives by various foundations are very encouraging. These groups are targeting disabled adults, disabled children, orphans or very disadvantaged children and indigent people with health problems.

You could look at this and, realizing the enormity of these problems around the world, ask “What is going to be changed by these efforts”. I think the answer is very simple. Ask Mrs Hanh how she feels these days. She has suffered from diabetes for a long time. Josh saw her, put her on the right medications and now she feels great for the first time in many years. Or ask Dieu who had a serious heart problem. The Hoi An foundation diagnosed it and paid for the corrective surgery. Dieu would have died within the next year without this surgery.

There are many individual examples of why this work is important. A few very dedicated, selfless people can make a big difference. People who have left the comfort of their home country to live and work here. People who were born here and want to help the less fortunate.

I feel very honored to know some of these people.











Jess Solomon

A Rewarding Experience

" Our experience volunteering for the Hoi An Foundation was definitely one of the highlights of our 5 week trip in Southeast Asia. My fiance, Emmet, who will be starting medical school this upcoming fall, was anxious to do some medically related work in Vietnam. He emailed Josh while we were in the U.S. and immediately got an enthusiastic response. Once in Hoi An, we were able to contact Josh by phone and get instructions on how to rent a motorbike and drive to his house. Along with a nurse from Australia and two translators, we paraded out to the countryside through towns and villages, dodging chickens, dogs and barefoot toddlers for a visit to a clinic in the provinces. The ride there was one of the best parts of the adventure! Once we arrived at the clinic, there were about 30 elderly people waiting anxiously to see a doctor, and it quickly became apparent that this was far too much for one person to handle with limited funds and money for medication. However, Josh got right to work efficiently and with a sense of humor. He had Emmet taking blood pressures and pulses as I jotted down the information on their cards. It was very eye opening to have up- close interaction with so many Central Vietnamese people, many of whom had injuries that were a result of the Vietnam war with the U.S. Josh was kind enough to take the time to let my fiance sit in with him as he consulted each patient so that it could be a hands on learning experience for him. After all of the patients had been seen, we were treated to a delicious lunch riverside by the woman who worked at the clinic year round. They were very warm and grateful for Josh's help.

The following day Emmet went to Josh's house by himself, where by 9 am there was already a line of local people waiting to be seen. Josh tirelessy helped each person and welcomed them into his home. Emmet was most touched by a family who came in with a young girl who had a hole in her heart. Knowing that she had hope because the Hoi An Foundation would help her fund the necessary surgery was proof that they were really doing miraculous work. We are so thankful that we had the chance to work with Josh, and it is clear that this non profit could do so much more for these people if it had greater funding. We wish the Hoi An Foundation and his staff all the best and hope that we can continue to support it in the future."


Merry Christmas, Josh! Hope you're well. Keep up the good work.

Best,
Meg and Emmet

A Long Day...

Today, we sent Nam, his grandma, little girl T. and her mother to hospital in Sai Gon for treatment. Nam, T and mother got HIV. It’s difficult to get them to the plane bcs Nam’s leg hurts and it takes twenty mins to get Nam a wheelchair. The people at the airport told us that Nam couldn’t get on plane bcs he couldn’t walk and grandma wasn’t strong enough to help him. They should help us instead of telling that. Finally, they arrived Sg safely and met the doctors there. They will stay there for long time. We hope both get better soon.

We rode straight from Da nang to Duy Xuyen to see patients at one local clinic which is very far. Thank to Carol and Vu for coming earlier to see patients because we don’t want to make them wait long. And we have a 87 year old patient that had been a farmer for 75 years. That surprised Dr Josh and Carol but most of Vietnamese in the countryside work really hard until they are too weak to work.

Luu Phuoc An

The Elderly in Viet Nam

One of the wonderful parts of our job is working with the elderly in Viet Nam. This country has seen its share of turbulence, turmoil and war. If you are over the age of 70 in Viet Nam, you have lived through things that most of us only read about in textbooks. During an average outreach clinic, we see 5 to 10 people above the age of 80. They all carry themselves with a certain degree of dignity and grace - traits i find amazing given the side of human nature they have been witness to over their lifetime. Their eyes are full of stories - stories i can only guess at given the language barrier and constraints on our time. Many times we are the first doctor they have seen. We are privileged to care for them.

Josh

Symposium

We just held our first symposium for doctors and nurses yesterday. We had 90 people attending and 3 lecturers. Our talks covered management of diabetes and hypertension and we presented our algorithms for treatment in central Viet Nam. We had Dr. Brian Penti from Boston and Dr. Jocelyn Nava from the Philippines helping us with the talks. The symposium went well. We are planning to have them every 2 to 3 months and cover a curriculum of general diseases of adulthood.

Josh