Category Archives: Vietnam 2014

Performing ultrasound in rural clinics in Loc Tri and Vinh Phu

7/25/2014

Today we set off early to visit two rural hospitals in the countryside of Hue. We were accompanied by some Cal undergraduate students who also helped out at the hospitals as a part of the Volunteers for Medical Outreach (VMO) program. After an hour of dirt roads, we reached our first stop; the Health Care Station of Loc Tri District (Tram Y Te Xa Loc Tri). It was in a very small town sparse with buildings, surrounded by beautiful green fields and hills. When we arrived, there were already around 60 patients, mostly elderly, awaiting medical care. After meeting the 4 doctors who were in charge of seeing the patients, they asked us to set up our machines and ultrasound all of the patients. They asked us to do all our scans on each patient but we quickly realized that the pace was too slow, so we switched to a focused ultrasound scan after briefly interviewing each patient for his/her chief complaint. Meanwhile, UC Berkeley’s VMO team assisted with taking in patients, measuring blood pressures, and distributing medication in the pharmacy clinic. The mobile clinics, supplies and medications were all funded by donations collected throughout the school year.

At first, we were hesitant to ultrasound patients since we were relatively inexperienced in regards to pathology in images, but our previous experience shadowing ultrasound doctors in Hospital 108 actually served us quite well. We were able to identify kidney stones, thyroid cysts, mitral regurgitation, ventricular hypertrophy, enlarged kidneys and masses in the thyroid and liver. As we saw more patients, we became more and more proficient as scans became much faster and easier. After receiving their scan, the patients were sent to see their respective doctors. After a few hours, we had finally finished scanning all 60 patients.

Our next stop was another small rural hospital which dedicated the day to administering Hepatitis vaccines to children, all around the age of 6. The Cal students with VMO conducted dental care lessons for the children after they had received their vaccinations. Nancy conducted one of the lessons on her own, and afterwards, Anh joined her and the Cal students as they applied fluoride gel onto the children’s teeth.

After getting home, we all watched MS2 ultrasound videos and studied as many scans with pathology as we could in preparation for our next and last clinic visit the next day.

The following day, we woke up early again to make our way to the last rural clinic. Although the waiting room was just as crowded as the last clinic, this clinic’s population was much more varied in terms of age, with children, middle aged adults and elderly patients. Our extra studying the night before paid off, as we were able to distinguish kidney cysts from hydronephrosis in a female patient. Again, we saw lots of the same pathology as we did in the previous day, including leaky heart valves, kidney cysts, and masses in the liver. We learned that the doctors working at this clinic were not very proficient with the ultrasound, so they greatly appreciated us being there to help. Although many patients showed up to the clinic, we ended up scanning only patients that were referred to us by the doctors, which amounted to about 30-40 patients scanned.

Ultrasound Workshop at Quang Dien Rural Hospital

Our second ultrasound workshop site was at a rural hospital outside of Hue, a big contrast to the advanced Central Military Hospital 108 in Ha Noi.

We had been corresponding with Dr. SaLy from Aid to Children without Parents (ACWP) since February to ask for her help in setting up an ultrasound workshop in Hue. Dr. SaLy is a practicing physician at Hue Hospital and a professor in microbiology at a local medical school. She is extremely involved in public health and is very knowledgeable of healthcare in her local community. From her, we learned the need for development of ultrasound training at a rural hospital outside of Hue. Through donations from family and friends, we were able to raise funds during the school year to donate a used ultrasound machine to that hospital following an introductory ultrasound workshop.

On July 28th, our team of UC Irvine medical students along with UC Berkeley’s Volunteers for Medical Outreach (VMO), Dr. SaLy and Co Tran departed from ACWP homestay enroute to Quang Dien Hospital. Quang Dien Hospital is located an hour outside of Hue City, and is the main central hospital in the rural area. Participants in this workshop were doctors from surrounding villages representing their respective hospitals to learn and practice ultrasound.

UCI SOM students, UC Berkeley VMO students, and Dr. SaLy ride to Quang Dien Hospital

UCI SOM students & UC Berkeley VMO students drive Quang Dien Hospital

Upon arrival at Quang Dien, we met with the hospital’s vice-director and participants of the workshop. We introduced ourselves, our ultrasound curriculum, goals and objectives. After doctors watched podcasts by Dr. John Fox at UC Irvine, we started the hands-on learning sessions in cardiac, abdominal, pulmonary, head and neck, and FAST ultrasound. Doctors were very enthusiastic about practicing ultrasound on the handheld Sonosite machines provided by UC Irvine. They were intrigued when we had to change probes when switching from cardiac to abdominal ultrasound. It turns out that though some hospitals had their own ultrasound machines, they only had one probe (the curvilinear) for all ultrasound purposes. Additionally, participating doctors were from various specialties and had different degrees of ultrasound exposure and training. There were a few doctors who work with ultrasound on a daily basis and they were generally well-versed in abdominal scans. However, they had never had the opportunity to learn cardiac, pulmonary, head and neck, and FAST ultrasound. Therefore they were very eager to practice scanning the various windows of the heart, lungs and thyroid.

Ultrasound hands-on session

Ultrasound hands-on session

Participants watching Dr. Fox's podcast

Participants watching Dr. Fox’s podcast


Following our workshop, we handed over a Sonosite 180 Plus ultrasound unit with four probes to Quang Dien Hospital. We look forward to receiving annual updates on the use of this machine and newly acquired ultrasound skills in clinic regarding number of patients, number of scans and types of scans.

Sonosite 180 Plus portable ultrasound unit donated to Quang Dien Hospital

Sonosite 180 Plus portable ultrasound unit donated to Quang Dien Hospital

 

Vice-director receives the ultrasound machine on behalf of Quang Dien Hospital

Vice-director receives the ultrasound machine on behalf of Quang Dien Hospital

UCI SOM and UCB VMO with doctors at Quang Dien

UCI SOM and UCB VMO with doctors at Quang Dien Hospital

Pediatric and Radiology Departments Shadowing at Hospital 108, Ha Noi

7/14-7/17/2014

During 7/14-7/17 at Hospital 108, we were placed with the Pediatric and Radiology Departments.  Because Hanoi has a high volume children hospital, the 108 military hospital does not receive many pediatric cases on a daily basis. However, we observed some urgent and more complicated cases including: a young girl with medulloblastoma and a unilateral medial gaze palsy, a child with nephrotic syndrome presenting with ascites, and several pneumonia cases varying in severity–some even requiring mechanical ventilation.

It was difficult seeing younger children suffer, and we could tell how anxious all of their parents were. We came to appreciate the importance of comforting and communicating with these childrens’ families, especially in a culture that places a strong emphasis on their future generations over themselves.

With the radiology department, we were able to observe different pathologies using CT, MRI, as well as ultrasound. In fact, Hospital 108 has a dedicated ultrasound department with radiologists that specialize in performing and diagnosing with ultrasound. The most prevalent diagnoses we observed with US were: kidney stones, stones found in ureter constriction sites, gallstones, thyroid cysts and nodules, carcinoma of the thyroid, hepatocellular carcinoma, and uterine and cervical cysts. With ultrasound guidance, we also observed OB ultrasound that examined the BP diameter, femur length, and cardiac Doppler of fetuses. It was also refreshing to see patients who were very excited for their doctor visits.

From 9am to 12pm, a large waiting room filled with patients were scanned and diagnosed by five ultrasound radiologists, as we were left very impressed with their efficiency and attention to detail in their work.

With the CT and MRI radiologists, we gathered in front of the computer and went through images of interesting pathologies that include a descending aorta dissection, spinal AV fistula, carcinoma of the cystic duct, intestinal obstructions from colon tumor vs. infection…etc.  In addition, we were introduced to advanced imaging techniques/procedures including virtual endoscopy of the large bowel using gas insufflation followed by 3D reconstruction of CT slides, and lung needle biopsies with CT guidance.

Overall, we learned a great deal about patient care, different pathologies, and new medical diagnostic technologies from this short experience.  What impressed us the most, however, were the doctors’ efforts in ensuring that we had a fulfilling learning experience. We really appreciated their patience in trying to communicate with us in English, as well as their taking time to show us their specialties.

Our last lunch with doctors of the radiology department: Bac Si Lam Khanh (director), Bac Si Diep, Bac Si Hang, Bac Si Chi and Bac Si Dung

Our last lunch with doctors of the radiology department: Bac Si Lam Khanh (director), Bac Si Diep, Bac Si Hang, Bac Si Chi and Bac Si Dung

– Mark Lin

Gastrointestinal Department Shadowing at Hospital 108, Hà Nội

7/11/2014

Today we were assigned to the gastroenterology department with Dr. Tung, a GI attending. Dr. Tung is an MD/ PhD who trained in Vietnam and Japan. Before we ventured out into the wards and outpatient facility, he provided us a brief overview about the types of patients his hospital encounters.  Gastrointestinal emergencies are serious conditions that develop suddenly requiring prompt attention. Upper GI bleeding accounts for over 50% of GI emergencies. Etiology is wide ranging and stem from chronic NSAIDs usage to vomiting. Portal hypertension predominantly due to liver cirrhosis accounts for 30% of GI emergencies.  Gastric cancer, gastritis, and Mallory Weiss syndrome  account for the remainder 20%.

Because the population of Vietnam has a high rate of people with Hepatitis B and chronic alcoholism, upper GI bleeding is a common occurrence at Hospital 108. With regards to Hepatitis B, the leading cause of death is portal hypertension secondary to ruptured varicose, hepatocellular carcinoma, and hepatic coma.

After the introduction, Dr. Tung brought us to the Outpatient GI Facility.  At this facility, there were 2 endoscopes and one hybrid endoscope/ultrasound machine.  The patient waiting room was packed to capacity with a mix of adult men and women and military officials. In order to see all the patients for the day, the endoscopic exams were performed very efficiently. Once the patients arrived into the procedure room, they were placed in the left lateral decubitus and quickly scoped.  No sedation (local or general) was used because of the increased cost and increased length of procedure.  The two physicians scoping the patients usually finish the whole procedure in 3 minutes. The sight of seeing patients endoscoped without sedation seemed at first disconcerting.  The patients’ gag reflex was in full force but once the procedure was over the patients reported no pain. We were amazed to see how after the procedure, the patients nonchalantly walk out of the room as if it was a routine procedure.

We then continued to see some patients who mostly suffered from acute pancreatitis and cirrhosis. Dr. Tung discussed the widely used Transarterial oil chemoembolization (TOCE) procedure for hepatocellular carcinoma. TOCE is a minimally invasive procedure aimed to restrict the blood supply of hepatic tumors through minimally invasive angiography. Microsphere therapy, a method of using drug eluting particles to allow for slow, sustained release of loaded anti-cancer drugs locally with embolic effect leading to tumor ischemia is commonly used at Hospital 108 to treat patients who are not candidates for liver resection. We made our way to the cath lab and witnessed a couple TOCE procedures.  The procedure lasted only approximately 30 minutes or less and patients were only under local anesthesia.

Overall, we had a wonderful experience shadowing in the GI department. Even when we were shadowing the cardiology and infection diseases departments, we encountered a fair amount of patients with hepatic disease.  This department opened our eyes to not only the treatment and management of hepatic disorders, but also the public health issue of the high prevalence of Hepatitis B and alcoholism contributing to hepatic disease.

Vietnam 2014 team with Dr. Tung of the GI Department at Hospital 108

Vietnam 2014 team with Dr. Tung of the GI Department at Hospital 108

– Benjamin Nguyen

Infectious Disease Department Shadowing at Hospital 108, Hà Nội

7/10/14

Although we have not learned pathology yet, listening to cases in the infectious disease department made us excited for the upcoming year. We had the opportunity to see cases such as mumps and measles, both of which are rare in the United States.

Case 1: Mumps

27 y.o. male who presented with enlarged parotids, left testicular swelling on day 11, mild fever for 2 days, and headache. Patient had elevated salivary amylase. The physicians ruled out bacterial infection because the neutrophil and WBC count was normal, there was no redness or inflammation of the parotids, and they weren’t able to squeeze mucous out of the glands. They treated the patient with supportive therapy: administering fluids and applying ice/heat to the neck or testicular area. One of the biggest concerns the doctors had was infertility. Other possible complications include encephalitis and meningitis.

Case 2: Measles

Patient presented with rash that spread from the head to trunk and finally to limbs (itchiness, redness that usually appears on days 3-5), continuous fever of 104 degrees Fahrenheit (without chills), headache, sore throat, runny nose, and dry cough. Some potential complications include pneumonia, meningitis, and rarely encephalitis. Like mumps, treatment for measles was supportive therapy: reduce fever and headache, administer fluids, and prescribe antibiotics to prevent infection due to weakened immune system.

Unlike the US where all children must be vaccinated to attend school, some of the patients were not. In fact, in Ha Noi, there has been an upsurge of measles recently because up to 80% of patients were not vaccinated, according to the National Institution of Hygiene and Epidemiology. Once vaccinated for measles, a patient will have life-long immunity.

 

Infectious Disease Department Shadowing at Hospital

Infectious Disease Department Shadowing at Hospital

 

 

 

 

Cardiology Department Shadowing

7/9/14

At hospital 108, we were scheduled to shadow various departments each day. Today was our first day: cardiology. We attended the morning meeting with the cardiologists and went on rounds with the attending, Dr. Son.

During our tour of the cardiology patient rooms, Dr. Son led us to a patient who likely was suffering from Brugada Syndrome. He told us that Brugada is a rare disease with higher prevalence in southeast asian countries. This particular patient presented with recurrent syncope during the night, and EKG showed slight ST elevations. After ruling out the usual suspects, the patient received sodium channel blockers. His ST wave heightened tremendously, Which Dr. Son said helped support the diagnosis of Brugada Syndrome. Dr. Son told us that Brugada is usually diagnosed when patients reach middle age. Unfortunately the only thing the doctors could do was install an ICD in the patient, which is not covered by insurance, thus costing the patient upwards of $10,000 dollars out of pocket. For some in Vietnam, this could mean years and years of salary. Other devices, like pacemakers, are covered by insurance.

Another case we saw was a patient with Wolf-Parkinsons White syndrome, a disorder where an abnormal cardiac electrical conduction pathway stimulates the ventricles to contract prematurely.  The patient’s EKG clearly showed a delta wave with shortened PR interval.  To treat this patient the doctor will perform catheter ablation tomorrow in order to destruct the additional electrical pathway—a procedure with over 95% success rate!

After lunch, we were invited back into the catheter lab and met the head of interventional radiology. We learned about the various IR services offered at the hospital including  angiography/angioplasty, ablation, and bypass graft. While at the lab, we had a chance to witness a Transjugular intrahepatic portosystemic shunt procedure (TIPS). As we watched the interventional radiologist perform the procedure, we also discussed the pathophysiology and anatomy. Our ability to draw knowledge during our first year courses and being ableto apply it to the clinical setting made our shadowing experience invaluable. We look forward to seeing more cases tomorrow.

Cardiology Department Shadowing at Hospital 108, Hà Nội

Cardiology Department Shadowing at Hospital 108, Hà Nội

 

 

Ultrasound Workshop at Hospital 108

The participants for the ultrasound workshop at Hospital 108 were mostly doctors from the radiology department, all with varying background in ultrasound. Medical schools in Vietnam briefly train students in ultrasound for a few months, but often the doctors who specialize in ultrasound are the only physicians who get additional training. At Hospital 108, ultrasounds were purely operated by physicians, not technicians. Some of these ultrasound physicians attended our workshop. We also had other physicians from the radiology department with little experience in ultrasound since attending medical school.

On day 1, we started off the workshop with a pre-test, and then showed Dr. Fox’s podcasts on Cardiac, GI, and Lung videos that were subtitled in Vietnamese by Anh and Nancy.

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Dr. Quyen, one of the ultrasound doctors, said he enjoyed learning about detecting pneumothorax using ultrasound, a technique he hadn’t heard of before.

All participants had a chance to use the ultrasound machine during the scanning session. The more experienced ultrasound doctors enjoyed trying the new compact machines versus the larger machines that they usually used for work. We demonstrated different views in cardiac, GI, and lung for the participants, and also learned from experienced ultrasound doctors.

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We learned techniques on recognizing pathology such as cysts, masses, stones, and even methods to find the appendix in most patients (from Dr. Quyen).

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On day 2, we wrapped up the workshop with Dr. Fox’s podcasts on Head & Neck (specifically for thyroid) and FAST videos subtitled in Vietnamese. We received feedback from Dr. Lam Khanh, Chair of Radiology, that he enjoyed the workshops and thought they were very useful. He hoped to have a longer session next year to help the younger doctors learn more ultrasound. Many of the doctors enjoyed the ultrasound videos and requested for the ones that were shown during the workshop, as well as more of Dr. Fox’s videos.

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Overall, the ultrasound workshop was very successful and we received a lot of positive feedback. We hope the ultrasound workshop we introduced at Hospital 108 this summer continues next year!

Vietnam, here we are!

After a long 16-hour flight, we landed in the capitol of Vietnam, in Ha Noi at Noi Bai International Airport.

Three young doctors from the radiology department at Central Military Hospital 108 greeted us with much warmth and hospitality. They shuttled us to our hotel which is conveniently located 5 minutes away from the hospital.  They were very proud to show us famous landmarks of the city such as the six bridges of Ha Noi as we drove by each and the 4 km ceramic wall depicting the rich history of the city.

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photo 1

After eating our first lunch in the hospital cafeteria with some staff members, we went back to our hotel. We were able to survive walking through the bustling streets where no one follows traffic lights or lanes, by learning to cautiously weave between mopeds as a group. During dinner we tried a nearby restaurant (Nha Hang Ngon) with many small Vietnamese dishes paired with fish sauce. Afterwards, we explored the city and walked around the park surrounding Sword Lake, a landmark mentioned by one of the doctors. The park was very lively, filled with many groups dancing to different types of music, including swing, zumba, and salsa. We stumbled upon a large garage where there were many dessert vendors and stopped for some freshly made ice cream bars– perfect for the hot & humid Vietnam weather.

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Random rooster pet outside a restaurant

 

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Very “ngon” (delicious)!

 

Vietnam 2014 – Meet the Team

Follow our journeys here!

Meet our team:

  • Audris
  • Mark
  • Benjamin
  • Victor
  • Nancy
  • Ngoc-Anh