Patient Care and Cardiac Training in Vietnam Continues

Project HOPE volunteer Dr. Frank Ing, a Cardiologist from San Diego, California traveled with a small U.S. Navy medical team to work with local Cardiologists and patients at the Binh Dinh Provincial Hospital in Quy Nhon, Vietnam in August as part of the Vietnam Interventional Cardiology humanitarian mission. This is Part 2 of his diary. (Read Part 1 here.)

Tuesday Aug 15, 2011
After a quick morning breakfast, we headed for the cath lab where there was already a crowd of patients lined up on stretchers awaiting our arrival.  We performed a total of nine congenital heart cases and two additional coronary cases.  Because of the complexity and higher risks of the congenital disease cases, more time was needed to accurately assess and measure the lesions using a combination of fluoroscopy, TEE and TTE before and after device implant.  All in all, we implanted three atrial septal defect (ASD) devices and five patent ductus arteriosus (PDA) devices.  Unfortunately, one patient had such a large ASD with deficient rims that we felt implanting a device might be too risky for either device embolization or erosion later and we recommended surgery for that patient. We also had to cancel two cases due to lack of available dilation balloons and lack of surgical expertise to repair a complicated congenital cardiac defect (truncus arteriosus). I was amazed at the extreme large sizes of the defects found. In my 13 years of pediatric interventional experience, it is not common to encounter ASDs with a diameter of larger than 30mm or PDAs larger than 6mm. In our group of patients, the smallest ASD diameter was 32mm and the smallest PDA diameter was 7.3mm.  In the USA, all of these patients would have had their lesions treated during infancy or at latest, by five years of age. In contrast, the youngest patient in our group was 14 years and majority in their 20’s and 30’s.  As in the previous day, we worked side by side with the local cardiologists.  There was a sense of comradery as we made decisions together and each teaching and learning from the other’s experience.  While the cath lab had limited supplies and equipment, I found they were quite resourceful and creative in overcoming these limitations.  I was most impressed at the stoic nature of the Vietnamese patients, all of whom received very little local anesthesia for the needle punctures and sheath insertions. Most receive little to no sedation for the entire cath procedure. When we urged that more sedation or anesthetics should be used, we were told, “the Vietnamese women are strong”. It was said with a certain pride that their people had the ability to handle pain and discomfort patiently. I watched in awe a 14-year-old boy winced in pain as the local cardiologist stuck a needle into his femoral vein.  He opened his mouth wide but did not make any noise nor did he move his legs. During ASD closures, a large TEE probe is passed down the throat to help visualize the defect and to guide the device implantation procedure.  Having such a larger probe passed down the throat is very uncomfortable and in the USA, patients usually undergo general anesthesia or deep sedation for this procedure. Here, only a few sprays of local anesthesia is used to temporarily numb the back of the throat.  One can hear the cath lab staff calmly instruct the patient to open their mouths and swallow as the probe is passed.  While their eyes show their discomfort, there are very few other signs. All in all, we were successful in implanting all of our devices and the patients tolerated the procedures well. As one patient is moved onto a stretcher to be transferred out, the next one is quickly rolled in and we able to complete 11 cases in just over nine hours.  Tired but with a sense of accomplishment, we had a late dinner and went to bed.

Wed Aug 16, 2011
We made rounds on all of the cath patients in the morning.  The patients were housed in large open wards separated by gender.   While it appeared that each patient had their own bed, the rooms were crowded by numerous family members and friends. As we examined each patient and raised the universal “thumbs up” sign to indicate that the procedure had been a success, I found we were able to melt their typical stoic expressions into a smile and that was very rewarding. Many asked for group pictures and we laughed over a few jokes even though I am sure they did not understand what we were saying. Again, it was particularly heartwarming to me when we visited the 14-year-old boy who was housed with the adult men. I recalled his initial apprehension of me during his initial visit at the clinic, then his wince of pain without crying during the procedure, and now his smile at me as if we were old friends.  As I listened to his heart with my stethoscope and did not hear a murmur, I knew we had successfully closed his PDA and normalized his circulation and this would change and improve his outlook on life forever. On the other hand, I couldn’t help but think of the 3-year-old child who we initially planned to perform a diagnostic cath but cancelled because we knew he could not have his operation at this hospital. I am sure there are many like him.

We were asked by the hospital director to put together a lecture conference for his staff for the rest of the day. While this was not part of the original plan, we complied and quickly organized four, one-hour lectures. The topics included; “Procedural Sedation in Pediatrics”, “Pre-operative Evaluation for Non-cardiac Procedures”, “Anesthesia for Thoracic Surgery” and “ Interventions in Congenital Heart Disease in Adults”. Our Vietnamese Counterpart also contributed a lecture on the “Cardiac Status of Vietnam”. It was interesting to hear how Vietnam has improved their delivery of health care and what advances they’ve made in the treatment of cardiac diseases over the past few years. That evening, we were invited by the Dr. Ty to a dinner where we spent more time discussing ways for further collaboration.