Friday, May 27, 2011

trauma systems development

McGrath is a small village in Alaska with 346 people located along the south bank  of the Kuskokwim River.  It serves as one of the checkpoints on the 1,049 mile Iditarod Trail Sled Dog Race.  It is located about 221 miles northwest of Anchorage and 269 miles southwest of Fairbanks. 

The provision of health care services including emergency care is administered through the McGrath Clinic.  It is funded by a federal grant through Health Resources Services Administration (HRSA).  The clinic may be staffed by a nurse, physician assistant, or community health aide.  They are provided varying levels of training to stabilize and deal with trauma patients, including ATLS.  There is no physician on-site, but there are some telemedicine capabilities.  For more information on the Alaska Community Health Aide Program visit

Trauma patients are transferred to Anchorage by air utilizing aero-medical transport services.  The McGrath Airport has two asphalt paved runways, and averages about 30 aircraft operations per day.  Given the size of the airport and runway dimensions, only certain types of aircraft can operate in and out of McGrath Airport.  The flight operation time for an aero-medical aircraft from Anchorage to McGrath and back would be roughly one-hour each way; thereby a trauma activation for transfer would require a minimum of 2 hours of flight time, in addition to activation time in Anchorage, medical service provision on scene or at clinic, and transport time from the clinic to McGrath Airport.  The McGrath Airport is located a short distance from the clinic (easily walkable), but would require a patient to be loaded on board an ambulance for the short trip to the actual air field.

After arriving in Anchorage, the patient would be taken to one of the three major hospitals in Anchorage which would have agreed to accept the patient.  If the patient requires any services outside the capabilities of the Anchorage hospital, they would then be subsequently transferred to Seattle.

The McGrath Clinic is a testament to the citizens of McGrath who work tirelessly to provide emergency care both through the professional health care providers who work there along with the community health aides and the aero-medical transport teams that travel to this small village and provide critical care in such an austere environment.

Wednesday, May 25, 2011

trauma systems development

Alaska is the largest state in the United States by area, and 47th by population with 710,231 persons according to the 2010 US Census.  There are innumerous statistics and factoids about our 49th state, but one that is the most clinically relevant is that Alaska despite its location, geography, population, and wealth, does not have a level 1 trauma center.  Furthermore, the entire state is served by only one ACS-verified level 2 trauma center located in Anchorage.  The University of Washington - Harborview Medical Center provides level 1 trauma services for the state of Washington, along with Alaska, Montana, and Idaho. 

This project conducted over two visits surveys the unique needs and amazing capabilities of this state and its physicians, nurses, EMS personnel, and citizens to provide trauma and emergency care in some of the most challenging and dangerous situations. 

The state of Alaska is committed to reviewing, improving, and further developing its trauma system, and enhance its ability to provide more definitive care and reducing the number of patients transferred to Seattle.

The initial visit involved meeting with the state's Trauma  Program Manager, Chair of the Committe on Trauma for Alaska, various members of the local Anchorage EMS community, the Trauma Registry Manager, and an executive with one of the aeromedical transport services in Alaska.  This was also supplemented with  participating in the Trauma Systems Review Committee Meetings held by the trauma/ems community there.

Saturday, May 21, 2011

More than MDR-TB at St. Peter’s, Missionaries of Charity, and Black Lion Hospital

Day 18: May 21, 2011. Addis Ababa, Ethiopia.More than MDR-TB at St. Peter’s, Missionaries of Charity, and Black Lion Hospital

Submitted by: Raquel Reyes, MD, MPA, PGY3, Internal Medicine and Pediatrics, Massachusetts General Hospital.

This experience has afforded me the opportunity to see more than MDR-TB, and more than a single health institution. Over the past week and a half, we have traveled to Gondar to visit Gondar University Hospital, where we met with the new CEO and got to see the MDR-TB ward there. We also met with the head of the Department of Pediatrics at Black Lion Hospital, Dr. Demte, and attended morning report and morning rounds. We visited the Missionaries of Charity (from where several of the MDR-TB patients at St. Peter’s were initially referred). We met with the local head of the Clinton Foundation and had the opportunity to discuss their new Maternal, Newborn, and Child Health initiatives. It has been a full week.

More than MDR-TB at St. Peter’s.

Approximately 1/3 of the patients in the GHC/St. Peter’s MDR-TB cohort are co-infected with HIV. All MDR-TB patients have initial laboratory evaluation including CBC, LFTs, bilirubin, creatinine, potassium, and HIV screening. Some patients are known to be HIV+ at the time of enrollment into a Category IV treatment program.

Such was the case for Zewdu, a 43yo man I met my first day on rounds. He was complaining of some vague abdominal pain as well as nausea, loss of appetite, and bloody diarrhea. His stool had already been sent and was negative for O&P. His exam was notable for diffuse abdominal tenderness to palpation and moderate distention. I looked through his chart and saw that his most recent CD4+ count was 36, down from 54 a few months earlier. I wondered whether he might have CMV. I also wondered about c. diff, as he had been on levofloxacin for his TB for some time. Neither of these were testable. I looked over his ARV regimen which included tenofavir, lamivudine, and efavirenz as well as clotrimoxazole prophylaxis. We sent a viral load. The next day his diarrhea was essentially resolved and he reported ongoing nausea and anorexia but improved abdominal pain. His abdominal exam was still notable for diffuse mild tenderness to palpation most prominent in the RUQ as well as mild distention. He seemed stable overall but he was definitely not thriving. We sent LFTs, electrolytes, and glucose. I wondered about CMV and c. diff (although neither can be easily tested for here). The next day he reported he had been able to take some liquids and was feeling generally better. He remained stable over the next several days.

When we returned to St. Peter’s from our visit to Gondar, however, Zewdu had taken a turn for the worse. We were rounding on some of the patients in the upper ward when a nurse came to us and requested our assistance with a critical patient. As I walked with Dr. Bekele toward the room, I asked for the one-liner. He told me that a patient was in a coma. “A new patient?” I asked. “No, no, you know him.” “One of the patients I know is in a coma?!? Who is it?” “It is Zewdu.” We arrived to the bedside, and there was Zewdu, lying flat, eyes open, with slow, stridorous breaths, not moving. He did not even resemble the man I had met 12 days before. He moaned and grimaced to sternal rub but did not localize. He had apparently been relatively normal about an hour earlier. 40% glucose had already been administered. We asked that an additional glucose bolus be given. His other vital signs were normal. One of his roommates (he was in a 6-bed room) told us that he had been seizing over the weekend. Shortly after he told us this, Zewdu seized; it began with right-sided convulsions and secondarily generalized. We raised the head of his bed and positioned his head. We gave him supplemental oxygen. We administered 10mg IM diazepam in case he was in status. We ordered him for IV dexamethasone, a loading dose of phenobarbital, meningitic dose ceftriaxone, and empiric treatment for toxoplasmosis. LP is not possible at present (due to lack of adequate sterilization of the LP equipment). We asked for CBC, Blood culture, chemistry 20. Zewdu never woke up. He never received the phenobarbital or the pyrimethamine. He expired at around 6pm. His labs still have not come back.

Once again, I want to recall and document that most of the MDR-TB cohort patients, including those with HIV/AIDS, are surviving. One patient proudly boasted to me about his last few CD4 counts, which were initially decreasing on the TB medications (common) and are now on the rise again. I wanted to write about Zewdu because I wanted to highlight the challenges of practicing medicine in a resource-limited setting with such serious illnesses. Physicians here practice with limited diagnostic as well as limited treatment options. And a greater proportion of their patients are so much sicker than the patients we treat back home. I also wanted Zewdu’s story to be told. As I wanted Girmay’s story told. And Abde’s. But GHC/St. Peter’s stories also are the ones that turn out well. In fact, most of them are the ones that turn out well. And these are also fraught with difficulty. People living in tiny single-room homes with almost no ventilation. People without refrigerators or electricity to safely store their medications. People suffering from food insecurity. People who have lost brothers, sisters, parents, children. People who have lost their jobs, their only source of income, due to their illness. And these people are being cured and getting well and their lives are improving.
Mural at the Missionaries of Charity

More than MDR-TB at Missionaries of Charity

On Tuesday we went to the Missionaries of Charity, known for the work of Mother Theresa. At the mission in Addis Ababa, which is near to St. Peter’s Hospital, approximately 900 people live there. Most of them have some form of medical or mental illness and have nowhere else to go. The Sisters of Charity care for men, women, and children with not only tuberculosis, but also different types of cancers and growths, infections (including HIV), disabilities including limb amputations, skeletal deformities, and blindness, severe mental illness, severe malnutrition, seizure disorders, congenital anomalies, and those who have simply been abandoned by all family and cannot care for themselves. There are many orphans and unwanted elderly. It is crowded, with as little as 5 inches between beds, but it is also almost spotless. It is neat and orderly. All of the beds in a given room have the same sheets. All of the equipment is uniform and in good condition.

GHC/St. Peter’s has focused on providing care for patients from the Missionaries of Charity from the very beginning of the program to make sure that the poorest in Ethiopia also had access to care. Some of the first patients to receive Category IV treatment were from the Missionaries. This week we met Helen, a young woman with an 18 month-old baby boy. She has confirmed MDR-TB and is wasting away. After it was discovered that she has MDR-TB, the sisters were able to move the several other beds in her room into another room to decrease the contact between Helen and the other women in the TB ward. Still, to get to her room you have to walk through a few other rooms with 6 or so patients each; definitely not ideal. She was thin, her heart was tachycardic, her respiratory rate in the 30s. Her lungs had crackles on the left and diminished air entry. Her artificial leg (she had to have a left AKA after an infection when she was younger) is causing her significant pain because it was fitted for her when she was about 20kg heavier.

With the arrival of more TB medications, Helen was able to be admitted to St. Peter’s for treatment yesterday. Next week I will go back to the Missionaries to take photos with her boy and bring them to her.

Helen's boy, Josef

More than MDR-TB at Black Lion Hospital

This week we went to the Black Lion Hospital, which is the main teaching and referral hospital for the country. It is large, and right in the middle of Addis.

We met with Dr. Demte, the head of the Pediatrics Department, and attended morning report and morning rounds. There is a NICU and a PICU (although no ability to ventilate patients). The children here are sick, sick, sick. We met one 2 year-old boy, Abu, with suspected MDR-TB (he has continued to get worse despite adequate Category I therapy, with loculated empyema and chest tube in place) and will try to facilitate testing of his sputum so that he can get treatment if he needs it. We also met several children with bacterial meningitis, children admitted with heart failure, renal failure, rhabdomyosarcoma, osteosarcoma, retinoblastoma, severe pneumonia, several children with infected meningomyeloceles, one child with tetanus, three with septic arthritis, several with complicated malaria, a few with severe acute malnutrition.

CXR Bad TB in 2yo boy
CT Bad TB in 2yo boy
The format of morning rounds is by department (i.e. wards, NICU, PICU), with the resident reporting admissions, discharges, and deaths. There are deaths almost every day, which speaks to the degree of illness.

Over the past week and a half we have also participated in home visits for the MDR-TB patients. We’ve met with officers from the Ministry of Health and the Ministry of Science and Technology. We’ve seen many different aspects of health care and clinical practice at multiple institutions. It has been an extremely worthwhile learning experience.

I can’t believe my time here is already more than halfway finished. In addition to daily rounds at St. Peter’s, my goals for the remaining time are as follows: 1) go back to the Missionaries of Charity to take photos with Joseph, Helen’s son and to let the Sisters know that she is doing well; 2) return to Black Lion to attend some morning reports, grand rounds, and morning rounds, checking on Abu; 3) draft some Quality Improvement suggestions for GHC/St. Peter’s; 4) develop flowsheets/clinical guidelines for the nurses and health workers at St. Peter’s; 5) participate in additional home visits.
Less than two weeks left!


Wednesday, May 11, 2011

Respiratory Failure, Respiratory Success at the Global Health Committee / St. Peter’s Hospital MDR-TB Ward.

Day 8: May 11, 2011. Addis Ababa, Ethiopia.
Respiratory Failure, Respiratory Success at the Global Health Committee / St. Peter’s Hospital MDR-TB Ward.

Submitted by: Raquel Reyes, MD, MPA, PGY3, Internal Medicine and Pediatrics, Massachusetts General Hospital.

The Ethiopian Global Health Committee (GHC) MDR-TB treatment program is the first and only MDR-TB treatment program in Ethiopia. From an initial cohort of 9 patients in February 2009, the program has grown to include over 200 patients enrolled to date. Approximately 30 of these patients at any given time are hospitalized with advanced disease requiring stabilization and usually remain inpatient until they are smear-negative x 2. The rest are treated as outpatients, following an adapted community-based model of care delivery initially developed by the GHC in Cambodia. The GHC/St. Peter’s MDR-TB cohort, in partnership with the Ethiopian Ministry of Health, is serving as the model for scaling of treatment nationwide and has the potential to inform TB treatment programs throughout Africa. A second site in Gondar (Northern Ethiopia) has recently begun treatment of MDR-TB patients, also in partnership with GHC. (see I am fortunate to be able to spend four weeks on rotation here, learning about MDR-TB treatment and treatment challenges.

During my first week, I have been able to participate in rounds, admission of patients, and participate in home visits. I have been so impressed with the magnitude of the impact that the MDR-TB program has had in this community. It has truly been life-saving and life-changing for so many already; and there are thousands more people infected with MDR-TB in Ethiopia who need this therapy. Prior to April 2009, there was no Category IV treatment available. This means that these patients have undergone several cycles of Category I and Category II treatments, sometimes failing Category II therapy three or four times, before enrolling in the MDR-TB treatment program at St. Peter’s. Often patients have languished for months and years before arriving. Tuberculosis truly is “consumption”.

Respiratory Failure.

Two patients have died on the wards during my first week here, both young males, both of respiratory failure. The first patient I met on my second day on rounds.

The MDR-TB ward is situated above the rest of the hospital (i.e. at higher altitude), which is situated above the city of Addis, heading north out of Addis up toward Entoto mountain. The patients who have not yet had a negative sputum sample are on a wing which is separated from and also slightly above the wing for patients who have converted from positive to negative but who still require additional inpatient therapy or who are not yet ready for discharge for other reasons (e.g. persistent hypoxia, inability to adhere to the medical regimen as an outpatient, etc). Most of the rooms in the sputum-positive wing are single-patient rooms. I met Abde, a 20-year-old male, on this wing.

On admission Abde had had a large left-sided empyema, which had been drained twice (see CXR below). When I met him, he looked relatively well over-all but was complaining of new right-sided chest discomfort and had a pleural rub on that side as well as focal crackles. His left side was slightly dull to percussion at the base with diminished air entry, but clinically he did not seem to have significant reaccumulation of fluid. He had a mild oxygen requirement. He was already on levofloxacin as part of his Category IV regimen. We added IV ceftriaxone for presumed superimposed pneumonia. We wanted to obtain a chest XRay, but there is no functioning XRay machine on-site and the nearby location where St. Peter’s typically sends patients for studies also had suffered a mechanical problem and was not performing XRays. The following morning, Abde looked worse. He was tachypneic and had an increasing oxygen requirement. He was in respiratory distress. We added vancomycin. We tried inhalers (there was no nebulizer available). We purchased ceftazidime (the broadest cephalosporin available in Ethiopia) for $21/gram. He died of respiratory failure around 4:00pm, before he was able to receive the additional antibiotic.

Abde's CXRs

I met Girmay on the sputum positive ward as well. He was 18 years old, so so thin, unable to move due to severe malnutrition and generalized weakness due to his TB. I could basically bring my fingers together in the space in between his radius and ulna. Girmay had been admitted one week previously and was noted to have asymmetric LE edema that turned out to be a DVT. I met him on Thursday. His lungs had bronchial breath sounds and dullness to percussion on the right, as well as some rhonchi. His left was a little crackly at the base but actually sounded fairly clear. His coagulation panel had been sent but was not yet back from the private lab that processes most of the laboratory studies sent from St. Peter’s. When I met him he didn’t have an oxygen requirement, only some shortness of breath and occasional hemoptysis. The next day, (the same day Abde died), Girmay still was stable, and the result still was not back. I was growing antsy. Finally, on Saturday, the result was back. His PTT and INR were slightly elevated (INR 1.6), likely due to his severe malnutrition. We were convinced that a PE would be devastating to him and decided to start the heparin (subcutaneous, gtt not possible for numerous reasons). There was no heparin available in the hospital, so we drove to another hospital to purchase it. The other hospital had only two 5cc vials (5,000U per cc). We bought the heparin and went back to the hospital to get him started. On Monday morning rounds, he was in respiratory distress with an oxygen requirement. We were immediately concerned that he had suffered a PE. Then we heard that the previous day, his heparin had been held due to concern for hemoptysis. He had had sudden hypotension, chest pain, increased work of breathing, and a new oxygen requirement. The clinical picture was completely convincing. Girmay looked like he was dying. His oxygen saturation was 83 or 84% on the 4ish liters of O2 delivered via oxygen concentrator. He was frightened and held my hand tight; looking directly into my eyes, in simple broken English, he begged me to be his mother (whom he had witnessed be crushed by a car and killed a few months earlier after traveling to Addis to get him treatment) and to please not leave him.

Later in the morning the power went out. We got the pulse oximeter and ran down to his room. He was in severe distress, saturating 56% (supplemental oxygen is delivered via oxygen concentrators which require electricity). We were in the process of bringing the one of the two 40L oxygen tanks on the ward to his room and hooking it up when the power returned. We put a mask over his face to pool the oxygen. It took twenty minutes for his oxygen saturation to come up to 80%. We gave instructions to his uncle and to the nurses that should the power go out, he should be connected immediately to the oxygen. I was worried he would die overnight, and worse, that he would feel alone and afraid as he died. He didn’t die until the next day, though. When we rounded in the morning, he was saturating 60% on the 4L available via the oxygen concentrator. We slipped the tubing from the supplemental canister into his mask and turned that up as well, repositioned the nasal prongs, and fashioned a non-rebreather out of a face mask with cut-off latex glove fingers slipped through the side holes and taped down. It’s difficult to explain, but we were able to fashion them to be sort of one-way valves. With all of this intervention we were able to get his oxygen saturation back up to 80%. He tired anyway a few hours later and died. I am so crushed and guilty that I wasn’t there holding his hand and stroking his face.

Girmay's pulse-ox several minutes into attempt at increasing oxygen delivery

Respiratory Success.

Despite these sad, devastating outcomes, the majority of patients treated with MDR-TB at GHC/St. Peter’s are incredible success stories, and it is so important to draw attention (yours and mine) to that. Without this program, these patients would have invariably died as well.

Of the 230 patients initiated on therapy since February of 2009, so far seven patients have successfully completed a full 2 year course of Category IV treatment for MDR TB, with cure. Out of 221 patients admitted for care to the GHC/St. Peter’s program over the past two years and 3 months, only 22 have died. Taking into consideration the limitations and challenges of working in a developing country (limitations with respect to resources including laboratory and radiographic studies, available medications, monitoring capacity, etc), as well as the bias introduced by the triage waitlist whereby more severely ill patients are admitted for treatment before the more stable patients, this is an impressive survival benefit and an amazing achievement.

Take for example the case of Yohannes, now a 29yo medical student. He acquired MDR-TB during his early medical school training. He received Category I therapy but failed, and within several months was diagnosed with MDR-TB. At that time there was not yet an MDR-TB treatment program. After several more months, he was sent home from medical school to die. The necessary drugs simply were not available. He weighed less than 45kg. Some months later, over a year after he had first acquired the disease, he became one of the first nine patients enrolled in the GHC/St. Peter’s MDR-TB treatment cohort. He is currently on his 28th month of treatment, is back in medical school and looking forward to completing his degree in one year, and his weight is back up to 60kg.

There are so many other patients like this. I haven’t been here long enough to witness the transformation for these patients as they recover, but I have met several patients already who appear healthy, smiling, happy; they are working or studying, living a relatively normal life (with the exception of having to take their TB medications twice per day) and the doctors and health officers who knew them before are able to tell me how sick they were at the beginning, how malnourished, how uncomfortable. The fact that I can’t even tell that they were ever so ill is a testament to the success of their therapy.

I am looking forward to the next three weeks of this experience. Tomorrow we will travel to Gondar to visit the MDR-TB Ward that has just opened there and to meet the nurses and physicians who are caring for that cohort of patients. Yohannes the medical student, is back in medical school there at the University of Gondar, and I will get to meet him.

Me and Yohannes enjoying yummy Ethiopian food

Next week I will visit the Black Lion Hospital and the Missionaries of Charity to see additional patients and learn more about how medicine is practiced here. I also plan to talk with Dr. Danny (the head physician here at St. Peter’s MDR-TB Ward) about some ideas I have for quality improvement and how we might implement them.

Kris Olson, who travels here regularly and who will be here for another week this visit, is working on a project to study the potential benefits of a portable cool-box in development in partnership with MIT and GHC. The box is designed to not only provide a cooling source for MDR-TB patients on Paser who do not have their own refrigerator (it is able to work with solar power if need be for patients who do not even have reliable electricity). It will also have a counting mechanism that transmits data about how often the box and medications are accessed to the DOTS-Supervisor. Soon they hope to begin developing the survey tool that will be used to assess the benefits and challenges of using the box, and I hope to participate in additional home visits to help design that survey tool.

I anticipate a busy, challenging, and rewarding three weeks with lots of opportunity to learn about MDR-TB and practicing medicine in Ethiopia.


Thursday, May 5, 2011

Esther Luo, Ho Chi Minh City, Viet Nam, Developing a Strategic Plan for Sustainability in Palliative Care in Vietnam

Blog 3 In addition to visiting home care patients and facilitating small group discussions on palliative care topics, one of the most exciting events was the development of a strategic plan making palliative home care program sustainable. We utilized the SWOT analysis (strengths, weaknesses, opportunities, and threats) to evaluate our palliative home care initiative. We divided into smaller groups for the SWOT analysis. Our Vietnamese clinicians astutely identified the challenges for sustainable palliative care including securing adequate funding resources, providing further palliative care training to doctors and nurses, and policy advocacy, opioid availability, and implementation.
Funding sources for international palliative medicine is not easy. In 2008, the Open Society Institute conducted a study to identify national and international palliative care funders that support hospice and palliative care activities in Africa, Central, Southern and Eastern Asia, Central and Eastern Europe, the Commonwealth of Independent States;, Latin America and Caribbean, and the Middle East. Of the 354 donors identified, 21% are active donors in Central, Southern and Eastern Asia.
Training palliative care doctors had already began in cities of Vietnam including Ho Chi Minh City and Hanoi. As I mentioned earlier, Dr. Eric Krakauer had already trained many local Vietnamese physicians and nurses on palliative care topics. In addition, two physicians were selected as international palliative care fellows at the International Palliative Care Program in San Diego in the recent years.

The Ministry of Health began its palliative care initiative in 2005 and conducted a rapid situation analysis of the need for palliative care for patients with cancer and HIV/AIDS. Based on these data, the Vietnam palliative care initiative was planned based on the WHO's public health strategy for national palliative care program development. Efforts to make opioids such as morphine available in Vietnam resulted in collaboration with the International Pain Policy Fellowship Program at the University of Wisconsin, a workshop in opioid policy in 2007 in Hanoi. Within one year of the workshop, the Vietnamese Ministry of Health liberalized opioid prescribing regulations that reflected international standards. Despite the current progress, cancer hospitals like the one we visited continue to face shortages of consistent opioid supplies.

Lastly, implementation of a sustainable palliative care internationally is challenging. However, the palliative care program already implemented in Ho Chi Minh City's Cancer Hospital is an example of the possibility of sustainable palliative care. With available resources, dedicated faculty (both American and Vietnamese), and enthusiastic learners and the support of the hospital administration and ministry of health, we are beginning to see the results of years of hard work. From no palliative care, to a dedicated inpatient palliative care unit, to a home care program, and dedicated fellowship training, I believe palliative care will become sustainable in the Cancer hospital in Ho Chi Minh City!

Teaching Palliative Care, Esther Luo, Ho Chi Minh City, Viet Nam April 2011

Blog 2 Teaching international Palliative Care
One of the skills I am learning during this trip is how to teach palliative care to an international audience. How does one present a power-point presentation with an interpreter? How does one teach home care not knowing the Vietnamese language? How does one facilitate small group palliative care teaching using an interpreter?

As it turns out, it was not as complicated if one remembers some of the basic principles. Some of the golden rules about presentations still apply. For example, "what's in it for me?" "Who's telling?" and "How do you tell it?" are important questions to answer in order to capture the audience and keep their learning proactive and motivated.
What's in it for me?

I was amazed to see the amount of interest in learning palliative care in an Asian country like Vietnam where death is often a taboo topic. When I asked this question recently to a physician researcher in HIV/AIDS epidemiology, she replied, "We are not as worried about such necessities such as food and are able to focus on other things that are important to the quality of life such as eating healthier, exercising, and palliative care." "For example," she continued, "in her apartment complex, there is a yoga club for the residents and it is for free." As Vietnamese people's economics and home security continues to improve, the focus on quality of life is palpated even more vividly. Even though the field of palliative care in Vietnam is a new field, the Ho Chi Minh Cancer Hospital is embracing it without any reservation. Under the mentorship of Dr. Eric Krakauer, two cohorts of approximately 32 physicians have already received basic training in palliative medicine. Upon the opening of the new inpatient palliative care unit, many clinicians including both physicians and nurses want to learn more palliative care skills.
Who's telling?

I was lucky to participate in the building of the palliative care home care program in Ho Chi Minh City's Cancer Hospital with two giants in international palliative medicine: Eric Krakauer and Frank Ferris. Given both of their extensive experience, knowledge, and expertise in this field, it was not too difficult to retain a captivated audience. Under their wings, fellows like myself, had a rare and unforgettable opportunity to experience their teaching styles and an opportunity to model after them. Teaching in an international setting means learning how to work with your interpreter, speaking clearly, concisely, and slowly, and demonstrating respect for your international audience. Having had experience with translation in the past and giving multiple presentations as an internal medicine chief resident, I was more at ease with these two aspects. Demonstrating respect was easier said than done. Even though we were here teaching them about how to do home care, it was paramount to respect the Vietnamese physician and nurses knowledge about their health care system and listen to their ideas on how best to incorporate the home care program in order to make it sustainable.

How do you tell it?

We taught using various methods including large group presentation, small group facilitation, and role play. For me, the most challenging and rewarding was facilitating in my small group. Each day after we saw our home care patient in the home, we returned to the hospital to discuss the case further in our small groups. A very useful tool we employed was called the "Squares of Care." This tool was developed by Frank Ferris as a model to guide patient and family care (Ferris et al. J of Pain and Symptom Management 2002). We had physicians and nurses complete separately the squares of care and then compare their information. Each square represented common issues faced by patient and family members during illness and bereavement. By using this model, we were able to teach our Vietnamese physicians and nurse how to make a palliative care assess including both the physical symptoms as well as the psychosocial assessment of our patients. Another technique we used in our small group teaching was role play. One of the role plays we did in our group included an interview of a patient and doctor visit. One person played the role of the doctor and the other person played the role of a metastatic breast patient who wanted to know whether where was going to be cure for her cancer.

My personal reflection on teaching as our two weeks of home care training came to an end was: "this is amazing work and what a privilege to have this international experience as part of my fellowship training!"

Esther Luo, Ho Chi Minh City, Viet Nam, April 2011

In 2005, the Ministry of Health of Vietnam launched a palliative care initiative for which Dr. Eric Krakauer has been the primary technical advisor. Dr. Krakauer is also an attending physician on the MGH Palliative Care Service and Director of International Programs at the Harvard Medical School Center for Palliative Care. The Ho Chi Minh City Cancer Hospital, where Dr. Krakauer has provided intensive training and technical assistance for the past two years, has taken the lead in developing palliative cancer care in Vietnam. I came to Vientam with Dr. Krakauer and Dr. Frank Ferris, Director of International Programs at The Institute for Palliative Medicine at San Diego Hospice, to assist the Ho Chi Minh City Cancer Hospital develop a palliative home care team.

We formed three home care teams comprised of American clinicians and Vietnamese physicians and nurses. In my home care group, I was paired with Mary Wheeler, an American hospice nurse. Together, we worked with three other Vietnamese physicians and six nurses. All the nurses had recently started working in the newly established 10 bed inpatient palliative care unit. From day one, I sensed a tremendous amount of energy, passion, and desire to bring palliative care to the patients at their homes.

Our first patient was a 73-year-old retired nurse diagnosed with metastatic lung cancer in 2006. In 2010, she had received 6 cycles of chemotherapy. She currently lived home with her daughters who were her caregivers. We traveled by van to visit her in her home. Our nurses carried with them a "medical bag" which included things such as stethoscope, blood pressure measurement, hand sanitizer, and gloves. She reported symptoms including back pain, dyspnea, and decreased appetite. We quickly learned that she was reluctant to use morphine for pain and dyspnea. Instead, she was using Diclofenc for pain. Her daughter told us that she "knows everything about her disease." The daughter also wanted to keep their mother at home and only treat her symptoms. She is Catholic and there was a rosary hanging close to her bed. Our nurses conducted the bedside interview while our Vietnamese doctors talked with her family.

During my debriefing session in the afternoon, we asked our group about their experience and concerns about doing home care. The doctors were concerned that they will be asked questions they cannot answer by the patient or the family members. The nurses had concerns about seeing patients at home since many of the patients are used to seeing only doctors. The nurses felt inadequately prepared in their communication skills in caring for patients with cancer and physical examination skills. In our small group we talked about the concept of a team and how this can help both the physician and nurse to out to each other for help. We did some role playing as a way to practice communication skills when talking to patients and their family members.

For two weeks, we traveled to patient's homes and conducted evaluations in the morning. In the afternoons, we discussed our cases using the Squares of Care developed by Dr. Frank Ferris. The most amazing thing was to see the collaboration between the Vietnamese doctors working side by side with their nurses.