Teaching Palliative Care in Vietnam – Part 2

Alex T.Q. Nguyen, M.D.

Clinical Fellow, Harvard Interprofessional Palliative Care Fellowship

PGY4

Teaching Palliative Care in Vietnam – Part 2

During the second week in Vietnam, in the hot and humid weather, we commuted daily to the newly open City’s Children Hospital in Binh Chanh District of Ho Chi Minh City to provide clinical training for the pediatricians who participated in the palliative care course. They were divided into smaller groups of 8-12 trainees and were asked to provide palliative care assessment for pediatric patients ranging from the NICU, PICU, to Infectious Diseases ward. As part of these exercises, they were given different cases selected by the Palliative Care Consult Service. Of note, this is the only children hospital in Vietnam with a full-scope palliative care service that includes two physicians, a nurse, a psychologist, and a social worker.

Bedside teaching by Dr. Melody Cunningham in the NICU at City's
Children Hospital in Ho Chi Minh City

The most challenging cases involved patients with neurological injuries. Again, the conversation surrounding withdrawal of life-sustaining treatments were difficult. A number of the trainees had a difficult time differentiating between withdrawing life sustaining treatments with physician-assisted death. In addition, the concept of brain death is not viewed as actual death by Vietnamese laws, and it is not uncommon for brain dead patients to have cardiac arrest while on prolonged ventilatory support.

We also had very interesting and stimulating discussions about pain assessment in pediatric patients who lack the ability of verbal communication, especially neonates. Often, when a patient becomes unresponsive, pain assessment falls off the checklist in the ICU. We discussed the importance of understanding how certain diagnoses afflict pain or discomfort to a verbally capable patient, then how to translate that understanding of pain-inducing mechanisms to provide adequate pain control for a nonverbal patient.

At the end of the course, each group of trainees had the opportunity to present their cases to the rest of the class. It was their showcasing of what they have learned from the course and what lingering questions they hope the audience could help answer. One of the themes throughout this course was the cultivation of resiliency and self-care for the physicians who are the front line providers taking care of very sick patients. Burnout is not a unique phenomenon that only occurs in the U.S. In the under-resourced Vietnamese medical system, the number of patients a doctor sees each day can easily triple that in the U.S., and the support that Vietnamese doctors receive from their supervisors and colleagues are minimal to none, especially in the community setting. Teaching this palliative course in Vietnam makes me become more appreciative of the medical training environment that I’m currently part of in the U.S., albeit its downfalls. And helping to spread the knowledge of palliative care globally is extremely gratifying as the field is still young and the needs are exponential.

Teaching Palliative Care in Vietnam – Part 1

Alex T.Q. Nguyen, M.D.

Clinical Fellow, Harvard Interprofessional Palliative Care Fellowship

PGY4

Teaching Palliative Care in Vietnam – Part 1

During the first week in Vietnam, I assisted in teaching a palliative care course to Vietnamese physicians who are pursuing their specialist training. The two-week course took place at University of Pharmacy and Medicine in Ho Chi Minh City and the specialists came from various disciplines of internal medicine and pediatrics. The first week of the course consisted of mainly didactics with some small group discussions. The topics of these didactics ranged from pain management to communication skills to ethical principles for patients with serious illnesses not limited to just cancers. Some of the course’s participants spoke English. However, many of the trainees came from provincial or rural areas, therefore, the course was taught in Vietnamese. There were faculty who was fluent in both English and Vietnamese who helped teach the course and also translate for the faculty who came from the United States and South Africa. As a bilingual Vietnamese American, I had the chance to improve my medical Vietnamese, help with translating the conversations, and participate in the discussions with the Vietnamese physicians.

What I found was most difficult was the discussion involving withdrawal of life-sustaining treatments. What governs Vietnamese medical ethics are not necessarily the same as Western medical ethics. Almost universally in Vietnam, doctors do not recommend withdrawal of life support. This is viewed as giving up. Often, life support is withdrawn when the patient’s family can no longer afford paying for the care. Many of the patients with serious illnesses do not have the financial capability to pay for prolonged hospitalization. Unfortunately, a person’s wealth dictates the type of care they receive in the medical setting. Interestingly, even though doctors in Vietnam tend to practice paternalistic medicine, and very often the patients and their families expect that type of care delivery, if the patients or families demand continuation of life support despite poor prognosis, their doctors would almost never decline.

During the small group discussions, I also learned about the lack of access to opioid medications in Vietnam. With a simple medication like morphine, which we take for granted in the US, many doctors in Vietnam feel uncomfortable with prescribing because they have never been exposed to morphine in their training. Therefore, patients can only get access to morphine if they come to a major medical center. In addition to the difficulty of obtaining a morphine prescription, now they have to find a pharmacy that can fill the prescription. For patients who live far away in a rural area, it would be impossible to receive good palliative care.

All the faculty and participants of the palliative care course

Another interesting topic that was taught in the course was grief and bereavement. Similar to medical training in the US, Vietnamese medical schools do not teach about this topic adequately. Although, culturally speaking, it is much harder for Vietnamese physicians and patients to talk about emotions and psychological distress. Besides talking about the various stages of grief, we also discussed the relevance of religion, spirituality, and psychotherapy in helping patients’ families coping with death of their loved ones. At the end of the first week of the course, each participant wrote down on a piece of paper a memory or name of a deceased patient whom they have taken care of, these papers were collected and burned at a local temple as part of the memorial service.

The LMIC Critical Care Patient – A Rwandan Experience

Nana Sefa

PGY 3

Emergency Medicine Critical Care Fellow

The LMIC Critical Care Patient – A Rwandan Experience 

I spent a couple of weeks in the Intensive Care Unit (ICU) of the University Teaching Hospital in Kigali. This was a very informative time during which I encountered a completely different patient population. Two aspects in particular stood out. First, the oldest patient I saw in the unit during the entire two-week period was a 60-year-old female. This patient was actually an outlier when is comes to age. On most days, the 7-bed ICU had patients aged between 18 and 39 years. This is contrary to the ICU population at the BWH MICU, where a 50-year old on most days could be the youngest patient. Additionally, about 50% of patients in the ICU in Kigali were patients with obstetric complications. During my multiple months in the BWH ICUs, I have known of only a handful of obstetric admissions to the ICU.

Without conducting a formal study, I also noticed that the mortality rate of patients was fairly high. The relative young age and the high mortality of patients in this ICU is very concerning. The quality-adjusted-life-years lost would be significant if calculated. It stands to reason that the socioeconomic value of the loss of these patients would be substantial. Additionally, given that these patients are dying during their most productive years, the country is also losing a significant amount of its manpower.  

My observations highlight the need for an investigation that would determine the underlying causes of the admission of a relatively young patient population to the ICU in Kigali, Rwanda and the issues leading to the relatively high mortality rate. Until the causes of these phenomena are elucidated, designing interventions that would meaningfully change these outcomes would be impossible.

My time in Kigali was not only educational on a professional level, but also on a personal level, inspiring me to focus part of my work on shedding more light on the uniqueness of this ICU population and improving mortality and patient outcomes in similar contexts.

Global Health Community Entry in Kigali, Rwanda

Nana Sefa

PGY 3

Emergency Medicine Critical Care Fellow

Global Health Community Entry in Kigali, Rwanda

I arrived in Kigali, Rwanda for a two-week elective rotation in the Intensive Care Units of the University Teaching Hospital (CHUK) and the King Faisal Hospital on October 26, 2018. This was my first visit to Rwanda. One of the objectives of this visit was to establish relationships for future global health collaboratives with staff at this institution and other Rwandan Healthcare facilities.

So how did I ensure a mutually beneficial trip with very limited time and no previous relationships to build on? I started off by meeting everyone I had email exchanges with prior to my visit. These were my initial champions. They helped introduce me to influential clinical staff who run the day-to-day activities in the ICU. Additionally, I tapped into the institutional goodwill and credibility of my mentor and the Brigham and Women’s Hospital. My mentor has been working with the ICU at CHUK for over 5 years and is well liked. This ensured that anyone she introduced me to welcomed me with open arms. Additionally, the Brigham and Women’s Hospital Emergency Medicine faculty were involved at the start of the country’s first emergency medicine residency about 5 years ago. Thus, I was able to tap into some of the goodwill that Brigham has at CHUK.

That said, reliance on the goodwill of people and institutions is helpful only to establishing an initial encounter. I subsequently had to roll up my sleeves and build on these links to establish my own relationships. I started off by asking lots of questions. The clinical practice and protocols used in the institution were relatively different from what I had used, which provided an avenue to learn more about why they did things the way they did. In asking my questions, I had to be tactful so that even for practices that were not evidence based, I did not come off as passing judgement or looking down on the care that was being provided. I also had to understand that some of their practices were influenced by unavailability of resources. This meant that even when I suggested changes, I had to first ensure that the resource I was suggesting was available.

My experience in Kigali also meant interacting with a completely different culture than I had ever been exposed to. But I dove right in. In doing so, I had to acknowledge that there were cultural differences and to let my hosts know that although I was not familiar with their culture, I respected the fact that their culture was important to them. I also had to ask questions specifically about what was culturally appropriate to do or to ask.

Additionally, for each frontline clinical staff I interacted with, I had to find out what was important to them and how I could be of help to them. This inquiry started during the email exchanges before my arrival. For instance, the residents in the ICU were eager to learn and sent me topics they wanted to discuss before my arrival. This provided an initial mutually beneficial relationship that ensured a fruitful interaction even on the first day. What is interesting about asking what was important to an individual is that each person had his or her unique evolving interests that were very different from what the institution or unit head had communicated. For instance, although not mentioned before my arrival, one resident’s main goal during my visit was to learn to do ultrasound-guided subclavian central lines. For this individual, my visit would not have been successful without teaching him this skill. Continually asking what would be important and meaningful to counterparts is thus crucial to a successful global health collaborative.

Although my two-week visit was short by all the means of evaluating a successful global health interaction, I deemed it successful because of the relationships I was able to build. I am sure I will be able to build on these relationships to ensure more productive interactions in the future. 

In Our Context

Mark J. Harris, MD MPH

Anesthesia

PGY 3

June 10, 2018

In Our Context

I recently finished reading the book The Power of Meaning, which was written by a college classmate of mine, Emily Esfahani Smith. The book addresses the question of deriving meaning and finding fulfillment in life. This isn’t your run-of-the-mill self-help book. Part journal and part thesis, it is a compilation of hundreds of hours of research, travel, and interviews with people who have been able to find meaning in their lives and what factors distinguished them from those who struggle to find it. She references the literary and philosophical greats throughout history, as well as the modern science and data that further support these ideas. She distills her observations into four different Pillars of Meaning: Belonging, Purpose, Storytelling, and Transcendence.

Items in the education building’s simulation center at CHUK which include models and equipment for anesthesia, emergency medicine, surgery, and obstetrics simulations. 

As my time in Rwanda ends, I have been reflecting on the ways in which I have found meaning. The staff and residents here have been extremely open and welcoming throughout our stay; we started as strangers and mere acquaintances but easily became colleagues and friends. Our goals, as I mentioned in a previous blog post, were the same: to inch towards that goal of safer and higher quality anesthesia care. We traded stories, experiences, and observations. When discussing differences in practice, the residents would explain how they provided care “in [their] context.” An excellent phrase that honored and expressed differences in setting without judgment or prejudice. Several of the more senior residents had spent 6-8 weeks in the US or Canada to observe anesthetic care those settings, and they would often reference those experiences and the lessons learned that they tried to apply in the Rwandan context. My own observations in Rwanda have helped me understand what components of anesthesia transcend context: what forms the core essential of anesthetic care, regardless of context.

Anesthesia machine in use at King Faisal Hospital. The main volatile anesthetic agents available are isoflurane (pictured) and halothane (not pictured). 

I would like to thank all of the people and organizations that supported me in this endeavor. Thank you to CASIEF and the ASAGHO for their many years of dedication and investment in Rwanda. Thank you to the BWH Department of Anesthesia and the ACGME for allowing me the opportunity to volunteer in Rwanda during residency. Thank you to Dr. Chritton for his dedication to teaching and mentoring, and for allowing me to join him on this trip. Thank you to the Centers of Expertise for the funding and support to make this experience possible on a resident budget. Finally, thank you to all the anesthesia residents and staff in Rwanda who welcomed us and made this experience meaningful. Murakoze cyane.

Reusable masks, blades, and other equipment cleaned and drying in preparation for next use. 

High Altitude Medicine in Nepal: Part 2

Carlo Canepa, MD

Fellow in Wilderness Medicine at the Massachusetts General Hospital

PGY-6

High Altitude Medicine in Nepal: Part 2

We’ve entered our second month of the high-altitude clinic being open and the patient volume has slowed dramatically. While in April there would be 15-20 patients per day, now we are seeing between 5 and 10. This coincides with the decline of trekking traffic in the national park. Another factor is that many of the guides, porters, and locals have been up and down the trek 7 or 8 times. Their bodies have acclimatized to the lack of oxygen and we no longer see as much altitude illness in that population. Trekkers will still come in with AMS, HAPE, and HACE, however.

We’re about to see our 500^th patient for the season, with close to 50 with high altitude pulmonary edema and around 10 with high altitude cerebral edema. We’ve had to helicopter evacuate about 15 patients so far, with another 15 at least opting to fly out on their own. This does not include the likely dozens or hundreds of trekkers who get flown out at higher and lower altitudes that never come to our clinic. This is a big change from the last time I was here in 2012. The number of helicopters has skyrocketed. Whereas before we might see 1 or 2 per day in the valley, now there are up to 50 flights in a single day, for commercial reasons and for medical evacuations. The industry has dramatically changed how trekkers plan their treks. Many will hike up to Everest Base Camp and then choose to take a helicopter down, rather than to hike down several days. Similarly, trekking companies are aware that if one of their team members gets ill while hiking there will always been helicopters available to evacuate them, weather permitting. We even saw one patient who was evacuated off the trek with acute mountain sickness via helicopter to Kathmandu and then returned for a scenic helicopter flight only to get symptoms of HACE during the flight. She was evacuated again via helicopter.

This means this extreme environment with its lack of available oxygen is now readily available to a wider population. We have seen people in their 70s and 80s trekking up to 18,000 feet! Similarly, we occasionally see parents carrying very young children (the youngest we have seen was 6 months old). Although the data regarding children at altitude is not comprehensive, it seems logical that the developing brain will not do well in a hypoxic environment. We’ve also seen people who are tremendously out of shape and ill-prepared for such an intense trek (with 6-8 hours days of hiking up and downhill at altitude). We’ve also seen many people with significant co-morbidities coming up the mountain, including auto-immune hepatitis, coronary artery disease with multiple stents and bypass grafts, pulmonary embolism, etc. Although the trek is now more available to all populations, it also means that people are undertaking the trek without being fully prepared or educated about the dangers of high altitude.

We give a free lecture every day at 3pm to educate the public about the dangers of high altitude and signs and symptoms of high altitude illness. Some days we have only a couple of participants and others we may have more than 30. People are always surprised at how dangerous even trekking at such an altitude can be. Every year there are deaths in the valley from high altitude illness and this year is no exception, with approximately 8 to 10 tallied thus far. We do our best to educate attendees so that they can then be on the lookout for trekkers and locals who appear ill.

 

A few of the more interesting cases we have seen recently include a homeless woman living among the mountains with severe frostbite of her feet, high altitude cerebral edema complicated by GI bleeding after severe vomiting, and a likely case of appendicitis at high altitude, which we treated with oral antibiotics. We have made a few house calls while here, trekking about 2 hours in the night and light snow to meet a patient with severe Acute Mountain Sickness who was unable to walk on her own due to severe weakness. We had a pediatric abdominal pain that was severe with fever that looked like a liver abscess on bedside ultrasound. He was treated with IV antibiotics and evacuated. Another female trekker who was taking acetazolamide and ciprofloxacin continued to feel ill and was diagnosed with a high-altitude pregnancy. Her medications were stopped and she made her way down the valley.

One byproduct of working at a high-altitude clinic is that there is a lot of downtime. After the clinic closes at 5pm we may see another 1 or 2 patients that come in overnight. Otherwise, much of the evenings are free to ourselves. We have a cook who prepares three meals a day for us (8am, 12 noon, 6pm), and I brought another bag’s worth of dried fruit and snacks. Then we’ll often watch a movie after dinner together from the wide array of DVDs available at the clinic. I’ve read about 10 books while here and have also worked on research projects and write-ups that had been previously ignored. We also have days off where we can trek throughout the valley. Between the three physicians, we’ve been to Everest Base Camp, Kala Pattar, Ama Dablam base camp, the central town of Namche several times, Island Peak base camp, as well as the nearby Gokyo valley. We have gotten a chance to explore the area in great detail.

Lastly, my research project is coming along well. I had my second set of research assistants pass through the valley and altogether we have thus far recruited 222 participants for the study. The goal is to reach 288 by the end of May. I have tried to recruit at different altitudes, with the higher altitudes covered well, which means I’ll have to descend to lower altitudes to recruit some more. Recruiting from big, English-speaking tour groups has proven to provide the highest yield of participants. Otherwise, it’s mostly hanging around the tea house dining areas and randomly approaching strangers to ask them if they would like to be part of a research study. That approach generally works fine, but the trek is very international and so there will often be huge groups of non-English speakers. On a different note, the daily temperatures hover around freezing and the nighttime temperatures drop below freezing, which make convincing participants to have a lung ultrasound with their chests exposed and cold gel applied a bit difficult.

Altogether my experience has been as I expected it to be: a lot of altitude medicine, a lot of primary care, excellent hikes in the mountains, and not-so-easy-to-conduct research. Working and volunteering for the Himalayan Rescue Association (HRA) is almost a rite of passage for anyone interested in working and conducting research at high altitude. I feel fortunate that I had the opportunity to spend two months working with such an amazing organization and in such a unique environment. This experience has encouraged me to continue to work and play in the mountains and to pursue further research ideas in high altitude physiology. It has been a once-in-lifetime opportunity.