Ha Long Day

The second day in Ha Long started a little late with such a late night. I wanted to go over to the town that is not the tourist part. They now have a new bridge which is very beautiful and we crossed over. I got the driver to take me to the market. Yesterday, one of the people I had talked to had told me I should go to the supermarket. I finally got out that she meant this market and I think it was pretty special. It was kind of like the flea market back home. Low fee to get in and then walking around with people demonstrating ginsu knives and veg-a-matics and lots of other cool and very retro stuff. I tried to negotiate prices but pretty low and not much of a budge on the wooded soup spoons. On the other side there was a kind of trade show and I checked out potted meat products for the next camping trip, rice, plants, building supplies and basically a lot of the basics you would need. I also visit the fish sauce people. Wow, that was some very pungent stuff. Everyone was very pleasant and helpful and I will try to get some more pictures up. I walked around and found a library and took some photos for Marci. The hospital looked nice and there is an old Catholic Church on the top of the hill that is impressive as well. Some of the houses are built into the rocks and caves. I came on back on the bus and let Cuong know I was safe and back and was able to negotiate all this with my basic Vietnamese. There is an insight in being a minority, something that doesn’t happen to me much. It is not quite the same because I know that I have resources and it is time limited

Back to 09 today. We went to see some follow ups and there were some nice successes with several people feeling much better. One patient that was so depressed last week is still so very sick; basically his body only works from the neck up; but he had enjoyed the food we had brought and pain was better. He was more relaxed and spontaneously taking were he has been so slowed by his depression before. When we asked what might help him feel better he told me that some cucumbers would be nice. We happened to find some on the way to lunch and it was great to give them to him this afternoon. I will visit with him again tomorrow; but I think he is a really palliative care success story that demonstrates the simple things can bring so much comfort. He was still getting injections he did not want. We have asked the doctor to stop them. He added pain medicine but did not stop the injections. It is interesting what we think it important sometimes.

Ha Long Festival Day

After being out on the bay for the morning I was now not sure what to do for the rest of the day. I walked down the promenade and noticed a more Western looking place and went in hoping that I might get some ideas about what to do next. After a little lunch I talked with some of the workers and it was clear that other than going out on the bay or getting a massage that there is not a lot of other things to do here. However, this was going to be a festival day. I walked on down to the festival and parade route. There was a neat stage and clearly a viewing stand. There were also some floats and more and more people were showing up. Not only to see the parade; but also to be in the performance. Some of the outfits were pretty outrageous. I was amazed that you could get so many people to dress up as flames, or bamboo shoots and I think some people were lumps of coal.

As it was getting closer to 4 PM I stationed myself close to the grandstand. Being a westerner and a little taller helps in this kind of situation but I still had to struggle like many others to get a good view as the crowd changed. There was a 2 hour performance starting out with traditional drumming, local pop singers, and dance routines and in the background on the boats dragons. The dragons were incredible. There were two sets and they did choreographed dances. Ha Long is descending dragon and the islands are seen as the humps of dragon sticking out of the water. I, of course, was the only Westerner in my group but I felt very welcomed and part of the group. After a while many of the people had to leave to be in the parade. Many of the people wanted me to be in pictures with them. I think that this was one of the best parades that I have ever seen.

Afterward, my usual luck and knack for publicity held up. I was asked by the local TV to be interviewed for the Westerner’s take on the proceeding. So next week I could be on TV here in Vietnam.

There was a fireworks show coming up and so I stayed for it. I had a good meal at a nice restaurant and I called Cuong to let him know I was ok. I waited outside with a new group of Vietnamese who want to know what I am doing here in Vietnam. Everyone is impressed that I know any Vietnamese. Finally the show begins and it was nearly an hour long and the best fireworks I had ever seen. The final blast of fireworks ended with the music of Dvorak’s, New World Symphony. This piece was written nearly one hundred years ago by a European impressed with the USA and now I think that in many ways the baton of the New World is being passed.

I knew that it was a long way to my hotel but I had hoped to get a taxi to take me there. However, with so many people this was not possible and I walked with thousands of people for nearly an hour to get back to my hotel a little after midnight. This was one of my most fun days here in Vietnam.

More on Ha Long soon.

Rouge Bus Gets Us There

Today I was off to 09 center. I had brought some oranges and rice cakes for the patient I had seen the day before and Dr. Thuy and I went to see him. She did talk with his attending and some changes to improve his symptoms will be made. I discussed if Doctors could work in groups or teams so that patients would have the assistance of several doctors reviewing the cases and have coverage when some one is gone. Apparently this is just not done here and I think that there are some patient ownership issues, just like in the USA.

Dr. Yin presented some interesting research she had done about pain control. It is interesting how similar the pain control problems are whereever you are. However, I know from experience you have to have your own information to present to your bosses to try to get changes made.

Socrates paid a visit and I did my Depression at End-of-life presentation and I think it came off very well. It takes time to do this with a translator. Thi was translating my English to Vietnamese and then I said "Xem lams gi?" (sounds like "seen lambs zi?") Which means something like what "So, what do we do?" and he translated my Vietnamese into English. He looked a little surprised at himself and everyone was amused. I also talked about addiction therapy and I think we need to spend more time on this project.

In the afternoon Cuong and I went to Ha Long. He came by about 5pm and then we went to the bus station. We really did not get a bus there but a rouge bus was gathering passengers and we got on this one. It is really amazing how many people you can put on a bus when you have stools in the aisles. Cuong was really exhausted. He has been burning the candles at both ends and he has a lot of work to do this weekend. It took about 4 hours to get to Ha Long and then to the hotel. I had asked if it was near to the things I needed it to be and it isn't; but it is nice and Cuong and I got a good night rest. I would have had a hard time making it to the bus and Ha Long without him. After breakfast we took the cab to the bus station so I would know where it was and then I went to the docks and he went off to work at the nearby hospital.

Ha Long bay is amazing and check out the pictures on flickr.com link. I got a boat tour, was the only non-Vietnamese on the boat, and off to caves and fishing village and amazing islands. The only down side was that it was smoggy. I talked with many of the passengers and one who worked for the tourism group asked my impressions and what could be done better. I said that more written information in English would be nice and then mentioned the smog and pollution. I think I was just a little too honest. However, she told me that she had read that the US had much more emissions then Vietnam for size. I have to say that that is true. However, the situation reminds me of the the Great Smokey's with a wonderful natural place in danger from the air pollution. So much so that the last trip to the Smokey's made me so sad to see the changes just in my lifetime.

My next post is going to be very exciting!!!!

Addiction Therapy and Last Hours

One of the things that I discovered is that a lot of patients with HIV have been IV drug users. They have been in what was called "treatment centers". When I ask the doctors how you treat a patient for addiction and if there was counseling it was pretty clear that that did not occur. Almost all of these patients have impressive tattoos that they put on each other to pass the time. It is clear that they could have shared TB, Hep B and C and some other things.

One of the fellows mentions that a patient we might see will just go back to the street. I asked him “Why people take drugs?” He clearly has never thought of it. I asked him if he thought that they like their life, or were they weak or what is their motivation? When I said that many might be depressed and self medicating the idea of addiction as a disease that might need therapy was clearly new. I will talk some about addition therapy tomorrow although this is not on the schedule. This will be interesting for both of us.

One of the most disturbing things today was to see a patient that was probably in his last days. He was alone and very sick not able to move from his bed. His family had hired another patient to be his sitter and he was feeding him. He needed to have a Safe Harbor clean up but I don’t know that he is up to it. It might just be too painful. I decided that we would focus on emotional and spiritual. He told me he was at peace but it did not look like it. He also sadly said that he felt that he was already dead but not dead completely yet. When I tried to ask him what we can do for him at this time he finally asks if we could ask his family to visit every other day instead of once a week. I think we can do this but we spend time talking about building community for those without one. Interesting, they use dry green tea to help with odor and I would say it works better then almost anything we have tried.

Home Visits

This was my second time for a home visit this afternoon. The morning was difficult. The 09 Center is not a real hospital or prison or treatment center. It doesn’t even work well as a warehouse. I went to see a patient with fellows. Information is scant. When I can’t do the interview myself it is difficult because the subtle hints and the way of asking questions is lost. However, this patient was supposed to have only been infected for a few years and now he is very sick and declining rapidly. Also, he is a professional, an engineer among most of the other patients that a drug addicts. I suspect that he has had the virus for longer than he says and that the route of transmission may be not as he as describe. However, I have seen patients who did have rapid progression of HIV to AIDS in a few years but is rare and then it is hard to judge what else people say as true or not. We must though start where we are which is with a very weak immune system and one of many common opportunistic infections and we will probably just have to do this by empiric treatment since he testing is limited. Your history and physical exam become more important and you have to think about this almost like when you are doing pediatrics. The thing that stumps me is that he has a rash. I know shingles, fungal and a few others but this is not like most I have seen. It is dry to wetting it might be a good plan but with what. Fortunately, the next day it was better and I and he have dodged a bullet.

Hung has arranged for us to see one of his patients at home. However, there is the matter of lunch. I had to ride with helmet on the scooter with Hung since there are just not taxis out where the 09 center is. I am doing ok with this but avoid this whenever possible. We go on a lot of back roads and by a flood diversion gate and finally are in a really nice neighborhood. There are a number of very nice looking cafes that we drive by to get to this kind of run down place that is more open air and you walk to a little cabana for your meal. I just don’t have much idea what to order so let others do that for me. I therefore am at there mercy. I had mentioned I liked corn and we did get some fried corn new experience and some other things that were ok. I was alarmed at the bottle of Vodka that appeared and mostly disappeared while we were there with 4 men consuming most and Dr Thuy and me only the polite glass.

After this we meet the rest of the group to visit our patient. I think that M most have well to do parents because of the treatment and the care they are providing. I did go into his room and discuss evaluation of home safety and particularly the bathroom. He then came out and we had our conversation. I know that he is sick but I think that depression is playing a big role and we discussed better symptom management more exercise and possibly medication. I think this was a pretty big success all in all and I think that Vietnam will have to come up with a plan to provide more homecare. The family asked me if I thought the hospital could provide better care or if he would be in a hospital in USA. I can tell you that the hospital is a dangerous place in the USA and certainly in Vietnam with risk of hospital acquired infections and home is the safest place to be if you don’t have something like surgery that you need to be in the hospital for and then home again as soon as possible.

There is a Balm in Gilead

Today was the first day for me to go to the 09 Center. This is a little hard to explain but these are centers that are apparently designed for people with HIV/AIDS infection. Some of the people are quite sick and some I think just don’t have a place to go to. I would say that if this was a hospital and in America a lot of the people would be in some sort of outpatient setting and not admitted. People are not required to stay here but I think that some don’t have a lot of other opportunities. We all wear masks when we go to see patients because TB is so common that it is often and must be treated empirically since with the HIV they can get sick with the TB very quickly. We discussed pain control and treatment management and I spent a lot of time discussing the issue of depression and how to evaluate and treat depression. This was an interesting way to spend time and I like to trying to get the emotional, social and spiritual aspects Palliative Care in the discussion. I think that the 09 center is pretty depressing as a place and I think that we need to focus on how we can make it less depressing.

I was very tired with my trip to Hue and so during the lunch hour I was able to lay down on a bench an take a nap that helped me feel more refreshed.

I was supposed to give a talk about the Balm of Gilead and Safe Harbor. I was able to talk about my work. I spent time talking about the choosing of names and the meaning of the names. It was difficult to explain the metaphorical meaning behind the names I picked. I always wonder how the culture will be able to translate and express the kinds of the mission statements I was presenting.

For some reason I asked if they would like to hear the Balm of Gilead song and then started to sing. There were some pretty big eyes and some applause. I really did not want to just talk about what we did, but how we did things and could I help them figure out how they can do a project for themselves. I decided the PDSA system of Plan Do Study Act was a good tool that people might be able to use. I think that we really need to work on a Vietnamese system of quality improvement and concentration on what is proven by study to be of benefit, and try to concentrate the limited resources on what is really helpful.

On the language front I am trying am now working on sentences. More on that later.

Wee What a day in Hue

Hue is an amazing place here in Vietnam. I had one of my best nights of sleep in the hotel. Hue is not nearly as noisy and busy as Hanoi. I had booked a tour with a group for the day. I was a little worried because the tour would end at 4:30 PM and I needed to be on the bus at 5:00 PM for the Camel back. They came to pick me up and stopped at several more hotels. A number of the people on the bus were families of Viet Kieu (Vietnamese that live overseas and often with families that they were bringing back to see the home country). Peter and Annie were a typical couple. She had left over 20 years ago and now she was bringing her Army husband, just back from Iraq, to meet her family that she had not seen for many years either.

The tour was of a village where they made incense sticks and also conical hats that the farmers wear. Then we visited 3 royal tombs of the Nguyen Dynasty. The tombs all had similar patterns of gates, elephants, mandarins and then a biography and then a special pond and then the head being the tomb itself. The area reminded me of home in many ways. The climate of course, but also the sandy hills with pine trees with lakes and clear water ponds and rivers just reminded me of the part of Florida I grew up in . Also the river goes out to something like the intercostal waterway and then the ocean. Look at it on Google earth and you can see. There were a number of small children and some become very tired. Our guide began to fade particularly in the afternoon after lunch.

Although I had been to the Citadel the day before I went with the group again. The got a very brief tour and I am glad I got to spend more time there. The final stop was the Pagoda. It has 7 stories and is one of the most famous here in Vietnam. It has been a place that had appealed for peace many times. There is a famous image of a Monk that in protest died in a terrible fire. It was in all the papers in the early 60’s and in the history books. He was from this place. I shared some of the incense I had bought with the members of our tour so that they could make their own offerings. There were many young novices there and they were helping in the temple. I wondered around back and an old man was sitting on some beds that were also cabinets and he invited me in to to talk to me. He was, as it turned out the Abbot of the monastery now. This room was where many of the novices lived and he was their teacher of Buddhist Philosophy. While I was there many came and went as they robed to go and serve in the temple. In the traditional Vietnamese way he asked were I was from about my family and children. He said that he of course could not marry and had no children but he had 90 novices as his children now. Also he spoke of the many of his friends were now leading Buddhist communities around the world and some in America. Why he choose to speak with me I don’t know and I almost always feel uncomfortable saying I am from the USA in light of the history but they are looking forward and not backwards while they live in the present.(the Buddhist way)

He told me that you should always have your incense in groups of threes. One for the past, one for the present and one for the future.

The present caught up with me and I realized I had missed my boat and needed to get back to the bus. There was no taxi and I had to take my first xe om (motorscooter) trip. Obviously, I am writing this so no worse for wear. Long trip back on the bus and then off to work. Will put a picture of the Abbot up on the web when I can.

Bang ca nhan

Well I had a little blister on my foot and needed a band aid. So I looked up how to say I need a bandage for my foot. There was no word for band aide in my dictionary. When I tried it out with the staff. It was clear that I had made an impression. They keep looking at my leg and me and trying to get a chair and have me sit down. Apparently the bandage I had asked for suggested that I might need an amputation. Finally Band aide or as they called bang aide is understood and I get one for my blister which helped a lot this. The above is how you say band aid but I can not put in the dicretic marks and so it means many things the way it is written now.

Spent the day exploring the Citadel and the Forbidden City. There was incredaible fighting here during the wars and it is surprising that anything is left standing. Hue itself is a very plesant town and I have enjoyed it greatly. I think it reminds me of the relative calm of Birmingham to the hectic nature of Atlanta

More about Hue later but soon time to board the tour

Camel Bus

The Camel did make it to Hue. However, the experience was and an experience. I was lead to believe that there would be other overseas tourist on the bus. I was the only one but my new Vietnamese friends shared some cake and I some fruit and I used my basic dialogue. Are you married? Do you have children? and right back at you.

The bunk could be comfortable if was the the size of most Vietnamese. Even at my scrawny 5 foot 10 inches I am taller than most Vietnamese and the berth was just too short. I must have sleep becuase I actually feel pretty rested. My bus mates wondered why I didn't take the plane? I began to wonder too when in reading the guide book it said the flight was only $35 dollars. However, that was 4 years ago and we know that the dollar is taking a beating so my 7 dollar trip is still a good deal.

The bus had air conditioning and that was nice and I think helped clear the air. The bus was very clean and nice and in Vientam style we were meet at the bus door with a bag to put your shoes in and option for paper slippers.

I talked for a little while with Thuy (this is another new one) who apparently is an employee of the Marine Protection Agency and was on his way down to collect some water samples. Our converstation was short since they started playing music videos loudly. There were 3 and they were very contrasting. Traditional Vientamese ballad, then some very martial sounding music with vigiorous singing and in the background soldiers marching and it looked like fighting in a battle. This was followed by a very graphic music video in English that had lots of double entendres. I hope that my fellow bus mates could not understand since it made be blush. Twain said that "Humans are the only animal that blushes; and need to."

Fortunately they did turn this off around 11PM. I awoke to see countryside and mountains in the distance and miles of rice paddys. Many people were in the fields cultivating; I don't understand how you grow rice but find it interesting. I think that there is growing prosperity in the country with many nice house and new ones under construction. Looks like people build then as they get materials. I saw people making bricks and carving beams. Not alot of wood to use and they save it for only the needed spots.

Liter is a problem but not as much as Hanoi and the sky is BLUE!!!!

I got off the bus at the stop in Hue which apparently is the first stop not the one I wanted. I had to take a taxi accross town and even with bargining it was almost 1/3 what it had cost me to come to Hue from Hanoi

The hotel is very new. Only open now 3 weeks. Even the push cabs did not know where it was.
The staff is a little too attentive but they are students at the Tourist Academy for Hotel Workers and Management and this is part of their grade so I understand.

Well off to see Hue with more news to follow later.

What do you say to Children; You don’t you listen

We have had some problems scheduling the lectures with different people absent and some of the people that are giving the lectures having there own busy practices. I know that several of the lectures that were done to day were based on materials that I wrote and slide shows that I put together. It is hard to know though how much of the nuanced material about risk and benefit and communications and team work is getting through. I know that the first one on surgery was pretty on topic. I then asked if they had talked much about ethics and we did review the concept of double effect. It was a little hard to get across the ideas of reviewing your motives.

When talking about children the lecture seemed to be a concentration on the issue of treatment and then I did talk about issues such as communication and the use of play therapy, art therapy and story telling imaging and acting out events as a way to understand what children understand and to communicate with them. This just seems like such a very strange to ask people to concentrate when you still are working to make sure that the medications you need are available.

I am now progressing to writing simple sentences. For example “Amos speaks Vietnamese; people laugh”. What I found out is that laugh and smile is the same word and the to make it laugh you add big to smile. Therefore there was a lot of laughter when I the amended sentence with “to” which means big was added.

WHO, Pain Control and a house call

Well today I went to the Ministry of Health for a Madame Cham’s presentation on the new national policy on a number of medications including opioids. Of course I could not understand much of what was said. I did recognize when I was being introduced so I could stand up at the appropriate time. This was part of an effort to bring Vietnam into compliance with the WHO standards regarding prescribing but also to encourage appropriate use. Ms Cham pointed out that 8 nations accounting for 15% of world population use 85% of the opioids each year and that many in Vietnam could benefit from better pain control.

I then had lunch with Cuong, Thuy and young women who works with the US AID. It is hard for them to understand the vagaries of the budget process and why certain things are OK during one government in the USA and not another. I did the best I could to explain but I am not sure I always understand. Still I did the best I could.

Later this day I went out with Cuong to visit a family friend. She has had cancer but is doing very well now and I am very impressed with her treatment when she must have been very sick when she had her cancer surgery. I think that she is part of the worried well. After the review and exam we chatted. Interestingly she went to Poland when she was in her 20’s to learn electronics and refrigeration. She lived in Warsaw for 3 years and she speaks fluent Polish. I think this is interesting in light of Andrew’s interest in Poland. Tomorrow we will have some lectures and then I will leave for my trip to Hue.

Von Recklenhausen makes a visit to Vietnam

I think that I have only seen one other patient with Von Recklenhausen Syndrome; better know as the Elephant Man syndrome from the move of the early 80’s. The patient had come to the hospital with recurrent tumor in his leg and unfortunately spread of cancer to his lung. This illness is now known to be related to a mutation on chromosome 7and from what the patient has to say he is the first in his family with the mutation. Usually there are café au lait spots, freckles and what are usually benign tumors of the nerves but in a few cases there is a malignant development and that is what has happened here. I guess that I though that I would only see this illness in Europeans because of it name but of course the mutation can occur any where in the world. It was tough when he asked several times what his prognosis would be. Finally when we were clear enough he had made his decision to go home to be with his family. I feel that although the Morphine can help that we are not even doing enough to help with the many problems people are having with symptoms and that support will be skimpy. I know that the Vietnamese will respond to this need with the same kind of rigor and effort that they apply toward so many things.

Every day I am seeing new patients with the fellows and today in my Vietnamese I tried out a few simple sentence constructions. The grammar is fairly straight forward with no conjugation of the verbs. Just the same form with different pronouns or nouns so not that bad. Like is many Latin based languages the discriptor is after the verb.

In the afternoon I made my way to Bach Ma hospital. Surely this must be one of the largest hospitals in the world. Certainly bigger than anything that I have seen. I went on to a conference on Infectious disease and HIV and it was nice to met some more colleagues here.

I now have a hotel to stay in when I go to Hue this weekend on the Camel bus. So my travel plans are fairly well set.

King Hung for a day

This was the second annual King Hung Day. As best I can understand he was kind of the George Washington of Vietnam only 600 or 700 hundred years before Europeans made it to what would be the USA. Apparently there has not been very many holidays except for Reunification and May Day and this one was added in the last year. The day is based on the lunar calendar so it is a movable feast day in that it will change from year to year and is not fixed as on our Western calendar.

I thought there might be a parade; but I might not just have known where to look. The hotel restaurant was short staffed and there was definitely less people on the street than usually. I took a walk around the city and did find The American Club which is apparently what the name suggests. I have been on the search for a newspaper. There isn’t much English language stuff to read and I have run a little short. You can read about the news on the internet but it is not the same. Unfortunately, I don’t know if The American Club has any newspapers since they were closed to celebrate King Hung. I walked on down the street and there is a quite spectacular Hilton Hotel. I though surely they would have a store and news stand but none to be found. Off to the Opera Metropole and it was the same. I did find a wonderful park to sit and rest in and watch people play badminton. After the storms it is cooler and a little more breeze and I do feel that there was a lot of energy that was built up waiting for the rainy season to begin that has been released.

While sitting their and older gentleman came over and asked greeted me in French to asked to sit down. He was hoping I spoke French because he wanted to practice. His English was fair and with my little Vietnamese we did get a small conversation. He was 72 and of course asked me all the obligatory questions. He asked about Hillary Clinton and I said I was hoping for Obama but he was clearly a Clinton partisan. I told him that even small children came up and wanted to practice English and he said yes it was the language of the world and he had only learned French because they had been in control of the country when he was growing up.

I have been a little weak in the stomach today and although I found some restaurants that I might come back to I retreated to dine at the hotel. The dining room was full and the waitress told some one standing behind me that there would be a wait. I am tired of eating alone and so I offered my table if they wanted to join, Terri and Emily and little Tri came to eat. I had seen Terri around obviously here to adopt a baby. Tri is a little boy and she has been waiting for 3 weeks for papers to take him home. Her mother was here at first and now her cousin to help with the baby. They all live in the San Francisco Bay Area and know the Ambassador Toy store that Amanda is an assisted manager of. I told them that they would like the new changes she has made so I am sure they will check it out. I also got to hold Tri when he was tired of the stroller and needed to be tended to. It was nice to hold a baby. The staff gave me an extra stamp on my card toward a free meal since I let them sit at my table and was nice to babies. I think this is called karma.

View from the Flag Tower

Earlier in the week my cab driver had taken me by a nice park with a view of the Flag Tower. I noted this because it looked like a pleasant park to visit and nearby my apartment. The Flag Tower was built several hundred years ago and is an interesting mixture of styles that is striking to see. Apparently most of the rest the Citadel complex has been removed and replaced with modern buildings but this was preserved. The Flag Tower has three levels and the first two are traditional ramparts that remind me much of the Spanish forts that I have visited in Florida. Then rising out of the center is a nearly 100 foot tall tower that has a striking oriental brickwork and design.

I had a good view of this from the park. I set there to rest and make some sketches. I noticed to my left a statue that looked familiar. It was a statue of Lenin also gazing at the Flag Tower. In front young people were taking advantage of the pavement to practice their skateboard tricks. Several people tried to sell me a variety of things. I notice if I say Khong Cam On; which is my version of No and thank you in Vietnamese that the conversation is cut short and I think with no hard feelings. However, one person I heard muttering khong, khong etc. I will check out with my friends the most polite way to deflect these offerings. One of my problems, as Marci, my wife, would tell you is that I look at people (she would say stare) and of course eye contact does seem to bring on conversation. I was able to make some nice sketches in my book and then noticed a nice coffee house under trees next to the base of the tower and went over there. There had been rain off and on all weekend and it was starting to look as if it might rain again and people were taking cover. However, after a half and hour there was another break in the weather and I notice people up on the ramparts and so went to see what it might cost to go up.

Surprisingly there were no one there at the entrance and I was able to go up to the first and second level. Immediately, I notice that even for the short American I am; that I had to duck my head to go through. Built hundreds of years ago the low staircase I am sure was not a problem for the original soldiers.

When I got to the top I was able to walk all around and on the back side which I had not been able to see before was a number of crashed planes and other weapons. The Military Museum is next door and I was looking into the courtyard. This was perhaps one of the saddest moments since I got here. For most Vietnamese that I have met the war is a fading memory or they were born after the war ended. I have never received any sense of anger toward me for coming from the USA. However taking care of Veterans in the US and having taken care of at least one veteran here that had been wound I wondered what we all had learned from the experience.

Rainy Day in Hanoi

We haven’t really had a good rain since I got here almost 3 weeks ago. Yesterday I worked in the morning and had some housekeeping and things to do. By the way, the combined washer/dryer machine kind of works. The clothes come out warm and dryer but still needed some time on the drying rack to really be done enough to put away.

Spent the afternoon at the Ethnography Museum which is quite excellent and I would highly recommend. Over the last decade the Vietnamese Government and the American Museum of Natural History have collaborated to identify, collect and record and then present important information and materials from the many different groups that live in Vietnam. Although 85% of individuals here are Viet there are 50 or so different minority groups with remarkably different cultures, religions and distinct way of life. In addition, with rapid industrialization and urbanization there were many ancient traditions and skills that are present in the Viet community that could be lost in the rush to the city.

The Museum did a lot of work going to different groups and settings and filming, recording, collecting and allowing the ethnic groups to tell their own stories and make many of their own special handicrafts for the exhibits. Also they brought groups of people with special skills to build houses and other parts of the exhibit. One of the things that becomes clear from the exhibit is that while I had thought of Vietnam as part of the China, Korea and Japan group of nations, they actually are culturally and linguistically linked in heritage and trade to Indonesia, the Philippines and then on to Polynesia itself. Some of the houses and artifacts remind me of things that I have seen on TV and in books about Hawaii, more than China.

Although most of the labeling is in Vietnamese there is some in English and French. I saw a few visitors from overseas but mostly I saw children and young people sometimes with older relatives visiting the museum and clearly discussing their own memories. For many, in just a generation, the experience of living a more traditional life is becoming a memory. It is incredible that they have done such a good job with documentation and preservation before the opportunity is lost. Clearly in the newspaper and from other sources that I have been reading there are many traditional skills that now only a few older individual have and that some young people are learning from these living cultural treasures. This makes you want to get out of the city and see more of the countryside.

The children are like any children, running and playing and running up to say hello and then screaming in laughter and running away. The brave ones stay to ask your name or where you are from. Already at 7-8 they are learning English better than most visitors will learn this language.

While there it started to mist and then later to rain more consistently. It continues hazy though and I am beginning to wonder if this is just fog or perhaps air pollution and smog.

In Search of the Camel

Yesterday I walked down into the Hai Ba Trung District. My apartment is on Hai Ba Trung Street. Hai Ba Trung means two sisters with Ba meaning honored Aunt. This would be the female equivalent of Ho. They apparently resisted the Chinese invasion about 1000 years ago and jumped into the river rather than surrender. The story has a “Remember the Alamo” aspect to it. I had hoped to walk over to their pagoda but places are always further away then you think.

My real purpose was to go the Camel Travel station. Camel buses are designed for overnight travel and have double-decker bunks. I took a picture of the brochure and will try to post so people can see. One of the things you notice is that after you walk a few streets away you are the only Westerner and English is hard to come by. I had been given good direction and had a leisurely walk down the Hue (pronounced Way) street. Often I was in the middle of the repair of the motor bikes or even cars, with the garage being on the street. I got to the street to make my turn and I walked right by it the first time. I walked a little further and decided to pass by the sauna hotel but there was a local café so I stopped. For the price of the coffee I asked for some guidance. I looked up Camel in Vietnamese, lac da and bus di xe buyt and I think they finally knew what I was looking for and told me I had passed by it. I made it there safely and next weekend I will go to Hue, the Imperial City on the Camel. Cuong was a little worried about me getting lost but he will check out my tickets to make sure they are right.

I walked back on different streets with different shops and tried to buy some index cards which I think are just out of style now a days. I did get some nice pictures of construction practices. However, with all this walking I was ready for a good night sleep. I have been able to stay in contact with friends at home and through some creativity got a phone call through to Washington thanks to Marci. This is my third week and really starting to miss family. Plan some work this morning and the visit to a museum this afternoon.

Building walls and Building Connections

My cab yesterday had a scooter bump into the door and get knocked over. No one was hurt and damage if any was little to the car or scooter. It did shake me up. It is a constant juggling of cars and bikes and scooters each into each other's lanes. Right now, 15 floors up, I can hear the constant rumble of horn blowing. I saw a little bit of a temper with the latest dustup but usually with all the horn blowing and aggressive driving for position there is a remarkable sangfroid. This is something I want to cultivate or; Binh Tinh in Vietnamese.

I spent time this morning working with the Cancer Report on Breast Cancer and treatment. Mostly straight forward modified radical mastectomy. Breast conservation is not a prominent issue here and I think that that is appropriate for the time being. We also discussed issues of screening. One of the things I am trying to help with is thinking about the psycho-social barriers. So why a woman would wait till the cancer has grown through the breast tissue and is an ulcer before coming to the doctor? We need to understand the reasons that she did not come earlier; while education may be part, the roots in psychology is much deeper. Later we went to see a patient that has a bad tumor not responding to radiation and now getting a first dose of chemo. He always looks so happy, vui ve, and the fellows are concerned that we not cause problems by negatively affecting his optimism. I countered that while he is optimistic, that anyone with a problem like this would realize that things were not going as planned. I complimented him on his positive outlook and then asked a few questions about how he manages stress and worrying about illness which I am sure he does. For a moment his mask fell and we all saw a glimpse of the terror behind. I told him that we did not need to talk more now but that if there are questions or worries that come to him that we could talk next week. I know, this sounds like such a small issue but it led to much discussion and request for more education on communications.

I am also interested in construction. Many houses are about 10 meters wide and maybe 20 meters deep and then as many as 6 stories tall. The first floor may be a business or dwelling depending on the street. All around I see the most beautiful hand made brick. Brick has been made in Hanoi and Red river delta for probably 2000 years. This kind of artesian brick would cost a pretty penny in the USA. The floor and then pillars and beams are made rebar with re-enforced concrete is poured into forms. The construction goes up one floor at time this way. The squares are then filled in with the brick and the whole will be plastered inside and out to cover-up the beautiful brick. Since the lots seem so small the only way to expand is up. The highest such house that I have seen is 6 stories and 4 stories is not uncommon at all. I wonder how tall you can go with formed concrete post and beam construction with what appears to be concrete floors at least on the first few floors and then wood thereafter. Maybe one of our engineer friends can comment. I will try to post a few construction pictures soon.

Hot, Hot and more Hot

This is apparently the time of the year when the temperatures go up and for 2-3 weeks people will be sleepy, as Bac Sy Thuy from Ha Phong tells me. I was so hot I had to take off my tie and not wear my white coat since it is so thick. I was a little embarrassed the other day to fall asleep laying on one of the tables the using my very thick new Vietnamese dictionary as a pillow. However, today some of my colleagues took a little nap by pushing chairs together and I think I will try that next time since it looks more comfortable. All the families and patients are looking for shade and a little breeze. I think this nap thing would be a good import to Birmingham. We seem to have similar climates and it is pretty restorative.

Another Thuy asked me to vote on line for Ha Long Bay as most beautiful place in world for some contest. I haven’t seen it yet but since I plan to go next weekend and I hear that it is spectacular, I did.

Despite the sleepiness I am getting a lot done and have a few more talks to work on this week and then should be able to be done preparing them. On these long days I spend most of my time at the hospital. At morning report, which is in English, even before I came, to practice their language skill, I am asked to give a little topic discussion. Yesterday and today we have had cases of possible gastric cancer which is very common, second only to lung cancer. I have no doubt that the incidence will reduce as Vietnam continues to invest in its infrastructure, since it is known that both preserved foods and H pylori plays a role. The hospital is just finishing another floor and will expand to 300 beds soon. In the morning I spend the time consulting on patients and discussing medicine and palliative care with the other doctors. Of course air pollution is a problem now but people seem concerned about the environment, and while they want development they want a healthy country too.

Today I gave one of my first official lectures which I shared with Yen to preview. They translated my slides into Vietnamese, and I was pleasantly surprised that I could read the occasional whole sentence. Granted, they were my original sentences, but it is still a thrill to be able to figure them out in a different language. As a bonus, because the hospital had electricity today, they were able to turn on the air conditioner in the conference room. I have a couple of others formal lectures to give tomorrow.

With Skype (a free downloaded computer program) I get to call home every day. For free! I highly recommend it. I can only imagine the loneliness that would exist when letters that might take weeks, and before that it would take months, to be delivered as your only way of staying connected.

What does Yellow mean?

Today I continued to notice that the color yellow has both secular and spiritual connotations. One of the ways that you know where a pagoda or temple is located is that the walls and the gate are painted a yellow color. The trim is usually red; particularly any inscriptions which are in character scripts. Many government building are painted this same hue of yellow although the trim is usually a green or blue. The flag is a red field with a yellow star and the river that Hanoi is on is the Red River. I have been here long enough to know that this can not be some random coincidence but has a meaning; just not yet revealed. If you review some of the photos on line you can check out the color scheme for yourself.

Today continues the important day for ancestors. I thought there was an accident on the way to work; but then it looked like a parade and then I thought it might be a funeral. The taxi driver told me it had to do with honoring the ancestors but with my limited Vietnamese and his limited English he was pretty pleased I had grasped that. Bac Sy Yen had made for us, Cuong and me, a special sweet. It was small balls of dough made from sticky rice with some sugar cane inside and syrup on the outside. It thought it was pretty good but I really can not think of anything that it would be like to help you understand what it tasted like. Cuong said that traditionally that this would be a day when fires are allowed to go out , so food would be prepared beforehand and eaten cold, but that this was not so common nowadays.

I was early and went down to see if I could help and was sent off to see Mr. F. I was halfway there when I realized I did not have a translator and would just have to do with my broken Vietnamese. I was making some progress but I think that about the same time they realized that they had sent me off alone and Huong came to help. This was good since I was trying to figure out how his stomach was doing and trying out my new words that I had not vetted with my teachers yet. Apparently I had a kind of slangy word from the dictionary; once again not very professional but all in all it worked out and he is feeling better.

I have some more writing to do tonight and some slides to produce. This is our half day for me at the hospital since they fellows are supposed to read and work on their projects during this time. I spent some of the afternoon visiting the Temple of Literature which is the over 1000 year old cultural treasure that was the equivalent of the national university. It still is a nice place to read, think and work.

I have appreciated the comments and responses. As someone new to blogging it is nice to know that your message is being received.

Special day for the ancestors

April 7, 2008

This was my first day without Eric, as he is in another city for a week. I got off to a good start with the best cab driver so far for the trip. He was able to go the back way and cut off some time. I spent time with Dr. Hinh and his morning report. I seem to be asked each day to give a short discourse on a different topic. Each day I also get sent a cup of “kafe den”black coffee that you could stand a spoon up in. Coung and I spent time going to see a patient which was very complicated and we reviewed with his doctor. I think that he may have cancer but several attempts to make a diagnosis was not successful and I don’t think that he is well enough to undergo radiation and certainly not surgery. We should be able to get started on treating his infections at least.

I need to review this further but it looks like MS 30mg pain killer is going for about 10 cents. This is a very good deal. This makes it all the more difficult to understand why people are using lots of what looks like Tylenol#3 and which more expensive than the more effective MS. I will look into this further while I try to help them plan for treatment. If MS is so cheap they really need to use more often.

The levity of the day comes from my continuing attempts to learn more Vietnamese. I was trying to figure out how to order an enema only to discover that it is a 6 word phase. As is the case, the same word means 6 different things and then a single word in English becomes a phrase. The day was cut short since this is the 6^th day of the 3^rd lunar month and for reasons unclear to me this is a special day to offer and spend time with the ancestors. Dr. Houng seems to think that I should know that this day is special. I guess I they have high expectations. I will put up when I can a picture of Cuong and a patient and the pain scale when I have a chance tomorrow. Lots of other writing to do today.

Uncle Ho

April 6, 2008

Uncle Ho

Here in Vietnam I can kind of direct what will happen but I don’t apparently have the last word. I have got up to have an American breakfast of bacon and eggs at a hotel nearby. I had thought I would walk by St. Joseph’s Cathedral to see if it would be open on Sunday morning. However, as is often the case you can get turned around on the streets (The cab drivers have the same problems.). I found that I had made my way over to the Citadel; which a walled military fort that was started about 1000 years ago. The area was very pretty, with wide boulevards and trees that are cool to walk under. I realized that I was walking next to what looked like a church and that there were a lot of people going in. There were not signs on the outside but it turned out to be Cua Bak Church; which means North Gate. It is one of the few churches in Hanoi and is the one the foreigners attend if they go to church. There were probably about 1000 people there and 80 percent Vietnamese but the service was in English and Vietnamese and some of the one of acolytes looked like she was European. I talked with some of the people and they were there with the World Bank or a NGO or some business and some had lived here for a few years.

Later I was walking along and a toddler was on the sidewalk with two older women, maybe a Grandmother and Aunt, trying to get the child to eat. I said “em be dep qua” what a pretty baby. They were so pleased and then prompted the toddler to say hello. He was saying hello in English and of course they are proud that he is smart too.

I turned a corner and then I saw something from TV many years ago. This was Ho Chi Minh’s mausoleum. I walked on over and there were many visitors and the guards. I did not get to go in to see him. Apparently he is being refurbished and so his body was not present. In about a month we will have Unification Day and May Day and this is where they have a lot of the parades and activities. This is also where the One Pillar Pagoda is. This was built about 1000 years ago to look like a Lotus blossom and there were several monks and nuns there to greet us.

I have taken some interesting pictures, dragon fruit, flowers and a number of street scenes and will try to put some up for you all to see.

Shrimp Bits versus Bacon Bits

Sleeping in?

Saturday morning here and will be late Friday night back home. I have finished another week and getting in the swing of things. Morning report and review of patients in AM with Professor Hinh continues. I am concerned that I got a younger doctor in trouble for not considering the probable development of second primary tumor in young women with breast cancer rather then a metastatic lesion to the other breast. Things got a little tense and then much discussion that I can only get part of then review with me. Basic issues like the development of chemotherapy resistance and how chemotherapy works are reviewed. People are trying so hard to do things correctly that the science behind is treatment sometimes not clear to them. I have to balance the science behind management with concrete discussions of next steps. Now that they know about Socrates they roll their eyes and groan when I start to teach but much more politely than they would in America.

I just am not very hungry with heat and travel so staying on bottled water. Cholera epidemic has been going on for a month. The government has finally openly spoken about it in the press and my sources tell me that 50 patients being admitted to hospital for dehydration daily. The source is still not clear but may be shrimp sauce. However, very common, almost universal condiment is tiny shrimp about 3-5mm in size whole dried and sprinkled on every thing. They are tasty with salty, shrimp crunch taste, Marci says that they most be like bacon bits in use only shrimp bits. I think that they might catch on in USA. Perhaps this is an investment opportunity.

In the afternoon we have had a lecture about HIV and although in Vietnamese I listen and can catch a few words. When I see on PowerPoint slide—Phat- I asked Cuong what did Buddha have to do with D4T and HIV medicine. He begins to laugh and starts to tell class and there is a row that breaks up the lecture for about 5 minutes. Apparently Phat means both Buddha or rash based on diacritic marks which I do not remember. Part of this is that I think that it never occurs to them that the words seem similar to people outside their language group.

Today I have had a longer sleep after talking with my mother via Skype and home as well. It is amazing that only a few years ago communication so difficult. The world really does seem flat. I am doing laundry shopping and some writing and then out to see some more Hanoi sights this evening. Eric has been called away to Ho Chi Minh City so I will the lonely American here for a few days. More about the Hanoi city later today when I post again. .

Whats in a name

Early Rounds

By going to bed early recovered and able to go on into hospital early enough for morning report. Even a few minutes can make a big difference in travel time. I enjoyed morning report and I am impressed that it is focused and serious but relaxed. Professor Yin expects results but people are not nervous or anxious and tense the way this often is in the USA. We had a discussion of liver tumors. They were rare in the USA before the Hepatitis C epidemic and now on the increase. They are one of the most common and deadliest cancers here. Discussed the relationship to Hepatitis B infection and Dr. Yin tells us that over the last few years a major push to vaccinate all children before they could become infected. This could make this cancer very rare in Vietnam in just a single generation. For the time being they are incredibly skilled at operating on the liver. I think more skilled then USA surgeons who would have had much less experience and practice on such a delicate surgery.

I am continuing my Vietnamese lesions and words like hope (mong) and careful (can than) and fever or hot (nong) I can only manage a few new words every day. Still it is thrilling to hear some one talking and understand one of the words although I can not understand the context.

Also much discussion of if I should have a Vietnamese name. Since the meaning of names are so important and they ask me the meaning of Amos ( a heavy burden) and of course Bailey not much better since it is a jail or jailer. For the time being Mong ( hope) and Phuc (Happiness) are in the running if you would like you can comment and vote.

I am working on presentations today and then supper tonight with director of the Infectious disease hospital and several other dignitaries.

Ma, Ma and Ma the many meanings of Ma

April 1, 2008

Ma, Ma and Ma

Today I tried to get to the hospital a little early but my taxi driver did not turn when I asked so we missed the hospital and had to turn around to go back. Still I made it in time for the end of morning report and to review a few films.

I then had my morning Vietnamese lesson. I am trying to learn 5-10 words or a phrase a day. I did learn "turn left' and "turn right" which will be helpful in the future. Vietnamese is a mono-syllabic language so there is no combining syllables to make new words. Instead by intonation you make one syllable have multiple meanings. Ma with different diacritics marks can mean ghost, mother, morgue and horse. There may be two others they haven’t taught me yet but the difference in the sound is difficult to reproduce. Oh by the way, pho the morning soup and national dish, also means street. That I am even trying to learn is thought to be unusual and nice. We did go check up on several patients and then saw a new patient with naso-pharyngeal cancer which is very common here (saw three cases in 2 days) but uncommon in USA with only 4-5 cases in my 20 year career. I am amazed at the physical strength and endurance of the Vietnamese. I think that most patients with a problem like his would be in so much distress that they could hardly talk. A lot of patients are on radiation but no one complains of a sore mouth for the radiation burn.

In the afternoon I walked over to the Temple of Literature which is 1000 years old and the original national university, a nice respite from the noise of the city. I have pictures and will post soon.

While I was writing this yesterday I was called by Cuong that he had tickets for us to go to a Vietnamese Opera so my writing was cut short. The Opera was long, hard to understand but beautiful and ultimately meaningful. The story is too long for here but this is an ancient culture.

Today I finally made it to morning report on time. Cuong having taught me "re phai" which means turn right!!! I was able to get to the hospital directly. I have worked with some residents, met with medical students and then reviewed more cases for palliative care and managed to work on some of the lectures. I am really tired tonight and we had dinner with the head of the Infectious Disease Center tonight at her house. So off to bed early.