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.