Focus on Vietnam – April 2013, Full Report

Medical Mission Report – Hue, Vietnam
April 15-19, 2013

Dr. Jose Banchs and a team of ASE-member volunteers recently returned from a self-organized medical mission in Hue, Vietnam. Dr. Banchs, a member of the ASE International Relations Task Force, submitted this report on the April 15-19 medical exchange and mission trip to central Vietnam.

ASE member participants
1. Dr. Jose Banchs, Assistant Professor, Cardiology, Director of Echocardiography, University of Texas – MD Anderson Cancer Center
2. Dr. James Kirkpatrick, Assistant Professor, Cardiology, University of Pennsylvania
3. Dr. Yen Bui, pediatric cardiology fellow, UCSF
4. Liza Sanchez, technical director, University of Texas MD Anderson Cancer Center (UTMDACC) echocardiography laboratory
5. Nova Sprague, sonographer, UTMDACC echocardiography laboratory
6. Ms. Joan Main, consultant for Zonare, technical support

Non-member participants
1. Dr. Thanh Kirkpatrick, pediatrician
2. Ms. Tu Nguyen, translator for Vietnam volunteers

Brief personal background leading to the decision to undertake the mission
This trip was originally planned after my first visit to Hue in December 2008. My wife and I were visiting relatives at that time. We landed in Saigon (now Ho Chi Minh City-HCMC) with my brother in law who, as our “guide,” had recruited a college friend who lived there and happened to be a US government representative responsible for following through on many US federal grants to Vietnam.

Through him we learned about all the help needed in Vietnam, and of course I was most interested in opportunities to help in the medical field. I was truly shocked at the vast basic needs in country with over 90 million people.

I was particularly interested in putting my passion and expertise in cardiac imaging to use by bringing Hand Carried Cardiac Ultrasound (HCU) to Vietnam. It was very important to me that we visit a place where there would be adequate follow-up for cardiac defects we would uncover.

I searched for a central “home base” medical center and came across information about the Hue Central Hospital (HCH). HCH was established in 1894, as the first Western-style hospital in Vietnam. The hospital has 2078 beds and is positioned as a high volume referral hospital, serving nearly 15 million people in central Vietnam. HCH has an impressive track record in providing cardiovascular services. It was the site of Central Vietnam’s first open heart surgery, performed by Dr. Bui Duc Phu and his team in 1999. Now, over 1200 complex cardiac surgeries are performed annually. In February of 2011, the first heart transplantation was performed, by the HCH team, without any foreign assistance.

Dr. David Adams and Dr. Khanh Nguyen led a surgical team from Mount Sinai to HCH in 2009. Their example convinced me to direct my efforts toward HCH.

The planning
We wrote to Dr. Bui Duc Phu, the medical director at HCH, and once he responded my foot was on the gas pedal. At Dr. Pellikka’s request, a formal proposal was sent to ASE for a Vietnam mission.

The ”” was selected due to image quality, Spectral Doppler, user-friendliness and battery capacity. Although Zonare did not have the resources available to support us financially, they very graciously provided 6 systems on loan, as well as a full time representative as on-site technical support.

Although the ASE Foundation had not yet accumulated enough funds through the Annual Appeal to fully sponsor this event, the Foundation leaders agreed to provide the funds from the 2012 Annual Appeal designated for philanthropic events. The funding provided generous travel support for the two sonographers and pediatric fellow, as well as a group dinner for our gracious Vietnamese hosts – a Vietnamese tradition.

The ASE staff then put me in contact with volunteers that had earlier expressed interest in participating, including Dr. Kirkpatrick. We were able to craft a plan with Dr. Bui and his executive assistant for the work to be done the 4 days in April.

In Vietnam
Travel to Vietnam takes approximately 22 hours. After landing in one of the major cities (HCMC or Hanoi), our participants had to take another 2 hour flight to Da Nang, then a 2-3 hour bus ride to Hue (the Hue airport is currently under construction). Our plans did not allow time for settling in—the next morning we visited the hospital and toured the facilities. We received a very warm welcome from an executive group of physicians from HCH in an official ceremony.

Our team members were struck with all that was accomplished at HCH with relatively few resources. We had the opportunity to scan and interpret with the physicians performing echocardiography. As in most of South America and Europe, the physicians perform their own echocardiograms and dictate reports while performing the scans. They save a few illustrative images on a desktop but otherwise have no ability to archive images. They have four echo machines, one of which was broken at the time of our visit. They are extremely busy and provide fetal, pediatric and adult echocardiography services. Dr. Bui Duc Phu mentioned that he would like to see the services separated to allow the provision of more specialized pediatric and adult services.

TEE is performed with minimal pre procedure oral sedation, and no post procedure monitoring. TEE is also available for OR cases on an as-needed basis.

The cardiac surgery list for the day of our tour was comprised of seven open heart surgeries, including a tetralogy of Fallot repair, a few mitral valve replacements and repair of an atrial septal defect. The one cath lab had over 20 cases scheduled, and we were told they start at 7 am and continue procedures until past 10pm on some days. They were performing an Amplatzer device closure at the moment of our visit.

We gave several lectures. Dr. James Kirkpatrick provided a review of the literature on Hand Carried Cardiac Ultrasonography. Dr. Bui delivered a very thorough review of congenital heart disease (a very pressing concern at HCH). My talk consisted of a review of methods for LV systolic function evaluation, including linear and volumetric methods, and our daily evaluation of cardiac mechanics via speckle tracking strain in cancer patients. Dr. Thanh Kirkpatrick gave a separate talk about Kawasaki’s disease to a large pediatric faculty audience with standing room only.

Village Health Center Outreach
Armed with a greater understanding of the capability and needs at HCH, we set off on our adventure to the village health centers. We joined specialty HCH faculty on outreach missions to remote clinics (in addition to cardiology and general pediatrics, there were physicians from a variety of different disciplines, including internal medicine, dermatology, and ophthalmology). These outreach events are crucial, since transportation into the city for medical care is very expensive in Vietnam, and much of the rural population remains economically destitute.

Patients gathered under a makeshift tent in front of the village clinic and were triaged according to predominant symptom. All patients with a cardiovascular sign or symptom were sent to our “department.” The approach we took was somewhat unconventional. While we would have liked to scan as many patients as possible, our first concern was providing high quality diagnostic care to patients taking full advantage of the capabilities of the system. This approach included the generation of a “real time” report that the treating cardiologist could use. However, we did not have access to a web-based reporting system. Therefore, we set up workflow into two “tag-teams”. While a sonographer scanned, one of the physicians generated an “over the shoulder” report which was then given to the treating cardiologist (see attached mini-report page). These reports were on carbon copy paper and all images were saved on “flash drives” so that reports and images could be later reviewed for quality improvement purposes.

We were able to perform a brief (5-10 min.) but fairly comprehensive echocardiogram which included the following views:

PLAX:  2D, MV and AV color
SAX:  2D AV, 2D LV
A4C:  2D, MV color, TV color, PW Doppler MV leaflet tips
A5C:  2D, AV color, PW LVOT*
A2C:  2D, MV color
Subcostal:  IVCCI
Other views as directed by physician at the time of the examination.

*The machine does not provide CW Doppler when not anchored in the docking station, which was not available to us in Vietnam.

These last two days were most rewarding. We scanned over 200 persons at 3 different village health centers, and those with a critical finding had a care plan implemented immediately by the on-site HCH cardiologist.

Final results and comments
In the end, some of the individuals we scanned were indeed in need of further care or intervention, including either invasive evaluation and /or eventually cardiac surgery.

It was our impression that the HCH cardiology faculty is excellent. They appeared to be grateful for our visit, and I believe doors were opened for future collaboration.

They seemed to be particularly thirsty for more interaction with the US and the exchange of medical expertise. In the future, more lectures or even a regional conference would provide much needed instruction and education. They would be thrilled to attend lectures by world experts in echocardiography and to share expertise in the real-world care of patients at HCH.

Since the outreach visits to the village health centers are a fairly regular occurrence and involve an established system of care, it would be very easy to repeat our missions to bring echocardiography to remote areas. I believe our scanning strategy provided a level of echocardiographic service that met the needs of the target population.

Future trips to Vietnam are needed, either back to Hue (they will be opening their own international airport later in 2013), or in association to the other 2 main public teaching hospitals in Vietnam – Bạch Mai Hospital in Hanoi and Chợ Rẫy Hospital in Ho Chi Minh City.

I think the world needs this. As ASE members, I believe it is our responsibility to share the knowledge and leadership in cardiac imaging quality that we value and is our treasure here in the US.

Submitted by:
Jose Banchs, MD, FACC, FASE