The Hoang My minivan picked me up in front of my hotel at 7:30 am and then stopped by the Sheraton to collect Charlie and Tony Demaria. We crawled through rush hour traffic to Hoan My Hospital #1. Hoan My actually is split into two separate facilities which are separated by about 2.5 km. At HM #1 we were taken to the ICU by the hospital head who took us to the ICU. The ICU director, a young physician who had just returned from one month at St. Mary’s in San Francisco, presented the 11 patients in this small two-room unit. One of the patients was feeling a bit shy and just laid there covered entirely by her blanket. I was reminded of Lien, my 13 year-old daughter, lying in bed fighting for an extra ten minutes of sleep. The air conditioned unit was very clean although a bit cramped with less than a yard between beds. Not a lot of privacy! Interestingly, Hoan My is a private fee-for-service hospital so all these patients are paying customers there by choice. The ER was even more crowded with patients lying on gurneys placed essentially side-by-side. Seems like business is pretty good at Hoan My. The director told us that they have about 600,000 patient contacts annually.
We got back in our minivan and headed over to Hoan My #2 for the conference. When my friend Thach Nguyen had asked me to go to HCMC for this event, he didn’t tell me much and I thought it would be just a small side trip to work with a few doctors. It turns out that our hosts had a bit more planned for us. We were greeted at the HM #2 by 3 doctors in suits and 6 lovely young ladies in the traditional ao dai tunics holding orchids. A red carpet (honest!) had been rolled out into the sidewalk for us. We were ushered by our hosts into conference room which had been lavishly decorated. A classically Vietnamese affair, there were quite a few speeches which had to be translated and we were given bouquets and plaques commemorating the event. Tony Demaria got up to give the first talk.
Unfortunately I missed both Tony’s and Charlie’s lectures because I was taken to the cath lab to prepare for the live case demonstration. As it turns out, they wanted me to do two interventions. The first was a 48 year-old man who had come in 3 months earlier with a heart attack. He was found at that time to have a very ugly, extremely angulated left anterior descending subtotal occlusion, a 70% stenosis in the distal part of a large co-dominant circumflex, and mild disease in a small codominant right. Dr. Huy, my host and soon-to-be scrub partner, had partnered with a Dr. Nghia from Cho Ray hospital to open and stent the LAD. They actually did quite a nice job with this difficult lesion. I must admit that I was pleased when Dr. Nghia was mentioned. Barry Hackshaw, my Desert Cardiology partner, and I had spent several days intensively training Dr. Nghia at Cho Ray in 2000. Dr. Nghia was very conscientious and earnest but extremely green at that time; it’s quite gratifying to hear of his strong reputation as a top interventionalist now.
The patient had done well and was on the schedule now to have his circumflex lesion stented. Dr. Huy explained to me that the patient was quite poor but fortunately a bare-metal stent had been donated by the stent company. This seemed like a quite reasonable case, certainly much more straightforward than the nightmare case from Bach Mai in Hanoi.
However, true-to-form, we found a major curve ball after we started. The LAD was totally occluded at the site of the earlier stent with collateral flow to that vessel from the small right coronary artery. The circumflex lesion looked unchanged. One of the nice things about being able to speak some Vietnamese is that I can communicate directly with the patients and I discovered that our patient actually felt quite well. He denied any symptoms of chest pain or shortness of breath. When pressed, he admitted to ongoing cigarette smoking. Compliance with his medications was unclear but I must admit that I had my doubts that someone described as “poor” by Vietnamese standards would be faithfully taking Plavix ($4/day) in addition to his other drugs. Based on all this, I recommended that we not intervene which seemed to follow Charlie’s lecture on the COURAGE trial (lack of benefit of angioplasty/stenting over medical therapy in stable patients) pretty well. I’ve found over the years that it’s a lot easier to train doctors, no matter whether in California or Vietnam, how to do procedure –even a difficult one – than when to do the procedure. Fortunately, Charlie and Tony backed me up and agreed that the patient should have a stress test first.
The second case was an embarrassingly easy distal right coronary artery stenosis in a 75 year-old woman. Low hanging fruit. It only took about ten minutes and could have been even faster except that I was interrupted several times to talk to the audience in the conference room. The A/V hookup was non-existent and I could only communicate by walkie-talkie held by another person. Furthermore I had to go back and forth between English for Tony and Charlie and Vietnamese for everyone else.
After the case I returned to conference room and took more questions, especially regarding the decision to not intervene on the first case. We heard a few closing remarks, posed for a few more pictures, and then we were treated to quite a nice lunch at a nearby restaurant. After lunch we went by the medical school at the invitation of a Dr. Phuoc, the dean of the medical college. I’ve met Dr. Phuoc on several prior trips to Vietnam as he also serves as the head of Cho Ray hospital. He told us that there were 15,000 applications annually for 450 spots which works out to an applicant:admission ratio of about 33:1 (in the US it’s about 10:1). We got a tour of nearby Cho Ray hospital, a 1,700 bed behemoth unlike any other hospital I’ve ever worked in or even been in. Anywhere. In Cho Ray, the census averages about three thousand which means that there’s quite a bit of bed-sharing. In addition, families help to take care of patients, adding to the mass of humanity and the sense of over-crowding. In fact, we saw two intubated patients in the ICU being bagged by family members. The ER was so crowded; it reminded me of a post-accident scene.
(We’re boarding so I’ll have to finish this later)
