Enthusiasm, need drive education in Hue, Vietnam: A hand Fellow’s international experience
The air was warm and humid - yet pleasantly refreshing - when I finally stepped off the plane in Hue, Vietnam, the final destination of a 30-hour trek that began in Detroit with stops in Shanghai and Ho Chi Minh City. I had come at the invitation of ReSurge International (formerly Interplast) and its medical director, James Chang, MD, who provides training in the care of children with congenital hand problems.
(Right) Kevin Chung, MD, MS, Ann Arbor, Mich., examines a young patient and explains his findings to surgeons and therapists during a surgical clinic in Hue, Vietnam
ReSurge's goal is to create sustainable, capacity-building efforts around the world by empowering local surgeons through the inculcation of new skill sets. Our Resurge team consisted of me, a hand Fellow at the University of Michigan; Kevin Chung, MD, my program director; and Pam Silverman, an outstanding hand therapist from San Francisco who has served on numerous medical training missions.
I had participated in medical trips before, but doing so as a hand Fellow in the final month of my formal education was a unique experience - it was time to see if I was ready to assume the role filled by my own surgical mentors as an independent educator.
A city of enduring spirit
I was graciously met at the terminal by Phan Huy Nguyen, MD, a plastic surgeon at Hue Central Hospital. I was tired but energized as we drove from the airport to the historic Saigon Morin Hotel in the heart of Hue. Along the way, I quickly learned that traffic signals are more or less suggestions, lane markers are optional and a loud car horn is the most effective form of communication on the street. I double-checked my seatbelt a few times and my hands gripped the edges of my seat as we raced through the city, whizzing among a sea of motorbikes, bicycles and cars.
I checked into the hotel, showered-off 30 hours of travel grime and, just an hour after landing, I walked into a busy surgical-screening clinic. The patients had been pre-selected by our hosts as potential candidates for surgery. The excitement and enthusiasm in the room was palpable among the cadre of surgeons, most from Hanoi, Ho Chi Minh City and Hue, with a few from smaller cities in Vietnam. Dr. Chung, who arrived a day prior, was surrounded by roughly 30 surgeons, nurses, rehabilitation specialists - and mostly residents who will form the backbone of the Vietnamese health-care system - as he gently examined a 3-year-old boy's hand, with our hand therapist, Pam, scrawling notes.
(Right) University of Michigan Hand Fellow Matthew Brown, MD, operates on a duplicated thumb while surrounded by observers.
The child had a flexed right-middle finger at the PIP joint for several years with no history of trauma. The PIP joint had no active motion and only few degrees of passive motion; X-rays did not reveal any bony abnormality. When Dr. Chung asked for a diagnosis, someone replied, "camptodactyly." Dr. Chung explained it was a flexion contracture but had an unknown etiology and would be an unusual presentation of camptodactyly isolated to the middle finger. He suggested it may have been a congenital trigger finger that went untreated, but it would be difficult to determine without exploration. Dr. Chung explained that an operation could help the child by exploring the joint, releasing involved structures, including the volar plate - and possibly releasing abnormally inserted tendons.
In fielding questions from the audience about the surgery, Dr. Chung explained his operative plan to first release the A1 pulley and then the PIP joint, but the most important part would be post-op therapy. Interestingly, the child did not have any of these pathologic processes; instead, he was found to have thickened digital fascia cords that restricted joint motion. After cord release, he gained full extension of his joint.
This was my introduction to our attentive, enthusiastic audience. As our surgical-screening clinic continued for another couple of hours, patients were efficiently shuffled in and out of our exam room as we saw duplicated thumbs, radial hypoplasia, cleft hand, radio-ulnar synostosis and various other congenital conditions.
We screened 19 patients and selected 10 for surgery, with three requiring bilateral procedures. We divided the cases over the next three mornings, and in addition to teaching in the O.R., we were giving a series of lectures every afternoon. This was all part of a symposium focusing on the treatment of congenital hand defects.
Centrally located between the north and south of Vietnam, Hue had been the de-facto capital of Vietnam when it served as the home of the Nguyen dynasty, which dominated the country for most of the 17th to 19th century. Hue Central Hospital had been established as the first western hospital in the country and has been providing medical care since 1894.
Hue has also experienced its share of tragedy through the years. It was a contested city during the Vietnam War based on its location near the border that divided the northern and southern forces, captured during the Tet offensive of 1968 by the North and retaken during the infamous 26-day Battle of Hue (one of the longest and bloodiest battles of the war). The city endured several mass genocides by the Northern forces during its occupation, and many of the city's historical sites had been severely damaged in multiple bombings by American forces.
Hue has endured atrocities, but it also resurrects itself. Monuments and historical buildings were restored, new housing is actively under construction near the city center, and the hospital continues to expand. It is a city of unique character and one we wished to experience during our short visit. Once clinic was complete, we ventured into the city for lunch - and each dish was unique and accompanied by its own designated sauce, some of which sizzled with a spicy heat, for an adventurous meal that expanded everyone's palates.
Hue has also represented the religious center for Vietnam with many famous Buddhist and religious movements originating in the city, so after lunch we visited the famous Thiên Mu Pagoda along the Perfume River. Constructed in 1601, the pagoda is a "must see" experience for all visitors to Hue. As we walked the majestic grounds, our hosts gave us insight into religion, life, culture and the history of Hue.
The lucky thumb
We were escorted from our hotel to the hospital the next morning to begin our first day of surgery. After a brief visit with the director of the hospital, we were led to the operating room. I am not the most well-traveled person, but I have participated in medical trips to Mexico in squatter villages surrounding Mexico City and others just across the Texas border. I have seen spartan operating environments and expected to find similar facilities in Vietnam. My preconceptions were quickly proven incorrect: The O.R.s at Hue Central Hospital are quite modern, with equipment that includes hanging lights, anesthesia machines and adjustable tables.
Patient (see series at right) with bilateral cleft hand treated with transposition flap to the left hand and on-top plasty of the right thumb.
Our day's cases had been distributed to two rooms to maximize efficiency. Preoperative practices were similar to those in the United States - patients were marked and consented in a holding area where they received intravenous antibiotics. When a patient was rolled into the operating room, we performed a "timeout" to confirm the surgical site and specific planned surgery.
The first patient was a 5-year-old with a type IV duplicated thumb. In the United States, this hand anomaly is usually treated by age 1 or 2; most of our patients were age 3 and above (the oldest was age 15). I asked our hosts if the older presentation was due to a lack of access to medical care, and they explained that these delays stem from a belief from some parents that a duplicated thumb brings good luck to those who have it. The continued deformity eventually overcomes this belief, prompting parents or the children themselves to seek surgical correction.
As the first patient was prepped and draped, the operating room began to swell with observers, many recording the operation on cameras and iPads. The dorsal incision was made and the anatomy of the extensor tendon was identified. The thenar muscle was detached from the radial thumb. The radial duplicated thumb was then excised, and a redundant portion of the metacarpal head was removed. The thumb was pinned with a k-wire, the thenar muscle was reattached and radial collateral ligament was reconstructed to the remaining thumb. It was a straightforward case that we hoped would not bring misfortune to the rest of our trip - despite removing the lucky thumb.
The rest of the day proceeded accordingly, with the next patient undergoing a centralization procedure for radial hypoplasia on the left hand and a pollicization for pouce flottant (floating thumb) on the right hand. Next we treated the 5-year-old boy with the contracted middle finger PIP joint, followed by a patient with symbrachydactyly who possessed an unstable distal small finger that was treated with a fusion and bone graft. The first set of operations was in the books, but our day was not done.
A captive audience
With the final dressing in place, we hurried to the lecture site in the hospital's "training center." I realized there was a deep dedication to education at this institution, as more than 50 people were awaiting our lectures. Some had been in the operating room with us that morning, whereas others had attended teaching sessions with our hand therapist. Dr. Chung later noted that he had never seen such a high level of interest from the local doctors during any of his prior trips. There was something different about this group.
(Right) Drs. Brown and Chung lecture on congenital hand conditions.
My first lecture was "The Treatment of Simple Syndactyly," during which, with the translating physician standing opposite of me, I presented the typical flap designs and highlighted critical steps to ensure safety and perfusion of the fingers. At the conclusion of the lecture, several hands flew up immediately to ask questions: "How do feel about not using skin grafts?" "What do you think of other flap designs?" "Why a long arm cast for these children?" This was a group possessing a keen interest and desire to learn, which was reflected in their inquisitive nature.
Dr. Chung and I fielded questions and did our best to emphasize key principles of the surgery. We would also cover several additional topics that afternoon, including complex syndactyly, camptodactyly and constriction band syndrome. Each lecture drew the same level of response, attentiveness and thoughtful inquiry form the audience.
Leaving a legacy
The following two days proceeded like clockwork, though each with its unique challenges. We treated a patient with cleft hand with different presentations between the right and left hands: The left had an extremely tight first webspace, and the adjacent index finger was minimally functional. A transposition flap was designed to create a wider first webspace while moving and rotating the index finger to close the cleft.
The right hand had complex anatomy with a duplicated hypoplastic thumb and several anomalous phalanges. The most functional fingers in the hand were the ring and small finger, so we performed an on-top plasty using the tip of the radial thumb to lengthen the more functional ulnar thumb.
Although these were not routine procedures in congenital hand, they highlighted the principles of focusing on the thumb webspace creation, prioritizing thumb length and position, and always safeguarding blood supply to the fingers.
On the final day, Dr. Chung and I each took the primary role of surgical assistant as local surgeons performed several duplicated thumb reconstructions, as we provided intraoperative feedback. Surgery proceeded efficiently; we were able to begin our lecture schedule by addressing the entities of radial hypoplasia and arthrogryposis.
After posing for many photos and shaking numerous hands, our course was finally complete. Tired but satisfied, we returned to the hotel for a final night of rest. The following morning over breakfast, Dr. Chung mentioned that he had never had a trip that proceeded without some sort of mishap. The clinic schedule had been concise and organized, surgery had proceeded without major complications, and the children had done well postoperatively. The lectures had been well-received and fostered great discussions. Undoubtedly, the organization of our host institution, the course director and the participants' desire for this to be an educational venture paved the way for its success.
It is common for any physician returning from a foreign medical trip to reflect on the meager resources of the host community and be thankful for his or her individual blessings. Memories of the joy of a child or parents after a successful, function-altering surgery - or the sheer number of patients treated in a short time - are certainly satisfying. Reflecting on this trip, however, yielded the conclusion that my greatest satisfaction lay in the education we provided.
Maimonides is often credited for the proverb, "Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime." In Hue, there is incredible desire to learn - and in one short trip, we left Vietnam with more "fishermen" than when we arrived.