Whitney Palmer

Beyond the South

Published in the Spring 2011 UNC Med Bulletin

By Whitney L.J. Howell

Based on his conversation with a neurosurgeon, Brent Senior, M.D., knew the patient sitting before him suffered from a non-hormone producing tumor lodged at the base of his skull. The man endured not only extreme headaches, but as the tumor continued to grow and press against the optic nerve, his vision was also fading. Surgical removal of the mass was the only option.

Senior, chief of the UNC School of Medicine division of rhinology, allergy, and sinus surgery, had successfully completed similar procedures in his operating room in Chapel Hill with a neurosurgeon at his side. But he wasn’t in Chapel Hill. He was in Vietnam, and the local neurosurgeon didn’t even scrub in.

“I wanted to have the Vietnamese neurosurgeon involved. But he declined, and I ended up removing the whole tumor on my own,” Senior said. “It was dicey and a little uncomfortable, but after it was over, the patient recovered his vision.”

For the past 13 years, Senior, who specializes in endoscopic minimally invasive sinus surgery, has provided medical care at any of nine hospitals in Hanoi and Ho Chi Minh City for one to two weeks annually. He travels to Vietnam with a larger group of eight to 14 head and neck surgeons and otolaryngology specialists from across the United States. They go to treat patients and share medical knowledge and equipment, and for the past several years, Senior has been the team leader.

The Colorado Springs-based non-governmental organization Resource Exchange International (REI) sponsors and coordinates the trips. The group’s goal is to share American training and resources with counterparts in emerging nations, including Vietnam, Cuba, Djibouti, and Kazakhstan.  The trip to Vietnam costs between $4,000 and $5,000 per person, and Senior and his colleagues pay their own way. Senior has personally financed the trip for one UNC otolaryngology resident yearly for the past decade. This spring, however, a Challenge gift funded the trip for two UNC otolaryngology residents.

Since the Vietnam initiative launched, team members have either personally given or facilitated corporate donations of more than $1 million in supplies to Vietnamese hospitals. The biggest focus has been on providing endoscopes, laser microscopes, and other equipment that promotes minimally invasive procedures. Senior spear-headed the donation of the most advanced gift – a BrainLab image guided surgery system worth more than $250,000 – to Ho Chi Minh City Hospital.

But the trips are about more than providing the latest technological advances in otolaryngology or even seeing patients, Senior contends. Over the years, purely professional relationships have evolved into family-like friendships, opening the door for an even greater exchange of cultural and health care knowledge. It’s the depth of that long-term investment that draws Senior – and now his wife and children – back to Vietnam.

“I love that what I do helps people who live on meager wages, who have outdated material, and who work in squalid conditions and struggle to do what we easily achieve,” he said. “For me, this is returning a little bit of the immense wealth and blessing I’ve received by living in a wonderful country, training in outstanding programs, and working in a fantastic university.”

Medicine in Vietnam: Time Stood Still

REI-Vietnam started in 1995 when Vietnamese otolaryngologists attended the Christian Laryngology Association annual meeting in search of American partners to help them improve the quality of care they provided to patients.

“The Vietnamese Ministry of Health officials were trying to identify medical resources to help them along their journey,” said Brian Teel, REI Vietnam director. “They knew what they needed, and they simply walked in and asked for help.”

Shortly after that first contact, REI assembled a team of physicians from the United States and nine other countries to go to Vietnam and meet with senior officials. Together they outlined the country’s goals and determined what equipment and information would be needed to bring the country’s otolaryngology specialty into the 21^st century.

Senior joined REI-Vietnam three years later, and what he saw in some hospitals and other facilities, even then, astounded him. Although the Vietnamese otolaryngologists professed a deep desire to advance their knowledge, the resources available were caught in a time warp. Patients received care comparable to services rendered in the American health care system in the 1940s.

Vietnam had no textbooks or medical journals published after the 1970s, the newest equipment dated to 1975, and even medical education didn’t give all aspiring otolaryngologists enough hands-on training. The Vietnam War and communist control had closed the country off from any outside influence, stringently preventing the medical community’s ability to remain current.

“Vietnam was a country where the health care system was really backward,” Senior said. “When we first went in, it was like we were dealing with kids. When it came to the equipment we brought, it was as if we’d given them a Ferrari, and they didn’t even know how to drive.”

At that time, according to Teel, Vietnamese operating rooms, in some ways, mirrored U.S. surgical suites from the 1920s. In other ways, they were even more rudimentary.  Doctors still ventilated patients with hand pumps, they used razor blades as scalpels, flashlights served as surgical lighting, and they had no way to monitor anesthesia during procedures. What concerned REI doctors the most, however, was that their Vietnamese colleagues operated without the benefit of CAT scans.

The lack of up-to-date medical knowledge and antiquated technology also impacted the safety and hygiene procedures Vietnamese doctors used. For example, before surgery, doctors would wash and sanitize their hands, but before donning gloves, they would put on their gowns and organize instruments, Senior said. Oftentimes, scrubs weren’t washed and were reused for multiple patient encounters.

Technically, the surgeries were clean, but they weren’t sterile. Addressing the need for improved sanitation strategies required tact and cultural sensitivity, Senior said. Instead of dictating how to properly sterilize an operating room, potentially embarrassing and angering the local physicians, the team demonstrated the correct techniques and sparked discussions that led to improved patient outcomes.

Still, Senior said his team is continually astonished by what the Vietnamese physicians accomplish for their patients with the meager tools they possess.

“We never cease to be amazed with some of the approaches our counterparts have taken that we’d never think of in the United States,” Senior said. “I’ve watched them use a hammer and chisel to conduct a procedure that we perform with a high-speed drill under a microscope.”

The medical education system also makes it difficult to ensure all otolaryngologists have the same depth of training, Senior said. Every physician completes medical school, but residencies differ greatly from those in American institutions. The Vietnamese medical system requires a three-year residency rather than one lasting five years, and it divides residencies into levels. Lower-tiered residents are often found in rural areas and are considered physicians after observing otolaryngologists in the hospital for several months. Residents who intend to practice in cities complete a residency nearly identical to those in the United States.

Senior’s Contribution: Making an Impact at the Bedside, the Lectern, and at Home

Despite the obvious differences in the available resources and breadth of medical knowledge, there is a greater prevalence and severity of only a few ear, nose, and throat ailments in Vietnam as compared to the United States. The country experiences a higher rate of nasopharyngeal carcinoma – a cancer that has a predilection for Asians – and citizens develop more head and neck infections than do Americans.

What has been most surprising, Senior said, is that the complaints he encounters when he’s in country are strikingly similar to those he hears in Chapel Hill. Until going to Vietnam, he considered himself to be mainly a “quality of life surgeon” – one who ameliorates annoyances but doesn’t save lives.

“I thought that we in America were so privileged that we got mopey because we might have a stuffy nose on the way to get our hair done,” he said. “But it turns out that the Vietnamese are the same. They might live in huts and have few modern conveniences, but they will be just as miserable with sinus discomfort when they bend over in 90 degree weather, picking rice in the fields for 14 hours a day. They’re going to seek relief.”

Senior is happy to eliminate their symptoms, and the Vietnamese doctors are equally as pleased to have his help. In fact, the physicians often save some of their more difficult cases for Senior and his team, including intricate and more invasive tumor removals. The patient who faced blindness received this type of procedure – Senior traversed his nose and sinuses to access the tumor at the base of the brain. The pediatric otolaryngologists perform many common procedures, such as tonsillectomies and ear tube surgeries.

But performing and demonstrating complicated procedures only advances the otolaryngology field in Vietnam so far. The longer lasting effects arise from the educational efforts – the books, journals, and daily lectures REI-Vietnam employs to share up-to-date medical knowledge.

According to Senior, he gives between four and six lectures weekly, and oftentimes more than 100 people attend. Over the past decade, his lecture topics have grown in complexity from the most rudimentary topics to discussions of minimally invasive approaches to skull-based tumors.

“Giving a lecture can sometimes be difficult because you really need to figure out who you’re talking to,” Senior said. “In the big medical centers, there’s a higher level of knowledge, so we can deliver more -complicated lectures. But as soon as you get out into the rural areas, the knowledge just falls off.”

This knowledge gap is the reason why, since he joined the Vietnam program, Senior has invited 12 Vietnamese otolaryngologists to visit and observe activities in the UNC Otolaryngology/Head and Neck surgery department. Not only does he pay for their travel expenses himself or split the cost with other REI physicians, but he also welcomes the visiting doctors into his home for their two week stay. While in Chapel Hill, the physicians walk through clinic, observe patient care, and learn more about the extensive requirements of America’s residency programs.

Vietnam’s Response

Even though Vietnamese physicians agree the country’s otolaryngology programs are still many years behind those in the United States, they are delighted at the progress the specialty has made with help from Senior and his partners.

“We’re grateful that Dr. Senior and his colleagues come to Vietnam because they want to improve our knowledge of otolaryngology and integrate our programs with the rest of the world,” said Le Cong Dinh, head of the otolaryngology department at Bach Mai Hospital in Hanoi. “His trips here give hope to poor patients suffering from severe illness.”

Noticeable changes have already occurred, said Teel, REI-Vietnam director. Within the first few years of the program’s existence, the number of operations dropped off dramatically because CAT scans now help physicians rule out cases for which surgery would be fruitless. However, when surgery is warranted, the Vietnamese otolaryngologists are now better equipped to conduct the more intricate procedures that previously caused them to shake their heads and throw up their hands in defeat. In addition, children who have their tonsils removed now go home the same day because Senior’s team taught local doctors the most modern tonsillectomy method.

Outside of improved patient outcomes, REI-Vietnam paved the road for long-term collaborative relationships between the physicians, Teel said.

“This is really a watershed project,” he said. “The doctors really like one another and enjoy being in each other’s company. There has certainly been cultural bonding.”

The Resident Experience

For Harold Pine, M.D., the first UNC resident to travel with Senior, working in Vietnam was a way to enhance his surgical skills – one of the Vietnamese physicians taught him how to perform a laryngectomy. But his experience with his first patient sticks in his mind as a valuable health care culture lesson.

“The surgery with this patient went well, but when I went to check on him the following day, his bed was empty. I found out he’d left the hospital to walk down the street to get breakfast,” said Pine, now a pediatric otolaryngologist at the University of Texas Medical Branch in Galveston. “I will never forget the image of him in his pajamas with all of the tubes and such, and the drains were wedged on either side of his pajama pants.”

Pine quickly learned that patients and their families are largely responsible for taking care of daily needs, such as meals and clean clothing, in both pre- and post-operative situations.

While absorbing the cultural differences in how patients and families engage in their health care, Pine also had the opportunity to bring knowledge to his Vietnamese counterparts. As a resident, he introduced many physicians to the radiofrequency Bovie method for conducting tonsillectomies because many were still using cold steel for these procedures.  Last year, as a practicing otolaryngologist who has returned to Vietnam for 10 years, he taught the local physicians about Coblation, a technique that uses a saline solution to reduce the pain associated with the Bovie method.

Karen Bednarski, M.D., an otolaryngologist in Cary, also accompanied Senior on the REI-Vietnam trip as a chief resident. Like Pine, she treated patients and was able to share as well as acquire medical knowledge with Vietnamese residents, but watching Senior with his Vietnamese colleagues impressed upon Bednarksi what it means to be a compassionate physician.

“Dr. Senior made a commitment to help these people, and he hasn’t abandoned them to fly by the seat of their pants,” she said. “He keeps going back and sticking with them. That dedication to helping another population advance their knowledge and skills is inspiring.”

It’s About More Than the Medicine

Thirteen years of medical mission trips inevitably produces relationships that often feel closer than family. While in Vietnam, Senior, and now his wife and four children, live with their Vietnamese counterparts. In return, they invite visiting Vietnamese physicians into their home when the doctors visit UNC.  Senior even hosted the son of one of his Vietnamese colleagues for two years so the youth could graduate from Chapel Hill High School.

“We’ve all gotten very close as we’ve spent time in each other’s homes,” Senior said. “We eat together, socialize in the evenings, and often take side trips on the weekends. We get together as much as possible with our friends while we’re all there.”

Senior’s family, however, goes beyond welcoming the Vietnamese physicians into their domestic lives. On each trip, his wife Dana and their children teach English to college students through the REI-Vietnam program. The focus is on simple phrases and words that describe life actions, but they also give the students books written in English to expand their vocabularies and language proficiency.

His family’s time investment, coupled with the support given Vietnam’s otolaryngologists are tangible representations of how Senior views this work.

“Life is not simply meant for living – it’s really meant for giving,” Senior said. “That’s why I return to Vietnam.”

To read the story online: http://issuu.com/robitaille03/docs/uncmbsp11, pg. 10

April 2, 2011 - Posted by wjpalmer | Education, Healthcare | allergy, and sinus surgery, Brent Senior, Brian Teel, Harold Pine, Ho Chi Minh City Hospital, Karen Bednarski, otolaryngology, out-of-date medicine in Vietnam, practicing medicine in Vietnam, REI-Vietnam, Resource Exchange International, UNC School of Medicine division of rhinology