Students working hard in prosthetics

Once again, our pharmacy students have no training in the fitting of a prostheses. However, with very good shadowing on the first morning, hands on in the afternoon, the second day they complete a prosthetic leg on their own with very little super vision. The gratification that they receive by fitting a new leg for a patient who may have not walked normal in years is so rewarding to watch. Im proud of their willingness to jump into something strange with a positive attitude and finished with a positive smile!!!

Met a New "Friend"

Inevitably on each mission, one or more people make an impression on my heart. Most times I meet a young child who makes my insides warm and puts a smile on my face. Meet Diem My, The daughter of a family who ate in the same café as us 2 nights in a row. First night, she was rather shy, keeping mostly to herself, although by the end of that night, she warmed up nicely. I was pleasantly surprised when her family arrived on the second night. There was no warm up time, she immediately recognized us and started to interact with all of our team. Her laugh was energetic and contagious. Her smile was bright and sweet, and her eyes cutely touch my heart!! I hope to see her each time we return, to watch her grow up.

Final Clinic day in Binh Phuoc

This is our second visit to Binh Phuoc province, last in 2015. If anyone who reads these blogs recalls, the final day in 2015 we treated 250 patients, most of who got bused in because they knew our work was successful and we would be leaving. I call the condition LDS (Last Day Syndrome). So having that history, I prepped our team for a very busy last day in Binh Phuoc. This year, as I was finishing my morning run at 5:45 am, there was already 30 patients waiting for the team to arrive at 7:00am. I knew from that moment, it would be similar to 2015, and I was correct. The sad thing is, it got to a point where the crowd of patients was hard to control. (Some literally begging to be seen). Because the care is so subpar here, and the availability is limited, patients do desperate things to be seen. For the team’s safety, we employed the assistance of the local authorities to regain order. Once order was once again restored, we were able to successfully treat most who waited. All 151 patients, even the rowdy most desperate ones, received the same hard working, compassionate care we treat everyone else. It is an example of blind compassion and understanding why it occurred makes it all worthwhile. The days in Binh Phuoc ended with a nice celebration, including a treat of traditional Vietnamese music and dance.

Dislocated shoulder

A little pain, a lot of relief for this patient who presented with a dislocated shoulder. After numerous injections of a numbing agent, and 2 of us stabilizing her body, Bac Si Ha was able to manipulate her shoulder back in place and provide her with much improved range of motion.

Assist in any way possible

During a mission of this nature, individuals are called upon to do a variety of tasks they may not used to. Each of our team members have done an amazing job of going beyond their typical boundaries and reaching outside of their comfort zone.

Surgery gone wrong

This young male patient presented with severe knee pain, really limiting his ambulation. Upon examination and interview, we discovered that he broke his tibia a while back and had surgery to repair it. You actually can see the head of the screw they used to hold it in place at the surface of his skin. Still not being able to diagnose the severe knee pain, we requested that he get an x-ray if possible close by and return to clinic the next day. Mystery solved. Viewing the x-ray which showed the surgical repair of the tibia, you can clearly see that one of the prongs of the screws is sticking right into the knee joint, thus every time the patient takes a step, he feels this piercing pain in his knee. Bac Si Ha said that even with his limited resources he could remove the screw, however, since we would be departing this location tomorrow, there is no chance for follow-up. Therefore for liability reasons, we could not relieve this patient’s issue.

From crawl to walker to walking

This 6 year old had to be carried into the clinic by a relative because he was unable to walk on his own. After review of his x-ray and examination by Bac Si Ha, we discovered that he had a severe L5-S1 compression for years. (Typical for a hard-laboring adult but rare for a child). His mother told us that he has to crawl out of bed in the morning because he can not control his legs. We treated him once with injections and manipulations to release the compression with the plan to follow-up 2 more times while we are in this province. The following day, his mother brought him back asking for a walker to assist with his ambulation, because he seemed to be able to walk more independently. Of course, we buy walkers each year to provide to patients as gifts and we were delighted to present him with one. Following the second treatment we watched in amazement, this young boy walk across the clinic to the pharmacy area independently with the assistance of only our walker. He then returned on our final day in Binh Phuoc, and with only slight assistance from his mother, we watched him walk with less dependence on the walker (Just enough for safety for now) From the first day, his face was sad and scared, to the final day where he felt comfortable and got to know us and left us with a huge smile. He spent a good portion after treatment taking selfie photos with many who treated him so well. Success!!!

Broken Patella

As I moved to work between 4 beds in the medical room, I glanced up and saw this x-ray. With a curious look, I then looked at the patient being examined on the bed. Now it makes sense. This patient had a traumatic accident a few years ago, which left him with a broken patella. This isn’t even the chief complaint that the patient presented with. He has no access to care, continues to work hard at supporting his family, and has tolerated the pain since the accident. The way he walks changed his gait and he developed severe sciatica pain, thus coming to the clinic for treatment. After treating his sciatica pain, he even joked with the student by moving the pieces of his patella around and laughing sinisterly. The shame is that without surgically repairing the issue, his sciatica will return.

Bone Infection

One of the first patients who arrived in clinic was a 40 year-old male who could barely walk to the intake table. He was assisted by his mother on one side and crutches on the other. At first our intake team didn't think much of it, considering the majority of our patients need assistance because of orthopedic pains. While I was setting up the medical room getting ready for a full day of patients, one of my students came in to inform me that we had a patient with a leg infection and we should see him immediately. We are used to seeing infections on this mission, however, what I saw when he walked through the door made me literally gasp. This patient was in an accident 3 years ago and broke his femur. What would occur in the US is that a metal bar would be placed in the femur to assist with the healing and provide stabilization. Well, what the doctors did here, was place screws through the lateral side of his leg and secure them with an external bar sticking out about 2-3 inches. He told us that this surgery occurred 3 years ago and he has had an active infection on and off ever since. He would take a short course of antibiotics but would never follow-up with any practitioner. To say the least, it took my breath away, just to witness the type of medical care that some of our patients receive. I looked at his face, which was one of dire need for help, and it broke my heart. Short of removing the implants and placing a "actual" replacement bar in his femur, we could only provide so much help. We cleaned, debrided, and and prescribed a long course of antibiotics. We will follow-up with him in a fews days to evaluate and clean the incisions again. Hopefully with our treatment, we can prevent him from one day soon being an amputee that we have to fit in years to come.

Binh Phuoc Clinic

Our second clinic site is in Binh Phuoc, on the border of Cambodia. It was a 7 hours bus ride from Ben Tre, so we arrived at 3:30 PM. We had a very quick lunch, unloaded the trucks nd did a survey of the facilities to organize a clinic space with proper work flow. As opposed to Ben Tre, this clinic site is at a main reception hall attached to our hotel. It takes some vision to evaluate the space. We decided to build a make shift medical room from plywood and curtains for patient privacy, a few tables for intake and interviews, another side area with pharmacy and the entire back of the hall for prosthetics. This makes for a challenging workflow to say the least as well as some difficult noise to perform all our functions. This is, however, the way most clinic sites have to work out. We make the best of it for the betterment of our patients.

Finished Clinic in Ben Tre

We worked for a total of 8 and ½ days in Ben Tre clinic. This is always our first and one of my favorites sites to do clinic. The staff is so helpful organizing and assisting in everything we request and it is an actual clinic so the facilities are conducive to medical treatment, including having an onsite X-ray machine. During the farewell thank you ceremony, The leaders of Ben Tre and the clinic offered these words to our team, “We have hosted many charity work teams in the past, and OUR team works the hardest, and provides the most effective treatment of all. They thank us for our hard work each and everyday, especially during a few very very hot days. They worry about our health because we arrive early, treat poor patients all day and leave late in the day. They want to continue to strengthen and grow our mutual relationship of treating needy and poor patients in Ben Tre. Totals for Ben Tre: 921 orthopedic patients and 291 prostheses and braces.

Bilateral AK / BK amputee

As this patient arrived at clinic, many of the student’s eyes got wide. He basically “maneuvered” himself by placing a sneaker on his right shin for cushioning and two very short crutches to get around on. He lost both limbs during the war from land mines. Post-war, he was fit with 2 prostheses but due to them hurting and causing abrasions and infections he ceased to use them. It has been 20 years since he has not worn a prosthetic. Today our team fitted him with 2 new legs and he even requested how tall he wanted to be. During the check-out process, he said that if the legs were “Made in America”, he promised to wear them everyday proudly!!!

More Pediatrics

Another pediatric patient this year who was carried in by his mother to clinic. This 4-year old fell from his bed 2 years ago, and suffered injury to his spinal cord, basically leaving him with poor nerve innervention to his lower extremities. His muscles atrophied and he has never been able to walk alone, unassisted by his mother. One of the methods to assist this child to regain muscle strength and learn to walk on his own is to wear special braces. Of course our supplies for this type of product is limited, but our prosthetic engineering team is quite ingenious. As you can see they used random materials to make him2 braces that will support his body, with the goal, after he strengthens his muscles, to walk independent. I know we will follow-up with this patient every 6 months to alter the braces as he grows and gets stronger. These are the situations that make working on this mission so rewarding.

Killing Me

After approximately 8 days with the full team, I suppose one misses the delicacies of home. The hotel has been doing a good job at making sure the "newbies" to Vietnam get their share of familiar foods. In all honesty, my stomach can better tolerate local street food, vs, pizza, pasta and burgers offered in Vietnam. Hey, there is always blood clams, chim se, and snake to look forward too!!!!

Disorders of Growth Plates

The majority of our patients are adults with chronic orthopedic pain due to hard labor and malnutrition. Periodically a pediatric case arrives at the clinic, with the parent’s hope of finding a solution to their child’s issue. This 4 year old was brought to clinic by her mother, stating that she has difficulty walking normal, and her legs were curved slightly. First off look at this face, prior to our examination and potential treatment, she brought smiles to our whole medical room. She was pleasant, patient, and playful. After Bac Si Ha initially examined her, we discovered she had a disorder of her growth plates. Before continuing, we sent her to get an x-ray of her lower extremities. Upon confirmation, Bac Si Ha explained that as she gets older, she will grow at a much slower rate than her colleagues, potentially only reaching a very short height. Although she is not in any pain, Bac Si Ha attempted to manipulate her lower extremities and stretch her tendons which have begun to contract. Her smile turned to tears, although our student did an amazing job of trying to keep her calm. Unfortunately, not much can be done with our limited resources for this beautiful young girl. An attempt to fit her with braces to straighten her limbs and increase her growth velocity will take place during our December 2017 trip back to Ben Tre. Until then, keep making the world smile little angel and hopefully we can improve your long-term outcome when we return.

Home cooked "meal"

“Home cooked “Meal” Having been to Vietnam on this mission 7 times over six years, I have gotten to know many of the individuals who are responsible for sending invitations to our patients. Our population is mostly impoverished and are accounted for by “The Association of the Poor”. Getting to know these individuals comes with “perks” periodically, including being invited to one of their homes to meet their wife and eat some home cooked snacks. Of course, many would not call this a “perk” when they brought out the main dish. Lucky for me, I have been fortunate enough to learn the true culture from my Vietnamese partners and have embraced everything, including the cuisine. This “snack” was crickets mixed with peanuts, apparently a good lunch snack for invited guests. I thank the Association for treating me like family, and for sharing a “Home cooked meal”!!!!

Prosthetics component of the mission

There are still approximately 100, 000 patients living in Vietnam that have lost limbs due to silent landmines, trauma, infections, and diabetic complications. The patients are a resourceful group, often times making a crude prosthetic limb out of anything available to them (wood, tree trunks, scrap metal etc…). While these certainly are useful, they are not properly fit causing pain, irritation, infection, and poor gait. They also weigh a great deal more than the prosthetics our team will provide. The Mercer team makes lightweight, universal fitting prosthetics that will be customized to each patient’s situation. The patients also arrive hours before our team does, and once in the prosthetic clinic area, a group of 2-3 students will assess, evaluate and determine the best approach to take to fit each patient. This process could take hours to a full day, however, each patient is so understanding and happy for our hard work, that rarely do you hear a complaint. Many times a patient has never worn a prosthetic and/or walked normal since their accident. This day for them is life changing. We are able to provide most patients with a new and better way of life, and the look of joy and gratitude on their faces is priceless. Fitting prosthetics also gives our team a new appreciation for the way of life patients around the globe live and struggle with each day.

First Official Clinic Day

After our team picked up the Mercer team from the airport, we traveled directly to Ben Tre where we will hold our first of 3 clinic sites. Our mission is comprised of 2 main components: 1. The fitting of prosthetic legs to amputees and 2. An orthopedic disorders clinic. Our entire team this year is the largest to date, which includes 50 members. The team members get divided into stations. Each member has to rotate through each station, including the prosthetics clinic. (Which I will discuss in the next entry). When we arrive at the clinic site at 7:00 am, there are already about 50 patients waiting. Some have traveled for hours just to get treated. The temperature of the first day is expected to reach a “real-feel” of 45 degrees C. (114 degrees F) . As you will notice, our light blue scrubs will not stay dry for long. After a typical chaotic first hour, the workflow is greatly improved. Our students get to use all of the clinical pharmacy skills they have learned through their years of didactic and practical training. The initial station is intake. This station is crucial to the entire clinic flow. We have excellent fluent Vietnamese speaking students to interview each patient to illicit a chief complaint, past medical history, and current medication list. At the same time, another student will perform all physical assessment techniques needed to evaluate them more thoroughly, including blood pressure, pulse, blood glucose, height and weight. The patient then enters the actual clinic room, where a student will evaluate, assess and make a differential diagnosis. This information is relayed to Bac Si Ha, and he confirms with a definitive diagnosis and performs his treatment. Once orthopedic treatment is completed, students assist with the prescribing of medications for longer-term treatment. The patient then enters a physical therapy station, and is taught basic techniques to relieve their condition long-term. Finally, the patient enters the pharmacy area, where proper medication dispensing takes place and accurate counseling is performed by another fluent Vietnamese speaking student. This care in most of our locations, is the only care some of these patients will get. It is our hope that we provide a thorough, complete and successful treatment to each patient. So far we will expect approximately 120 patients per day for the first few days of clinic.