Resident Scholar Report: Dr. Heckman in Vietnam

IVUmed Traveling Resident Scholar Report

Jennifer Heckman, MD
University of Wisconsin
Hue, Vietnam
March 11 – 19, 2016
Mentor: Steven Kahan, MD

Sponsored by:  North Central Section of the AUA

Hue is a city in central Vietnam on the banks of the Perfume River, where I was fortunate to be able to spend a week working alongside local urologists.  While in Hue, I had the opportunity to observe and participate in the delivery of urologic care, from didactic instruction in conferences to teaching at the bedside and in the clinic to involvement in the operating room in a variety of surgical procedures.

Through my wide range of experiences, I was able to appreciate both the similarities and differences in urologic practice and training in comparing Vietnam and the United States.  Fundamentally, in both settings, the focus is on evaluating and managing medical and surgical diseases of the male and female urinary tract systems and male genital system.  Basic surgical principles and techniques, too, transcend geographic borders.

The burden of disease as well as the access to and delivery of health care, however, differ vastly between countries.  With regard to urologic disease burden, the diversity of cases I saw in Vietnam was very different from that which I have become accustomed to in the United States.  A large majority of the operative cases for stone disease, for example, were performed using open or percutaneous techniques (as opposed to endoscopic management), a testament to both the differences in presentation of disease as well as in the readily available technology and skills in Hue.

The striking difference in disease presentation was apparent not only in cases of benign urologic conditions, such as the finding of a four centimeter ureteral calculus, but also in cases of malignancy.  In making rounds with the local urologists on inpatients in Hue Central Hospital, I met a woman with advanced bladder cancer whose initial presentation was with gross hematuria, anemia, renal failure, and bilateral hydronephrosis.  She and her family had traveled quite a distance from a more rural area to seek care in Hue after the agriculture season (the family’s livelihood) was complete. 

Such a presentation is not an uncommon one to encounter in Hue.  As one of the local urologists explained, in Hue, as well as in Vietnam in general, patients often present with later stages of disease, as limited resources, including time, money, and transportation, often contribute to delays in patients seeking necessary medical care.  Many people must often continue to work and defer medical care in order to support their families, sometimes at the expense of their own health.

The urologists in Hue are well-trained, and in a city of about 350,000 people, there are 12-15 urologists who practice in three hospitals and numerous clinics throughout the city.  Training is different from that in the United States, with medical school graduates paying to participate in residency programs.  Urology residency, like other specialties, is three years in duration, and in early post-residency careers, one sees young urologists practicing and operating alongside more senior urologists.

Urologists in Hue face unique challenges in working in a resource limited setting.  While in Hue, I had the opportunity to observe and/or participate in 11 cases, ranging from ureteroscopy to open ureterolithotomies to an open radical cystoprostatectomy with ileal neobladder.  There were notable differences in accessible equipment.  In the operating room, for example, there were limited instruments available, and fluoroscopy, too, was not always readily available or reliable.  In addition, certain disposable items were often sterilized and re-utilized out of necessity.  Different surgical skill sets were also apparent.  While open stone surgery was commonly performed, flexible ureteroscopy is far less often performed, and urologists cite lack of equipment and training as reasons for this disparity.

Despite the material, financial, training, and infrastructure challenges faced by urologists in Hue, the practice of urology is well-adapted to the environment.  The capacity for fundamental urologic interventions exists, and while technology is not as advanced as it may be elsewhere, the surgeons have excellent technical skills, and though resources are limited, the urologists are very resourceful.

It was a privilege to have the opportunity to work alongside the urologists in Hue and participate in the delivery of urologic care.  I was able to view urology through a new lens, and through this experience, I gained practical experience in a new environment.  To see another country and its people and to begin to understand not only a different healthcare system and its challenges, but also a different culture, has afforded me a unique perspective.   I have made new connections with colleagues that will hopefully prove to be long-standing relationships, as I incorporate global health practice into my urology career.

Dr. Kovell Reports on Resident Scholarship Experiences in Vietnam and Mozambique

In December 2014 and May 2015, Dr. Caleb Kovell participated in IVUmed’s Resident Scholar program, traveling to Vietnam and Mozambique.  Dr. Kovell’s experience was made possible by the generous support of the Mid-Atlantic Section of the American Urological Association.   He was accompanied by Joel Gelman, MD in Vietnam, and Ryan Terlecki, MD in Mozambique. 

Reflecting on his experience, Dr. Kovell reported, “From these trips, I will take with me lasting friendships, mentors, and connections from here at home and across the globe.  Over the course of my IVUmed experiences, I had the chance to work with some incredible surgeons and innovators in the field of reconstructive urology.  (Joel Gelman, Johan Naude, Igor Vaz, John Lazarus, Sanjay Kulkarni, Aldo Marchesini, Pippi Salle).  These are names that I had always heard about and read about in the world of international reconstructive urology, but thanks to IVUmed, I have had the chance to meet them, learn from them, and count them as colleagues and friends.  During my two trips, I interacted with numerous urologists from Vietnam and specialists from around Africa.  We had the chance to share our teaching with them, and assuredly they taught us a great deal about their cultures, patients, and health care systems.   Most importantly, we formed lasting bonds with the patients who we cared for and their families that I will never forget.  Hopefully we have been able to change their lives for the better as well.”

He added, “Over the last year, I learned a great deal about urology and reconstructive medicine.  Thanks to IVUmed, I also was able to experience first-hand what it takes to successfully translate these skills to international locations.   These trips have confirmed for me that I will make international medicine a significant part of my urology career moving forward.  I hope that a large part of that will involve continued collaboration with an organization as wonderful as IVUmed.   I was truly humbled by the experiences.   Thank you again for everything.”

Resident Scholar Dr. Tan Travels to Senegal

Dr. James Tan’s IVUmed scholarship experience in Dakar, Senegal was made possible by the generous support of the South Central Section of the AUA. During his time in Senegal, Dr. Tan was accompanied by mentor, Francis Schneck, MD.

Dr. Tan, reflecting on his experience, reported, “We quickly got through our intake of 30 plus patients with efficiency despite some of us still recovering from severe jet lag.  Amongst these we chose the most appropriate cases to proceed with and scheduled them appropriately on each of the operative days.  Despite the facilities being much different from what we were used to we were quick to unpack and start cases the following day.  It was clear from the get go that the aim of our time would be focused on training the local doctors new techniques and procedures.  There was a willingness to allow the local surgeons to have as much hands on time and struggles as possible much like during our residency training.  This would not be a time of pure observation.  They would get valuable experience with cases they’d never seen before.  Each day was long and tiring but at the end of the day there was a satisfaction I had in working with a great group of people as a team helping the kids we operated on.

My goal as I progress in my career is to eventually do continuous short-term mission trips.  I made many valuable observations.  Organization was key as we had a set schedule from the minute we landed.  This demands an established relationship with the local people and doctors that can only be developed through years of working together much like Dr. Schneck had with the Grand Yoff hospital.  As I learned, two of the local urologists had spent time in the U.S. and had visited Dr. Schneck and Tina the nurse who traveled with us.  An additional element of a successful trip was the need to teach your skills to as many as possible.  As the old saying goes give a man a fish and he eats for a day, teach a man to fish and he eats for a lifetime.  The same can be said for doctors.  The most helpful thing for the local people besides sending more doctors is to teach the doctors already there new skills and techniques so that they may reach as many people as possible even when the team leaves.”

The Latest from Rwanda

As our IVUmed team wrapped up their week in Rwanda, Dr. Alli Greening reported,

“I’m now finishing up about 40 hours of air travel in a little over a week, am confused as to what time it is, and exhausted from a busy OR and teaching schedlue. I am also really excited to have identified some problems with the anesthesia education and hopefully our next steps in Rwanda. I am already figuring out how to improve anesthesia education there, and hopefully not only bring it up to a  level commiserate with their surgical capabilities,  but make it self sustaining by beginning to work with a core group of providers and develop a curriculum that they can then teach and disseminate to others, something both myself and Bob Nguyen feel is a key concept in this project.

Despite the jet lag and exhaustion, when Bob asked if any of us would like to return next year, every one of us immediately raised our hands. As I sat at the Hotel Des Mille Collines (former Hotel Rwanda) celebrating with a drink on the way to the airport with part of the team we remarked this was each of our favorite mission ever. The team dynamic had been phenomenal, we had seen really substantial progress in the two surgeons, and were talking about future direction with very appreciative and committed higher ups at both hospitals.

Cheers to Rwanda 2016!”

IVUmed Resident Scholar Dr. Michael Amirian Travels to Ghana

Surgical Team

Dr. Michael Amirian’s IVUmed scholarship experience in Kumasi, Ghana was made possible by the general support of the Mid-Atlantic Section of the American Urological Association. During his time in Ghana, Dr. Amirian was accompanied by mentor, Carlos Angel, MD.

Regarding his experience in Ghana, Dr. Amirian reported, “I immediately felt the warmth and selflessness of the other team members upon my first meeting with them.  Some, like Dr. Carlos Angel and Michael Felber RN were international mission veterans, having done many of these types of trips. Our other attending, Dr. Christi na Ching, had participated in IVUmed as a resident scholar during her urology training and could not wait to return as an attending.  It was my first trip of this nature but knowing others had been in my shoes before made me much more comfortable.

In the OR – Ghana

While there were numerous complex cases of varying degree, one that I found particularly challenging was that of an 11-year-old girl. She was born with bladder exstrophy and had suffered her entire life with this condition.  Her bladder, after years of exposure to the environment, was ulcerated, and excoriated.  She was in constant pain.  She was completely incontinent. Needless to say, her quality of life was abysmal.  Many of the usual reconstructive options were limited as she would not have any long term accessibility to catheters. We reimplanted her ureters into her sigmoid colon, in a procedure named the modified Mainz II Pouch. It was remarkable to see her joy and big smile the next day when she looked down and no longer saw her constant source of pain.

Now that I have returned from my trip and have had a chance for introspection, I realize that I am included in the “many” of IVUmed’s mission statement, “Teach One, Reach Many”.   Thank you to the IVUmed organization for giving me the opportunity to be a part of this life altering trip as well as to the Mid Atlantic Section of the AUA for sponsoring me, and to Dr. Edouard Trabulsi for his mentorship and support.”

IVUmed’s Work Helps Combat Global Poverty

IVUmed experts provide hands-on training to build local capacity and increase access to quality healthcare.

According to the World Health Organization (WHO), 2 billion people lack access to basic surgical care. Access to specialized care like urology is even more restricted with critical shortages of trained personnel. The United Nations cites the unavailability of healthcare as one of the root causes of extreme poverty. Debilitating health conditions not only drain family resources, but also affect productivity and prevent many throughout the world from earning a living. A breadwinner unable to work due to illness, or family members obliged to stop working or attending school to care for a relative can lead to considerable loss of income and long-term poverty.

IVUmed works to make quality healthcare more accessible in resource-poor areas of the world. We build self-reliant surgical teaching programs capable of meeting the needs of their communities. By providing expert surgical training to physicians and nurses throughout the world, children and adults in need of care will not have to live for years with debilitating conditions that threaten their economic and overall well-being.

The Year Was 1995…Look How Far We’ve Come!

Twenty years ago, IVUmed was incorporated by its award-winning founder, Catherine deVries, MD, to address the enormous need for patient care and professional training in urology in resource-poor areas of the world. From common congenital malformations to pelvic floor injuries, various cancers and other diseases, urology represents a vastly underserved area of global health.

Initially established to help meet the staggering need for pediatric urology in developing countries, IVUmed has grown to include virtually all areas of urology and incorporates education for nurses, anesthesiologists, radiologists, pathologists and other related areas of medical and surgical care. IVUmed’s services have been requested in over 30 countries in Africa, Asia, Central America and South America. With a proven model that has helped to successfully build surgical training programs in countries as diverse as Honduras, Vietnam, Senegal and Mongolia, IVUmed tailors its efforts to the needs of each of its many partner hospitals and communities.  Our partners in these sites have demonstrated strong long-term commitments to IVUmed’s work and mission and will ultimately serve as a bridge between today’s investment of resources and our shared vision for access to quality healthcare in the future.

Our success is based on uniting peers and strengthening relationships among medical providers with a common shared purpose of ensuring access to quality urological care.

* We connect physicians and nurses in low-resource settings with experienced colleagues for peer to peer interaction.
* We provide hands-on education through ongoing on-site surgical workshops.
* We build self-reliant surgical teaching programs capable of providing local and regional education.
* We are the chosen provider of care and education in partnership with multiple global urological organizations.
* We identify, support, and develop future generations of IVUmed volunteers and host colleagues.

We have refined our capacity-building model over two decades and have become the go-to organization for urology training in developing parts of the world. Our intensive, onsite hands-on workshops equip physicians and nurses throughout the world with the skills they need to serve their communities. Meanwhile, the greater objective of IVUmed training is to develop future generations of medical personnel by building lasting surgical teaching programs. Your support helps ensure that children and adults in resource-poor areas of the world will no longer have to suffer for years with treatable conditions that greatly affect their quality of life.

Our surgical workshops are complemented by distance consultation and other means of instruction and support to help ensure that our partners progress toward their training goals. We also utilize telehealth technology for distance education and are collaborating on educational modules comprised of surgical video, lectures, medical animation, and testing.

Please join us this 20th anniversary year, on Facebook, Twitter, Instagram and Pinterest.  Together, we will make a difference!

IVUmed – Helping Children Around the World

IVUmed in Rwanda

IVUmed’s Pediatric Urology Capacity Building Program makes quality surgical care available to children around the world – especially in low-resource areas. We accomplish this by building a global network of train-the-trainer centers of excellence. There are no pediatric urologists in sub-Saharan Africa, Haiti, and many places in India, leaving millions of children without access to care for debilitating urological conditions.

Pediatric urology diseases, malformations and injuries are among the most common conditions affecting children worldwide, and are up to 10 times more common than cleft lip and palate. In the US, when a baby boy is born with a condition such as hypospadias (a congenital condition in which the opening of the urethra is situated on the underside of the penis instead of at its tip), surgery can be performed before the child is even out of diapers, and there are few to no lasting effects. In countries where this type of surgery is not available however, shame, poor self-esteem and secrecy surround this condition, which often results in adult infertility if left unrepaired.

IVUmed’s teams of volunteer physicians, nurses, and anesthesiologists provide hands-on surgical workshops, lectures, online educational materials, telehealth consultation, and impact measures to equip doctors and nurses with the skills they need to care for children in their communities. In turn, these newly trained medical professionals build future capacity for care by passing along IVUmed training to their colleagues, fulfilling IVUmed’s motto, “Teach One, Reach Many”.

IVUmed’s focus on education stands out among global health organizations, as does our focus on urology. Another unique element to IVUmed is our collaborative model. While IVUmed is guided by a dedicated board and staff, leadership of our programs stems from the dynamic doctors and administrators at our many partner hospitals around the world. Their priorities lead our efforts, which are put into action by our volunteer doctors and nurses. Together, and with the generous donations of many benefactors, we are building a worldwide system of pediatric training programs, ensuring that children everywhere will have access to the care they need.

With the help of supporters like the Ronald McDonald House Charities, the Societe Internationale d’Urologie (SIU), the American Urological Association (AUA), the Pan-African Urological Surgeons Association (PAUSA), and regional surgical associations, IVUmed is building a strong global network. Teaching hospitals throughout the world, skilled medical volunteers, ministries of health, local community leaders, international medical societies, regional colleges of surgeons, and charitable foundations combine strengths to give children everywhere the opportunity to lead the healthy, productive lives they deserve.

You can be involved too, whether a physician, engineer, photographer, philanthropist, medical student, etc.  We invite you to explore our volunteer opportunities here.  http://www.ivumed.org/how-you-can-help/

IVUmed in Vietnam

“Movember” is Here!

As you probably know, “Movember” is a global movement each November aimed at raising awareness of men’s health risks, especially prostate and testicular cancer and mental health challenges. Using the mustache as a catalyst, Movember encourages men to invest in their own health by more openly talking about their health concerns and more proactively seeking necessary medical care.

This is important stuff!  Did you know that the WHO (World Health Organization) expects the number of prostate cancer cases to double to 1.7 million in less than 20 years?  

IVUmed experts provide education for treatment of common urological cancers such as bladder and prostate cancer all around the world.  

Go get checked, and if you need to, get treated.  In countries that IVUmed serves, these treatable conditions go undiagnosed and can cause untold suffering and death.  

You can help! 

Encourage your man to grow a mustache…unless you don’t like them.  If that’s the case, just encourage them to make an appointment and get a physical.  Women get mammograms – let’s get guys to take their health seriously too!

You can also make a donation to the life-saving work of IVUmed in honor of the man in your life.  Instead of new mustache wax for the holidays, make a gift to IVUmed in your guy’s name. 

Go here for more information regarding the Movember movement.

Notes from the Field: Hue, Vietnam – Part 2

Lawrence Jenkins, II, M.D. , an IVUmed resident scholar, volunteered with our general urology workshop in Hue, Vietnam on March 10-22, 2014. This is the second half of selections from his field notes:

Notes from the Field:  Hue, Vietnam

Day 5

There was a ceremony with the university directors and urology senior staff where Dr. Hampton was given the title of Visiting Professor. It was nice yet very formal and Dr. Petrossian and I received small wooden plaques with the university and hospital name on it to commemorate our trip. Drs. Hampton and Petrossian left to go back to the US.

Day 5-7 – I took a bus to Hoi An, which was 4 hours south of Hue. I arrived in town at night and went into town to see a lantern festival where they turn off the lights and businesses only use candlelight and lanterns, and people place paper lanterns in the river. The next day, I took a tour to My Son Holy land, a sanctuary dating from the 4^th to 13^th centuries. We stopped at island on the way back to see sculptures and carvings being made. Later, I walked around the old town for a bit, then found a cooking class and made some delicious meals. In the morning before leaving I took an 8.7 mile / 14 km bike ride into the countryside and saw life outside of the tourist area.

Day 8

I met Dr. Kahan, from New Hampshire, who was the faculty mentor for the second week. This was his fifth or sixth trip to Hue. There were several open stone surgeries that day, one renal and two ureteral. The technique that the Vietnamese doctors had was superb and they were able to efficiently remove the stones without unnecessary manipulation. The afternoon surgeries were performed in the same room and at the same time as a general surgery case, which is unheard of in the US at the present time with infection concerns.

Day 9

We performed another nephrectomy, this was for a kidney with chronic infections. That evening the urology staff took us out for dinner and drinks. It was fun and we were able to socialize not only about urology but about life in Vietnam vs life in the US.

Day 10

We did 2 percutaneous nephrolithotomies with new renal access gained with the assistance of fluoroscopy. Both were for lower pole stones. The only method they have available for lithotripsy is laser; however, in the US we have pneumatic and ultrasonic lithotripsy as well. They were having difficulty gaining access and I was able to show a different method that I learned during residency. It felt good to be able to show them something new since they were showing me so much about open stone surgery.

Day 11

I did my third presentation for their morning conference. Most people seemed interested and had some good questions. We then went to see some surgeries and in the afternoon I spent some time in the clinic with one of the attendings. The clinic was one room amongst a group of many clinic rooms that likely rotated specialty. In the evening, we had a closing dinner on the river with the department. It was very nice to see everybody again and enjoy the authentic Vietnamese cuisine.

Day 12 – 13

Dr. Kahan left to go back to the US. I rented a scooter and rode around the countryside with one of the Vietnamese doctors, Dr Fu. We went to see several Buddhist temples and a lookout point with a great view over the Perfume River. That evening, I left for my extremely long trip back home.

Overall, it was an amazing experience that changed my perception of not only urology but the general delivery of healthcare. Seeing what they were able to do with much less equipment makes me appreciate what we have so much more. In Hue, medicine is pure, not overwhelmed by the need to order extra tests in fear of malpractice lawsuits. The Vietnamese doctors were very welcoming and I hope to go back one day.

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