Neuro Trauma in Saigon: A Vietnamese Perspective
By Karthik Sarma, MD
I have had the amazing opportunity of
experiencing neurocritical care in an extremely
challenging setting, rich in neurotrauma, over
the past five years. My association with Choray
Hospital in Ho Chi Minh City (Saigon),
Vietnam, began as a visiting fellow with Hearts
Around The World (HATW), a volunteer group
of cardiovascular surgeons and physicians. My
mentor, Manuel Fontes, had recognized the
abundance of head injuries and need for better care and support
of traumatic brain injury (TBI) victims in Saigon. I had just
returned from another enlightening trip to Choray, as the brain
among the HATW group.
As true for most large Asian cities, the dense population, large
number of two-wheeled motor vehicles and minimal to no head
protection makes Saigon a hot spot for neurotrauma. Choray
Hospital, with 1,800 beds, is the largest hospital in southern
Vietnam, serving a population of approximately ten million in
the bustling metropolis. The fact that the Neurosurgical Intensive
Care Unit (NSICU) houses forty-two beds while the general ICU
only has a capacity of thirty beds is very much indicative of the
overwhelming case load. On a typical day, about 80-85 percent of
the patients in the NSICU are head injury victims, with an average
of five to eight new trauma admissions per day. The unit is headed
by Dr. Tran Quang Vinh, chief of neurosurgery, and his team of
ICU physicians, fourteen in all, made up of neurosurgeons and
dedicated intensivists.
As a visiting neurocritical care physician from the U.S., my
initial goal was solely to observe the system and understand
their perspective, methods, challenges and restrictions. Vietnam
offers a very unique combination of difficulties to the practice
of neurocritical care. Most hospital care is based on the patient’s
capacity to pay for services, and treatment is commenced only
once finances are ascertained. There is also an acute shortage of
devices and basic patient monitoring systems. When available,
the cost is prohibitively expensive to the average populace.
Hemodynamic monitoring is only available for a small subset
of ICU patients. All invasive pressure monitoring systems are
largely avoided because of high costs. This includes invasive
blood pressure and intracranial pressure monitoring catheters.
Intravenous (IV) drugs and infusions like IV Fosphenytoin and
Levetiracetam are not available on a regular basis. The NSICU,
which is usually packed with extra gurneys and stretchers with
new admissions that occur overnight, has a shortage of ventilators,
though the available numbers of which have improved over the
years. It is not uncommon to see either family members
being requested to bag-mask ventilate the patient ad infinitum, or
patients being disconnected from the ventilators without actually
being extubated. The latter scenario is a safety net for the minimal
or nonexistent allied services like respiratory care and a sparse but
overworked nursing contingent.
While some of these practices might seem outlandish to the
fortunate first-world practitioner, in Choray, they are a forced
necessity. This causes the intensivists to rely on clinical judgment
or empiric management of scenarios like raised intracranial
pressure (ICP). In contrast, surgical intervention is surprisingly
cheap and the preferred management in many scenarios that
would be managed conservatively in the U.S. Human labor is
cheap in these parts, and this seems to apply to neurosurgical
skills, too. I have come to understand that while an ICP
monitor insertion can run up a bill of around $500, the cost of
a craniectomy is around $100 with the surgeon benefiting not
more than the equivalent of $15. The skill and confidence of the
surgeons at procedures like bifrontal hemicraniectomies is quite
laudable. Services like nursing, physical therapy and rehabilitation
are severely lacking, and the concept of follow up and tracking
outcomes is near nonexistent.
My early, fly-on-the-wall approach helped me appreciate better
the efforts of Dr. Vinh and his team. The language of instruction
and education is Vietnamese, and this is a slight barrier, but most
of the physicians have a functional command of English. Rounds
initially would be a tête-a-tête of the Vietnamese way of doing
things followed by excited and curious questions of how I would
deal with it in the U.S. setting. This fueled discussion in each
realm of neurocritical care. I must emphasize that this has been
the most useful and educational experience for me. Physiology
and therapeutics that we take for granted needed breaking down
and reworking from first principles. As an exercise, this made me
hit the textbooks, latest recommendations, evidence in literature
and eventually tailor answers to Choray’s unique setting. There
has been a progressive acceptance of simple measures that could
positively affect outcomes, like use of checklists. Observation
leading to interaction, increasing discussion, mutual education
and suggestion of change has been productive.
We recognize that TBI is a spectrum of pathologies and
presentations that each behave differently. A one-size-fits-all
approach has yielded limited success and the relative paucity of
civilian trauma numbers in the Western world makes powering
trials difficult. The biggest strength
11