REMINISCING

Oh Hoian. Writing postcards in my living room, reading, admiring tiles. 

- Contemplating, bidding farewells, saying thank yous, making last-minute lists, going. This week has been a bit of a scramble: job application starts (not complaining though! I was sipping on a late night distilled coffee in a local cafe as I read through incomprehensible documents), finishing up the research, presented in the academic meeting, late afternoon ward round as the gentle afternoon glow fills the empty beds, trees turning golden and blooming voraciously, dinners (and ice cream parlours), more lake runs, wanderlust (imaginary bike tours around the country park, Huế, Saigon - they would have to wait). Happy to be going home while sad that I am leaving. Listening to CocoRosie.

xx

SPIRIT OF PLACE

In the early 1980s, Vietnam was at the beginning of a difficult period following the war end. Sir John Ramsden, arriving in Hanoi as part of the British Diplomatic Service’s mission, found himself in the middle of the poverty-stricken and chaotic society. Amidst the post-war living environment, however, one could feel a sense of hope and a relentless fighting spirit of the Vietnamese people.

Sir John went for long walks around the city of Hanoi, bicycled out to the surrounding villages and made trips during the weekends, always bringing along his camera. More than 1,800 photographs of Hanoi had been taken as a result between 1980 and 1983.

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Sad to be missing the exhibition Hanoi Spirit of Places starting from 19th October, but always enchanted to hear old stories about a place you thought you knew well already - and how the storyteller felt, revisiting the city 30 years later, in his own words, in pictures.

TEA

Whereof one cannot speak, thereof one must be silent.

- Ludwig Wittgenstein 

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I stumbled upon this beautiful tea house while wandering around old town - it is part of a local social enterprise and run by speech and hearing impaired persons. So to place your order you are provided with little wooden blocks that say 'hot water' or 'bill' or 'thank you', alongside with pencil and paper to scribble. It opens unto a street with only bicycles and pedestrians and on another side, a small rustic courtyard where a local gentleman teaches you to play his self-made pentatonic instrument. 'So you play the piano?' I smiled. My snow mountain jasmine tea arrived, and I drank slowly, pouring gently, as if it is ceremonial. Here every one, as if captivated by the extraordinary silence, stops speaking and starts devouring the sounds of the rain, leaves fluttering with the wind, book page turning. And there she stands, making tea, quiet and resolute.

Reaching Out Tea House | 131 Tran Phu, Hoi An | their story 

IATROGENIC

The term iatrogenesis - means brought forth by a healer from the Greek ἰατρός (iatros, "healer") and γένεσις (genesis, "origin") - is an inadvertent adverse effect or complication resulting from medical treatment or advice.

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A 16-year-old girl lied on the bed in the ward. Her skin over her youthful face and body is all dry and peeling. She has had high fever with an itchy, extensive rash for the past few days - she is soft spoken, utters a few works occasionally, obviously distressed and in agony. Her rash and itching started a few weeks ago. It was suspected to be eczema and she was treated as an outpatient in the allergy/dermatology department in the teaching hospital nearby, but cortiosteroids, the mainstay of treatment, have not done her well. On the contrary, she started developing a fever that would not go away. A few transfers later, she came here from the provincial hospital. Blood culture shows actinomycetes. Heiman frowned. "There is no way she could have got this in the community. Do you know if she has any risk factor or possible exposure?" The doctor in ICU shook his head, looking puzzled. In the medical notes there is no record of previous medications either. We resolved to asking the girl directly with the doctor translating.

It turns out that she had received an injection from a private clinic before going to the teaching hospital when the rash first appeared, although she did not remember what the drug is, she remembered she did not have the fever then. Forming a microbiological story (i.e. always, always ask: Where is the source? What are risk factors?) it is suspected that she might have had an injection that is contaminated, and in fact this is not a rare occurrence in Vietnam. Children are often taken to receive treatment if they fall ill (be it flu or sore throat) and there is a belief that injection is a far more potent treatment than oral medication - and sometimes if the injection vial is contaminated either during manufacture, transport or storage, bacteria grow and the injection becomes unsafe to use. An iatrogenic outbreak accompanies the influenza season.

Iatrogenesis could sometimes have more lasting and serious consequences. There were cases where children, undergoing chemotherapy for leukaemia, have contracted the hepatitis C virus after receiving blood products. I have met one of them here (a 7-year-old girl, happily folding origami cranes for the end of her bed - does she know what might be in store for her?) and she would hopefully be started on treatment soon in the hope of eradicating the virus. The hospital and blood bank have been notified but no one is sure whether the responsible batch of blood products is destroyed yet. It still leaves me shudder with half-disbelief and half-anger that blood transfusion is not ensured to be 100% safe, especially for a population so young and vulnerable. Screening of blood donors and tracing contaminated blood products remain a mounting challenge as the prevalence of blood-born diseases is high in the region (for instance, with HCV prevalence at 6.1%, compared to a global prevalence of 2.8%) and the accountability system is unclear. Patient safety must be at the heart of all therapeutics and medical practice and "never" events like these really should never happen again. There might be difficulties but there should be no excuses.

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Further (but unrelated) reading | Genetic History of Hepatitis C Virus in East Asia (the common HCV found in East Asia is of a different genotype than its American/European counterpart, and is associated with higher viral load but more susceptible to a shorter course of interferon treatment)

ON THE CARPET

A somehow irrelevant thought (to my elective here/Vietnam) but as I stumbled upon this image, of a beautiful oriental rug, it reminded me of a story vaguely related to medicine. Hence I will write it down here.

I remember the first few weeks of starting clinical rotation, freshly landed into the busiest wards in a north London teaching hospital. Still learning how to take history properly within a certain time frame, I often found myself eventually diverging and chatting to patients who were longing for some company during their long stay in hospital. One day I was chatting to this lovely lady in her eighties (who is usually well until she tripped over at home and had a few bruises - the usual set of tests and scans were ordered ?mechanical fall. She was just waiting around and doing crosswords) when the occupation therapist came to tell her that they had a look around her house and recommended that she should add some railing to her toilet, (some other recommendations) and remove the carpet in her living room because it is a significant hazard. She mumbled and protested and was clearly upset. I forgot the rest of the story but I remembered her saying,

I might not be young and beautiful anymore but this is my living room and I will do anything to defend my rug!

We chuckled. Somehow I imagined her as a knight ferociously defending her rug against a torrent of army (which may be known as medical advice) - with the kind of grace and tenacity that only the wise and experienced possess. I don't even know if this counts as any kind of meaningful reflection or contemplation anymore but stories like these are the things that I really cherish about the vocation, of healing and caring for maladies and sufferings. Triumphant and humbling moment like this that lights up the journey, that consoles and reminds you that in front of illnesses all souls are equal, vulnerable but capable of even greater loving and feeling. 

I cannot help but feel extremely blessed and lucky that I have come this far, and just so close to having the responsibilities and being trusted as a doctor, and surrrounded by people who know how this feels too.

xx