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    Monday, July 09, 2012

    Lang Co Clinic

    Three days of working in a rural clinic went by like a whirlwind. This is incredibly different than my previous medical experiences in Hanoi and Ho Chi Minh City (HCMC), but, it really is about what I expected. The disparity in care (and life) is amazing here. Some stats from a Vietnam News article I read yesterday:

    1. HCMC accounts from 21% of the nation's GDP (this is an improvement, I think, because it used to be 75%. Now Hanoi and Da Nang have grown tremendously, siphoning this off) including 44% of tourism dollars.
    2. Average income is 2.4 times higher in HCMC than the rest of the country.
    3. The city has an average economic growth rate of 11% over the last 25 years - 1.5 times the national average.

    What does all this mean? It means if you live outside of HCMC (and definitely outside of it plus Hanoi and Da Nang) you are markedly poorer than the rest of the country. It logically follows that your health care will also suffer, since all the major hospitals are in HCMC or Hanoi, and you will have little if any ability to travel for medical services.

    Consequently, clinic saw both run-of-the-mill malnutrition and parasites (probably 80-90% of cases) mixed with really interesting cases that had little to know previous medical follow-up.

    In the three days I was in Lang Co, I saw an average of 40 patients per day. One young boy, about 2 years old, came in with his mother who complained about a large lump behind his left knee. On examination, I noticed he had a rather large (7cm by 5cm), non-tender, immovable, solid mass behind the right knee. Nothing noticeable on the left. Mother stated that the mass had been there since at least 3 months of age, and had gotten bigger as he had grown. A local physician had seen the child early in the course, performed no tests, and said it was totally normal.*

    *(aside: this is common in Vietnam, where medical tools are scarce and money to pay for them more so - to do almost no tests, except an ultrasound of the abdomen which is done for everyone regardless of chief complaint because ultrasounds are so prevalent - and not explain to the patient anything. Although, in America we explain everything and the patient never hears or understands what we say, so perhaps that is just universal...)

    So, I ordered some xrays of the bilateral knees and femurs and told the mother to return the next day. Early the next morning, in she walks with xrays in hand, showing growths on both femurs (left markedly greater than right). Luckily, one of the other physicians on the team, Mark, is an orthopedic surgeon, so I walked next door to get a specialist consult. He had the child walk, looked at the xrays, then declared it was most likely an osteochondroma - a benign tumor of the bone. It's monitored through periodic xrays and removed if it impacts function (walking in his case) or grows rapidly (small chance of becoming malignant).

    Mother went away happily knowing a diagnosis, and knowing what to look for, and I moved on to the next patient - more worms.

    In all, I saw probably three or four cyanotic heart lesions, a previously undiagnosed brain mass, juvenile idiopathic arthritis, hodgkins lymphoma not receiving treatment because of no money, cleft lip, and - jewel of the diagnosis crown - Russell-Silver Syndrome (stories for another day). Sleep was welcome each night. It's amazing how much good you can do with so little.

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