Dr. Le's Vietnam Volunteer Adventure

October 22, 2008. Cardiology conference at Hoan My Hospital; Cho Ray Hospital

2008-10-24T07:36:00.000-07:00

The Hoang My minivan picked me up in front of my hotel at 7:30 am and then stopped by the Sheraton to collect Charlie and Tony Demaria. We crawled through rush hour traffic to Hoan My Hospital #1. Hoan My actually is split into two separate facilities which are separated by about 2.5 km. At HM #1 we were taken to the ICU by the hospital head who took us to the ICU. The ICU director, a young physician who had just returned from one month at St. Mary’s in San Francisco, presented the 11 patients in this small two-room unit. One of the patients was feeling a bit shy and just laid there covered entirely by her blanket. I was reminded of Lien, my 13 year-old daughter, lying in bed fighting for an extra ten minutes of sleep. The air conditioned unit was very clean although a bit cramped with less than a yard between beds. Not a lot of privacy! Interestingly, Hoan My is a private fee-for-service hospital so all these patients are paying customers there by choice. The ER was even more crowded with patients lying on gurneys placed essentially side-by-side. Seems like business is pretty good at Hoan My. The director told us that they have about 600,000 patient contacts annually.

We got back in our minivan and headed over to Hoan My #2 for the conference. When my friend Thach Nguyen had asked me to go to HCMC for this event, he didn’t tell me much and I thought it would be just a small side trip to work with a few doctors. It turns out that our hosts had a bit more planned for us. We were greeted at the HM #2 by 3 doctors in suits and 6 lovely young ladies in the traditional ao dai tunics holding orchids. A red carpet (honest!) had been rolled out into the sidewalk for us. We were ushered by our hosts into conference room which had been lavishly decorated. A classically Vietnamese affair, there were quite a few speeches which had to be translated and we were given bouquets and plaques commemorating the event. Tony Demaria got up to give the first talk.

Unfortunately I missed both Tony’s and Charlie’s lectures because I was taken to the cath lab to prepare for the live case demonstration. As it turns out, they wanted me to do two interventions. The first was a 48 year-old man who had come in 3 months earlier with a heart attack. He was found at that time to have a very ugly, extremely angulated left anterior descending subtotal occlusion, a 70% stenosis in the distal part of a large co-dominant circumflex, and mild disease in a small codominant right. Dr. Huy, my host and soon-to-be scrub partner, had partnered with a Dr. Nghia from Cho Ray hospital to open and stent the LAD. They actually did quite a nice job with this difficult lesion. I must admit that I was pleased when Dr. Nghia was mentioned. Barry Hackshaw, my Desert Cardiology partner, and I had spent several days intensively training Dr. Nghia at Cho Ray in 2000. Dr. Nghia was very conscientious and earnest but extremely green at that time; it’s quite gratifying to hear of his strong reputation as a top interventionalist now.

The patient had done well and was on the schedule now to have his circumflex lesion stented. Dr. Huy explained to me that the patient was quite poor but fortunately a bare-metal stent had been donated by the stent company. This seemed like a quite reasonable case, certainly much more straightforward than the nightmare case from Bach Mai in Hanoi.

However, true-to-form, we found a major curve ball after we started. The LAD was totally occluded at the site of the earlier stent with collateral flow to that vessel from the small right coronary artery. The circumflex lesion looked unchanged. One of the nice things about being able to speak some Vietnamese is that I can communicate directly with the patients and I discovered that our patient actually felt quite well. He denied any symptoms of chest pain or shortness of breath. When pressed, he admitted to ongoing cigarette smoking. Compliance with his medications was unclear but I must admit that I had my doubts that someone described as “poor” by Vietnamese standards would be faithfully taking Plavix ($4/day) in addition to his other drugs. Based on all this, I recommended that we not intervene which seemed to follow Charlie’s lecture on the COURAGE trial (lack of benefit of angioplasty/stenting over medical therapy in stable patients) pretty well. I’ve found over the years that it’s a lot easier to train doctors, no matter whether in California or Vietnam, how to do procedure –even a difficult one – than when to do the procedure. Fortunately, Charlie and Tony backed me up and agreed that the patient should have a stress test first.

The second case was an embarrassingly easy distal right coronary artery stenosis in a 75 year-old woman. Low hanging fruit. It only took about ten minutes and could have been even faster except that I was interrupted several times to talk to the audience in the conference room. The A/V hookup was non-existent and I could only communicate by walkie-talkie held by another person. Furthermore I had to go back and forth between English for Tony and Charlie and Vietnamese for everyone else.

After the case I returned to conference room and took more questions, especially regarding the decision to not intervene on the first case. We heard a few closing remarks, posed for a few more pictures, and then we were treated to quite a nice lunch at a nearby restaurant. After lunch we went by the medical school at the invitation of a Dr. Phuoc, the dean of the medical college. I’ve met Dr. Phuoc on several prior trips to Vietnam as he also serves as the head of Cho Ray hospital. He told us that there were 15,000 applications annually for 450 spots which works out to an applicant:admission ratio of about 33:1 (in the US it’s about 10:1). We got a tour of nearby Cho Ray hospital, a 1,700 bed behemoth unlike any other hospital I’ve ever worked in or even been in. Anywhere. In Cho Ray, the census averages about three thousand which means that there’s quite a bit of bed-sharing. In addition, families help to take care of patients, adding to the mass of humanity and the sense of over-crowding. In fact, we saw two intubated patients in the ICU being bagged by family members. The ER was so crowded; it reminded me of a post-accident scene.

(We’re boarding so I’ll have to finish this later)

October 21, 2008. Return to Ho Chi Minh City

2008-10-23T17:44:00.000-07:00

Susan, Teddy and Cindy departed early this morning for the lovely, mysterious, and peaceful Ha Long Bay. Unfortunately I couldn’t make this leg of the trip because I was asked to fly to Saigon (oops, Ho Chi Minh City) to participate in a teaching program. Anthony Demaria and Charlie Shaeffer would give talks and I would follow with a live demonstration angioplasty/stent case.

While waiting in the hotel lobby for my ride to the airport, a Vietnamese woman in western dress sitting nearby asked me if I was enjoying my book. Every time I return to Vietnam I try to shore up my faltering language skills by reading Vietnamese fiction. Right now I’m laboring over a collection of short stories by Bao Ninh, a Northern Vietnamese war veteran from Hanoi whose characters and stories focus on the human impact of the war. We talked a bit about the writer and she told me that he was a close friend. She even offered to introduce me to him when I return to Hanoi. It turns out that she’s a published author as well. Although sightseeing can be educational and enjoyable, meeting and speaking with people is, for me, the best part of travelling and is a large part of why I find these medical trips so stimulating.

We arrived in HCMC in the late afternoon, fortunately before rush hour. Traffic was still difficult though and was made worse by all the road construction and sewage revamping. Despite the congestion, noise, and pollution, it still felt familiar and comfortable to be back in Saigon. The route from the airport to the hotel district took me by two places that we lived, the cathedral where my family had our secret rendezvous on the morning of our departure, the park that my friends and I used as a soccer field, the post office where my friends and I used to go to look for foreign stamps, etc… In fact from my 9th floor hotel room, I can see my mother's old law office and boys playing basketball in my old schoolyard.

The conference will be in the morning so I have the evening free to see some relatives and wander.

October 21, 2008: The Hanoi Athletic Club

2008-10-23T17:43:00.000-07:00

We got up early this morning to take a walk around the nearby lake. This is a favorite activity of mine in Hanoi, a real “must see.” The entire area – sidewalks, open squares, streets, lakeside paths – transforms itself into a gigantic sports club. Badminton matches abound with singles, doubles, and even triples on every available open space. The nets are supported by apparently delicately balanced bamboo poles held taut by thin cords anchored to spaces in the tiled sidewalks and courtyards. A small park across the street from the lake serves as the dance aerobics gym with about two to three hundred women gyrating as loudspeakers blare American oldies (…by the shores of Babylon…) overlaid with counting in Vietnamese (… hai, ba, bon, …). The street around the lake is used as a track by joggers and power walkers.

There are several aspects of this that are particularly fascinating to me. In marked contrast to the usual modesty in dress, the exercising men and women of Hanoi are fairly scantily clad. All are in shorts, many are in tank tops, and quite a few men are shirtless. All wear athletic footwear. This is remarkable because as a rule Vietnamese are very conservatively dressed. One only sees shorts, tank tops, or spaghetti straps on the western tourists. No matter how hot or humid, Vietnamese are invariably in long pants and often long- rather than short-sleeved shirts.

There is an overwhelming sense of community spirit. It seems like everyone is out there from callow youths to gray seniors. And everyone appears to be having a great time. Although I’m sure it happens, I can’t recall ever witnessing a heated argument about a line call in badminton or a hard foul in soccer. We are surrounded by smiles and laughter. It’s like a big street fair or a block party except that it happens every single morning. I’m incredibly envious on many levels: as a healthcare professional and especially one who deals with cardiovascular disease who is always trying to get patients to be more active; as a person who finds solitary and “non-game” exercise somewhat of a chore, even a bore; and as one who simply enjoys watching people having fun.

This all starts around 5 am and melts away well before 7. The exercising crowds start to thin, badminton racquets are put away, waves of motorcycles reclaim the streets like a tide coming in to wash away the walkers, and there is a crescendo of revving engines and honking horns as the aerobics tunes fade. I guess it’s time for a shower and breakfast. And nobody breakfasts like the Vietnamese. Just ask Charlie Shaeffer. But that’s a subject for another time.

2008-10-22T03:45:00.000-07:00

20 October, 2008: Day 2 of the Congress

I was scheduled to give two talks today. They went reasonably well although it’s hard to know how many people understood. I did get some good questions especially after the second talk (Anticoagulation for Acute Coronary Syndromes). For this Congress, speakers were asked to provide 2-3 talks of their choice and the organizing committee then created a program. Unfortunately, this ended up resulting in a lot of redundant talks. In fact, Franz van derWerf, editor-in-chief of the European Heart Journal gave the exact same talk as me just one hour earlier. I sat on the panel for his talk and he for mine. During my time at the conference I sat on three panels which allowed me to meet leading cardiologists from Indonesia, the Philippines, Malaysia, Singapore, and Belgium; all countries which I would very much like to visit.

I also finally got a chance to meet Prof. Vang Chu, the head of the Laotian Heart Institute that I missed in Vientiane last week. He’s in the process of creating a cardiology fellowship program and is quite interested in bringing us over to participate in a teaching program. He feels that language skills, especially English, will be very important for Laotian cardiologists. I can think of quite a few people from my days in Boston, San Francisco, Emory, and the desert that would bring a lot to this kind of a program.

In the evening we joined the other conference attendees at a “gala culture night” celebrating the Congress. There was song and dance competition amongst the different countries. I got to join the spirited Vietnamese delegation which was really fun but which might explain our finishing out of the medals. The Philippine contingent took first followed by Malaysia and Indonesia.

On to Ho Chi Minh City in the morning with Anthony Demaria and Charlie...

Day 1 of the Congress

2008-10-19T08:36:00.000-07:00

What a day!

I was picked up at the hotel at 7:15 to go over to Bach Mai hospital to do my live case. Returning to Bach Mai is always a thrill for me. I have so many powerful memories of this place. Bach Mai was partially destroyed in the bombing of 1972 and there is a very moving memorial in the front of the hospital dedicated to the patients, doctors, staff, and medical students who died at that time. Fresh flowers and incense can always be found placed in front of the memorial – these people are still remembered and mourned today.

Bach Mai is also home to so much of my work in Vietnam and with so many wonderful American colleagues and friends including Charlie Shaeffer, Barry Hackshaw, John Douglas, Eugene Braunwald, Thomas Bump, Sam Shubrooks, Thach Nguyen, Steve Oesterle, Steve Burstein, Bruce Macrum; the list goes on and on. Invariably these US-based physicians have remarked on the heartfelt warmth of their reception and the kindness of the Vietnamese people. They are surprised that the Vietnamese are so willing to put aside the memories of the destructive war. Yet these same physicians have all paid their own way and taken time away from their families and their work to volunteer their time and expertise to help these people on the other side of the world. And on the other side, the patients and doctors at Bach Mai have always appeared pleased and grateful for whatever we did, never expecting more than what we were capable of bringing, or questioning our motives. They are genuinely delighted to see us and have given me the impression that even apart from the work we do for them, that they just plain liked having us as friends. I think there’s a lot of goodness and mercy on both sides of the ocean. And so Bach Mai over the years has come to represent for me the best of my medical life…

When I got to Bach Mai I was pleased to be greeted by so many familiar faces. Although I must admit my pleasure at this reunion was tempered by anxiety regarding my live case. I reviewed the diagnostic angiogram a few more times which did nothing for my peace of mind. Total occlusion of the ostial left anterior descending, complete occlusion of the mid circumflex, poor left ventricular function with an EF of 20%. And I was supposed to do an intervention to the distal portion of a right coronary that looked liked Lombard street. On a Vietnamese VIP. With the cardiology congress of the Association of Southeast Asian Nations watching and an expert panel critiquing. To be fair, there were a number of reassuring factors. First of all, Bach Mai hospital actually more of the latest stents, wires, and balloons than we stock at Eisenhower. I guess they’re free of the FDA and hospital contract restrictions that limit our inventory. Secondly, I was working with a team that did much exactly the way I would: the same way of getting arterial access, the same five diagnostic viewing angles that I take, the same way of thinking of problems, the same philosophy of trying to minimize risk by keeping matters quick and simple. There are definitely advantages to working with people that one has helped to train! Thirdly (and maybe best of all), no matter how the case turned out I would not have to do any paperwork or dictating.

My assistant was Dr. Thai who makes me look like an old man. Really. A very large old man. Despite his youthful and dimunitive appearance, Thai is a hugely experienced interventionalist and I was quite pleased with this partnership. We decided, not surprisingly, to keep things as simple as possible but to be prepared for the worst. After placing a sheath in the right femoral artery, we did an aorto-ilio-femoral angiogram to make sure that the vessels would be suitable for placement of a balloon pump (a device to assist a failing heart) should one be necessary. A sheath was then placed on the left to be used in case of an emergency. We then repeated the diagnostic angiogram (for the benefit of the expert panel and viewing audience). The targeted right coronary artery was then engaged and we decided to place 2 coronary wires instead of just 1 to provide backup support. We decided to try to directly stent the vessel in order to minimize trauma to the vessel and shorten the duration of the procedure. Dr. Thai suggested a Noburi stent as an extremely flexible drug-coated stent that would be easy to deliver. To my immense relief the stent floated down easily.

Meanwhile, the expert panel and the audience, clearly saddened and disappointed with the lack of drama from what appeared to be such a promising case for blood, sweat, and tears, gave us grudging congratulations while trying to goad us into doing less essential and yet more risky lesions while we were there (frustrated Schadenfreude!). They reminded me of a Roman audience at the Coliseum all standing with their thumbs down. Happy to let them down, we finished up with a second stent and escaped with a very satisfactory angiographic result and a live VIP. The patient, who was wide awake during the whole procedure, assured us that he felt fine and had had no discomfort during the entire case. I changed back into my formal clothes for the conference, spoke with the family, posed for some pictures, and then ran out to catch a ride to the conference. Dr. Thai was still doing the case paperwork as I left. I love medicine in Vietnam.

At the conference (which it turns out has about 1700 attendees) I was able to catch most of a great lecture on the global burden of cardiovascular disease given by none other than Michael St. Louis, a high-ranking official from the Center for Disease Control in Atlanta, who also happens to be my brother-in-law. As luck would have it, I was seated right next to Charlie Shaeffer, one of my partners from Desert Cardiology who has so given so unselfishly to Vietnam over the past eight years. Charlie must have been Vietnamese in an earlier life: he starts every day in Vietnam with a jog followed by a bowl of pho (beef or chicken noodle soup).

Later that morning, I served on an “expert panel” where I got to critique someone else’s live case. Many of the other members of that panel were actually holdovers from the earlier group that had tortured me. Somewhat belatedly a number of them told me that I had done a “wonderful job with a terribly difficult case.” I bit my tongue and tried to be the inscrutable Asian.

After lunch I was interviewed by a very pretty Vietnamese reporter who wanted to know what I thought of the progress made by the Vietnamese cardiology community, how interventional cardiology in Hanoi compared to the cardiology in the US, etc… A true test of my language skills, I won’t know how I fared until I get the morning paper. If the police come knocking, I’ll know that I got a few words wrong. Or that my morning patient did poorly overnight.

Well, time to turn in. I’m giving both of my lectures tomorrow morning although I must say the pressure is off after seeing some of today’s performances.

October 18, 2008

2008-10-18T04:51:00.000-07:00

We arrived in Hanoi today from Luang Prabang. We’re in a completely different environment! Luang Prabang in Laos is a small, sleepy hill town with a population of 100,000 known for Buddhist temples, beautiful scenery, and refreshing mountain climate. The recently built Lao-Chinese provincial hospital is clean, spacious, and – at least while we were there – decidedly uncrowded. The airport is tiny and can only accommodate small planes. We only saw props (and not too many of those).

Hanoi on the other hand is now a sprawling metropolis of over 6 million people. The airport is modern and expansive. The streets are congested rivers of humanity with potential catastrophe everywhere. At least now motorcycle helmets (“insurance hats” is a direct translation) have become mandatory.

After checking in to our hotel, I took a taxi to the National Conference Center located clear on the other side of town. I will be performing a live angioplasty/stent case tomorrow and there was a meeting to select and assign the cases. That’s definitely a meeting that one doesn’t want to miss unless one relishes the idea of doing something crazy and difficult with a lot of cardiologists watching. The NCC, a brand new gigantic and beautiful complex which cost over $268 million US, is yet another symbol of the new Vietnam.

I found the meeting room and was warmly greeted by my dear friends Tuan and Thai. I’ve worked with both since my first trip back in 1997 and in fact Tuan and I were part of the team (along with Dr. John Douglas from Emory) that placed the 1st stent in Vietnam that year. Tuan and I share many special memories. Since 1997 we’ve travelled throughout Vietnam lecturing and performing coronary procedures. Tuan has been over to the US many times for conferences. He stayed with us a few years ago and visited Eisenhower. And he was with me when I got stranded in Washington, DC on 9/11. I remember Tuan, a survivor of the 1972 bombing of Hanoi, bringing quite a different perspective to that day as we stood by our hotel window watching the smoke rise from the Pentagon. I was with him in 2000 when his daughter was born (actually we were working together in Hue as she was being born in Hanoi). He even named her Anh which is the name of my oldest daughter. Tuan today is recognized as one of the leading interventionalists in southeast Asia and is a regular on the international lecture circuit. Thai is Tuan’s second; he is loyal, reliable, and a skilled interventionalist in his own right.

I was very happy to see another familiar face in the room. Aaron Kugelmass, MD is the head of the cardiac cath lab at Henry Ford in Detroit. Ari and I shared an apartment my first year at Harvard Medical. We were both intent on saving money and decided, rather than a room in Vanderbilt Hall which was the medical dorm, to rent a place in Mission Hills, an incredibly dangerous place a short walk from the medical campus.

Tuan presented the clinical history and angiograms of about 10 patients. All appeared extremely challenging, some prohibitively so. I was happy to have Ari, who has always been as blunt as he is bright, looking over these cases with me. Anyway, I somehow ended up with an elderly man with 2 out 3 coronary arteries (the LAD and circumflex) completely occluded and the sole remaining vessel (RCA) compromised by a critical lesion. To make matters even worse, this last vessel looks like a total minefield: extremely tortuous, filled with plaque with multiple significant lesions, and moderately calcified. As it turns out, the patient is somewhat of a VIP with important political connections. Tuan assigned me this case. Evidently they had requested me because of my long history of clinical work at Vietnam Heart Institute over the years. I have to say this case is a lousy reward. Not at all the kind that anyone would want to tackle in front of a panel of experts and a crowd of conference attendees...

15.Oct.08 Vientiane, Laos

2008-10-15T02:04:00.000-07:00

Earlier in this year I accepted an invitation from the Vietnam Heart Institute (VNI) to participate in the Association of Southeast Asian Nations (ASEAN) 17th Congress of Cardiology meeting to be held for the first time in Hanoi. I had worked with the VNI cardiologists at Hanoi's Bach Mai hospital many times dating back to my first trip back in 1997 and was eager to return to see my friends and colleagues again.

I decided to take this opportunity to visit Laos as well. Laos has always been somewhat of a mystery nation to me. Along with Vietnam and Cambodia, Laos was formerly part of French Indochina. Its' modern history has similarities to Vietnam: Laos was also severely impacted by the war in Vietnam and actually was bombed more heavily than Vietnam during that long and costly conflict; Laos became a communist nation in 1975 (several months after the Saigon government capitulated, ending the US-Vietnam war); and Laos has had a difficult struggle to rebuild itself politically and economically since '75.

However, unlike Vietnam, Laos is a relatively sparsely populated country with about 6 million compared to Vietnam's 84 million and the Laotian capital of Vientiane has only about six hundred thousand (Hanoi and Ho Chi Minh City boast about 4 and 6 million respectively). Economic development has lagged behind that of other southeast Asian nations with more poverty, worse living conditions, less industry, and more limited infrastructure and technology.

Anyway, given the fact that Laos remains underdeveloped economically, I was curious about the current state of health care, and specifically cardiac care in this country. Fortunately I was able to talk my wife Susan and our friends Teddy and Cindy Berenson into taking this "detour" to the Laotian cities of Vientiane and Luang Prabang prior to going to Hanoi.

We arrived in Vientiane yesterday midday via a smallish prop plane from Bangkok. The small airport reminded me a bit of our compact Palm Springs airport, quite a change from our embarkation point (the ultramodern and gigantic Suvarnabhumi airport) in Bangkok.

Unbeknownst to us, we had arrived right in the midst of the Awk Phansaa festival celebrating the end of the three month Buddhist lent. We could see, smell, and hear firecrackers and fireworks. Crowds of people milled along the banks of the Mekong river where numerous food vendors sold all kinds of exotic (for us) wares including whole grilled fish, pork, chicken, and duck; bamboo tubes filled with sticky rice; a variety of fried meats; dumplings; duck eggs; etc. It reminded me of the food vendors in the Sapa hill region of north Vietnam. Many sold beautifully crafted banana-leaf and bamboo boats filled with flowers and candles to be lit and released on the river.

This morning we visited several Buddhist monuments and temples. We drove down the Lane Xang boulevard in Vientiane modeled in a very limited way after the Champs Elysees. Vientiane’s version of the Arc de Triomphe is the Patouxay (Victory Gate) monument which compensates for lack of grace with tremendously refreshing candor, “From a closer distance, it looks even less impressive, like a monster of concrete” boldly proclaims a sign on the wall.

The highlight of the morning’s explorations for all of us was a visit to the local food market. Filled with hundreds of stalls, the market sprawled over about 3 blocks. My daughter Mai would have been fascinated by the pyramids of dragonfruit which she learned to love on her first trip to Vietnam eight years ago. The seafood stalls impressed us with the technology (hose bubblers pumping into vats), cleanliness, and surprising lack of smell – a sure sign of freshness I’m told. I only got a bit queasy when I looked into the thick dark liquid in the large vats of fermenting fish. The way the chicken and ducks were laid out with their feet extended made me think that they all died of fright.

This afternoon I went to visit the Mahosot Hospital, home to the Lao-Luxembourg Heart Institute. I had been given the name of Prof. Vang Chu, section chief of Cardiology, and he had arranged for me to come by the Institute. Unfortunately, these plans were made some time ago and apparently he had forgotten about the Buddhist holidays. Nevertheless I received quite a nice tour of the Institute by Dr. Tomkham in limited but courageous English. The Institute is extremely clean and bright. One enters into a large atrium with a seating area. A long hallway leads on the left to an outpatient clinic, an echo room (with 2 machines and the capability to do transesophageal studies), an ECG room, and the offices of Dr. Vang Chu and a few other cardiologists. On the right, the hallway takes one by a number of patient rooms which also seemed large, bright, and clean. At end of the hallway is a 4-bed combined neuro-cardiac intensive care unit. The ICU appeared to be the only air-conditioned suite. All 4 beds were occupied; the first had a woman with unstable angina, the second, a young man on a ventilator with a CNS hemorrhage; the third, a man in congestive heart failure; and the last a middle-aged man who had presented with a myocardial infarction. I saw many nurses but the only doctor there was the friendly Dr. Tomkham.

The second floor is for the cardiac surgery service. There are rooms for pre- and post-operative patients as well as the operating rooms. I was told that a team of French heart surgeons were there operating. Interestingly, although there is a cardiac surgery program in place, they do not have the capability to do coronary angiography or angioplasty/stent procedures.

All in all, the hospital visit was interesting but quite limited by the language barrier. Although I was unable to meet with any other cardiologists today, I might have an opportunity to do so later during this trip since ten will be attending the ASEAN conference in Hanoi. Perhaps I will get a chance to get more information regarding the current state of cardiology in Laos yet.

Anyway, tomorrow we leave for Luang Prabang.