Author: Sarah Painter

The ICU was full each day we visited, with what seemed to be an entirely different group of patients. It appeared that patients declared themselves quickly, in one way or another. During our time, there was only a small number of patients who remained in the ICU for more than a few days. Health insurance in Vietnam exists, however only for the young, the elderly, or those with money. For the rest, they must pay for treatment, which can be too expensive for some families. I couldn’t imagine making a decision to withdraw care based on how much a family could afford, which was a reality for many of the families we saw in the ICU.

The ward was busy with patients overflowing into the hallway.  Despite being crowded it was not chaotic.  In fact, the ward was very quiet with patients either sleeping or resting and there was very little talking.  Nurses were busy administering medications and many patients had family members at their bedsides providing personal care. There was mold on the walls and ceiling, water dripping being collected into buckets and no evidence of a bathroom or shower for the patients.  Hand hygiene was essentially non-existent and patients receiving chemotherapy were in communal rooms with others admitted with infections. Despite being run down, the floors were clean and there was no odor. 

In 2005 Vietnam’s Ministry of Health launched a palliative care initiative that worked to increase accessibility to morphine and create a one-week and three-month training course in palliative care.  However, a long term plan for the implantation of palliative care with ongoing advocacy and education around opioids along with sustainable training programs has yet to be established. The need for palliative care with collaboration between hospital and community services has been identified but not yet addressed.  For the time being, death and dying in the province of An Giang will remain in the domain of family; a non-medicalized natural event in everyone’s life cycle.  I just worry that without a palliative approach the days/weeks/months leading up death aren’t being addressed, which I personally feel represents a large gap in patient care. We are fortunate to be at the receiving end of a Canadian health care system. There is no doubt that the physicians I worked with in An Giang are eager to learn new skills and knowledge and this gives me hope that palliative care will gain traction to become a standard of care for patients in the near future in Vietnam.

So this is where I was coming to visit again. The sewer trough was now covered by metal sheets, and so I was spared its smell in the air. The doctor I was working with apologized for the A/C not working. The heat never bothered me (my blood is Mediterranean after all), but it is possible the heat could affect the patients.  We started walking through the beds of the PICU, the physician explaining the diagnosis for each child: meningitis in one toddler; diarrhea in an infant; hypertension of undiagnosed etiology in a young teenager who was to be sent to Ho Chi Minh City in the next couple of days for further work up. He came in to hospital with headaches, and was admitted several times in the past for the same thing. There are only two monitors beeping away in this PICU. The nurses do not position themselves at the bedside but at the nursing desk. There are one or two babies on nasal prong cpap. Two ex 28-weeker twins, now 32 days old, are the last patients we see. They managed to get off CPAP and oxygen and are managing oral feeding too – two cute little babies, lying still under their blanket looking adorable in their toques; mama and grandma standing by on guard to meet their every need. These babies were lucky. I learn there are 3 ventilators in the unit, but one is not working. Two ventilators, looking a bit old but working, and that’s all that matters. The defibrillator looks pretty old too, but it works.  They will be getting 2 more ventilators from the adult ICU stock of ventilators.

The will is definitely here. 

After lots of hand gesturing and group handling of the leader role (what else would you expect from 5 to 8 doctors all trying to run a sim case? :), the case ends successfully. And then my favourite part: the smiles, the clapping that is the applause for a job well done, and the mutual appreciation of what was just shared, what was just understood from both sides.  Because of the language barrier, the smiles we share have so much meaning. Respect and appreciation. We are moving forward, together.

During one of the first mornings we were here, I had an opportunity to tour the hospital with some colleagues and obtain a bit more perspective of local practice.  Their OR facilities are on the second floor and situated on the opposite side of the campus from the labour floor.  All the caesarean sections are performed in the OR, as there is no OR attached to the labour floor.   During our tour, a baby could be heard crying down the hall, fresh from the womb.  Continuing our journey across the campus, we eventually made it to the OB emergency/delivery area.  It is a very humble facility where deliveries occur in a communal delivery room with 5 or 6 birth tables facilitating lithotomy position.   A surprising sound for me was to hear the familiar “Thumping” of a fetal heart rate monitor.  I was definitely not expecting to hear that comforting sound or to see the two women who were actively labouring being attached to monitors.  Their labour room is definitely a change from home, where nurses are usually abundant, an OR is down the hall and the luxury of anaesthesia is merely a phone call away.  It is very difficult, and almost guilt-inducing in a way, to explain the luxuries we have at home when comparing the two facilities.  The concept of a crash C/S is definitely a foreign concept as the woman would need to be transported from one side of campus to another on a rickety metal stretcher (similar to an OR table,) a decent 10 min transit time.    On their antepartum unit, the ticking of another fetal heart greets us as a woman with severe preeclampsia at 25wks is resting in bed.  I did try to learn what her clinical course/plan would be and was unable to get a clear answer.  She was being treated with methyldopa, but that is the best I could elicit.  I am very uncertain how her case would be managed as she is quite preterm and the neonatal facilities are very limited at best with the age of viability being around 28 weeks.    

Coming to the end of the mission, I have been able to build up some relationships with the OBGYN department.  Today has been highlighted by some opportunities to attend the department’s OR and a local private hospital.   Getting ready to attend a semi-urgent caesarean section was a bit of a comedy.  I am learning that I am a bit taller and bigger in the hips than most Vietnamese women.  We ended up going through a few scrub changes to find some that “fit”.  In addition, the pants were more of a Capri as they ended halfway down my calf.  Seems as though the problem of “expecting a flood” persists here too.  We needed to change our shoes to dark blue Crocs to walk from the change rooms to the OR rooms.  At this point, we needed to change our shoes again to light blue Crocs.  It definitely showcases their efforts to maintain a sterile environment within the surgical corridor.  I was impressed that they let me wear my own personal scrub cap instead of the bright, green cloth ones provided.   Within the corridor, there were several OBGYN staff milling around.  I felt like I was a bit of an anomaly or possible celebrity as the students I had been teaching all week were following me around with Dr. Hieng.  In the first OR we visited, they were finishing a surgery to remove a large renal stone from the renal pelvis which was causing bad pyelonephritis.   You know it is a bad situation when the gynecologist can see the stone on an old school abdominal x-ray.   From this OR, we moved to the C/S.  It was remarkable to see how many similarities exist between here and home.  The best I could figure was that she was having her C/S due to being 38yrs old (old in their minds), being term, and having ruptured membranes for 6+hrs.  It appears that no efforts are made to try and induce labour here.  Anaesthesia used spinal anaesthetic for her surgery; unfortunately I was unable to see the drug choices used.  Once it was complete, she was placed in the supine position without a left lateral tilt.   When I asked about a wedge, it seemed to start a buzz in the OR and perhaps it is a normal practice that was forgotten or a new, novel idea.  The remainder of the case was very similar to home, but their instrument tray consisted of significantly fewer instrument choices.  There were no Kochers or Green Armitages, but it mainly consisted of Kelly clamps, haemostats or Snaps, a pair of Debakey pickups, a needle driver and one pair of Mayo scissors.  They do not perform a bladder flap and were quite concerned about bleeding, which is their reasoning for not performing it.  Entry into the uterus was very similar, with the baby crying shortly after delivery.  I didn’t even think to look if it was a boy or a girl.  A significant difference here is the lack of a partner in the room to support the mother or having the mother and child reunited for skin-to-skin after delivery.   Once the cord was cut, the child was whisked away by the circulating nurse.   It was interesting to watch as they closed the uterus and incisions.  They did do a two-layer closure on the uterus and were concerned about closing the serosa.  Additionally, there seemed to be limited concern for the bladder.  They were quite adamant about closing the peritoneum and re-approximating the rectus abdominus.  The fascia was closed in a similar fashion.  They re-approximated the scarpa’s and subcuticular adipose tissue.  The most interesting thing I noticed from today was how all ties were instrumental and very rarely do they perform any hand ties.   Additionally, the surgeon would place the sutures but the assist or scrub nurse would perform the ties and they would always use a Debakey or snap to hold the knot during the process.  I am uncertain why they perform their knots in such a fashion.  I think it may be for suture conservation or perhaps for personal safety, as everyone was wearing either glasses or safety glasses.  Their skin closure used a synthetic, monofilament suture similar to biosyn or monocryl with a subcuticular stitch; however, the knots were always placed above the skin and not hidden like I would do at home.  Skin prep consisted of being washed with soap and water, followed by an iodine prep.  It was good to see that they did use the iodine to prep the vagina as well.  Monitoring was limited, with mainly an automated BP cuff and O2 sat probe.  There was no electronic monitoring of the heart rhythms.  A new technology experience I had was how the surgeon, Dr. Ttuc, continued to wear his Bluetooth ear piece throughout the surgery.  Fortunately, his phone did not go off during the case, but I am uncertain how this would have been managed intraop.  Throughout the surgery, Dr. Hieng would regularly ask me questions about how the procedure in Canada compared to their procedure.  I was quite impressed by how similar their technique is compared to home.

The labour floor has a dedicated holding area for anaesthesia and they have four available ORs for the labour floor.  The doors are hermetically sealed with sliding doors, a digital clock with distinct red lights and a temperature monitor is placed at the top of the wall, similar to home.   I think the ORs were even bigger than the ORs I use at home allowing the team members to easily move around.

Overall, the trip has been very insightful and rewarding.  Areas I thought I would contribute to became disappointments.  I would experience unexpected, rewarding surprises from observing the learners.  I had an opportunity to see how my Masters could be applicable in the future as an education consultant, which was a new discovery for me.  I am very happy I went and look forward to seeing where my new perspectives take me.

By: Aaron Webb (partnered with Dave Easton)

I have to say that this mission has been very different from my two prior missions to Africa.  One: the team has been amazing, creating a very supportive environment for troubleshooting and problem solving.  Two: being part of an education-based mission has been quite eye opening.

My second presentation and my simulation scenario addressed postpartum hemorrhage and preeclampsia.  These topics highlighted another area of confusion, namely their local practice consists of giving oxytocin 10 IU IM and misoprostol 600 to 1000mcg SL as a prophylactic treatment to actively manage the third stage.  It appears from the stories I am told that about 5 years ago a patient received a 5 IU bolus of oxytocin IV which resulted in profound hypotension, prompting a change in practice within the hospital. I am quite surprised by this change in practice and was shocked that they are looking towards me to provide an answer and almost endorse that a 5 IU IV bolus is OK, or that if they mix the 5 IU in 5mL of NS and give it slowly, that is… an adequate dose.   These brief conversations that are parsed together with broken, simple English have started to show me that there can be a distinct difference between academic/book knowledge and practical or actual practice.  Unfortunately, I have had very little opportunity to see or experience their clinical practice.

The teaching goes both ways, though. We’ve been humbled by the hospital staff’s willingness to include us in their rounds about patients they are managing. Despite our obvious language barriers as Canadians, we have been treated with great respect when we try to understand or join in a medical discussion. It has taught us the true meaning of collegial professionalism and hosting.

The hospital staff have a wide range of cases. Their beds are full and their workload busy. Their resources must be doled out carefully to where the need is greatest and the greatest good can be achieved. It is a difficult job they do, much more difficult than what we are used to in Canada. They do it with great grace, however. Each family we have come across in our patient discussions is treated with respect and dignity despite the limited space and resources.

In medicine, this is learned and extremely different from the traditional approach. In Canada, we have the benefit of robust resources and access to education allowing for the uptake of this type of practice.   During a demonstration of CPR, we had inquired as to the normal approach from the hospital and were informed that they follow these standards and use a team approach. Lisa and I were assigned to the Advanced Cardiac Life Support station – which takes CPR/defibrillation and introduces advanced functions such as airway management and medications. 

What we quickly discovered in the skill station, was that there was an opportunity to improve this area. We often enter these situations with a preconceived notion of what we can anticipate. I had expected a team approach that we have become accustomed in tertiary centres at home. But even introducing this structure at our own hospitals at home has been difficult. It takes time and focus to implement this practice. Teams do not practice this way by accident. You have to learn. So once we realized that this would be a great area of focus, we found a way to incorporate it into our symposium.

Everyday after lunch, we would gather the participants (including those video-conferenced in) at the front of the room and focus on a new area. First, the CHKV team members did a demonstration of an ACLS code. The next day, we focused on a trauma patient. The next day, we did a pediatric case. All of the cases included a team leader and team members modelling good communication strategies and an organized systematic approach. 

Once participants were more aware and comfortable, we encouraged them to participate in supported way and provided feedback as the cases progressed. By the end of the week, we could see the participants developing new skills  that they could incorporate in their practice. As with every new approach, it takes time for practice to evolve in the complex world of in-hospital care. However, we were able to give them essential building blocks and introduce the concept of effective team strategies.

Aaron stirs up action. We’ve all got bruised shins from joining him in the bumper cars. He’s also part of the crew who won the kayak race and the three-legged race with Joanna. We suspect that he cheats a lot, considering he’s always winning things. We almost lost Aaron when he decided on an impromptu beer run during a traffic road block. We got him back, though, much to the group’s relief.    

Anne started the whole group reading a book called “Turning Breath into Air.” It’s a book about a neurosurgery resident that dies of lung cancer. It’s been a bonding experience to read the same words and discuss the commonality of residency and death. As a counterpoint, Anne is usually in the middle of anything with laughter involved. She’s a great seatmate in any long-hours van trip, regaling the crowd with stories of her family and crazy new dog. She has a soft heart and we are suspicious that her carry-on to home will contain all the stray pups we’ve come across.    

Hareishun has the best pirate head coverings, mostly in camouflage pattern. Don’t know what you call them… a babushka is what Dave suggests I say. He can eat. Man, can that guy eat. If there’s left over meals, it’s automatically assumed we should give it to Hareishun. He is one of the jogging crew, and has a soft heart for the pups he sees on the runs.    

Our next stop is the obstetrical area. Our team includes an Obstetrician – Stephanie Johnston – and she is eager to see where this work takes place. At this point, I depart from the group as I needed to prepare for my presentation. Fear not dear followers – there will be many more reflections on the hospital in coming entries. 

I watched as Gabriel, a handsome boy just two years of age, came face to face with sick children his own age to learn the virtues of generosity and kindness. He will grow up to be just like his parents and grandparents, no doubt.

But little did we know there was something much bigger in store…