Through the looking glass... - By Sarah Painter

The sunlight peeked through the curtains of my hotel window. Daytime had returned to Long Xuyen. I laid in bed undecided for a moment. Although we are now inextricably engaged in our free fall, there is still a subtle impulse in my mind to retreat. Each day unpredictable; bringing new challenges that cannot be identified or planned for. I contemplated how the day might unfold as I simultaneously attempted to will myself from the security of the hotel bed. Whether ready or not, the moment had arrived. 

With day one under our belts there was a new sense of comfort that I felt returning to the hospital. It was less unknown to me now. I have always taken solace in the fact that if you can survive day one of anything, then day two should theoretically be within your realm of capability. I showered and prepared for what would be our first official full day of teaching. Although I found myself more at ease than yesterday, there was a sense in the back of my mind that our experience would be completely different today. Instead of just standing in front of the mirror - this reflection of ourselves and how we perceive what we see - today we would peer through it. An opportunity to gain real perspective on the day-to-day world as it exists in the An Giang hospital.

Armed with learnings from the previous day’s lectures, we returned to the hospital. Small clusters of participants were hovering around the various skills stations that had been constructed the day before. Their inquisitiveness was evident as they sheepishly admired the various props, instruments, and machinery that covered each table: untenably curious but too cautious to explore further. I smiled as I watched them carefully peruse the stations. All would be revealed in due time.

Our morning started with Hareishun delivering a lecture on Pediatric Advanced Life Support and was followed by Stasa, who would present on the topic of pediatric sepsis. We were aware of the presence of many Pediatric physicians both in the physical audience and also by Telehealth. These presentations were undoubtedly highly anticipated.

One of the internal dialogues that took place within our team following yesterday’s presentations was that it was very difficult to get a sense of the crowd. Of course lecture always has this inherent challenge, however it was identified that many of us had questions about the way the hospital functioned and what types of resources were at practitioners’ disposal. Chau arranged a guided tour for Aaron, Joanna, Stephanie, Lisa, and myself during the pediatric lectures. It was a golden opportunity to gain perspective on the clinical environment before the afternoon started.    

We traveled from outpatient to inpatient areas with a physician who spoke some English. Communication was not easy, but our appetite to learn was insatiable. There was so much to grasp here. We visited some outpatient clinic areas and were subsequently escorted to the front of the hospital. An enormous crowd of people congested the seats in front of the registration area. There was overflow to the hallways and the outside of the building. I noticed a tall wooden sign commanding attention from the adjacent wall. It is a menu of procedures, diagnostics, and services with corresponding prices. Money is to be received first before care will occur. A social net of sorts catches the very poor; at what threshold of poverty and degree of coverage I am uncertain. Otherwise payment is out of pocket unless one is fortunate enough to afford or be eligible for insurance. Many of the same issues exist here as the US; including ineligibility if already ill. I imagine there is a large demographic that is not poor enough to qualify for basic government coverage but too poor to afford insurance and certainly not able to pay hospital bills without selling property and sinking deeper into the cycle of destitution. Medicine is not provided. If pharmaceuticals are required, the family takes the prescription to the pharmacy, fills it, and returns to the unit. Many medications are even administered by family. If you cannot afford it, you will not receive it. Food is not provided. Family presence is a constant as they provide much of the minute-to-minute physical care. I stare at the menu of prices and contemplate the complexities of the system. When we know illness is so intimately connected to poverty, how can so many disenfranchised people who need care the most receive it? The challenge for access here seems insurmountable for what I suspect is a significant portion of the population. I think of the many blessings of the Canadian health care system as we travel to our next stop. Even with all of the trials we face, our privilege of access to health care based on need and not ability to pay has never been so cherished in my heart. 

On our way to the ICU, we walked by an indoor area. Military style cots and mats were densely strewn all over the room. People scattered about; some lying lifelessly on the floor, others seated in solitude. There were illustrated educational posters on walls overtop peeling paint, no doubt the result of decades of relentless muggy heat. This is an area for family, we are told. A thick cloud of despair was suspended in the heavy, humid air. I could feel my heart sinking in my chest. 

We are led down a hallway and brought to a staging area outside of the ICU. No double HEPA filter doorways. No appealing table of hand sanitizer and mask with polite signage requesting due caution when visiting patients. We are cued to remove our own footwear. White plastic slip-on mules are offered to the group. Our new shoes carry us into the unit. I stand quietly and absorb my surroundings.

Twelve beds are packed tightly in this small room. There are no curtains here, no partitions. The heat is sweltering despite the fans and family members attempting to cool their loved ones with paper or other items. Compressible plastic bottles hang from the ceiling with IV tubing connected to arms. The hum of ventilators and the staccato of intubated bellies accent the room. People are looking up from their cots, interested in our presence. Despite the extraordinary humidity and human congestion in this space, we are all impressed. There is no odor, no mildew. The effort that is dedicated to keeping this space as clean as possible does not go unnoticed. We tour around and get a sense of what resources and capabilities are offered in this area. There are ten ventilators of various denomination, monitors (although not for every patient), dialysis, and many familiar medications. The hard work of the physicians and nurses is evident here. Despite insurmountable odds, they provide care as best as they are able within the walls of this 100-year-old building.

We briefly peek our heads into the surgical area. The post-op beds are mostly empty as the operating theatres are sterilized and not accepting curious visitors at this time. We drifted back down the stairs to visit the emergency area. Three of us in the group have emerg backgrounds and are keenly interested. We are delivered to a small room where naked metal gurneys are packed tightly. The sick are resting atop the cold, unforgiving surfaces. There are no monitors or defibrillators. In Vietnam the ER is used as a master triage area. Anyone requiring resuscitation or critical care intervention is carted to the intensive care unit. Otherwise there seems to be a method to sort all of these patients out and distribute them to various units, although what it is I cannot say. A few diagnostic machines are available such as an ultrasound and EKG that I presume produces 12 leads. A few people have IVs in situ that have likely been initiated here. There is so much here to discover however we are not always communicating with superb accuracy with the staff physicians and translators. Chau and Dr. Trung have plans to develop the emergency program here and Lisa Bryski will be presenting, in the coming days, on the history of the Emergency Medicine in the world and key concepts for developing a program. There is a great opportunity for advancements in this area and it is exciting to know that dialogue is already underway.

Our next stop is the pediatric intensive care unit. We are once again prompted to don white plastic shoes prior to being granted entry. There are about ten patients in this area. The oldest appears to be a toddler. However, in the mix are three or four premature infants. Some weigh only a few pounds, resting on their backs bundled in blankets, tiny nasal prongs taped to their miniature hats. We inquire about the age of the tiniest little one and discover that all were born at about 30 weeks’ gestation. There is no cardiac monitor for this tiniest babe as there is only one in this unit. Each bedside has a stool with a family member. Many appear to be mothers and grandmothers; seated at the bedside at all times, worried and waiting for the infants to get better. It is not clear what happens to babies that become orphaned by families who are unable to pay for lengthy and expensive stays in this area.

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 returned early to deliver my presentation. My topic is Basic Life Support and I’m planning to cover CPR, rescue breathing, and obstructed airway sequences highlighting the 2015 updates. Past experience has taught me that explaining critical elements such as high quality compressions, switching compressors, and minimizing interruptions are items that are better demonstrated than explained. Initially, I had considered asking audience members to come up and we would walk through a demonstration. The more I contemplated this, the more apparent it became that this plan would be far too unpredictable and potentially make participants uncomfortable. We determined as a group that the best approach would be to have CHKV members come to the front to show the team process. After I described the sequence, we announced our plan to the audience. It was incredible to see the response; Participants rising to their feet, cameras out attempting to film our little skit. We resumed our seats and I continued the presentation. By the end, I asked the crowd what a typical hospital response would look like. After a lengthy pause, a physician rose to his feet to comment that their team is comprised of physicians and nurses, and the BLS and ACLS processes are followed. Our team left the lecture considering what we could do to improve this process if it’s already in place.

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Before we broke for lunch, we had a special mission. Gabriel attends Making Roots Montessori School and his class had collected new toys and clothes to distribute to the hospitalized children in An Giang. The goal of his project was to show the children in his class what it feels like to give to other underprivileged children in need. The pediatric intensive care was our first stop and then we moved on to other areas in the hospital where children are found.

Gabriel and team members offered small gifts, one by one, to these ailing little ones - an incredibly humbling experience. These families living the nightmare of a sick child in an ICU in Vietnam; the financial and emotional strain nearly unimaginable. How frustrating to offer nothing more than a toy. But in a way it was something… a simple act of kindness demonstrating that their suffering weighed on our hearts and minds.

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.

We dashed away for another expedited lunch as our skill stations would begin at 1:30 p.m. sharp. Upon our return, we moved into team formation and completed any finishing touches requiring our attention. Armed with meticulous plans, we were ready for the onslaught. However, what would happen to us this afternoon was very much a mystery. A few of us had remarked that it would be best to remain flexible and open to the unknown. Nothing could have prepared us for the tsunami that was bound for our unsuspecting team.

 

After everyone had returned to the auditorium a brief attempt was made to organize people into groups and communicate the process for rotation. To describe what happened next as a “free for all” would only scratch the surface. The entire afternoon was nearly riotesque in nature. Completely disproportioned groups assembled en masse to whatever station grabbed their interest despite the instructions. Translators mysteriously disappeared, swept away in a sea of irresistible curiosity driven by the wonders in store at stations to which they had not been assigned. Participants drifted in and out of stations as they saw fit, as though they were at a trade show window-shopping for what was most exciting to them on a moment-to-moment basis.

Team leaders at stations saw a variety of performances. The crowd was often an unknown mix. Many participants landed initially at the station that best suited their specialty. However, certain groups offered a diverse blend of physicians - seasoned and freshly-trained, with backgrounds specific to adult, pediatrics, and obstetrics.

Lisa and I had prepared numerous cases for our ACLS station. We had an overwhelming number of people flock to our area, perhaps fifteen instead of the four we had planned. Based on the mixed bag of participants, we decided to change our approach and start with a more basic case. We designated a team leader and a small group, and fed them instructions on the case through our translator.

As we would in Canada, we waited for the group process to unfold. An awkward period takes place, everyone looking at each other waiting for the other person to make the first move. It suddenly dawns on us that the process is unclear. Lisa and I abandon our plans and direct each person through the sequence. We had not anticipated this in our planning. This process in fact is completely foreign to them. How foolish of us to plan to teach assuming that education here is administered in the same method as at home. It suddenly became clear to us that our role over the next week will be to start from scratch.

The calamity of the afternoon thankfully drew to a close at 1600 hrs. I glanced around the room and sought out a few of my colleagues. We shared the common appearance of having aged ten years in about three hours. A cold beer on the rooftop was in order STAT.

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