Thoughts from Vietnam
By: Anne Sutherland
Walking into the
hospital in Long Xuyen was a different experience than walking into a hospital
in Winnipeg. The open-air hallways were crowded with seats for waiting patients
who looked over our group with curiosity.
The emergency
department was a small room packed with stretchers. People lay directly on the
cold metal, with not a mattress, pillow, or blanket in sight. It seemed to lend
a sense of urgency to each patient - there was no time for comfort; people
are sick! At one end of the room were a series of desks where the emergency
staff tended to paperwork. I wondered to myself what their triage system was,
as I never saw a tracking board of the patients currently being treated or
waiting to be seen. Even without a visible system, patients were seen quickly
as they walked in or were carried by family. Vitals were taken along with a
brief history and physical exam. The staff moved around us in order to get tasks
completed. We were visitors in their house.
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.
General Tour
On our second day of the mission,
Hareishun, Stasa, and I were taken on a tour by one of the physicians. Our tour
of the hospital included the outpatient clinic department, the pediatric wards
& ICU, the emergency department, adult ICU, stroke ward, tuberculosis ward,
pre-operative holding room, operating theatres, and post-operative ward. I was
struck by how large the hospital was.
The multiple buildings seemed to be
bursting at the seams with patients and families. Patients on stretchers in hallways were
accompanied by multiple family members, many of whom seemed to be carrying
thermoses and bags of cooked food. It struck me that this was not much
different than the hallway medicine that many hospitals in Winnipeg have been
struggling to rectify for many years. This was coupled with the knowledge that
the residents of Long Xuyen had a brand new hospital that would soon be
operational - set to open the week after our team would be leaving. The next
CHKV mission will be able to see the new hospital in full swing.
Speaking
with the members of the previous mission in 2011, most have remarked that much
has changed in Long Xuyen since that time. More people, new buildings, and more
businesses line the streets of the city. It will be interesting to see how much
will have changed between 2016 and the next mission. I can only imagine how
much more the city will have progressed, let alone the delivery of health care
in the brand new hospital.
Intensive Care Unit
By: Dave Easton
I look forward to the next "family"
reunion!
By: Dave Easton
Looking back at what was my second visit to
Vietnam and An Giang General Hospital, I was reminded about how warm and
friendly the Vietnamese people are. I
felt like I was kind of coming back home and being reunited with my extended
family. People are people no matter
where you go in the World. The ICU team
do their best with limited resources that make us from North America cringe at
the thought of not being able to provide the kind of care and interventions we
are used to in our day to day practices, yet they make it all work. You can always learn from others, and one
thing that stands out in the health care system is the importance of family in
all aspects of care. We are just now in
North America focusing on patient and family centred care, but we could learn a
few things about how family can help care for patients as they do in Vietnam.
Palliative Care in An Giang Hospital
By: Joanna Webb
By: Joanna Webb
I felt fortunate to be presented with the
opportunity to join the 2016 CHKV medical mission, although I was very aware
that I lack the acute care skills that the majority of my colleagues have. Being married to an emergency medicine
resident was my ticket in, but I worried about what I, with my background as a
family physician who also works in palliative care, could bring to the
table. The offer of a palliative care
lecture was declined during the needs assessment with our receiving team, so
instead I focused on women’s health, another area of personal interest and one
which was in high demand.
On the second day of our conference a small
group was taken on a tour of the hospital.
On that tour, we came across the oncology ward that I recognized would
be the closest I would come to finding a palliative care unit. I had the opportunity to return to the ward
with Christian La Rivière, a fellow palliative care physician, along with a
translator on two subsequent occasions and have been able to develop a bit of
understanding of palliative care, or the lack of it, in Vietnam.
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.
There was one oncologist managing the ward
comprised of roughly 35 patients. He
came across as busy and overworked. His
day consists of rounding on his patients in the morning, followed by admitting
and charting on new admissions, ordering and reviewing tests and creating
management plans. It appeared that
patients were either sent from emergency or outpatient clinics with a presumed diagnosis
of cancer that needed work-up, were receiving chemotherapy or were admitted for
symptom management. It seemed as if
patients went home if work-up was complete and no further interventions could
be offered, if symptoms improved, or if patients ran out of money and could no
longer afford to be in hospital. He
emphasized that patients didn’t want to die in hospital so if end of life was
near they would go home to die.
The cultural differences in patient care
were acutely apparent when we joined the oncologist on morning rounds. There was essentially no dialogue between
physician and patient; no discussion of results or management plans. To be fair, these discussions may occur later
on in the day once rounds are over but I suspect medicine remains very
paternalistic where the doctor decides and the patient follows suit. Objective
findings such as bleeding or vomiting were treated with blood transfusions and
nasogastric tubes but subjective symptoms, such as pain or nausea, were not
addressed. If a patient were to mention
a symptom it was glossed over and seemingly not treated. Despite the lack of apparent symptom
management all the patients appeared comfortable and not overtly
distressed. No one was grimacing with
pain, working hard to breath or obviously delirious. Perhaps the culture here is to suffer in
silence.
The majority of patients on the ward had
widespread cancer that is not curable.
Back in Winnipeg these patients would be enrolled in the palliative care
program, gaining access to homecare, nursing and physician support at home. If symptoms or patient care were to become
unmanageable, admission to a designated palliative care unit could be
arranged. No such services are available
in An Giang, however this is the norm with no expectation for comprehensive
palliative care. Patients want to die at
home and palliation during the final days of life is the responsibility of
family.
I got the sense that palliative care is
seen as the management of patients who are actively dying, rather than a
philosophy to be introduced earlier on in the disease trajectory. With family members caring for patients as
they die out of hospital I felt there was the impression that palliative care
was not a needed medical subspecialty. I
would argue that nearly all the patients on the oncology ward would have
benefited from palliative care – to fully explore and manage symptoms and to
discuss prognosis and goals of care.
True, access to resources is limited compared to Canada but they are not
non-existent. I came away with the
impression that a lot could be taught surrounding a clinical approach to pain,
trouble breathing, nausea and delirium, as well as patient centered
conversations at the bedside. However, I
wonder if the desire to expand this skill set is currently present.
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.
Pediatric Intensive Care Unit
By: Stasa Veroukis
I have had quite a few people ask me about
my trip, so I thought I would share something I wrote while in Vietnam, and I
believe will be shared on the CHKV blog. It was written in one sitting; it's a
little off the cuff. Writing was never my forte, so apologies in advance if my
grammar is off.
The PICU in Winnipeg is my second home;
well, actually sometimes it feels like my home. I can feel that comfortable in
the PICU and the people I work with feel like family. I have flown thousands of
kilometres to the city of Long Xuyen in Vietnam, for a medical mission with the
organization CHKV. This is my second
time here. I have seen the PICU of An Giang Hospital before. I remember walking through it with the other
doctors and nurses who travelled with me in 2011. It is a room roughly 30 by 40 feet. There is
no way to isolate patients from each other; it is one big open room. There are
roughly 12 beds and about 6 beds for neonates. There was a sewer trough passing
several feet in front of the main entrance. Every morning I was greeted with a
waft of sewer smelling air. Inside, no
A/C, and the air does not move within the room apart from the air set in motion
from family members' paper fans. The small beds have inch-thick mattresses on
metal frames. A family member is seated on the bed of each patient, taking up
more space on the bed than the patient. The parent is responsible for providing
food and for feeding the child. They fan their child to keep them cool and swat
away flies. Children over 6 years of age are not covered by government funding.
That's right, they pay, unless they have insurance. Insurance would be
unaffordable for many here. Everyone in our group notices and feels something
when they see a grandmother hand-bagging her grandchild. This baby required
intubation and mechanical ventilation, but a ventilator was not available. Baby
would have to wait for another patient to be extubated in order to get a
ventilator.
The intensive care unit has 8 patients
today, none intubated, one on CPAP. This province has a population of nearly 2
million people. Manitoba has a population of one million people. Our acuity
seems higher and our census is usually 6-10 patients. How is it there is no
septic patient here on inotropes? A trauma patient? Renal failure patient?
Severe asthma, allergic reaction, seizures, first time diagnosis of cancer? I
ask this question to the attending physician. In the case of sepsis, they often
arrive too late. The hospital services a largely rural population. There are no
ambulances. The sick are brought in by family members using the 'family car',
known here as the moped. They come from afar, precious minutes and hours pass
before entering the hospital before they can get help. Trauma patients are seen
and taken care of by the attached adult hospital. Sicker children likely get
transferred to Ho Chi Minh City.
I may be wrong, the sentiment perhaps lost
in translation, but I feel the doctor was apologetic. But I do not know why.
She and the doctors who work with her are very hardworking and dedicated. They
are doing their best with what they have. And if you are doing everything you
can with what you have - your training, your experience and your equipment, -
then it is the best you can do. There is always room for improvement, and where
there is a will there is a way.
The will is definitely here.
That is what I see every day when we do our
afternoon sessions: the simulation extravaganza! And truthfully, our simulation
sessions feel quite a lot like the street markets here. Just a little out of
control, but still keeping on task and a whole lot of fun! The simulation I run in Winnipeg runs as a 20
to 30-minute-scenario where reality is suspended and residents humour my whims
by pretending the mannequin is a real child. They work as if in real life; to
save the sick child whose disease and its course were designed in my head weeks
before, or sometimes the night before. In Long Xuyen, simulation runs a bit
differently. Reality and time are
constantly suspended and interrupted, as this sim is done through interpreters.
We both are learning. I am understanding how one practices in a resource-limited
country and reflect on my own practices. Do I really need all this blood work?
Does my patient really need monitoring?
I am working with Dr. Hareishun Shanmuganathan and we have two scenarios
for them: one sepsis and one trauma. In the world of simulation, we are doing
it as low fidelity as it gets. One pediatric intubation head and one 'space
baby’ mannequin is all we have. So that our intubation head looks like it
belongs to a body, I suggest we draw an infant body. From several pieces of
paper towel, Hareishun draws out the body, with hip and right arm injuries in
place. Vitals and changes in course are given to the participants as one does
in good old paper cases.
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.
Smiles. The power of a smile is huge,
especially in the absence of a shared language.
I pass by people walking in the streets, in
the hospital, and in our van as I sit by the window looking out at the families
on mopeds. I can't help but smile at the moment of eye contact. I am a visitor
here after all, and I appreciate the welcome we have received from the hospital
staff, and the people of Long Xuyen. The smile exchange feels like a handshake.
We are different but the same, and I wish I knew Vietnamese. I yearn to know
what your life is like, and your views on life.
Homes. I think everyone has one here. In
Long Xuyen I have not seen a homeless person or a beggar, although of course
they may exist and I have not seen it. Many live in homes of corrugated steel
with no running water. My parents grew up in post WWII Greece. Running water was
a luxury. My father grew up poor in a small city, yet he describes his
childhood as a good one, with lots of fond memories. There was not a lot of
food but his five siblings and he would spend their free time teasing each
other, playing and listening to stories.
My father cherishes the time spent this way, connected to his
family. Maybe I am wrong to think this
way, but is it the same here? Poverty
yes, hunger yes, but are people more connected to family and their friends, to
their community? I don't know.
My mind recalls one of Bono's lyrics,
"A House doesn't make a Home" (from 'Sometimes you can't make it on
your own'). I think that's what my dad's experience was like. ‘Home is where the Heart is’, I think that’s
what he was describing. I would wish that kind of home, 'where your heart is',
for everyone.
Thank you doctors and people of Long Xuyen
for giving me the opportunity to work and live alongside you.
Last one from Bono. The song 'Crumbs from
your table' was running through my mind during a part of this trip:
'Where you live should not decide
Whether you live or whether you die'
And for those who know me well, believe it
or not, I do listen to other bands/musicians besides U2 ;)
Obstetrics
By: Stephanie Johnston
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.
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.
Overall, my experience so far on this
journey has been somewhat as expected and informative. It has definitely driven home the point of
needing a proper “Needs Assessment” prior to commencing any educational
intervention. Trying to accomplish this
assessment has become the new challenge for future missions. It would be interesting to see the curriculum
for the year long OBGYN residency program offered within Vietnam, as this could
help drive future educational interventions.
Watching the rest of my colleagues present
on the BLS, ACLS and ATLS/PTLS, helped to highlight some of the challenges I
was experiencing, as many of their topics are driven by protocols and
algorithms. It definitely helped to
facilitate structure, but trying to convey the concept of multitasking and
following an algorithm concurrently was challenging and compounded by the
language barrier. It is quite inspiring
to watch my teammates run daily afternoon simulation scenarios depicting ACLS,
ATLS and PALS. The Vietnamese students
were crowding around to film with their phones/tablets to capture the high
yield moments. It has definitely showcased a great way of teaching locally.
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.
Once this case was completed, we proceeded
to the emergency OR where they were preparing a woman for surgery due to a
ruptured ectopic. She was apparently
transferred from a district hospital, where she had received blood to stabilize
her. Their method for diagnosis seems to
be based upon clinical symptoms, a positive BHCG, an ultrasound and maybe a
diagnostic peritoneal tap. Her clinical
picture pre-op was quite stable with a heart rate of 80 to 100 and a BP of
115-130/70-80. She was slender and you
could convince yourself that her abdomen seemed slightly distended. She received a general anaesthetic, becoming
quite tachycardic post-intubation, suggesting that she may not have been as
deep as would be done at home. Within a couple
of minutes, her heart rate settled down to 70 to 80. The skin prep was the same as for the
C/S. The surgeon, a lovely female,
proceeded with a small pfannenstiel incision and progressing via sharp entry
into the peritoneum. The familiar site
of clot welling up through the incision was treated with scooping and
suctioning it away to localizing the offending tube. She quickly packed the bowel away to find the
left fallopian tube where an evident ruptured ectopic covered with old clot was
clearly visible. She efficiently used a
similar technique to home, double clamping along the mesosalpinx and using a
standard tie. It is fascinating to see
that the surgeon places the stitch and the assist or scrub nurse performs the
tie, ensuring that someone always holds the knot with either the Debakey’s or
snap. Within the same OR, they did have
some old school laparoscopic equipment that would rival the era of R2D2 and
they did mention that they would normally perform the salpingectomy for an
ectopic laparoscopically if there were less blood loss. Overall, my OR experience has been quite
informative and insightful to see the multiple similarities between Canada and
Vietnam.
Yesterday, I had the opportunity to visit
the private hospital, Hanh Phuc An Giang General Hospital. All I can say is WOW. The discrepancy between public and private
care was very distinct. A Toyota Camry
with a leather interior came to get me, along with the translator Phuong. Upon arriving at the hospital, it felt like
I was walking into a high-end hotel. The
admissions area was lined with multiple clean, white leather couches with a
modern black and white background on the walls.
The floors had multiple sticker footprints directing patients to their
desired destinations. The rooms are
mainly double occupancy, but it truly felt like I was walking through the halls
of a hotel. Every so often, a used food
tray, similar to airplane food, would be seen sitting on the floor beside a
door. My escort was quick to explain
that visiting the private hospital provided additional perks. One difference that was apparent was the
lack of family members sitting and waiting in the halls to see loved ones, as
they were allowed to stay with their loved ones in their rooms.
Proceeding from the halls of the inpatient
wards, we wandered over to the labour floor.
They have a lovely early labour or obstetrical triage area that is air
conditioned, providing a reprieve for the labouring mothers from the heat
throughout the hallways. Once they reach
4 to 5cm, they are moved via a private hallway at the back of the triage to
either the OR or delivery room. The
delivery room is bright and clean with pink paint and bunny rabbit wall paper
covering the walls. There are about 7 or
8 delivery stations separated by privacy curtains. They have a large medical cabinet stocked
with a multitude of drugs including implanon and digoxin. They do have doptones and fetal monitors
available for use for monitoring. A
metal fetoscope can still be seen in the tray beside the fetal monitor
suggesting that some old school skills still exist. Moving from the labour room to the VIP labour
room was a very eye opening experience.
I felt like I was in a suite at another hotel, considering the room had
a sitting area, resting bed, labour/delivery table and a fully functional
bathroom with shower and bathtub. There
was even a flat screen TV mounted on the wall.
This room significantly surpassed the available ward rooms at the
Women’s Hospital or St Boniface Hospital.
It definitely made me envious and looking forward to the new Women’s
Hospital in Winnipeg that will allow for more private rooms that don’t have
paint peeling off the walls.
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.
Upon leaving the hospital, my curiosity
started to get the better of me and I started asking about the pricing of the
hospital. Apparently, the pricing for
medical care is controlled by the government and private care can only have a
markup of up to 15%. The price I was
quoted for a standard vaginal delivery was 5 million Vietnamese Dong or $333.33
Canadian. If you want the VIP
experience, it would cost 20 million Vietnamese Dong or $1,333.33
Canadian. The difference in comforts is
definitely apparent. I kept commenting
on how beautiful the hospital looked and my host was very adamant in explaining
that it is not just a beautiful hospital.
There is a higher expectation of their staff. The physicians are expected to be Level 1 or
Level 2 trained and to be continuing to pursue further education. The standard almost reminded me of the expectations
within a teaching or university hospital.
Being the advocate for women’s health, I had to ask how easy access to
abortion care is at their hospital. It
became clear that the sensitive nature of the topic existed in Vietnam
too. She quickly answered that her
family did not believe in abortions and due to the ethical reasons, it was not
offered. The awkwardness within the car
was palpable and I quickly tried to redirect to a new topic of
conversation. Similar to the atmosphere
that has been generated with the pharmaceutical companies, I could see the same
effect happening when dealing with the representative from the private
hospital. She started highlighting how
the private hospital would like to host the symposium as their physicians are
unable to attend the symposium at An Giang Public General Hospital. I almost felt like she was trying to sell me
on her hospital as she highlighted that they could deliver more services. She even made a detoured stop at the family
restaurant to pick up descriptive flyers highlighting the many aspects of her
hospital. It seems that no matter where
you go in the hospital, the capitalism of industry is ever present.
I am happy to say that when I asked about
abortion care at the public hospital, I was greeted with a much more reassuring
answer of it being easy to access as he began to explain how they use MVA
(manual vacuum aspirators) or medical abortions. I am uncertain what their upper limit for
termination might be. When I asked about
cost, I was never given a direct answer but it seems that women who are from a
poor socio-economic class would have the service provided for free.
My multiple experiences in Vietnam have
prompted me to do some reading about the healthcare system. Completing this task prior to the mission
would have been a much wiser decision and prevented some of the embarrassment I
dealt with earlier in the mission. I
came to Vietnam expecting a developing country similar to those I have visited
in Africa. I was sorely mistaken and the
research clearly supports this observation.
Vietnam has experienced a great deal of growth and has become a “middle
income country” with a rapidly expanding middle class. Unfortunately, this growth has only caused a
widening gap between the rich and poor.
Vietnam seems to have embraced the Millennium Development Goals and has
made significant progress with maternal health, becoming a poster child for the
United Nations and World Health Organization.
They have successfully brought their maternal mortality rate down to
less than 100 per 100 000 live births.
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.
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