Written by Hamad Zafar, DPM, PGY-2 at Kaiser Permanente Santa Clara Podiatric Surgery Residency Program while on Global Health rotation…
Written by Julie Chatigny, DPM (A second year Podiatric Surgery Resident at Kaiser Permanente, Santa Clara while on a global health rotation in Da Nang, Vetnam at Da Nang Orthopedic and Rehabilitation Hospital.)
I left my home in Dublin, CA at 8:00 PM on May 15, 2014, checked into the airport at 9:00 PM, flew out of San Francisco International Airport at 1:00 AM on May 16, 2014, was to have a one hour and 45 minute lay-over in Hong Kong, China, and arrive in Da Nang, Vietnam at 8:45 AM on May 17, 2014 for a total traveling time of 22 hours and 45 minutes. Well, that was what was supposed to happen. Instead, as the plane full of passengers was waiting for take-off on the tarmac, the announcement came that one of the pilots was ill and that another pilot was not available in San Francisco, rather the flight would be re-routed to Seoul, South Korea and another pilot would be picked up for the flight to Hong Kong. This turn of events completely altered my travel plans. Due to the lay-over in South Korea, my connecting flight from Hong Kong to Da Nang would be long gone by the time I arrived. Once in Seoul, we waited for about one hour for the new crew to board and get ready for our flight to Hong Kong. Once in Hong Kong, I had to completely change airlines as there were no other flights to Da Nang. The airline arranged the transfer, but the lay-over turned into a wait of 6 hours and traveling alone, I sat near the check-in counter and waited to check-in for my flight. I was carrying a duffle bag with the Kaiser Permanente logo and Northern California Residency Program embroidered on the side that I had received from Kaiser when I first started by residency program. A couple sitting in the same waiting area looked at my bag, and the young woman asked me if I worked at Kaiser. It turned out that she was a Resident Physician in Internal Medicine from Kaiser San Francisco, and she was traveling to the same destination as I and had brought along her husband. The two were kind enough to befriend me for the remainder of our travels to Da Nang, which eased the anxiety I had as I was traveling alone and my travel plans were taking me to multiple destinations of which I was not expecting. From Hong Kong, we flew to Hanoi, Vietnam went through customs, boarded another plane after another long lay-over, and finally arrived in Da Nang at 9:00 PM on May 17, 2014. I called the resort where I was staying, and they sent a shuttle out to pick me up. It was 90 degrees Fahrenheit with 80% humidity. The shuttle van arrived at 10 PM, greeted me with ice-cold water out of a cooler and air-conditioning for the ride to the resort. I arrived at the resort at 10:20 PM for a grand total time of 36 hours and 20 minutes from door-to-door. The hotel staff greeted me with a Dragon fruit drink and were extremely courteous and checked me in quickly. Needless to say, I passed out when I finally got to my air-conditioned room and slept until 10 AM the next morning.
Sunday evening, May 18, the group of us who had come from the Santa Clara residency program met up with Dr. Kaschak – organizer and Podiatric Surgeon at Kaiser Fresno, his wife, Cissy, and we were introduced to the physicians with whom we would be working over the next week. Dr. Thanh and Dr. Kaschak had been working together annually for many years and obviously had become very good friends. Mr. Coup, the administrator for the Orthopedic and Rehabilitation Hospital, was also present and highly regarded by all. The lovely couple that I had met and traveled with also came to dinner, as she was going to work at the General Hospital for 3 weeks. We had a wonderful evening getting to know everyone, which made our first day even more enjoyable as we had already met the night before.
Monday morning, May 19, we arrived at the Orthopedic Hospital and met with Bac Si (Dr.) Do Van Thanh, Mr. Coup, hospital CEO, the administrative assistant and translator, Nga, and strategies were discussed to ensure continued cooperation and support between the Vietnamese government and the KP Global Health organization.
The news cameras were on site for an interview with Dr. Kaschak about the collaboration he and Dr. Thanh had developed and how the relationship had grown over the years. This interview was done in our presence, and was later broadcast on the Vietnamese news. It was very exciting and inspirational to hear the story of how one trip to Vietnam developed into a lifelong friendship and the growth and education of all those involved with the achievement of a new Orthopedic and Rehabilitation Hospital.
Patients were already lined up in the hallways for our clinic that day. We spent the entire day seeing patients with lower extremity pathology ranging from congenital birth deformities such as clubfoot or polydactyly to cerebral palsy neuromuscular deformities to post-polio deformities to injuries sustained in the Vietnam War in the 1960s and 1970s. Many patients were treated with referrals to physical therapy, which the hospital had on-site, or with non-surgical modalities such as orthotics or joint injections. The patients were screened throughout the day for those who were able to be helped by surgical correction and each one scheduled for surgery over the next two weeks.
Tuesday morning, we arrived at the hospital and prepared for surgery. Six patients were scheduled for surgery that day. The operating room setting was very similar to what we experience in the US with respect to the anesthesia cart, lighting, and air conditioning, but what was typical for these surgeons and staff, was a bit foreign for us. Operating on two patients in the same room would never occur in the US, yet in Vietnam, this was a regular event. The most remarkable difference was the lack of trash/garbage compared with a typical US OR. Everything from the surgical scrub brushes for the surgeons, to the surgical gowns, to the operative drapes were reused. The amount of trash at the end of an entire day of surgery was far less than what is generated in the US for one surgical case. And even more remarkable is the rate of postoperative infections, which is very low. This begs the question, is all of the one-use, disposable gowns, drapes, towels, etc., that we use in the US actually lowering our infection rate, and is it necessary? Another detail worth noting is the dedication and the work ethic that all of the staff demonstrated. Efficiency and teamwork was outstanding.
Our first case was a woman who had a prior triple arthrodesis with painful hardware and had subsequently developed a painful large bony prominence on the medial aspect of her foot. The hardware was removed successfully and the bony prominence was resected. Concurrently, on the operating table on the right side of the room, a painful, large, benign bone tumor on a teenage boy’s knee was excised. Next, a woman with a prior ankle fracture, which was malreduced at the original surgical procedure was taken to surgery and the hardware was removed. An arthroscope was used to remove the scar tissue that had developed and the ankle was realigned and new hardware was placed. The other operative procedures for the day included a soft tissue mass excision from a woman’s forefoot, a bunion and hammertoe correction, and another painful retained hardware removal from a previous triple arthrodesis.
The evening of May 20th, I was invited to dinner with Dr. Kaschak, his wife Cissy, Bac Si Thanh and his wonderful family. Also in attendance were Tina and her husband, the couple who had befriended me at the airport. We had a delicious dinner at a restaurant where we sat outside in the 80 degree weather, had fresh vegetables, seafood, wonderful dinner conversation, and I was privileged to hear the stories about the previous years that Dr. Kaschak and Dr. Thanh had worked together and how the relationships and hospital had developed and prospered. It was one of my favorite evenings of my trip.
Wednesday, May 21, our 2nd surgical day was another day of very interesting pathology. We began the day by rounding on the patients who had surgery the day before. We walked into the air-conditioned communal room where all of the post-op patients were lying on beds, so had family nearby, but the remarkable site was that each person was calm or sleeping and would smile when we on-by-one came to her or his bedside. Not one patient had received a narcotic pain medication, only Tylenol for pain, yet no one was crying or complaining. This was impressive, as most post-op patients in the US “require” narcotics for pain management and often, high doses for the same operative procedures.
We then began our day in the Operating room. Aberrant toes were removed from an 18-month old girl with multiple limb deformities (Ectrodactyly), while at the other OR table in the same room, a woman with severe hallux varus of her left foot secondary to rheumatoid arthritis had a 1st metatarsophalangeal joint arthrodesis with excellent correction of the mal-aligned foot. The next patient was an 8-year old girl with bilateral cavus foot deformities who had a posterior tibial tendon transfer of the left foot with the goal of helping her walk on the plantar aspect of her foot instead of having recurrent ankle sprains and walking on the lateral column. The visiting Orthopedic Surgeon, Dr. Bob, and Da Nang Orthopedic Surgeon, Dr. Vu, performed a semitendinosus tendon harvest and an anterior cruciate ligament repair of a man’s right knee in the next OR suite. The next surgery was a complete right foot reconstruction on a post-polio syndrome cavus foot deformity on a beautiful 31-year old woman. She was amazing with her bravery as she was told it would be a painful recovery. When she arrived she had shaved her head as this was a sign of good luck. The operation took 3 hours and included a percutaneous tendinoachilles tendon lengthening, a subtalar joint wedge resection with arthrodesis with a 7.3- mm screw, and a dorsiflexory wedge osteotomy at the 1st metatarsocuneiform joint with screw fixation. When the surgery was completed, the foot was in rectus alignment, and the correction was remarkable. The last case of the day was a hardware removal from a previous subtalar joint fusion with a 7.3-mm screw and 2 staples. All hardware was successfully removed.
Thursday, May 22nd, was my 15-year wedding anniversary. When I texted my husband to say Happy Anniversary, it was 14-hours earlier in California. He texted me back and said he was going to try to text me first, but I had beat him to it. Although we were not together and would celebrate when I returned home, he said he would not have it any other way because he knew that this trip was important to me and that I was helping make a difference in peoples’ lives. We arrived at the hospital at 8:00 AM and rounded on the post-op patients. The only person who had received Morphine was the woman who had the STJ fusion, but she had only one dose. We recommended that she get it scheduled as she would likely need it. All patients were resting comfortably and doing well.
The surgeries started out with a 3-year old boy with rickets who had bilateral tibial and fibula osteotomies by the Orthopedic Surgeons. On the OR table on the left side of the room, a 51-year old man had a pantalar fusion of the right foot secondary to an untreated congenital clubfoot deformity. Four more surgeries were performed that day including a percutaneous tendinoachilles tendon lengthening on a 6-year old girl for a flatfoot deformity, a Steindler stripping and percutaneous tendinoachilles tendon lengthening on a 9-year old girl, a total hip replacement on a 78-year old woman, and a cavus foot reconstruction on a 43-year old woman: Cole osteotomy, percutaneous tendinoachilles tendon lengthening, and Steindler stripping. That evening, we went for what had become the traditional dinner with all of the doctors and staff. It was a wonderful occasion for everyone to get to know each other better. It was a relaxed and enjoyable evening.
The next morning, Friday, May 23rd was our last day to work with this incredible group of people. I was already getting sad to leave. We rounded on our post-op patients, cast a baby with clubfoot, and made our way to the OR. We saw the little girl with the Ectrodactyly who had the aberrant digits removed, who was only 2 days post-op, and she was smiling and up in her father’s arms. We performed four surgical cases including a previously failed clubfoot correction, a young man with macrodactyly who could not fit in shoes and had bilateral transmetatarsal amputations, a 10-year old girl who was born without peroneal muscle strength who underwent a percutaneous tendinoachilles tendon lengthening and tibialis posterior tendon transfer for her dropfoot cavus deformity, and an ankle hardware removal.
We went around and said good-bye to all of our new colleagues and friends. It was difficult to leave not knowing how the patients were going to do, but knowing that they were in excellent hands with the incredible doctors who work at the hospital. I left Vietnam on Saturday, May 24th and had a very uneventful flight back to California.
Reflecting back on my experience, I would not change a thing, except perhaps for the long detour I took to get to Vietnam. But then again, I would not have met Tina and her husband. My only regret is that I did not have the opportunity to stay longer. I know that I will seek out opportunities such as this in the future and would love to go back to the same hospital to work with and learn more from everyone there. I recommend this experience to all Residents as everyone can learn from different cultures, and the people of Vietnam have many characteristics from which to learn: courage, dignity, humility, and kindness.