A Kaiser Global Health Experience: Da Nang General Hospital, Da Nang, Vietnam

Caroline King, PGY-3, Internal Medicine, Kaiser Oakland

Earlier this year, January 2014, I had the opportunity to spend several weeks at Da Nang General Hospital in Da Nang, Vietnam through Kaiser’s Global Health Program. As I’m not the most experienced traveler, I was fortunate enough to have a travel buddy, my fellow Kaiser Oakland IM Resident, Meme Wu – who also has a written account of her experiences on this blog. To preface my account, I chose to go to Vietnam because I wanted to learn more about a people and culture that I had little familiarity with, outside of the tasty cuisine, the French influences, and the Vietnam War. My goal was to get a better understanding of the structure and provision of medical care in a non-US health care/hospital setting, particularly in a developing country with limited resources. The Da Nang General Hospital was a good location as it juxtaposes being the largest referral and subspecialty hospital in Central Vietnam with the modest resources of an evolving developing country with elements of a strong cultural influence. I do not speak or understand Vietnamese outside of the few phrases I studied prior to going to Vietnam, which likely limited more hands on interactions with the patients we saw there.

We started our journey on Jan 9, 2014. After 2 days of sitting on an airplane and camping at the Hong Kong Airport, we arrived at Da Nang International Airport. The first few hours in Vietnam consisted of exchanging money, obtaining a working sim card (definitely a must), and bargaining for reasonable transport from the airport to our hotel (moderately successful). We spent the weekend prior to the start of our rotation exploring the city and nearby cultural sites by foot and taxi. The city has a multitude of places to stay, by the beach as a prior GHP resident had done, by the river – which is where we stayed, or in the main part of the city, all at a variety of price points. Da Nang is a bustling city filled with countless motorbikes, small family owned restaurants and cafes, and tall skinny office buildings and apartment complexes. It is far less touristy than its sister cities of Hanoi and Ho Chi Minh City (Saigon). Walking proved difficult as hundreds of motorbikes lined the sidewalks and live electricity wires hung from the sky making a casual stroll more of a scramble through an obstacle course. Crossing the street felt like stepping into a live personal game of Frogger. We were also there during the month leading up to the Lunar New Year so construction was in full swing for the installation of public decorations and light displays. Given our language barrier, having a working cell phone and sim card with map services and Google Translate were key to getting us where we needed to go in a timely and safe manner.

Our hospital rotation began the following Monday after our arrival. Before we were allowed to enter clinical areas of the hospital, there was a day of processing of paperwork and observing official channels of introduction to be approved to rotate in pre-determined subspecialty departments. Due to the language barrier, we were reasonably recommended to spend time in departments that had an attending doctor who could speak English, as no translators were available for us to use. The partnership Kaiser has with Da Nang General Hospital is relatively new and primarily based upon the strong relationship between Dr. Kashack, one of our Kaiser NorCal Podiatry attendings, and its sister hospital, Da Nang Orthopedic and Rehabilitation Hospital. Thus, overall they were not quite sure what to do with us, but they were open to some requests and we did meet many welcoming and friendly doctors while we were there. We wanted to get a sense of the type of patients that were seen in this hospital so we arranged to spend the first week in the Emergency Department. Both Meme and I were also interested in how the critically ill patients were managed so we arranged to spend the second week in the ICU. For our third week, we wanted to experience a hospital ward, but as the cardiology attending who spoke English was no longer there, we arranged to spend time in the Nephrology Wards.

Our first week in the Emergency Room initially started rather awkwardly but became my favorite time at Da Nang General. After brief introductions every morning, we would stand behind the large counter overlooking the bustling main room of the ED. Two rows of metal gurneys lined the open triage room with nurses in crisp blue scrubs and young doctors in long white coats, jeans, and sandals quickly examining new arrivals and processing paperwork, ordering labs and imaging, and talking with family members. Several of these “resident” doctors spoke a fair amount of English, so we would shadow these doctors and get quick blurbs about what brought the patient in and any medical history that accompanying family members might know. There usually were no prior medical records available (only what family members could relate) and definitely no EMR system there. If the doctors had time to introduce us, we would also have a chance to examine the patients. At other times, we would require our reliable Google Translate to look up words on order forms, lab sheets, and imaging results, as well as learn words for body parts, pain, and medical diagnoses. Fortunately, the chief of the ED, Bach Si (Dr.) Minh, also spoke a fair amount of English and had time to show us around the department and nearby imaging facilities. He also spent time discussing several of the ongoing cases being worked up with us while he was there. Once a preliminary diagnosis was developed, specialty departments were invited to consult and admit the patient to their specific ward for further medical or surgical care.

There were a variety of cases that came through the ED, from the usual CHF, COPD, ACS, and (lots of) stroke, to trauma cases from minor to deadly motor vehicle accidents, to infectious cases of TB/Pott’s disease, and dengue fever, to an unfortunate case of a suicide attempt with liquid pesticide. Some patients were transferred from 2-3 hours away for neurosurgical evaluation. Children were transferred to the nearby Women’s and Children’s hospital so there were very few pediatric cases. In the main triage area, there were no curtains to separate patients and pretty much no telemetry units to give immediate vital signs or other objective data except for critical patients. The critical care room contained a portable telemetry unit, an EKG machine that used clamps on the patient’s limbs, and an old ultrasound machine that only the radiologist was allowed to use (the ED doctors did not know how to use it). Metal cabinets lined the walls containing rows of medication vials ranging from morphine (surprisingly not used very often), lovenox (which they used for ACS), dopamine (which they used as the first line pressor peripherally) and adrenaline (which they used in code situations), to antibiotics, saline, and electrolyte repletion meds – all with slightly unfamiliar yet familiar names. For patients on oxygen but requiring transport for admission or to imaging, portable oxygen was administered via deflating a pillow sized yellow and blue bag filled with oxygen connected to a nasal cannula, with the rate of flow determined by how hard the nurse pushed on the bag to deflate it.

Early in the week, an unfortunate middle aged man was shuttled in after a motor vehicle accident between a motorbike (the patient) and a truck. He was whisked into the small critical care room and hooked up to the only portable telemetry box with a loose plastic pulse ox sensor that had to be scotch taped to the patient’s finger. The patient had lost his pulse en-route and CPR was initiated once he arrived. Chest compressions were given but to my eyes, the administration was rather haphazard as they did not use a team approach to run their code. In addition, from my understanding after talking with the ED physicians, there is no formal EMS/first responder system. Ambulance vans there are purely transport, with no equipment or trained personnel to stabilize or resuscitate patients outside of setting broken bones. The patient was also intubated, but the critical care doctors are the only ones allowed to intubate patients and thus had to be invited down to participate. Most cases requiring intubation were for airway protection as there were no ventilators in the ED, and many patients were just left with an endotracheal tube down their throat with oxygen administered via nasal cannula tubing placed down the opening in an open system. The patient did regain a weak pulse, but culturally as we later learned in the ICU, while families want everything done to keep their family member alive, if they are about to die, family expects the patient to die at home. Given his poor prognosis (large brain bleed), the patient was sent home via an ambulance van with the ET tube still in place and an Ambu bag to try to keep him breathing until he reached home. A profound story I heard while in the ICU was of a family who decided to take a very sick patient home, and among the family members took shifts at home to bag the patient around the clock for three days before he passed away.

As an internal medicine resident, I have had very few if any opportunities to see surgeries in the OR since medical school. While in the ED, we were able to follow a patient who had been diagnosed with an acute abdomen on exam after an MVA (a very common occurrence if you haven’t noticed), from the review of his CT scan with the ED team, to the discussion with the trauma surgeon (who also spoke English as he had trained in the US), to the OR where the patient had an exploratory laparotomy. The surgical suite itself was small in size but very standard, with familiar equipment to any basic operating room. We changed into scrubs but what interested me the most was the fact that we had to change into yellow open toed sandals while barefoot to go into the OR! Very few things were disposable, which is completely understandable in a resource limited hospital. Basic protocol such as time outs and counting at the end of the surgery were performed as expected. The patient was found to have a small bowel perforation which was repaired quickly, his abdomen washed out efficiently, and the patient closed up in a matter of minutes. The charge nurse also felt as strict and seemed as highly competent as any charge nurse I’ve seen during my medical school training.

We also had an opportunity to follow a patient through the hospital ward experience. A Chinese tourist had come in with a lower GI bleed and because Meme spoke Chinese fluently, she was able to help translate the medical process for the patient. He required blood transfusions while in the ED, and I was pretty amazed at the bedside confirmation assessment for blood compatibility that was performed on a glass slide by mixing the patient’s blood with the transfusion blood to evaluate for coagulation. Unfortunately we did not have an opportunity to see his EGD performed, but the diagnosis and treatment was as expected. We visited the patient in the GI ward who was doing well and we were able to speak to the gastroenterologist (who spoke Vietnamese and French – amazingly Meme also knew French and was able to converse with her as well). From this experience, what we could gather was that most patients were kept in the hospital until they were completely recovered – what would be maybe a two day stay for a lower GI bleed based on my own training would be at least a week or longer in the wards over there. In addition, I found that families played a huge role in the care of patients there. Nurses primarily provided dressing changes and medications. From what I could observe and asked (so I may be wrong), family members were the ones to bathe patients, walk patients, manage toileting needs, provided the blankets and pillows and nutritional supplements (unless the patients were on tube feedings). There definitely was a substantial sidewalk industry outside the hospital with hawkers selling blankets, Ensure supplements, urinals, and other equipment. It was interesting to note that I could always tell if a hospital was nearby in other cities by what was being sold by the sidewalk vendors.

Based on a contact we made in the ED (a young doctor who had also met a prior Kaiser Oakland resident while working in the ED the previous year), the next week we were approved to spend two days in the Burn Unit and Plastic Surgery Department. There were both children and adults in this unit, and delicate wound care was provided by nurses to partial and full body burns. We scrubbed in to observe a skin graft placed on a large thigh wound under local anesthesia – with strips of skin finely grated from the right leg placed over the burn on the left leg. I’m sure there is a more surgical term for that procedure but that is what it looked like to me. The young “resident” plastic surgeon who was our “in” also explained to us that most of the new doctors straight out of medical school usually start in the emergency room for 6 months to a year, then rotate for 6 months to several years in the ICU, then are determined by hospital management to go into a specialty that they deem to be the best fit. The doctors themselves have fairly little say in what specialty field they may end up in, although they can request preferences as this resident had done. He was also debating about whether to go back to school to pursue advanced training or to go the research route rather than a clinical route.  

We spent the rest of our rotation through the beginning of the third week in the ICU department. Although we had arranged to spend time in the Nephrology department during our third week, this was unfortunately and somewhat unexpectedly rescinded as they were not allowing visitors to rotate through during the Tet (lunar new year) holiday week because the hospital was scaling back as much of the staff were heading home to be with their families. However, our time in the ICU department was also a great experience. Unlike my own experience with the Kaiser Oakland ICU, with private rooms and high nursing ratios to patients, there were three large ICU ward rooms with about 10+ patients each in the highest acuity rooms and 20+ patients in the lower acuity room. About 40-50 patients would routinely require ICU level care every day. A hodgepodge of ventilators were set up, each one a different model and year, some with dials and some that were digital – a veritable museum of ventilator types collected through the years. There weren’t always enough ventilators to go around, and sometimes they had to get family members to bag the patient for hours to days while waiting for a ventilator to become available. They also had few portable telemetry units and so in some cases would share the units between two neighbor patients, which initially greatly confused us as one patient had been coded with Vtach on the heart monitor, while the oxygen saturation read as stable 100%. The oxygen probe was on the finger of his neighbor rather than on the coding patient.

The Chief of the ICU, Bach Si (Dr.) Young spoke English fluently but was a very busy man and so we did not get to interact with him much, however many of the young doctors in their 1^st to 5^th year of training spoke great English and were open to discussion (the source of the anecdotes in the prior paragraphs). When we tagged along on rounds, they would sometimes present in English to include us in the discussion and give us an opportunity to ask questions, which was greatly appreciated. One of the charge nurses of the ICU could also speak English and was a great source of information. There was a young Japanese nurse who was volunteering and training in the ICU, and Meme, the multi-language speaker extraordinaire (other than Vietnamese) also knew Japanese so we could follow her performing her daily nursing duties as well.

While we were in the ICU, we were invited to give an hour long power point presentation and they had one of their bilingual doctors translate for us. Meme and I decided to review the resuscitation process including reviewing important cardiac rhythms, the ACLS protocol with its new updates, correct techniques, and Megacode team approach, and several studies regarding hypothermia and having family at bedside during codes. We felt this to be an important topic because in both the emergency room and the ICU, we were surprised that when a patient coded, there was no team formation and no standard approach to chest compressions or giving medication. We knew that as visitors we could not jump in to run a code due to liability issues, but we wanted to bring our training and knowledge to our peers and people we had come to be friends with. We also had the opportunity to give a 30 minute presentation on the same topic to the young ED doctors as well which also was a great teaching experience. During a casual discussion over lunch with some of the younger ICU doctors, I found it quite interesting how culturally families want their sick family members to either completely recover or die at home. Thus, families expect doctors to spend hours trying to resuscitate family members in the ICU and get them stable enough to be transferred home to die again. The goal is not neurologic preservation, but to restart the heart enough to get the patient transferred home “alive”. But, if the patient then did not pass within a few hours, the doctors would be placed in a difficult situation of being blamed for not doing enough to keep the patient alive in the hospital. There is no palliative care team and there is little discussion about prognosis with family members until the moment of cardiac arrest.

In our last few days in Vietnam, we had the chance to enjoy the Tet holiday and see families celebrating and honoring their ancestors with outdoor altars and offerings. Many of these offering tables covered with fruit, food, and burning incense were also scattered around the hospital buildings as well to wish for good luck for individual departments. Most shops and stores were closed during the holiday week, so we took the opportunity to go north to Hanoi for a few days to see the Old Quarter and to tour the famous Halong Bay before we returned home. We wanted to try the sleeper train but unfortunately it had all sold out as everyone needed to travel home for the holiday week. In addition, during the entirety of our Global Health adventure, we made sure to eat the amazing food that Vietnam has to offer – from Bahn Mi sandwiches and strong Vietnamese coffee for breakfast to tasty My Quang, Bun, and Pho noodle dishes, Bo La Lot (beef wrapped in betal leaves and grilled over an open charcoal flame), and fresh Vietnamese spring rolls for dinner. There were tons of small cafes to sit in and relax while sipping affordable fruit smoothies and fancy coffee drinks. During the weekends, we made sure to travel to the nearby cultural cities of Hoi An known for their lanterns and textiles (via local bus – now that was a memorable experience) and Hue, the ancient capital of Vietnam, as well as the nearby Cham museum and the Linh Ung Buddhist Pagoda.

The time I spent in Vietnam at Da Nang General Hospital will stay with me for the rest of my life. While it was primarily observation, the people I learned from and the cultural tidbits I discovered truly made the experience one of a kind. Although unfortunately the resident who rotated through the hospital the month after we did had quite a bit of trouble and red tape (see Yi-Jen Fong’s account), it definitely is a program that is worth working out the kinks for future residents to explore and experience. I went there to learn about health care systems in a developing country and an unfamiliar cultural environment, and I definitely gained a new perspective and hopefully some understanding of a unique place and people.