Written by Christina Kinnevey, MD, Fellow at Kaiser Permanente Napa-Solano Community Medicine & Global Health…
Posted by Chuong Dang, MD (Pediatrics resident from Kaiser Permanente, Oakland).
Monday: I arrived at Da Nang airport at 5PM after about 36 hours of travel and lay-over from San Francisco to Seoul, Korea and Saigon, Vietnam. I got in contact with Da Nang faculty to set-up our meeting for the next day. I checked-in at the hotel and rented a motorbike.
Tuesday: I met with the International Affair Officer at the hospital, Dr. Ngoc, the Director of the hospital, Dr. Vinh, and the Vice Chief of the Pediatric department, Dr. Hoang. Dr. Hoang introduced me the logistics of the department and then walked me through the sub-departments under Pediatrics. They gave me the wide opportunity and encouraged me to take part in many activities at the hospital (education, English training for residents, procedural performing…)
Wednesday: The day started at 7:00 AM, when I participated in pre-round/rounds with the residents and the attending physician. At 9:30AM, I participated in the department meeting for which they discussed about M&M and update the census and patient status. The meeting was followed by a presentation (morning report) in English. Then, I took part in working rounds in the NICU and was able to directly examine patients and contribute on rounds. The NICU ward was a standardized ward but with very limited resources (no IV indomethacin, only old respirators for about 45 patients, no nutrition service, no pharmacist, thin nursing staff, and absolutely no paper towel after hand washing-reusable handkerchief instead), but the unit is run very efficiently. NICU was ran by Dr. Hoang, an MD in Vietnam who earned her Ph.D. and MS degrees in Melbourne, Australia, then decided to come back to devote her service in Da Nang. I learned a lot from her. It was a very friendly environment to work with. They had a patient who passed away earlier that day due to unknown etiology. They also admitted a new patient with rare condition (CCAM). This will be a case presentation that I will help with later.
In the afternoon, I rotated through the ID department and topical disease ICU where I was able to examine patient with measles and hand-foot-mouth complications (meningitis, pneumonia, gastro-enteritis, dermatological findings, etc…) since I rarely see measles cases in the United States, let alone its complications. This is truly an opportunity to learn. Again, the trend of lacking resources were very clear: no disinfection, limited amount of alcohol hand-sanitizer, no true isolation rooms, triage rooms, and pressure rooms, multiple patient rooms (up to 6 beds per room in a hot-moist climate and contagious conditions). However, there was completely no complaint from the patients or family members at all. It’s because there was limited room for the patient, parents must stay in the hall way. I ended the day with two consultations for ID service in the inpatient ward and ended up to transfer one of them to the ID service with dx of HFM disease.
Thursday: I started the day at 7:15AM sign-out at ID department, joined the morning report (which talked more about updating current issues within the department). Then, I participated in a discussion about antibiotic use and antibiotic stewardship by the head of the department. After the meeting, we continued to see patients, wherein I had a chance to directly participate and contribute my own assessments and plans to the care of the patients. Again, the majority of cases were HFM diseases with GI and pulmonary complications. Despite limited resources and crowded setting, the environment was very supportive and friendly.
In the afternoon, I joined an inpatient ward with Respiratory team. They saw a great amount of pneumonia that was oftentimes treated with a broad spectrum antibiotic. Although patients seemed well in appearance, many of them remained in the hospital for observation. I also had a chance to chart-review a case with suspected pulmonary TB for which I have learned a lot. I also participated in admitting patients who have been admitted from the ER or urgent care clinic.
Friday: I participated in continuity/urgent clinic as a provider. I have seen at least 20 patients in one morning. Their conditions ranged from mild viral symptoms to testicular hydrocele, to ASD. The criteria to be admitted to the hospital is not very stringent, we ended up admitting about 5 patients.
In the PM, I spent time at the Heme/Onc floor where I had a chance to deliver IT treatments. They were still using Fralle 93 trial in comparison to COG trial in the U.S. The head of the department admitted that they were trailing the world in cancer treatment perspective and also acknowledged that their successful rate was not high, but changing the system will need time and they were actively doing so. The Heme/Onc floor was a very busy ward with about 30 patients (both heme, blood tumor, and solid tumor patient). They also carry the most complicated general ward pediatric patient with only 4-6 nurses at any time (2 of them Heme/Onc nurse), it was an extremely challenging task to take care of all of them. This lack of resource, especially in a Heme/Onc ward truly touched me; I felt overwhelmed and sadden with this as I love Heme/Onc and took everything for granted with the U.S. condition. At the end of the day, it made me appreciate very much of what I have and what we can do for our patients in the U.S.
Sat: off day
Sunday: Attended a national conference regarding Updating on Diagnosis and Treatment of the Most Common Pediatric Diseases.
Monday: I started the day by attending the sign-out at 7:30 AM on the 11th floor where the Heme/Onc, neurology and nephrology housed. It was a very quick sign-out that mentioned only the most severely ill patients. Then, I participated in the morning report and M&M session at the pediatric department. Then, I returned to the Heme/Onc work-rounds where I was able to examine several patients being actively treated on the floor with ALL, Wilm’s tumor and HLH. This service had 60 patients with about 5 doctors and 12 nurses. I was able to see the sheer amount of work that they have been doing, an amazing work. The patients were seen very quickly and labs were ordered at the same time. There were rarely any questions from the family members, even when they are asked if they had any questions.
In the afternoon, I participated in teaching the new interns at the NICU floor. I also examined new patients who were admitted to the floor. One of them had HIE and asphyxia but since we didn’t have body cooling technique, the patient was treated with conventional supportive care and hoped for the best. The full-term baby was to have a much better prognosis if she was born in the U.S., something for me to think about.
I also briefly met up with the Newborn Vietnam coordinator to exchange ideas about the whole project and what I had in mind. The conversation gave me some thoughts about how to start future affiliation with the hospital and possible project that we, as partners, can contribute to help caring for the pediatric population in Da Nang.
Tuesday: I spent the whole day in the PICU where I started the day attending sign-out with the overnight team. There were some patients with diagnoses that I had never seen in the U.S. One of them was beriberi (due to Vitamin B1 deficiency). The PICU was a 30-bed unit that could easily exceed to 45. There were mixtures of multi-level severities from severe pneumonia and brain damage that required mechanical ventilation to cyclic vomiting that outpatient did not feel comfortable to handle, hence, the child ended up in the PICU! I volunteered to participate in some of the patients’ care. I also had a chance to come down to radiology department to read a head CT for a patient with periodic fever without an infectious focus. I was able to admit a child with intracranial hemorrhage induce seizure. Amazingly, I saw my classmate from the U.S. She traveled to Vietnam for a volunteer mission and accompanied the child to the hospital due to his illness; what a small world!
Late afternoon, we had a child with tachycardia (280 per minutes). Due to lack of resources, the PICU did not have synchronized cardioversion nor IV adenosine or procainamide. Their protocol in handling a tachycardia case was so much different compared to PALS. This difference really surprised me.
Wednesday: I started the day in the NICU, participated in the work rounds. After the department report at 8:30 AM, I gave a talk about common pediatric dermatological disease and terminology. The talk was in English since it was an English club. Then, I continued to follow-up with the patients that I saw the day before in the PICU and made rounds on some more patients in the NICU. Then, I joined other residents on consultations at the newborn nursery with various issue such as hyperbilirubinemia, skin conditions. I was able to go over some common neonatal findings with the residents.
In the afternoon, I visited the ER department for the first time. They see about 150 patients on average daily in which approximately 2/3 are pediatric (the rest are obstetric patients). There were fairly low acuity conditions that they see. All they had were 3 pediatric beds, 2 OB beds, 4 waiting beds along with 4 thermometers, 1 monitor, 1 ventilator, 1 used crash cart with 1 malfunctioning defibrillator, 2 pediatricians, 1 pediatric surgeon, 1 OB/GYN doctor and 4 nurses. Most of the patients came for fever and mild injury. A lot of the patients were admitted for monitoring in the hospital. It seemed that the criteria for admission were fairly low.
Thursday: I started at 7:30 AM in the urgent care clinic where I have seen more than 20 patients in one morning. The patients had mostly viral syndromes and some complications of pneumonia. I started to write prescriptions but did not have the right to sign them. Most of the patients had health insurance and were asked to go home on some medications regardless of their health condition. I spent a lot of time consulting patients with management protocol about antibiotic usage and medication use. I spent about 4-5 minutes per patient which was a longer time compared to other physicians (1-2 minutes).
In the afternoon, I joined the newborn team to participate in a WebEx teaching session about newborn skin conditions taught by a professor from Scotland. After the teaching, I ran a small workshop on medical English and terminology with the residents. I also taught the residents with skin findings and terminology that were most commonly found in pediatric population.
Friday: I took half of the morning off to start on a QI project in which I will collect opinion from patients and family members so that the department can apply some changes to improve the services. I also had a meeting with several senior doctors of the departments and talked to them about issues that they were facing in the hospital. Then, I had a meeting with the chair of Foreign Affairs office to have the Affiliation Agreement signed by the Director of the hospital. They asked for my help in translating some educational training document provided by a group of doctors from Texas University. I agreed to help.
In the afternoon, I conducted the first phase of my QI project starting from the ID department. I collected the data and discussed with the head of the ID department. The findings were included in the final report that I submitted to the leadership of the hospital.
Sat & Sun: Off days. I had several meetings with the doctors of the hospital and discussed about other projects that I planned to do.
Monday: Follow recommendation from several doctors at the hospital, my wife and I had a chance to visit several other hospitals in Da Nang by motorbike in the morning. As Dermatology is one of my interests, we visited Da Nang Hospital for Dermatology which has about 100 inpatient beds. The hospital was not as overcrowded as other places, partly because dermatology is not a huge health issues compared to others. Most of the patients were adults, and most of the treating conditions were infectious and venereal diseases. The hospital is very small compared to the Women and Children’s Hospital. It was quite old but still functional as the main referral place for skin diseases around Da Nang and the vicinity.
The second hospital we visited was Da Nang’s Center for Hematology-Oncology. It’s a brand new hospital (2 years old) with a state of the art of its kind compared to Vietnamese health standards. The infrastructure made me think that the place was in a developed country rather than in Vietnam. However, the hospital was clearly functioning below its own capacity with only about 1/2-1/3 number of beds filled. Most of the patients were adults with solid tumors. There were a small number of pediatric cancer patients that referred here from around the Central Region of Vietnam. I met a 17-year old patient with ALL and was returned here from Saigon’s Center of Hematology-Oncology since the family did not have enough money to pursue treatment there. In this facility, his family was only required to pay 20% of the cost. Thanks to the health insurance system similar to MediCal in California.
The third hospital we visited was the famous Da Nang General Hospital, the oldest, most skilled but most crowded, and most visited by international organizations (including Kaiser Permanente). It was in the central part of the city (other hospitals are about 4-7 km from the central area of the city). Due to the extreme heat of mid-day, the overcrowded and on-going acute gastroenteritis, I left the hospital in about 20 minutes, feeling exhausted.
I returned to the PM shift in the PICU totally drained and dehydrated. I asked to leave early after updating the parents of a patient with infantile spasm, the plan and recommendation from UCSD’s neurologist, and observation of a case with respiratory failure due to pneumothorax and post-op complication. The respiratory distressed child later became extremely critical and died that night. I left the hospital not knowing if I can return tomorrow.
Tuesday: In the morning, I continued to complete my QI project at the NICU department where I had a chance to interview about 20 family members who were currently in the NICU. All of them highly commend the NICU and the staff. They absolutely were happy with the whole process and suggestions for improvement. I, then, discussed the findings with the staff and the head of the NICU, Dr. Hoang.
In the afternoon, I helped one of the residents with her case presentation, which took place the next morning report on Wednesday (in English). We spent about 2 hours to practice and revised her PowerPoint presentation. Then, I participated in the NRP training session which Dr. Hoang presented to the nurses and the new interns. The NRP training was the first lesson of the series of 5 lectures and workshops. The session started with a pretest, then, Dr. Hoang lead the discussion and lectured the first lesson. The training was modeled after the AAP and AHA 2011, which was the most updated version of its kind.
Wednesday: I returned to the PICU in the morning where I continued my QI project. I interviewed about 12 family members who also rightly commend on the service they received in the hospital. One minor thing that they would love to change would be the number of caregiver each patient was allowed to enter the PICU ward at a time. Currently, they are allowed to have 1 visitor/caregiver at a time due to high rate of nosocomial infection.
In the PM, I came to the respiratory unit (inpatient) ward to continue my QI project. I was only able to interview about 7 people. The rest of the time, I spent helping diagnosing a case of chronic cough which I suspected whooping cough. The respiratory unit was a busy place; hence, the rating here was not as good as the ICU wards. People mainly complained about the thin staff and low action when their children needed help. At the end of the day, I was able to exam a couple more patients and review some of the treatments options for pertussis with the residents.
Thursday: I was back at the urgent care clinic in the AM to continue on my QI project, at the same time, I was able to consult and examined more than 15 patients. I loved it since it gave me more time with each patient and it helped establish trust from patients and their family so that I may continue on with questions for the QI project.
In the PM, I was at the respiratory inpatient unit to follow up with one of the patients who I suspected to have whooping cough yesterday. The child continued to do well with the current treatment but his lung sounded rougher with copious amount of secretion. I also helped examine and consult several more patients; one of them with suspicion of pulmonary TB infection. I, then, joined the asthma clinic of the unit where the physician sees about 10-15 asthmatic check-up patients. Most of their parents do not know the significance of asthma and the importance in using the correct medication to control their symptoms. Hence, I volunteered to consult those parents and emphasize how critical it is to have those symptoms under controlled.
Friday: I volunteered to help a group of U.S. physician from University of Texas Medical Branch to translate at the Ob-Gyn conference held at the Da Nang Children of Women and Children. The topic was mainly Ob-Gyn, but I learned a lot about prenatal care and post-partum related medical issues. The conference also helped me establish networking with many doctors in Da Nang (both Pediatric and Ob-Gyn) and U.S. physicians who were interested in Global Medicine like I do. Translating medical language at this type of setting gave me a very different experience. It augmented my medical language skill. They also organized a dinner at one of the most famous restaurants of Da Nang, for which my wife and I were able to attend. I truly enjoyed our time there.
Sat & Sun: Off days. Worked on my last talk (PPT presentation); my final report of the QI project and set-up some field trips to visit the pediatric surgery cases at the Rehabilitation Center of Da Nang.
Monday: I spent the whole day on the 10th and 11th floor where the Heme/Onc and General Pediatric wards were housed. I continued my QI project which I interviewed about 15 patients and family members about the care they have been receiving. Most of the parents were pleased. Several of them were concerned about the issues of overcrowding and nosocomial infection rate. I spent a significant amount of time consulting several leukemia patients whose parents had a lot of questions regarding prognosis and treatments.
In the afternoon, I continued to visit several more patients both in the General ward and the PICU. I also spent some time talking to the residents about fever without origin diagnosis. I had a chance to go over the CT scan from one of the patients who suffered from extreme headache that was undiagnosed for days. This time, with the help of the CT scan, the family was glad that sinusitis was the diagnosis.
Tuesday: I was invited to the graduation ceremony of a Neonatal nursing class. This was a special class, an inaugural class that was totally funded by foreign organizations and taught by the British Canterbury Christ Church University’s faculty and teachers. The class consisted of 26 fully trained neonatal nurses who underwent 18 months of training and workshops. They were the “most expensive nurses of Vietnam”, per Dr. Hoang, since the total funding was extremely high in Vietnamese standards. I was able to meet and speak to many leader figures of the City of Da Nang and the city’s Department of Health. I also met with the Dean of Faculty of the CCCU, the coordinator of the famous Newborn Vietnam Foundation, and the acting British Ambassador to Vietnam, Mr. Giles Lever. We ended the ceremony early afternoon. I decided to spend the rest of the afternoon working on my QI project, summary report, and finishing up my last PPT presentation, which I delivered the following morning. Late that PM, I was invited to the nurses’ dinner to congratulate them on their graduation. This was also a good-bye dinner to me for some of the doctors depart for training in Saigon and won’t see me on Friday.
Wednesday: I started the day in the NICU at 7:30 AM for morning rounds. I, then, gave a talk at the department’s sign-out, my last talk of the rotation. Then, I split up my time in the private wards of the hospital and the PICU. The private ward houses, the more affluent population who can afford to pay out of pocket to stay in a better environment, less crowded and with a working air conditioner. The severity of the patients was not as high as other pediatric wards but should the patients’ condition worsen, they will be transferred to other wards. I continued to then follow-up with the infantile spasm patient in the PICU. His condition was deteriorating, but he was still able to be extubated. I talked to the family for long while before heading out to lunch with the bad feeling that he won’t ever recover from this condition. This sad feeling stayed with me for a long, long time. I felt that we did not do all we can for this child!
In the PM, I worked at the pediatric GI inpatient unit. They had just discharged a large population of patients hence most of the patients were AGE or hepatitis, no severe cases. I spent the majority of the time discussing about the GI cases and the difference in disease etiology compared to the U.S. and was able to learn about tropical pediatric GI conditions. I visited a young child who was from the highland of Vietnam with umbilical herniation and jaundice along with the symptoms of hepatic failure with unknown etiology. I planned to return to the unit to follow-up with the child when all the lab test results came back.
Thursday: A busy day! I started the day at 7:30 am in the Urgent Care clinic seeing some patients before attending the training/workshop in nutrition in pediatric population, the instructor was a doctor from Saigon; her name is Do Thi Ngoc Diep, the director of the Nutrition Center of Saigon. She was trained in the U.S. and Australia, and one of the famous people of the field in Vietnam. I learned so many things from her 2 lectures in the morning. I spent lunch time trying to see some of the patients that I have been following in the past couple of days. I would like to say good-bye to them before I left Vietnam.
In the PM, I drove to Da Nang Rehab Center to meet up with Dr. Thanh, an orthopedic, to visit some of the cerebral palsy patients. My hope was to scrub in for the OR but there was no pediatric case during the week. I ended up examining 12 pediatric patients with “cerebral palsy” which the doctors usually call them. I answered lots of questions from the parents to the best of my knowledge. The Rehab center was recently re-innovated but they still lack lots of necessary tools of an orthopedic center. I am not an orthopedic surgeon but I can see very clearly the need of the pediatric population is enormous but the center can only provide so much.
My day ended with a small party that the infectious disease and the PICU doctors organized to say good-bye to me. It was an honor to have this party! I know I will miss them a lot.
Friday: My last day of rotation– a strange feeling just like the first day when I started 4 weeks ago, but my heart filled with friendship and hospitality that I received from the hospital’s staff and doctors. Time flies really fast! In the morning, I saw several patients at 7:30 am and then attend a small breakfast party that the NICU organized to say good-bye to me. The NICU also gave me a small Buddha’s status carved from a stone from a local mountain! I felt very touched! I gave my QI project report to Dr. Hoang and also presented my findings about the NICU to the NICU department.
The rest of the morning, I attended the part 2 lecture about nutrition at the hospital. Then, I had lunch with the lecturers and the new Nutrition Department head, Dr. Linh. I, then, spent the rest of the afternoon saying good bye to everyone, every floor that I have had the chance to work with. They were all very friendly and gave me the family-like feeling. I felt so honored and fortunate to be able to work at the hospital in the past 4 weeks. Upon my last meeting with the director of the hospital, Dr. Vinh, he gave me the good-bye souvenir that bore the symbol of the hospital. He told me that I am always welcomed here! My last day ended with a dinner with Dr. Hoang, Dr. Ngoc (International Affairs), and the nutrition lecturers from Saigon. I said good-bye to them, then back to the hotel to pack up, ready for my flight to Saigon the next day and then to Seoul. I will be back to the States next week. I can’t wait to tell people about my experience here!