Written by Hamad Zafar, DPM, PGY-2 at Kaiser Permanente Santa Clara Podiatric Surgery Residency Program while on Global Health rotation…
Written by Marshall Jex, DPM PGY2 Podiatric Surgery Resident at Kaiser Permanente, Santa Clara while on Kaiser Permanente Global Health rotation in Da Nang, Vetnam at Da Nang Orthopedic and Rehabilitation Hospital.
May 25, 2015 Day 1 – Triage
I am not sure I could have been prepared for a day like today. In anticipation of our arrival, the hospital lined up a group of patients to be seen. Each patient and their family patiently waited their turn in the hot, un-air conditioned hallway of the hospital to be seen. Each patient was then brought into a large room where their feet and gait were examined in a group setting. In the space of about 7 hours, I was able to see more complicated and extensive pathology then I had seen thus far in my medical career. From young children with deformities from cerebral palsy, to geriatric patients with long standing, untreated gout, each patient presented a new challenge. With only limited medical history/imaging available and with a language barrier, we were able to triage those who would benefit from surgery from those who could be treated conservatively. Although the clinic triage was very fast paced, we were able to keep tract of the patients with pictures and videos. Once all the patients were seen, the Vietnamese doctors put the surgery schedule together and arranged to have the patients report on different days for their procedure. It was a great start to a week of new experiences.
May 26, 2015 Day 2 – Surgery
This was our first day in the operating room. Our cases of the day consisted of a medial double arthrodesis, a percutaneous Achilles tendon lengthening for clubfoot, some forefoot reconstruction surgery, as well as some tendon transfers. The cases were interesting and set the stage for what would come in the following days. However, I want to focus on the interesting differences between how the operating room functions in Vietnam when compared to the USA. First of all, we operated in a room with two tables, so that at any given time, two people could be having surgery in the same room. The patients walked themselves into the OR. Regardless of the surgery performed, all patients were given spinal anesthesia. Although a conventional tourniquet was available, the surgical techs and the Vietnamese surgeons seemed to prefer the use of esmarch tourniquets. Despite the limited resources, the surgical techs were very helpful, knowledgeable, and resourceful with what was available. In order to have the hardware needed, it was necessary to pre-operatively look through what was available so that it was sterilized prior to the case. Intraoperative imaging was difficult to maneuver so most cases were done without fluoroscopy. Almost everything used for a given procedure (drapes, gowns, esmarchs) were saved, washed, or autoclaved so as to not waste anything. The preoperative area was one large room with the patients sharing beds and the post-operative area very similar. Although somewhat primitive, their protocols and procedures seemed to be effective in providing for the patient’s needs. I learned very quickly that I was in a place where resources were limited and nothing went to waste. It was a good lesson in resourcefulness and it showed me the value of using what was available.
May 27, 2015 Day 3 – Rounding and Surgery
The day started with rounding on our surgical patients from the previous day. This was a very humbling experience. There were anywhere from 6 to 10 patient in any given room. Some did not even have pillows to rest their heads on. Their families stayed with them in the hospital to care for their needs. Pain medication was very limited, yet the people seemed so thankful for the surgery we had done. It was amazing to see how people could remain happy in what seemed to us very difficult circumstances.
This was another day of firsts for me in the OR. Two cases stood out from the rest. The first case of the day was done on a 25 year old male who had been involved in a motor vehicle accident. He developed a compartment syndrome in his leg that led to a drop foot. This unfortunately led to early ankle arthritis and severe pain and difficulty with walking. In order to keep his foot in a better position, we fused his ankle joint with an arthroscopic approach. To our knowledge, this was the first arthroscopic ankle fusion performed in Vietnam. The second case was a 35 year old male who had been stricken by polio in his youth. This caused him to develop a severe cavus foot which made walking very difficult. This pathology is rarely seen in the United States due to the wide spread use of vaccination. In order to put his foot in a more anatomically appropriate position, we performed both a dwyer and cole osteotomy to reposition the bones. We also released the musculature and ligaments in the plantar aspect of the foot and transferred his posterior tibial tendon.
May 28-29 Day 4-5
Peppered throughout the last two days were many interesting cases, however the children who we were able to help seemed to bring the most satisfaction. We had the opportunity to meet a 5 year old boy who was born normally and was walking without problems until his leg was crushed under a cement wall that fell on him. This caused significant soft tissue contracture and caused his foot to be fixed in a plantar flexed position. He now had to be carried everywhere by his mother since he was unable to ambulate. His situation was difficult, but it was decided to perform a talectomy to allow his foot to be brought back to neutral. This was a tough decision to be made, but this would allow him to walk again with the use of a brace. Once the procedure was done, his foot was repositioned and casted. His foot will be stiff for the rest of his life, but he now will be able to walk. We saw him the next morning and with a smile on his face, he posed for several pictures.
Another boy I had the opportunity to help was an 8 year old boy with cerebral palsy and a severe scissoring gait. He would benefit from some tendon lengthening procedures. I had the privilege to tag team with a Vietnamese surgeon on this case. While he performed adductor and hamstring tendon releases, I performed gastroc recessions with posterior tibial tendon lengthening on both legs. This allowed his legs and feet to be better positioned and the patient’s mother was so grateful for our service to her son
All in all, my experience in Vietnam was priceless. I enjoyed getting up at 4 AM to run along the beach and meet the Vietnamese people as they exercised in large masses. I was able to see pathology that I may never again come across and arm myself with new and different techniques of performing surgery. I hope to be able to participate in similar missions or go back to Vietnam in the future.