Written by Andrea Bowen, MD PGY4 at the Kaiser Permanente Santa Clara OBGYN Residency Program while…
Written by Sai-Wing Chan, MD, PGY-4 at Kaiser Permanente Santa Clara Ob/Gyn Residency Program while on Global Health rotation at Da Nang Hospital for Women & Children in Da Nang, Vietnam in October 2017.
On 3rd Floor Labor & Delivery at the Da Nang Hospital for Women and Children, at exactly five minutes to nine o’clock in the morning, a procession of gravid women in turquoise gowns assemble outside a small linoleum-tiled room filled with three well-worn examination beds. The dozen women take their seats on a row of blue plastic stools. A few of them have the tell-tale signs- wincing faces and heavy, rhythmic breathing – that reveal the fact they are clearly in active labor. One by one, they hop onto an exam table, each face disappearing behind a swollen belly as they…
recline back and place each foot into a weathered metal stirrup, barely exchanging furtive glances with the woman lying adjacently supine just a few feet from her. Without a single curtain in sight, the concept of privacy during cervical examinations seems to be far from the mind of both patient and obstetrician alike. “9cm,” one young doctor states matter-of-factly to the nurse. His long white coat with short sleeves are a necessity in the humid, tropical climate of Da Nang. On his nearly bare feet he wears the same yellow plastic slippers as the rest of his colleagues- the mandated attire for all doctors and nurses on L&D. Changing his gloves, the young doctor instructs the laboring soon-to-be mother to walk to the next room in preparation for delivery. She rolls off the bed and shuffles off to the next room, stopping momentarily to brace herself on the paint-chipped door-frame as a uterine contraction sweeps over her body.
Da Nang is the third largest city in Vietnam with just over 1.3 million inhabitants, and is situated directly on the coast of the South China Sea. On an average day, the Hospital will have between 30 to 50 deliveries, 50% of which are by cesarean section. Six to eight hysterectomies are performed daily, and while only two years ago nearly all were completed through a traditional open abdominal approach, the surgeons now boast that 50% are now completed laparoscopically. The hospital building itself was originally constructed less than a decade ago as a 600-bed hospital, but ever-increasing demand for competent Western-style obstetric, gynecologic, and pediatric care has led to a daily census of between 900-1000 patients per day, with nearly every patient room being multiple occupancy. In the Antenatal Diagnosis Clinic, eight patients lie in beds situated around the perimeter of the room. Each woman with a high-risk pregnancy is attached to fetal heart rate monitors as she undergoes non-stress tests to assess fetal-wellbeing. In the PACU, upwards of 25 women, half of whom are lying skin to skin with their hours-old newborns, are cared for in a single, open room monitored by a small cadre of nurses. Everywhere I look, the hospital appears to be bursting at the seams, and yet it never feels chaotic; the providers never raise their voices, they maintain professionalism at all times, and rarely appear overwhelmed by crawling lines and hallways filled with patients and families who have made a day trip of coming to the hospital.
In the hospital’s operating rooms, all surgical drapes, sterile fields sheets, and gowns are reusable, a stark contrasts from most American hospitals where nearly all the same linens are disposable. All operative instruments and devices, including laparoscopic trocars, light handles, and bovie electrocautery pencils are also autoclaved and recycled- a common theme I noticed all throughout my trip. In fact, the only single-use items on the sterile field are the sutures, scalpel blades, and laparotomy sponges. As I learned to carefully conserve suture by exclusively performing instrument ties (as they did), the Vietnamese doctors would good-heartedly chuckle, “American tie!” whenever I left the tail of a knot longer than a couple centimeters. Even empty plastic saline bottles were reused as sharps containers. On my day off one weekend touring the countryside by motorbike, my guide pointed to a small, paint-chipped canoe tethered to stilts propping up an old fishing hut as we passed by a lake. “B-52 bomber,” he explained, wrapping on the hull of the boat with his knuckles- a relic from and sobering reminder of that gruesome War in which an estimated 1.3 -3 million Vietnamese lost their lives between the 1954-1975. In Vietnam, regardless of the setting, it seems that nothing here is wasted; anything and everything can be repurposed to suit the needs of its next user.
During rotation at the Da Nang Hospital for Women and Children, I had the privilege of working alongside local Vietnamese obstetrician-gynecologists and caring for underserved patients in Central Vietnam through observing, assisting in, and performing various gynecologic and obstetrical procedures, including laparoscopic cystectomies, total abdominal hysterectomies, open myomectomies, and cesarean deliveries. I also had the opportunity to teach some of the trainee physicians through case-based learning and lead a hands-on workshop on minimally invasive surgery techniques using a laparoscopic box trainer.
Observing the patient care experience in Vietnam and learning about the practice of Western medicine in resource-poor, high volume settings through often-broken dialogue was challenging but certainly a highlight of my global health elective, but I also left with a newfound appreciation for certain luxuries of practicing medicine in the United States. I developed a profound admiration for the dedicated physicians whose long work hours often extended into their own homes, where they would regularly see patients after completing their workday within the hospital. I had an immense respect for the patients who would travel from far away to receive care, and would undergo nearly all abdominal surgeries under spinal anesthesia- never once crying out in pain, or showing any signs of anxiousness that so many of the patients that I normally care for experience (understandably) when going under the knife for the first time. I was impressed with the resourcefulness and culture of waste-lessness evident in and outside of the hospital setting, which will certainly give me pause next time I call for that extra suture.
As I prepare to enter the next phase of my career after residency, I am so thankful to have had this perspective-changing opportunity afforded to me by the Global Health Program. I hope that in the not-so-distant future, we might be able to one day reciprocate and host a medical resident from Da Nang at Kaiser Santa Clara, strengthening the relationship between our hospitals, and opening up greater opportunities for cultural interchange in our shared experience as Women’s Health providers.