Imploding an OR

All of us came to the hospital early our last day to do a few cases and wrap things up. On the way in, I noticed a few crowds of nurses out on the balconies, probably just starting their shifts. You can see how large the hospital is.















Everything was done at about noon and we began to tally, check-list, clean, toss, and disassemble all the parts. My two anesthesia colleagues were remarkable at helping, especially given that they had never done this before. Their abilities and their energies were an inspiration to me during both of my weeks in Quang Ngai. I feel I have made four incredible friends.

It baffles the mind to see the equipment balloon out of these many boxes, many of which are filled with "soft" supplies that we leave, and then to repack what is left at the end of the trip back into the Pelican boxes. We came with 28; we leave with 16. The biggest job was Frankie's, but we all chipped in where needed to get it all done.











































The lunch man arrived with our daily food, as he always does, making sure that we all got something to eat. The meals have been good and they brought great veggie meals for me.





Being the lightweight, I really have to choose which meals I am going to eat; usually two out of three a day. Any meals that were left, Phi took out to the families to have something to eat while they waited. She is an amazing charity of one!






I caught this photo of the local OR crew just after lunch. It seems to be everyone's habit to take a nice siesta after lunch, and we were left surrounded by a very empty recovery room and operating unit. The room next door was full of napping women, but the blinds had been pulled and I would have had to use a flash.













The afternoon after we packed was the first real daylight we had in Quang Ngai. Wendell, Frankie and I took a long walk looking for a street market we had seen last Saturday on our way out of town to Hoi An. We couldn't find it, but did make our way into a Buddhist Temple. A delightful young man showed us around, and gave us incense to show respect to the various shrines they had inside. It was one of those wonderful, unexpected, random and spontaneous moments in another culture that can make a trip so memorable.

After the temple, we made our way to a supermarket to buy a few items, and then made our final trek back to the hospital to get the boxes loaded. We borrowed a guerney to get the 16 boxes onto a truck for the journey to Da Nang, and while we were waiting, we saw a nurse carry out two tiny twin babies. The young father had an expression of both sheer delight and wary apprehension. It is a daunting moment that no parent every forgets, and Frankie caught it perfectly in this shot.













The twins each had a piece of tape on their foreheads to tell them apart. They were both so quiet, but very well-looking. This appearance of new babies at the operating doors had been happening all week, as there is a busy OB service here.

We took a taxi home, hot and tired, and got a drink to take up onto the 7th floor balcony. In the heat and humidity, we spent awhile looking out over a city we knew from up close, and finally got to see from a more overhead perspective. We could see the stunningly high mountains to the west, with the sun setting behind them. The ocean lies to the east, and except for the East-West flip, is a setting not unlike Southern California. It is an odd city for us though, full of motor scooters, thin small buildings, and funny top floor porches and gardens.

Next came the traditional party given by Resurge at the end of each trip to thank the hosts and local co-workers. We had this in our restaurant at the hotel and about thirty people showed up, including a couple of local officials. Everyone made speeches and then the drinks began to flow, especially for the locals. Vietnamese like to party!

Of course there was dancing, karaoke, group photos, and certificates. Most of our important players made it there, and we got to recognize them for their contribution to the effort we all made here. A job well done by all, and a party to show for it.

Intensive scare

The wireless here at the hotel is quite a piece of work. It comes and goes, gives us five options that may or may not take us to a connection, and when we call the desk to complain there is a fire drill of hustling clerks playing musical chairs, calling someone on the phone, smiling and explaining in Vietnamese, and suddenly there it is. Sometimes I see 4 out of 5 bars, but most of the time it is 1 or 2 and my computer is not happy. So the blog limps along...

Also at odds with the blog are some long days - Thursday night went until 10pm with a sick child, but more on that later...

I love our walk into the hospital, because we can peruse the city and see how the people function from day to day. We are getting pretty good at dodging motor bikes, which unlike some cities I know, do their best to gracefully dance their way around us without hopes of carnage. Sometimes we see signs that look funny to us, but I'm sure they sound and mean something totally different than we think.
















Our Vietnamese surgeon, Dr. Tuong, is our barefoot doctor. He slips off his blue plastic slippers and keeps his feet cool on the OR floor. Also shows a level of confidence that he won't get too much bleeding. His assistant had cute socks with on spot for the great toe and the rest of the sock for the four little toes. So many cute details when you look closely.


















One little two year old patient had a very gnarly cleft which involved both sides and left a central island of gum, lip, and bone. These are so strange to look at and condemn a child to a lifetime of inability to eat or speak correctly, as well as the cruelty that comes with being different. You can see the transformation here, and the look on the mother's face as she sees her child's repair for the first time. It is a moment we all treasure.

































Thursday was cataract day at the hospital, and I enjoyed seeing these two men sharing their post-operative bed. They were laughing and talking and having a good ol' time, and after I caught this photo, they gave me a big chuckle and a wave.













Our very capable Vietnamese anesthesiologist, Dr. Thinh, sitting on his sandals to have his lunch. What a great idea!





















We had one child keep bleeding after a palate, and he even had to come back to the operating room for a touch up. He kept oozing later, and just looked like he was working too hard to breath. We worked with him for awhile, and finally decided that going up to the dark ward with very little attention was not going to be safe. We had him transferred to the intensive care unit, and there he stayed for the night. But I have never seen anything like it in my life.

Twenty-eight or so patients, five nurses, and one doctor. The doctor was kind enough to give us a bit of a tour of his patients, which included enough critical and complicated medical problems to scare even the most seasoned of us. Many of them had a breathing tube in, but not to a ventilator. Only a lonely thread of plastic with oxygen made its way to hang into the end of the tube and give that vital boost to what looked like an otherwise dire situation. The bed with a lady's feet you see in the foreground, perpendicular to the others, was an older woman who was ashen and barely breathing. She had a can of Ensure at the head of the bed next to her, and was intubated with an endotracheal tube going to room air. I'm not sure if this is Hospice care, if she is waiting for a bed space, or being transferred to a room. Probably not, with an endotracheal tube, but no one is watching her, so why not?













Our dear intensivist to the rescue. Our little guy did very well under his care, and was fine by morning.

Floods and pests

The streets in Quang Ngai and even throughout Vietnam are fairly homogeneous. The sidewalks in Quang Ngai are not paved, but inlaid bricks that we pay a lot for in the States to landscape the yard or build a small walk. Each morning the little shops that line the streets throw open the doors and spill out onto the street. Most of the time this requires pedestrians to walk around the cafe tables or stuffed animal displays, but sometimes it even requires a step down into the street, which results in a symphony of horns and beeps from cranky motor bikes. The variety of stores is impressive, but most often a store simply offers a variety of items, from phone Sim cards to newspapers, gum, clothes, toys, and fruit.














These store fronts are actually home fronts as well - most of the shop owners seem to live upstairs. If you look in the way back of any shop, there is a stairway going up. The balconies over the stores have birds in cages, hanging laundry, potted plants, and sometimes a staring face watching the passer-bys. Some of the buildings even have three stories, but even with this added space, the living area must be small as the buildings are not very deep.











The "gift shop" as we call it is a store at the ground level of the hospital. It is mostly items related to an admission - cots, covers, packaged food items, and a variety of colorful plastic bowls and tubs.












Most of the patients we see are accompanied by the whole family - who clearly participate heavily in the care of their family member - and there are usually 4 beds in a room, spaced about 18 inches apart. The frames at the ends of the beds have hanging laundry, and it appears each family shares the one bed allocated to their patient. There are of course no electronics to entertain but everyone seems quite happy together. The beds have no railings, no matteresses, there is no nurse call button, and no one uses sheets or bedding - just woven mats over the slatted bed frame.

Once a patient hits the operating room, all hands are on deck. Everyone swarms the table and gets the patient immediately to sleep, usually with one provider hugging and reassuring in some way while the rest attach monitors and ready supplies.












I wish I had more personal stories to share about the patient histories, but at 13 cases per day, it is pretty much a dash to get a patient safely tucked into the recovery area and then ready the table for the next patient. One thing that is sometimes a problem is that the area where the patients must wait for us is around a corner and not staffed with a nurse. We have our two support people, Catherine and Phi, who do a great job getting the patients' arm bands on and getting the charts ready to go. Our pediatrician, Alice, does a great job getting the patients screened and putting out medical fires. But it is not a safe place to give pre-medications, so often the younger patients do not like leaving their families with these strange looking aliens. As each patient leaves, the others left behind get more bug-eyed than the last as they listen to the receding wails, and this behavior crescendos throughout the day. We are working on solutions, but it is a difficult scenario of concerns to balance.

Meanwhile, back in the OR, we have our own balancing act. I put up little signs and reminded each person about moving cell phone calls to outside the patient care area. It seemed to work, as our Vietnamese colleagues are so very eager to please and do their share. I hate to be the mom and post the notes, but for once it has seemed to work. Are my sons reading this?!! ;^)











Another issue burst our way - flood! A hose behind the scrub sink outside our room burst and gushed under our surgery door to one side and our supply room to the other. The sinks are large free-standing units that can be moved around, with attachments to a water source not unlike our sinks at home have under the kitchen cabinets. But the water source is about a 1 1/2 inch pipe, so the volume of water that can come out is quite torrential. Within minutes, there was about an inch of water around the sink, and a make-shift levy of towels around the OR. The handy man of the OR, who has helped us periodically with structural, electrical, and technical difficulties, came running to the rescue and turned off the water. Meanwhile, cases continued unabated, and the clean-up and box-moving began.



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Sweet letter from Thao, our first nurse helping with anesthesia. She is going to be a hard act to follow.














Dr. McClure demonstrating one of his techniques for helping add symmetry to these very difficult noses that result from repairing a cleft lip. We are getting many patients who come in for a revision after prior closure of the open lip. That first step of closing a cleft lip gets the teeth covered and makes it possible to later repair the palate, but often flattens one side of the nose. The nose is not very forgiving with its framework of cartilage pieces, and fixing one is a challenge.











Usually both tables finish about the same time at the end of the day, but today one case went a bit longer and the Vietnamese team took over. Dr. Bill worked on the patient's nose, and Dr. Tuong revised the lip. It was fun to be able to step back and see the all-Vietnamese team hard at work, using the Resurge model.













Clever tips are coming my way from my colleagues here. Kwuong shared with me his ingenious way of using the face mask as a funnel to fill the machine's CO2 absorber with granules.












And no trip is complete without a visit from some kind of animal. Frankie got a nice surprise as she was moving bottles around, and when she jumped back, we thought she had gotten an electric shock from the sterilizer and been thrown off her feet. But she stood pointing, like Dicken's ghost of Christmas to Come, and there scurrying around the bottles was a moving clothespin. This was the Cadillac of Cockroaches, the King of Krud, and here he was at our feet, looking for somewhere to hide. I tossed a glass to cover him and just got his legs, so Bill rearranged it and enabled me to get this picture. Our brave OR cleaning lady just grabbed it up in her hand with a paper towel, and as she walked past us all, the people parted to give her a wide berth. All I remember Frankie saying was, "They have a spine!" Made me think of Peter Lorre, "It's alive!" What is it about cockroaches that makes us so squeamie?

The team morphs

Mondays are the same everywhere. Get up, get dressed, and wonder where the weekend went.

This day brought us a surprise - we lost four people Friday and Hien leaves Tuesday, but we got three new workers. The bad news - they didn't show up until their 14 hour train ride from Ho Chi Minh City ended and they made their way to the hospital. While we waited, we started off the day working with Dr. Bill on two tables - doing his paperwork and pointing him where to go, and he went simply from one case to another with no down time. It is not as fast going as two tables running simultaneously, but almost.

Up we got and headed for breakfast. We have found a corner at the hotel dining area with a long table that accommodated us all, and we sat and got some techie computer time while eating needed calories for the morning's work. The connection was not always great, but enough to check our email and read the news.

Frankie, Wendell and I left a bit early so we could take a detour and see a street market we drove by Saturday morning. We took a left where I believed the driver to have come out. Wendell and Frankie followed loyally, but I bet their eyes were rolling the farther we walked. Wendell got his photo of himself with a Sacramento newspaper in front of a buddhist monastary. We made a couple of turns, got pretty close to the hospital, but not quite there.

We passed a small table of school-age girls, sitting with their mother. They were all giggling to themselves and staring at us (I am getting used to this), and as we passed, one girl reached out with one finger and quickly touched me, like forbidden fruit or "tag - yer it". I'm sure it was to show her friends how brave she was, and they all laughed. I stopped and held my hand out to her, and she showed me very large eyes. She slowly reached out and she let me shake her hand, so tiny and very tentative like a butterfly. We made eye contact and I couldn't help but smile, and walked away. I could hear gasping and tittering behind me. Close Encounters of the Quang Ngai Kind, and I'm the alien.

We finally asked and got a direction to turn at the next street. We did that, but still nothing familiar. So we stopped at another spot - a young group at a table together outside a cafe ("Ca-phe`"). Lots of people sitting at sidewalk tables today. I asked where the hospital was, and they looked at me like I was a Martian. More alien complex coming my way. Wendell, thinking on his feet, pulled out his stethoscope and imitated a nurse. All four of the people simultaneously swung their arms east and pointed down the street. I guess they got the idea! Off we walked and made our way - finally - to the operating room, only about 10 minutes late. Dr. McClure was very calm about it, but we were all in a sweaty huff and ready for some air-conditioning and recovery time!















Nice surprise when we arrived - ANTS! They invited themselves into our storage and food room, and were trying to picnic in our food. Luckily most things were wrapped, and with a bit of clean up they made their way back outside. If that is the worst invasion we have, we will count ourselves lucky.















Soon after we started, one of the two operating lights (Frankie's pole) went dark. Presumably a new light bulb needed, but no way to find out except to dissemble the thing. It isn't until one begins to handle an apparatus close-up and in detail that the intricacies and innovation can be fully appreciated (sorry for the sarcasm). I presumed an outer glass casing came off to access the bulb, and began to try to unscrew the rusty screws. Only two of the three would budge, and then I noticed the whole glass casing would twist off. So I put the screws back, got the outer layer off, and by now our local "bio-med" guy had arrived and he replaced the bulb. Luckily that was all there was to it; problem solved. I think I threatened his job security though, so I will have to be more helpless next time.

A couple of people have mentioned how safe they feel here. I have to agree. I don't know what it is, but I had no qualms about walking anywhere. The town is fairly homogeneous in terms of neighborhoods, and these people are very family oriented. Except for the gaggles of guys we saw at restaurants now and then, smoking and talking, most people were with families or had children along. No one was really interested in us except when they were amused or inclined to give us a greeting.

Someone also commented on a photo I posted with a young father and child. Dr. McClure had mentioned earlier that it seemed so very family oriented here. The fathers were very involved, and the parents clearly dote on the children. I asked one of our co-workers if she had any children, and those around her laughed and said, "She's not married!" I guess that is the only time anyone has children; very different expectations. The government encourages having no more than two children, and most families seem to comply. The men did seem very gentle and it was difficult to envision any of them at war, but at the same time I could see how if their homeland or especially their families were threatened, that they could be very fierce.

This young child was done early in the morning, and I realized as I passed the recovery room a bit later that she was being held by a young man. This boy, at 17, was the responsible family member for his sister. His mother was sick at home, and although his aunt was with him, his sister could only be consoled by him and he was there to do just that. Many of these families are very poor, but they are rich with family bonds and the right priorities.















One of our helpful Vietnamese scrub techs had a moment of fame - her pants fell down. I have not heard so much giggling and squealing since slumber parties in 6th grade. Her friend came to the rescue, and made it right.















Our new crew members finally arrived. They came straight from the train station after 14 hours of train travel and jumped into the mix. This photo was taken of the two new anesthesia providers - nurse Khuong and Dr. Thinh. We were doing our best to pronounce their names, but there are so many nuances to the language that one can only hope to keep the mangling to a minimum. But I wahs starting to fehl at home whith the extrah lhetters.











These team members had some English skills, one of them even understandable. But we managed and I wrote lots of teaching points down so they could see the numbers and read the words. That seemed to work better.












I did have a complaint - they all had cell phones that rang all the time, and they answered no matter what they were in the middle of doing. This was the same in Africa and China. It was kind of annoying, and I certainly felt that what we were doing in the OR was more important than any call. But we tried to observe and see how things were done by the locals, as long as no patient was harmed or neglected. As much as they answer phones, they don't do paperwork. Different ways. Here is a photo of an all Vietnamese host team - scrub tech, surgeon, and nurse anesthesia.













Nurse Khuong...













Setting a good example - Dr. Bill helped with turn-over. He's a keeper!















There was sometimes confusion among patients who come to see us as to what procedures we could do. Some women came right out and asked for cosmetic procedures. A mother may bring in a child who has already had procedures, wanting a small tweak to make something look better. But usually what we offer is to improve function, and although the surgeons try to use the most aesthetic approach, function trumps appearance. We are doing quite a few nose-lip revisions for those who may have had a lip repair done in the past that pulled apart over the ensuing years, and these are in a sense more cosmetic, but do make a big difference in the lives of these young people.

Frankie is always the last one out - doors glued shut with an official paper, lights out, and a lonely dark walk down the operative suite corridor.

It has been a long day. This is about what time we arrived "late" this morning, and now the sun has been long down.













As I walked out, I noticed the many dark hospital corridors above us with the lights shining from the rooms and the shapes drifting along in front of them. Even the lobby was quite dark; often the hospitals use very few lights to save electricity. This is common in many of the places we visit. Electricity is a luxury, and is used sparingly; as is everything else. We have much to learn from our host countries.















I didn't go down to dinner, because I lay down in my room, my legs said, "Yes!" and I decided R+R would win over food. Monday was national Health Care Providers Day in Vietnam, and the hotel honored us with some flowers, of which Frankie sent me a photo. Nice touch!















Frankie is tired. She said her feet hurt, but then she realized her shoes were on the wrong feet...












But we forgive her - she is really a one-woman band!

http://www.youtube.com/watch?v=uXMuWi0dUBc

Enjoy.