I realise that I have been pretty slack
with writing blog posts, but here is my excuse: I have been spending the past
two weeks undertaking a student placement at Military Hospital in Hanoi, and it
has been intense.
Hoan Kiem lake, central Hanoi. Sunrise.
The hospital:
Military Hospital, otherwise known as 108
Hospital, was built by the French colonial government in 1894, originally to
serve their military. Since then, it has (obviously) ceased to be French
controlled, but maintained it’s military function over the various
international and domestic conflicts experienced by Vietnam from the 1940s to
1970s. Now, it is a huge hospital of approximately 1500 beds (and rapidly
growing) that is open to the general public.
Military museum, not Military hospital (I don't have any photos of the hospital as yet).
Overall, my impression of the hospital has
been good. The hospital currently has 7 students from the University of Sydney
undergoing placements (1 x 1st year medical student, 5 x 2nd
year medical students including myself, and 1 graduate nurse). The hospital has
been extremely friendly and accommodating to us and we really could not have
asked for more. They have even gone to the effort of taking us on weekend
excursions, which is much more than any of us expected.
The hospital is quite modern and well
resourced. There is a large 9-storey building at the front of the hospital that
contains the critical care and surgical departments. I have spent quite a bit
of time in there up in theatres and they are clean and well equipped. They are
making some efforts to prevent nosocomial infections, however this is mostly
limited to during actual surgeries and doesn’t extend to simple things like
regular hand hygiene on the wards.
Again, not Military Hospital, but also a large multi-storey building.
To be honest, the biggest differences that
I’ve noticed between hospitals in Vietnam and hospitals in Australia is not a
resource difference but a cultural difference. This is particularly marked when
it comes to pain management and patient interaction. In Australia we are very
mindful of the patient and his/her overall wellbeing. Several things that are
taken as a given in the Australian healthcare system (pain relief, reassurance
of patients, asking for consent before certain things occur, and even having
examinations, especially the sort that you see in gynaecology, done in rooms
without a queue of on-looking patients) are just not common-place in Hanoi.
I felt like I needed pain relief after watching this guy performing his morning exercises by the lake.
The placement:
My placement in obstetrics and gynaecology
lasted for two weeks (I’m spending the upcoming fortnight in the intensive care
unit) and I managed to see and experience a lot of things in that time. I can’t
possibly cover all of what I saw in this time, but I will attempt to cover, in
roughly chronological order, some of the things that made the biggest impact on
me.
Child innocently playing on old tank at the military museum. I wonder how aware the child is of the tank's history (former American tank captured by the Vietcong) or whether he is just awed by the impressive piece of military hardware.
Ovarian teratoma removal via laparoscopic
surgery: early in my placement (first or second day) I scrubbed in to two surgeries
during which I was asked to participate. The first was laparascopic removal of
an ovarian teratoma (if you don’t know what this is, google it and prepare to
be horrified). My job was to hold
the laparoscopy camera and make sure that the surgeon was getting a good very
of the particular areas of teratoma that he was cauterising and then excising,
which was all well and good until I saw something that you don’t expect to see
in an ovary: a tooth! Basically a teratoma is a tumour made up of tissues that
form from different layers of embryological origin (eg teeth, hair) that is
encapsulated and contained within an ovary. Whilst I knew that this was likely
to be there, I couldn’t help but react poorly when I actually saw it (I became
tachycardic, sweated through my scrubs, developed tinnitus and had to dismiss
myself because I was sure that I was about to lose consciousness). Altogether
extremely embarrassing. I attended several surgeries after that, including one
immediately after where I was asked to press hard on a breast abscess to
essentially drain it of pus like you would a zit. I didn’t have this problem in
any of the subsequent surgeries, so I’m hoping that it was a result of the
particularly disturbing pathology and not any sort of problem that will recur
during other surgeries.
National flagpole at the Military History Museum.
Breast abscess drainage: as mentioned
above, we had a patient with a breast abscess. She was a young lady who had
given birth to her first child 3 weeks earlier and subsequently developed a
terrible necrotic breast abscess that was starting to ulcerate through her
skin. She had some sort of heart problem (which I gathered through a range of
translations was probably Tetralogy of Fallot) so the anaesthetists were
reluctant to give her general anaesthetic, so for the actual operation she had
to lie there with just local anaesthetic to numb her pain. The operation itself
was like draining a giant zit containing about 400ml of pus and then removing
the necrotic fluid and inserting a drain. As if this wasn’t traumatising enough
for her, she had to have the site re-drained everyday that week, but instead of
having local anaesthetic she was given absolutely no pain relief and was only
under the care of one doctor and a dumb medical student (me). She was clearly
in absolute agony and I will never forget the look on her face. Never once did
she cry out or complain.
My first labour: on the Wednesday afternoon
of the first week I decided to sit in the delivery ward. It can be quite hard
to see a vaginal delivery when you are running around to different parts of the
hospital for surgeries and outpatient clinics, so I was hoping to see one that
afternoon. There was only one lady in the ward that afternoon, so I sat with
her for the during of the afternoon shift (about 3 hours). Again, she was in
agony with no pain relief. She was younger than me, and clearly scared witless.
She kept asking me whether I was worried about her baby, as her labour was not
progressing, the foetal head was not descending and the cervix would not dilate
past about 6cm (10cm is required for delivery). Due to the language barrier and
the fact that I’m only halfway through my degree, all that I could think to do
was hold her hand and comfort her. So, I sat with her throughout the whole
process until she was whisked up for an emergency c-section, hoping to just
provide a modicum of comfort during her ordeal. Interestingly, only staff and
patients imminently about to give birth are allowed in the birthing room. The
room is sterile and uninviting, and I think that it would be a horrible place
to be stuck in agonising pain without any human contact other than occasionally
having a nurse insert two fingers up your vagina to measure your cervical
dilation. I found this girl on the ward the day before she was discharged (3
days later) and was glad to see that both she and her little baby boy were
happy and healthy.
I'm pretty sure this is how you wind up in the obstetrics ward.
Vaginal deliveries: I saw my first vaginal
delivery with a male friend of mine, who seemed to be quite shocked by the
whole experience. I personally think that I have more right to be shocked, as
I’m the one who might have to do that one day! The first vaginal birth I
witnessed was during a night shift a week ago. My supervisor called me into the
labour room and asked me to measure the cervical dilation. When I inserted my
fingers I felt an entire baby’s head just sitting there, about to come out. I
said that much, and within about 10 mins the baby was born. What shocked me
most was the last minute (less than 10 seconds before the baby was delivered)
episiotomy without pain relief. This occurred during both of the vaginal
deliveries that I watched. No thank you!
Maternal haemorrhage and neonatal
resuscitation: On the final day of my placement I saw something really heavy
and distressing. I went to watch a c-section, and didn’t think much of it
seeing as it was my 6th and they had all preceded pretty simply
(except for one where the epidural failed). I had seen the mother receive an
abdominal ultrasound that morning that showed her foetus was sitting
transversely, rather than with its head in the pelvic cavity. Initially it was
business as usual with the pre-op prep and incision, however, when the surgeon
had been feeling in her uterus for the foetus for about 10 seconds (it usually
takes around 3-5) I started to worry. Then the mother started to haemorrhage.
She lost an extreme amount of blood, probably about 3 litres, and there was
blood gushing out of the incision, all over the patient, surgeons and floor.
The foetus was sticking his arm out of the hole, but the surgeon could not pull
him out using it because of brachial plexus damage. Eventually, after about 10
mins the surgeon managed to extract the baby and both baby and mother were in
critical condition. The baby had an Apgar score of zero, meaning that it had no
pulse, no respiratory effort, it was cyanotic all over, it was completely
flaccid and it did not respond to any stimuli. For several heartbreaking
minutes I watched my supervisor (the primary surgeon) try desperately to
resuscitate this poor little baby whilst his co-surgeon stabilised the mother.
Eventually, the baby emitted a feeble cry and started to breath and recover.
After about 10 mins the baby was doing quite well and was pretty much left to
his own devices (once being wrapped up in baby blankets) at the side of the
room. I stood there hawkishly watching him because I was worried, however
irrationally, that some harm would somehow befall him if he was left to his own
devices. Both mother and baby were OK. The mother was transfused 3 bags of
packed red cells and 2 bags of plasma. The foetus was taken with us back to the
ward whilst the mother was receiving her infusion.
Vietnam is an impressive fusion of new and old, beautiful and tragic. Here, the foreground contains objects from the Military History Museum, just a small vestige of decades of war, whereas the background contains old city walls, a relic of the ancient civilisation of Vietnam (first Kingdom established in 1010 AD).
Hanoi:
I won’t write much about Hanoi in this
post, as I feel that the city warrants an entire post, not just a footnote to a
post about my first two weeks of placement. Just briefly, Hanoi is an interesting and varied city and I
have had a great time getting to explore it past the level that most travellers
can experience when passing through briefly. I’ve found the food both rewarding
and challenging. It is rewarding due to the variety and the frequent pleasant
dining surprises, but frequently challenging because I don’t eat pork (on
principled grounds I prefer a vegetarian diet, but I’ve found this difficult to
maintain due to my endometriosis causing me to suffer from recurrent anaemia,
so instead I eat mostly vegetarian and eat meat meals when I feel like I need
them, but I seek out free range meat and totally avoid cruelty meats such as
pig meat, fois grois etc). One thing about Hanoi that has surprised me is the
bar scene and emerging alternative arts scene. My favourite place in Hanoi
happens to be hidden in some Brutalist Soviet-era warehouses just behind the
hospital. I will write more about it in my Hanoi culture blog post, but for now
here’s a link: http://www.wordhanoi.com/features/item/4085-zone-9
Modern Hanoi.
I will try to be slightly more regular with
blog posts from now onwards. I am aiming for one every 1-2 weeks, but this will
all depend on what I have to write about.
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