By Cesia Quintero (MEDS 2020)

In June and July of 2017, a cohort of six first year medical students from Queen’s University conducted a month-long observership in Vietnam and Cambodia. The goals of the trip were to provide the students with a valuable clinical experience and exposure to Global Health, and to establish connections that might expand the availability of Global Health experiences for future Queen’s medical students. We also hoped to explore the possibility of creating unique partnerships with overseas institutions that would boost the global profile of Queen’s University.

We examined a Neurocysticercosis patient at NIMPE

 Overview

The bulk of our two-week Vietnam stay was at St. Paul’s Hospital in Hanoi, Vietnam, where we had a chance to observe in a variety of departments, including ICU, ER, Pediatric Infectious Disease, Pediatric Cardiology, and Endocrinology. Our visit was initially sponsored by the director of the Endocrinology department at St. Paul’s, and throughout our stay we managed to make good connections with several other physicians, including the director of the ICU. All of these physicians expressed interest in a similar arrangement next year. We also had a chance to have a one-day observership at the National Institute of Malariology and Parasitology (NIMPE), where we saw patients with parasitic infections that we would not have an opportunity to see in Canada.

The connections we made in this portion of the trip allowed for the possibility of more in-depth observerships at NIMPE in the future, and for expanding this opportunity to the National Hospital of Tropical Diseases. We also made connections that could allow us to similarly access the health system in the Lao People’s Democratic Republic.

During our Cambodia stay, we spent one week at Battambang Provincial Hospital, which is one of the larger provincial hospitals in the country, and at the Pailin Referral Hospital, a very under-resourced hospital that serves 75,000 rural residents. We quickly learned that Battambang Hospital routinely hosts students from Australia and the UK; during our stay there, there was a group of four medical students from the UK and 22 nursing students from Australia. Both the coordinator for foreign students and the director of the hospital indicated that they would love to form a relationship with a Canadian medical school. In Pailin we became closely acquainted with the Deputy Minister of Health of the province, as well as with the director of the hospital, and several department directors. At both Cambodian hospitals we spent our time in the ER, Pediatrics, Labour and Delivery, and OR.

Clinical Experience

Battambang Surgery Observership

In all of the hospitals, our role was strictly that of observers. The physicians who oversaw us facilitated a learning model in which the goal was for us to begin to recognize common signs and symptoms and gain first-hand experience with positive findings. Our activities consisted of observing patient care, impromptu mini-lectures from supervising physicians to illustrate relevant findings, and non-invasive supervised physical examinations. We were introduced to patients as foreign medical students by our supervising physicians, and in Battambang by our medical translator. We found that it was very helpful to point to our student IDs and highlight the word ‘student’ whenever it seemed that a patient was mistaking us for a doctor.

Throughout the day we did a lot of research on our own to answer any questions that came up. We found that having the ability to observe the same patients multiple times a day, several days in a row, was a huge advantage, as it allowed us to observe the progression of disease and treatment. For example, we had the opportunity to follow a patient with diabetic ketoacidosis from his admission to the ER to the ICU, and his eventual passing away, at each stage observing and researching the changing signs and symptoms, treatment efforts, and reactions from his family. We also found that seeing so many positive findings and performing so many physical examinations on actual patients greatly increased our confidence and clinical skills. Depending on our setting, we had the opportunity to observe a variety of procedures, including intubations, central line placement, wound care and debridement, deliveries and surgeries.

Managing Impact

A former soldier was awaiting a toe amputation in Battambang

In all of this, we strove to be mindful of how busy and overworked the physicians were, and to operate by the principle that no patient experience or outcome should be negatively affected by our presence; if possible, we tried to be a positive presence for the patients. We are proud to say that we honestly believe we were able to live up to this goal. By separating into small groups, rotating departments frequently, and being independent learners for the majority of the time, we were able to avoid being a major burden to hospital staff. We also respected patient privacy as much as we could. Nevertheless in all hospitals there were a number of patients to whom a group of foreign students was an exciting event, and there were many occasions in which we thought our presence had been beneficial to a patient’s experience or outcome. In Battambang, a former soldier and his family burst into tears after some of us gave him a very respectful greeting in Khmer language; they said they had never received so much respect from someone in a white coat, and this was very meaningful to them. In Hanoi, we were able to comfort a very anxious ICU patient by listening to her heart several times a day when the physicians did not have time to attend to her emotional distress. There were multiple emergency situations throughout in which physicians borrowed our stethoscopes and other equipment, such as during a failed intubation.

Pailin’s TB ward houses both patients and their families, who don’t have protective equipment.

It was in the understaffed and under-resourced Pailin Referral Hospital where there was the biggest opportunity for us to be a beneficial presence, and where one of the most impactful experiences of the trip took place. I went to check in on a TB patient who was faring poorly, and found that the physician on duty had not looked in on her for several hours. When I arrived, there were no nurses of other staff in the ward. She was alone, struggling to breathe, and her family was very distressed. I immediately phoned her admitting physician, who arrived minutes later. Nasal cannula were the only available tool to provide oxygen, but luckily we had a rebreather mask with us that could be connected to the oxygen tank. There were no monitors to keep track of her vitals, but we had brought a pulse oxymeter with us. When, despite the oxygen, her pulse and breathing stopped, three of us medical students were the only ones available to assist the doctor in performing CPR. The doctor himself would have been performing CPR without an N-95 mask if we had not been able to provide one to him.  Unfortunately the patient passed away despite these efforts, but we were satisfied that our presence there had afforded her a better chance, and that at least her family witnessed medical staff making their best effort to save their wife and mother, who would have otherwise died alone and without medical help.

Global Health Experience

Empty shelves at Pailin Hospital’s Outpatient Pharmacy, which serves 75,000 people

Due to the low-resource setting of these observerships, a lot of our learning went beyond the clinical. Both Cambodia and Vietnam are undergoing rapid economic development and demographic changes; the consequent epidemiological transition was highlighted time and again by physicians. We also witnessed the impact of patient crowding and severely exacerbated conditions due to lack of access. Particularly poignant were the struggles of physicians to provide medical care under extremely exacting conditions, such as limited resources and training, and political difficulties. We gained a better understanding of the multifaceted nature of these challenges, and of how difficult it is to bridge these gaps effectively. We also saw, however, that it is possible to make a difference. For example, we brought medical equipment with us that is currently filling some gaps at the Pailin Referral Hospital.

 Future Possibilities

With the director of Pailin Hospital. Fundraising efforts throughout the school year allowed the students to donate medication and equipment

While all institutions that we visited expressed an interest in hosting Queen’s medical students in the future, near the end of our trip the director and several physicians at the Pailin Referral Hospital requested a meeting with us. They wished to explore the possibility of a closer relationship with our university. There were a variety of areas for collaboration that were proposed at this meeting, including the possibility of hosting clerks and residents who, unlike us, might be able to provide medical assistance to patients while being exposed to new situations and gaining useful skills. The director and staff indicated that the most critical needs for the hospital are 1) diagnostic equipment, and 2) advanced training for staff. The only imaging available at the hospital is a rather outdated x-ray machine that generates fuzzy images. In terms of training, their most emergent need related to the management of diabetes. Due to the epidemiological shift, widespread diabetes is a fairly recent phenomenon in rural Cambodia. Nevertheless, Pailin Hospital physicians estimated that currently up to up to 60% of their patients have diabetes. They are very motivated to improve their knowledge of and experience with managing this disease at such high frequencies, and asked about possible training methods they might be able to access, such as online modules or intensive training by diabetes specialists.

In response, we took notes of their concerns and promised to pass them on to the appropriate stakeholders at Queen’s Medical School. We also began independent efforts to find a digital x-ray machine for donation, and continue to look for ways to support the development of this hospital.

Conclusion

The trip exceeded our expectations in terms of the quality of clinical experience and global health exposure that was achieved, the receptiveness of our hosts to continuing this project, and the possibility for future in-depth, mutually beneficial collaborations at the institution level.


 All photographs were taken for fundraising and educational purposes only, after obtaining informed consent from all parties.