March 19, 2024
Through the Mayo Clinic Global Health Program, David Turay, M.D., Ph.D., a trauma surgeon at Mayo Clinic in Minnesota, witnessed trauma care in Da Nang, Vietnam, in September 2023. In this article, Dr. Turay responds to questions about his participation in the program and observations at Da Nang General Hospital.
Dr. Turay traveled to Vietnam with other representatives from Mayo Clinic. On arrival, they divided into groups and spent time at Da Nang General Hospital, Da Nang Oncology Hospital, or Women and Children's Hospital. This trip reflected Mayo Clinic's larger humanitarian effort to foster cooperation, exchange and friendship with international institutions.
Here, Dr. Turay responds to questions about his observations at Da Nang General.
What prompted you to go on the Vietnam trip?
The program extended an invitation to participate in this trip partly due to knowledge of my prior volunteer work with faith-based international medical missions in Africa, Asia, and Central and South America. I saw an opportunity to join a team going to Vietnam to represent my institution and disseminate its core values abroad.
Why did Mayo Clinic Global Health Program go to Vietnam?
The program signed a memorandum of understanding during the September trip with three hospitals in Da Nang: Da Nang General Hospital, Da Nang Women and Children's Hospital and Da Nang Oncology Hospital. Over 20 Mayo physicians from all three of its sites encompassing 18 different departments and divisions were represented on this trip. The idea was to offer Mayo Clinic staff the opportunity to teach Vietnamese colleagues the knowledge and skills we have at Mayo through voluntary global health collaboration.
What was the setting of your Da Nang work, and how is trauma care structured there?
Da Nang General is a major teaching institution in a city of over 1 million people. Its capacity is over 1,000 beds. Absence of a trauma registry made it difficult to know the exact yearly trauma admission volume.
One morning at the hospital, I rounded with the trauma service. Four trauma admissions had occurred overnight, with severe orthopedic and traumatic brain injuries, and a patient with hemorrhagic shock requiring therapeutic laparotomy. I heard reports of patients with less severe injuries treated and released from the emergency department.
As in most developing countries, prehospital trauma care included a patchwork of few ambulances, often out of reach to the poorer masses. Da Nang General's emergency medicine (EM) physician team seemed well-trained in trauma care and resuscitation principles.
When a patient arrived, the EM team quickly assessed and determined injuries, then consulted with individual specialties to determine definitive care. The hospital admitted a patient with a single-system injury to the corresponding specialty. In noncritical polytrauma, the hospital admitted a patient to a specialty based on the organ or system bearing the highest abbreviated injury score or equivalent. For example, the hospital admitted a patient with moderate traumatic subarachnoid hemorrhage not needing ICU-level care and an ankle fracture to the neurosurgery service, and orthopedics co-managed the patient. The default service for all critically injured trauma patients was the surgical ICU staffed by nonsurgical critical care medicine physicians. There was no dedicated trauma service.
Gastrointestinal and visceral surgeons addressed abdominal cavitary traumas and assisted EM and ICU physicians in some major trauma resuscitations. The surgical specialties rounded on their patients in the ICU and established daily plans with the team there. During my visit, patients always occupied the surgical ICU's 40 beds, with over half the patients sedated and on ventilators.
What did you observe in Da Nang General's ORs?
I observed reasonable operating room (OR) access, even for unplanned or emergent cases. Each surgical specialty had a large OR suite that could contain up to three OR tables and overhead surgical lighting, all within the same space. It was intriguing to observe the looks on patients' faces as they rolled into the operating room suite and staff prepped them for surgery with a neighboring patient fully draped and undergoing surgery right beside them.
I observed junior and senior attending surgeons exchange information and advice while performing surgeries on cases beside each other. Despite this communal surgical space-sharing, physicians told me surgical site infection rates weren't dramatically high.
How did the healthcare professionals office there?
In every surgical subspecialty's dedicated floor, physicians, nursing and ancillary staff shared a large common office. Everyone sat around a long table with computers. The department chair sat at the head of the table; all junior attending surgeons, nurses and residents sat around it. I can't think of any more ideal way to have good communication among healthcare professionals, although it may not be ideal for private or sensitive conversation.
What trauma care did you observe?
I didn't observe a patient with severe injuries undergo trauma resuscitation. I visited patients in the ICU and other floors with intra-abdominal, chest wall, blunt renal, head and orthopedic injuries. The trauma patient who had a laparotomy required splenectomy and bowel resection, which occurred overnight.
The hospital admitted a young male involved in a motorcycle collision one night who'd sustained traumatic brain and chest wall injuries and severe road rash. I saw him with the team the following day. While rounding on the thoracic surgery unit, I encountered trauma patients with chest tubes and various chest wall injuries. I was surprised to not see any burn injuries, but I saw injuries in nearly all systems.
What are the biggest trauma care challenges you observed at Da Nang General?
The hospital always seemed at maximum capacity. It wasn't uncommon to see patients admitted in beds along hallways. The ICU had a 40-bed capacity with 100% occupancy throughout the week I was there. Imagine the daunting responsibility of the one critical care physician and about six nursing staff on call per day trying to care for that volume of critically injured patients. What was more amazing is they were doing this without written protocols or care bundles. The healthcare professionals there tailored each care plan to the patient's needs for that day, even on non-ICU floors.
From laparoscopic towers to CT scanners, most of their equipment was two or three generations older than what's used in the U.S. Thanks to their resourcefulness, they were able to provide amazing care with older instruments. I watched them perform advanced procedures such as laparoscopic-assisted thyroidectomies, adrenalectomies, and ureteral or renal pelvic stone extraction. One could imagine what these healthcare professionals would be able to accomplish with technology like we have in the U.S.
One need our Vietnamese colleagues expressed consistently was for more access to cutting-edge knowledge on management of trauma and other conditions. These healthcare professionals were so busy caring for patients that they didn't have time or ready access to such information. While the Advanced Trauma Life Support course principles weren't unknown to healthcare professionals there, no one's taught the course at Da Nang General. Of many talks and presentations I gave, a memorable one involved sitting with urology department members in a roundtable format discussing current concepts in urologic trauma management. They were engaged in the discussions and appreciative.
What hopes do you have for future Da Nang General trauma care?
Pioneers in global health have left us a rich legacy of what partnerships and cooperation with institutions abroad can do. I benefited from the hospitality and simplicity of my Vietnamese partners. There is tremendous potential for Mayo Clinic and Da Nang General to benefit each other in research collaboration, sharing patient outcomes data and learning about unique pathologies uncommon in U.S. hospitals. Sharing clinical protocols such as a ventilator bundle or sepsis bundle in Da Nang may allow us to observe their transformative and lifesaving potential.
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