Saturday, June 4, 2011

Privacy and Personal Space, Gia Dinh Hospital, Ho Chi Minh City, Vietnam

Even in Boston I'm taken aback considering the experience of the sick, sharing rooms and experiences that are only making illness harder. The actively dying share rooms with the nearly well, and young, and I wonder if the thin curtain in the middle helps or hurts, if it would be better to just draw it back and share the spectacle of the illness.

In Vietnam this question has been in part answered for me.

When I'm told to see the patient in bed 42, I forget to ask a simple question: “Which one?”

Gia Dinh Hospital was build in the early 1950s, and has not been expanded since that time. A bed shortage forces patients to share beds, head to toe. This has been unfamiliar in the US since people stopped sleeping in the same bed in the 19th Century. However, I'm understanding more about the medical exam format note.

Most notes involved a general section, usually noted as NAD (no apparent distress), starting off the physical exam. 

However, the reason for this section dates back to when everyone worked in large open plan hospitals, where telling apart “a redheaded mustachioed man with a bandaged R arm” from the “redheaded mustachioed gentleman with glasses and a scar on the cheek,” would be your best bet to find the patient of interest among 30 other patients in a crowded ward with bed lined up against the wall.

So I've learned to ask for the bed and at least a few identifying features. At times this will include descriptions of a few family members who will volunteer extra information, and often spare the patient, no matter how well, the burden of telling the story, and will speak for them. 

We are surrounded by a gallery of spectators from the moment we walk in the ward, and they don't seem to want to disperse when we start the interview. Initially I asked if they were related to the patient. No, just passing the time. A family member may be down in the canteen, or having a smoke outside, but they'll be right back to help out.

So, two to a bed, every other patient and family member poking in, we start the interview. 

I'm surprised how much the bedmate, other patients, and other family members chime in when the patient has been interviewed many times before. They will describe if the patient was different yesterday, or what the last group of doctors has said. 
For a woman with likely bulbar ALS, her bedmate starts to share how the patient's husband has left her several months back, due to the illness. 

Once it comes time for the exam, and everyone crowds in to see as I push, pull, tap, prick, and walk with the patient, and much like the US, wonder what else I'll pull out my neurology bag.

Then, when we must speak with the family, and give the bad news, I'm left dancing, explaining that the damage is most likely in the brain and spinal cord, but shying away from the difficult discussion of prognosis. As you can see the subject of palliative care and end of life care is slowly being approached in Vietnam, and I am completely ignorant as to how to tell this woman that she will pass away soon. I promise to speak with the attending physician, to come back and check in. I take some small comfort in knowing she is not alone, that her children, and strangers sharing her bed and the hospital room will listen to her, and provide some of the comfort that we alway struggle to give as physicians.

Dan-Victor Giurgiutiu
Partners Neurology

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