Dr. Miiri Kotche, faculty advisor for the UIC chapter of Engineering World Health, is bringing two students on a site assessment trip to Vietnam in March 2015, with the goal of building long-term relationships between the pediatric hospitals and our EWH student organization. Our student group is interested in developing biomedical solutions for low-resource environments.
EWH-UIC Bioengineering trip to Vietnam
Now that we are back at UIC and catching up on the classes and work we missed, we've had a bit of time to reflect on our experience and what we can bring back to the rest of the EWH-UIC group. Our group just had elections, and as the students begin to think about what we want to accomplish in the next year, we hope some of what we've learned can be the building blocks for future projects.
Hospitals are all concerned with infection control and preventing contamination, and Nhi Dong 1 and 2 Hospitals in Ho Chi Minh City and the Da Nang Women and Children's Hospital are no exception. We would like to help the hospitals address a need that they've identified as an area of concern by designing and building a laminar flow hood for medication mixing in an aseptic environment.
Being a part of IPSAC was extremely beneficial for us, because of their long-standing relationships with these hospitals, as well as being able to learn from the physicians and surgeons from across the United States. Many of these clinicians have contributed to many medical missions and have excellent ideas about ways our engineers can contribute.
In addition, this experience was incredibly helpful to us as we consider our future work as engineers. Engineering is an applied discipline where we design and build within a set of goals and constraints. We found that the engineers working in these hospitals, although limited in supplies and materials, are incredibly resourceful and are able to design simple solutions to address many of their needs using low-cost materials. Personally, I found this very inspiring. I look forward to finding ways we can connect and work with the engineers we met in these hospitals in the coming year.
This trip was one of the largest eye openers I have had in my education as an undergraduate student. It helped me gain exposure to a culture literally halfway around the world and a different angle on engineering.
It is one thing to sit in a machine shop and build something that I think might work in another country but it’s a whole different world of perspective to actually go to the country where the device is destined to be delivered to. There are many important factors that I would have missed had I not gone and visited the target locations of the potential devices. Factors such as functionality in high usage environments, expense of the materials, ease of access to replacement parts, complexity of usage, ease of construction to name a few. This insight will be a breath of fresh air to Engineering World Health as we begin to write the project proposals and begin construction on the laminar flow hood project. It will be an exciting year as the project progresses and I can’t wait to go back next spring to give the flow hood to the hospitals we visited so that they can start saving more lives more effectively.
Hẹn gặp lại lần sau Việt Nam!
See you next time Vietnam!
A view of Da Nang city (left) and ferry boat in Hoi An (right)
A Buddhist pagoda in Ho Chi Minh City
A Buddha idol in the marble caves of Da Nang
The psychedelic hues of Ho Chi Minh City, Hoi An, and Da Nang pervaded my senses. The animatedly spoken Vietnamese, delectable aromas of the local cuisine, the multicultural architectural feats, and the constant effervescent melodies of the mopeds all contributed to my fondness for Vietnam.
Hoi An, Vietnam
Aside from the kaleidoscopic cultural experience, I, most importantly, gained valuable insight into the labyrinth workings of the hospitals via my observations and my personal conversations with the medical staff and engineers. It brought to the forefront the many constraints we would have to work around including access to replacement parts, frequency of equipment usage, and local technician training. Furthermore, our observations allowed us a holistic view of the nuances of the habits, work procedures, and schedules of the staff, which we would need to take into consideration when designing and building to optimize usage of potential biomedical devices. This first-hand experience was constructive in allowing us to further our ideas into reality.
Our potential itinerary for the year includes attaining funding, writing proposals, and subsequently designing and building our device technology in collaboration with IPSAC and Vietnamese pediatric hospitals. We hope our efforts come to fruition by next spring!
Lastly, to my EWH cohort, the IPSAC contingent, and the Vietnamese hospital staff and denizens, who elevated this medical mission trip into an exhilarating experience, Cảm ơn!!
Hoi An, Vietnam
Until we meet again!
Our final day of observation was actually a spontaneous decision by our engineering trio. This day would be a short live demonstration of a pediatric surgery led by Dr. Mark Holterman. This was a wealth of information for us as we saw a GI catheter and got to observe a live surgery from the beginning.
After getting dressed into full scrubs upon our arrival we met in a meeting room with Dr. Mark Holterman to discuss a medical device known as a GI (Gastrointestinal) catheter. Dr. Holterman explained that when the device was inserted into a patient the operator of the device would then turn a screw on a pump to apply air pressure to the plastic stent at the end of the catheter. This allowed the device to clear blockages deep in the GI tract of the patient. Dr. Holterman then went on to explain that this system could cost an upwards of $1000 per unit. This was a product that that could very much be used in the pediatric sections of Vietnamese hospitals but couldn’t be implemented in their current states due to the current cost of the device. This could be another area of research that we could perform to develop a cheaper and just as effective device for gastrointestinal care in pediatrics and potentially beyond.
After being introduced to the catheter it was time for Dr. Holterman’s surgery. We were led into the operation room as we began to see the preparation for the surgery unfold. It was fascinating to see the setup required for a surgery including the hustle and bustle of all the nurses, anesthesiologists, surgeons and assistants. During the setup the nurses showed us a particular device known as an electrocautery knife which made incisions in the patient’s tissue. There were two types and they were going to use one of the two to start the surgery’s first incision with. One was a mono electrode cauterization blade that was less accurate but had a wider surface area for cutting. The other was a dual electrode cauterization blade that was more accurate due to the cut being between the two electrodes. For the first cut they were going to use the mono blade. But since it was a mono blade it meant that there was only one electrode making contact with the tissue. So they put the other electrode as a patch on the lateral side of the thorax of the patient. This allowed the mono electrode in the surgeon’s hand to complete the circuit through the body of the patient and cut the tissue at the contact area. After learning the operation of the device my next question was how the device was powered. The nurses then pointed to a about a two by two foot squared device that had leads sticking out of it. They said that this was the normal power source for this type of device but it didn’t seem to work. They then explained that this type of machine in the United States would normally have a price tag of around $10,000. However the day that we observed the surgery they managed to find a different power source. This power source originated from a $40 abdominal workout device that varied the voltage at certain frequencies. The power source would output voltages a certain frequencies to cause a vibrator strip that would be wrapped around a user to vibrate at the frequency that was set. Instead of connecting an abdominal strip for a workout they hooked up the electrocautery knife with a pair of alligator clamps that came from the voltage device! It was an amazing feat of resourcefulness that the Vietnamese surgeons and nurses put together to make up for the lack of a working power source. The next thing we knew the knife was working and allowing Dr. Holterman to make the cuts he needed for the surgery. It was jaw dropping to see that something that costs $40 effectively replace a $10,000 machine to do the same job. This opens large possibilities for us to design something of our own that can do a similar job but be easier and even cheaper to make.
The pump gauge (from a different model) (left), screw lock (right), and catheter full assembly (bottom pictures):
The $40 power source for the electrocautery knife along with the electrodes displayed (right):
After a day of exploring the Batman-esque caves of the Marble Mountains and the long-standing ruins of the My Son Sanctuary, we once again made a trip to Da Nang’s Women and Children Hospital with Dr. Mark Holterman to look at more equipment and its uses in pediatric surgery.
Marble Mountains in Da Nang, Vietnam
Prior to the pediatric surgery, we examined a Gastrointestinal (GI) catheter brought to the hospitals by the IPSAC team. The GI catheter is a thin flexible tube with attached air pump that can be utilized to drain or administer fluids in the GI system. Each of these GI catheters costs around $1000-2000 for pediatric patients and is disposed of after each use. However, due to financial and availability constraints, the few GI catheters the Vietnamese pediatric hospitals have are consistently reused and potentially prompt high infection rates due to lack of adequate sterilization.
Thereafter, we entered the Operating Theatre to observe Dr. Mark Holterman and the surgeons use an electrocautery blade to remove the scar tissue around the patient’s anal sphincter to allow more bladder control. Electrocautery is a process that utilizes AC or DC (alternating or direct current) traveling via an electrode, inducing the electrode to heat up. The heated electrode can be employed to remove tissue, often scar tissue, or facilitate hemostasis. There are two types of electrocautery, unipolar and bipolar: the former with one electrode and the latter with two. The unipolar electrocautery, with relatively less precision than its bipolar counterpart, along with a grounding pad, is used for a wide surface area. On the other hand, the bipolar electrocautery has far greater precision due to its two electrodes. The power source for electrocautery can be quite expensive, so the surgeons and engineers at the hospital had instead innovatively used a power source from a inexpensive workout device for abdominal muscles. The device allowed different voltage outputs at varying frequencies and was linked to the electrocautery via alligator clamps. It was impressively astounding to witness the surgeons and engineers at the hospital work around their financial constraints to create a unique and functional electrocautery system. I not only look forward to potential collaborations between our EWH students and Da Nang Hospital’s clinicians and engineers, but I yearn to glean their plethora of knowledge and work-arounds that has maintained and often enhanced their healthcare delivery.
Inexpensive power source
The difference between the Ho Chi Minh City and Da Nang was much larger than I anticipated. I was expecting very hot and humid weather and being drowned in the sounds of honking scooters. It turns out that the Da Nang city was a very calm place. It was certainly less humid and hot due to the close proximity of the river and Pacific Ocean. The population was about a tenth of what Ho Chi Minh’s which was the reason that the streets were much more peaceful on the way to our first hospital visit of the day. The first item on the day’s agenda was a meeting where Ai Holterman was awarded for her work in the hospital for the past few years. Soon after the award meeting all of us proceeded to the hospital’s NICU. Upon entry we noticed many similarities to the previous hospital’s NICU. We were then led to a storage room where they kept some working equipment that they would use for replacements. We then noticed that some of the machines were donated or made in Germany, Japan or the USA. Among some of the machines we noticed that they had many blue light LED lamps already in stock while there were many in active use in the NICU. While exploring their stock rooms we were led to their dialysis room. They told us that the dialysis machines were German in origin as we began to inspect how they worked. Directly adjacent to the dialysis room was the water filtration room for the dialysis machines. Here they had a large reservoir, the removable filter, and the robust piping system to carry the newly filtered water. After we had documented the dialysis systems we were escorted to Dr. Kotche’s next presentation room. On the way out we noticed their drug and electrolyte mixing room. It was apparent that they had the same problem as the previous hospitals because they mixtures were being made by nurses in the open aired environment. This was good news for the potential laminar flow hood project as it was becoming more evident of its need in these hospitals.
Shortly after Dr. Kotche’s presentation one of the engineers came up to use inquiring about our ECG boards. He seemed very interested in their operation and potential use with the existing machines. We then explained to him that the boards were only used for testing and potentially calibrating the machines that malfunctioned. Shortly thereafter the engineer took us to his office and showed us some of the projects that he had been working with. As we entered the room we noticed that much of what he and his team of four engineers worked with were mainly electrical problems with the equipment that had malfunctioned. We then walked over to a machine shop where some of the mechanical issues with equipment could be resolved. As we looked around the machine shop area we saw the garage sized unit that provided hospital wide air and suction supply.
After perusing the hospital campus we were allowed access to a surgery room for a quick look at the environment that the surgeons worked in. As the giant automatic steel door slide open we witnessed a very different quarantine like environment. There was a cold air in the room as the surgeons spoke among themselves while operating on their patient. We stood behind the main surgeon as he progressed with his work and we started to take a brief look and some notes of the operation room. With the five or so minutes that we stayed we tried to see as much as we could from our position in the back of the room. One of the main points that captured most of our attention was the advanced equipment beeping away as they monitored the patient. This essentially wiped away our preconceived notions of the hospital and its capacity to serve its patients. This was a fairly modern hospital with a very dedicated medical staff each of which were doing their best to serve the thousands of patients that entered the hospital doors every year.
Dr. Ai Holterman receiving a gift from the hospital staff:
We drove amidst a serene harmonious melody of sea sounds, ferry horns, and chirping birds to Da Nang's Women and Children Hospital early in the morning. The difference between Da Nang and Ho Chi Minh City were striking; the former emitted a tranquil aura, while the latter embodied an unconfined resounding vitality.
A glimpse of the Marble Mountains and the Han River in Da Nang, Vietnam
Upon our arrival at the hospital, we were graciously greeted by our hosts. Dr. Ai-Xuan Holterman was warmly welcomed with flowers and plaque for her outstanding contributions to the hospital.
Da Nang's Women and Children Hospital in Da Nang, Vietnam
After introductions and opening remarks, our bioengineering cohort took a tour of the NICU and the Operating Theatre at the hospital. The NICU was relatively well equipped with an array of biomedical technologies including dialysis machines, LED blue light lamps, CPAP, and incubators with some of the equipment donated. The NICU was sufficiently managed and despite the prevalence of biomedical equipment, there still existed a great demand for them. As with all of the hospitals we had toured, and hence observed, the number of patients greatly outnumbered the amount of biomedical equipment readily accessible which often led to co-sharing between patients. We further noticed, a phenomenon analogous with the other hospitals we had observed, that the Da Nang Hospital lacked a laminar flow hood or its equivalent and medications and TPN were compounded in an open-air environment. The lack of sufficient sterile environments to compound medications in the pediatric hospitals here prompts a growing crucial need for laminar flow hoods.
A nurse mixing TPN and other medications for NICU patients
An array of biomedical technologies
Da Nang’s Women and Children Hospital has a group of a few multifaceted engineers that troubleshoot all engineering-related problems at the hospital. It was a humbling experience to speak with the engineering team and I hope for future collaborations with them.
The Operating Theatre was our final tour site and just like the NICU, it was equipped with new and advanced technology, including the surgical lamps and the monitoring machines for vitals signs. We, however, observed that the low-key parts of some of the surgical equipment, such as tubes and wires, were constantly reused and held together with electrical tape despite sterility issues. Financial constraints and availability issues actuated the reuse of the equipment parts; this was another common phenomenon we observed in other pediatric hospitals.
Our day concluded with another rousing presentation by Dr. Kotche, which subsequently led to exuberant discussions amongst the surgeons, the engineers, and our team in regards to potential collaborative projects.
Dr. Kotche's presentation
The setting of Ho Chi Minh City’s streets resembled our activities for today, bustling and hypersonic movements coupled with resounding energy and excitement. Our itinerary for today was jam packed with lectures, tours, OR observations, and a flight to Da Nang, Vietnam. After observing the several procedures needed to compound TPN and other medications at Nhi Dong 1 hospital, we planned to visit the University of Medicine Pham Ngoc Thach and thereafter, the Nhi Dong 2 hospital.
We departed the Nhi Dong 1 Hospital and traveled like clockwork to the Pham Ngoc Thach Medical School where the Director of the medical school, several physicians, engineers, and other biophysics and engineering specialists welcomed us. After a rousing lecture presentation from Dr. Kotche and the subsequent enthusiastic discussions about future collaborative projects, we toured the medical school facility. I was pleasantly surprised by the simulation center, which boasts practice areas for pre-operational, operational, and post-operational care and also includes specialized practice areas for care for expectant mothers, neonates, and elderly patients. The highlight of Pham Ngoc Thach Medical School’s simulation center technology encompassed the presence of adult, child, and neonate sized manikins that mimicked many normal human characteristics including constant heart-beating, breathing, shivering, and blinking. Pham Ngoc Thach Medical School’s emphasis on providing improved training grounds for medical students and our focus on low-cost biomedical systems coincide in our collaborative goal to improve quality healthcare in Vietnam.
Pham Ngoc Thach Medical School
Adult, child, and neonate sized simulation manikins
Our last visit was to Nhi Dong 2 Hospital with a lecture presentation from Dr. Kotche for the pediatric surgeons, with an added bonus of the presence the hospitals in-house team of bioengineers. Our presentation and subsequent engaging discussion provided our team with a lot of possible ideas for future collaborations. The team of pediatric surgeons and bioengineers were not only kindly receptive to our potential efforts, but they themselves had seamlessly worked with the local resources and around the financial constraints to solve many of the hospitals biotechnological and biomechanical issues. When we took a tour of the NICU, we discovered that the team of seven bioengineers had made 2,000 blue light lamps for treatment of jaundice from increased bilirubin in a period of three years using locally sourced materials. In fact, it often seemed from our discussions and our observations of their resourcefulness that we had more to learn from them than they from us. I personally am enthusiastically expectant for an opportunity to work with Nhi Dong 2 hospital’s in-house bioengineers and the potential improvements our joint efforts and ideas can conceive.
Nhi Dong 2 Hospital's NICU
LED blue lights constructed by in-house bioengineers for NICU patients with jaundice
We concluded our vigorous schedule with a flight to Da Nang, Vietnam and were greeted with a tableau of the Han River and the Marble Mountains. It was a satisfying way to end the day.
Balcony view of the Marble Mountains and the Han River in Da Nang, Vietnam
Bright and early the next morning we returned to the same hospital as the day before because the hospital staff mentioned the concern of sterility in their NICU drug mixing rooms and they wanted to show us how they mixed. The next thing we knew upon entering the NICU we were snapping pictures and taking video footage of their process for drug and electrolyte mixing. It was quite a show as we watched the staff begin to mix the drug supply for the day. Nurses were flowing in and out of the mixing room with fresh syringes filled with electrolyte solutions and therapeutic drugs for the neonates they were looking over.
After the short observation in the NICU we all went to take a taxi to make a visit to our first destination of the day. We traveled to the nearby medical school to see the equipment and the environment for medical training. The medical school was a modern looking building that was full of surprises in every corridor. Our adventures began with a meeting where we gave our presentation to a few medical students and some of the staff. They were very happy with many of the things that were mentioned in the presentation and a particular interest was given to the laminar flow hood as they saw many advantages in its employment. Then we began our tour of the building’s simulation devices and the classrooms containing them. Our jaws dropped after entering the first few simulation rooms because of the technology contrast between the hospital and the world outside of it. The amount of detail and modularity of the machines was very similar to something that we would find in the United States. They had a very effective way to simulate many medical situations including suture, ear infections, child birth, acupuncture and even a manikin that would physically breathe, shiver, blink, and have an actual heartbeat.
Once we had finished our look around the medical school it was time to visit another hospital. In this hospital we also went to view their NICU facility. There were many similarities to the hospital from the previous day but there was one large difference. The bioengineers went above and beyond the responsiblities of normal technicians. With their small team of seven bioengineers they managed to build more than 2000 blue light neonatal lamps each costing about $500 dollars each! We were stunned at the work and progress that they had accomplished within the 4 years of their work. After speaking with the bioengineers about their work we got to see some of the equipment that they had built themselves and took note of their thought and engineering process behind their creations.
Shortly after leaving this hospital we boarded a flight to Da Nang where more adventures await our arrival.
Some of the nurses preparing durgs (left) and electrolyte solutions (right):
The medical school that we visited (Top) and a simulation manikin (bottom):
Here is some of the equipment built by the bioengineers:
The neonatal heater and blue light device (left) and one of the 2000 blue light lamps built (right):
On the third day of our trip with IPSAC, we traveled north of Ho Chi Minh City with a portion of the group to visit the Danang Women and Children's Hospital. We had a large turnout for our presentation, and we had a nice conversation about potential project collaborations. It's been incredibly helpful to hear perspectives of the caregivers here in Vietnam, as there are some things we never considered. For example, we learned that solar-powered cookers were given to some families in the provinces to allow them to cook rice, but since it is a rainy season half of the year, they are unusuable. In addition, the cookers are placed on the roof of the home, and we learned that it is difficult to position correctly to best capture energy from the sun, and the users have to scramble all over the roof trying to make sure the cooker works properly. We need to consider these issues as we continue development of the solar powered autoclave.
One of the very important opportunities we have had here in Vietnam is the chance to learn what the engineers at the hospital (if they exist) do. The lead engineer at Danang Women and Children's Hospital heads up a team of 10 electrical engineers and technicians who support all of the medical equipment, the HVAC, water filtering, and O2 system for the hospital, as well as other hospital infrastructure! The engineers are incredibly resourceful, and observing ways they addressed issues was very informative and beneficial to us. They built their own CPAP (continuous positive airway pressure) machines, rewire broken pulse oximeters, and many, many other workarounds.