On October 19, 2009, a team of American clinicians boarded the first flight in their journey from Newark, New Jersey to Dali, Yunnan, China. The team, lead by Dr. Cary Chiang, consisted of three emergency physicians and three emergency nurses from Hackensack University Medical Center, in Hackensack, New Jersey, U.S.A. Together with a medical team from the Dali Oriental Women’s Hospital, in Dali, Yunnan, China, they would form the first joint American-Chinese outreach program in the Dali area.
Dali is located at the southern tip of Lake Erhai, approximately 197 miles (317 km) west of Kunming, the capital city of China’s southwest Yunnan province. Many small villages are nestled in the mountains surrounding Dali. These are some of the poorest villages in all of China. There is limited access to health care, and when available, the people are unable to afford to pay for treatment.
Many years ago, Dr. Chiang learned of the circumstances of the people in this region through a charity run by a relative. This charity, the United Mom’s Charity Association (UMCA), headed by Chun-Hwa Cheng, works closely with the local Chinese government to identify villages in need of support. In addition to providing money to build adequate schools and sponsoring individual children, UMCA also raised money through the Coin Foundation. The Coin Foundation is an American charitable organization founded by Dr. Chiang and his wife, Julia Chiang, to purchase supplies to bring a health care outreach program to these villages. Without the cooperation of the local Chinese governments, and the funds provided by these charitable organizations, this mission would not have been possible.
With the money donated by UMCA and the Coin Foundation, the Dali Oriental Woman’s Hospital purchased medications for the mission. The hospital is a private facility in Dali that works with the local government to provide healthcare. Patients can receive both inpatient and outpatient care, and the doctors practice both Eastern and Western medicine.
The American team had very little information about what to expect once in China. There was no advanced contact with the Chinese team, so the itinerary was not known. Despite the fact that Dr. Chiang had toured the region two years prior, there was no specific information regarding what kinds of medical needs the people had, making it impossible to know what kinds of supplies to bring. No medications could be brought into the country; instead, the Chinese medical team would provide them. Due to their familiarity with the local patient population, Dr. Chiang deferred to the Chinese team to choose the types of medications to bring on the mission.
CLINICAL DAY 1: Drug Rehab facility, Lian Tien Shang, Binchuan County
After two days of travel the teams drove to the first clinical site at a drug and rehabilitation facility in Binchuan County, Yunnan. The state-sponsored facility, which has received donations from UMCA in the past, was located apart from the local villages. With so many unknowns, and no experience to guide them, the local police brought a small group of patients from the local villages to be seen by the doctors. This allowed them to have control over the number of people that would be seen at the clinic.
The Dali team set up a small pharmacy and provided the American team with prescription pads written entirely in Chinese. They also provided a list of all the medications available in the portable pharmacy, written both in Chinese and English, but many were unfamiliar to the American clinicians. After a quick survey of the physical layout, the American team broke down into three doctor-nurse teams, with one translator to share between them. Despite the fact that Dr. Chiang spoke Chinese, he still needed assistance with unfamiliar medical terms and with understanding the local dialects. The language barrier was the most significant challenge. The Chinese team stood back while the American team started seeing patients.
As the first patients arrived, there was confusion among the American teams regarding the role of the nurses and doctors. Not knowing what was expected, the teams obtained blood pressures, pulse rates and performed thorough assessments including lung and heart sounds. After obtaining a history of the chief complaint, and performing a review of systems, the doctors prescribed any necessary medications by writing the number of the medication from the pharmacy list on the prescription along with the number of pills the patient should receive. Patients then proceeded to the portable pharmacy to have the prescription filled.
After the clinic was closed and the supplies were packed up, the American team discussed what could be done to improve the process of seeing and assessing patients. Jane Burke, RN, drew upon her years of experience participating in medical missions in Haiti and made some suggestions. The lack of interpreters was the most important challenge to overcome. In her past experiences, each clinician was paired with a translator, allowing the nurses and doctors to each provide care specific to his or her role. Unfortunately, during this first clinic, the clinicians were tethered together due to the necessary sharing of the interpreter.
Overall, the team was encouraged and looking forward to the next day’s clinic armed with the first day’s experience.
CLINICAL DAY 2: Town Hall, Deju, Midu County
The second clinical day began with a two-hour drive up winding mountain roads. The view was simultaneously breathtaking and terrifying. The most impressive feature was the plots of farmland cut into the near-vertical sides of the mountains. Villagers could be seen maneuvering gas powered tilling machines up steep slopes and carrying the day’s harvest in baskets strapped to their backs or slung over poles balanced across their shoulders. The American team began to understand the physical nature of the lives these farmers led.
Once on location, the Chinese medical team went ahead and set up their own stations in the town hall, directing the American medical team to the stage behind them. Again, there was almost no communication between the two teams. The Chinese doctors began seeing patients, while the American team discussed whether or not they should follow the Chinese or Western customs.
The Chinese doctors performed very little hands-on physical assessment. They obtained a blood pressure and a pulse, and then interviewed the patient. Based on this, they rendered a diagnosis and prescribed medications if appropriate. The patients sat across a small table from the doctors and everyone remained seated during the interaction.
The American team discussed the benefits of conforming to the local cultural expectations versus practicing the hands-on medicine they were accustomed to. The team began the day using the Chinese format by sitting behind desks provided by the village, but quickly migrated out from behind them to be able to perform physical assessments. The nurses shared one blood pressure cuff between them since the Chinese team was using the ones they had provided the day before.
At one point, Michelle Kobayashi, RN, spent time in the back of the room at the pharmacy. She attempted to identify some of the unknown medications by looking over the packaging and the package inserts. While this was somewhat helpful, there were many mystery medications still on the list. A list of Chinese generic names was compiled with the intention of contacting the Hackensack ER PharmD for help with the list. Unfortunately, there was no way to contact him. The team was having difficulty with cell service, and they wouldn’t be returning to the hotel that night, so Internet access was not an option.
At the end of the clinic, the American team was feeling very unbalanced. The ever-present language barrier created a lot of downtime while the translator bounced back and forth between doctors, and the nurses were feeling very useless sharing one blood pressure cuff. In lieu of providing medical care, they handed out lollipops and small toy cars to the children. It was satisfying to see them smile and get excited about their treats. Soon, more children began showing up at the clinic. Once the clinic was finished seeing patients for the day, the American doctors also got involved with handing out the little cars.
Overall, the American team was feeling dissatisfied with the process. The nurses felt useless, and the doctors felt constrained by the language barrier. Again, there was no feedback from the Chinese team.
CLINICAL DAY 3: Courtyard of local government offices, Yilang, Midu County
After sleeping at a local inn, the clinicians began the morning on a friendly note. The different teams smiled and waved at each other, with face and role recognition now setting in. After breakfast, the teams travelled to the summit of the mountain to the local government administrative offices to set up another clinic.
Here, the physical layout of the courtyard made it so that all of the interview tables were lined up in a row down a narrow sidewalk. The American team was now set up directly next to the Chinese doctors. The American nurses pulled one table aside, and Michelle Kobayashi, RN, and Eric Kobayashi, RN, took turns with the blood pressure cuff, obtaining blood pressures and pulses, while Jane Burke, RN, brought the “triaged” patients to the next available American doctor. The Chinese doctors continued to perform their own blood pressure and pulse assessments
In this case, triage consisted of writing the name of the patient in Chinese on the prescription pad, which was done by one of the support staff from the Chinese team, as well as obtaining and documenting the blood pressure and pulse rate. Once the name was obtained, there was no need for the nurses to have a translator. It was relatively easy to convey to the patients the need to expose their upper arm for the blood pressure cuff.
As time passed, the triaged patients were also brought to available Chinese doctors. Without intending to do so, the American team began to develop a patient flow process. At the end of the day, this system seemed to work better for the American team. The nurses were performing a function appropriate to their role, leaving the American doctors to focus on obtaining histories, physical exams and prescribing treatments.
Overall, the American team was more satisfied with the care they were providing. Dr. Chiang discussed the new system with the Chinese doctors, and found that they also appreciated the triage being done before the patients arrived to their station. The new process was significantly more efficient and better utilized the skills of all of the clinicians. It also utilized skills from non-medical support staff. Through this cooperation, the clinic served approximately 60 patients.
CLINICAL DAY 4: Hospital, grounds, Pingpo, Yangbi County
Due to illness, one of the American nurses was unable to participate in this clinic. The teams drove to a village nearer to Dali, unfortunately arriving later than intended and in the middle of market day. The streets were so packed with people that the vans could not get to the local hospital site where the clinic would take place. The teams ended up walking a short distance, and carrying their supplies with them.
Here, the physical layout lent itself to the newly discovered triage and flow system. The hospital had a porch, where the pharmacy and the doctors were set up. The parking lot in front of the hospital was large enough to support a queue of people who were signing in for treatment. The American nurses brought a desk down in front of the stairs that descended from the middle of the porch. Someone from the Chinese team sat nex to the nurse and wrote the patient’s names on the prescription papers. The patients checked in, were given a prescription paper with their name on it and told to stand in line to have their blood pressure taken.
Once triaged, the second nurse took the patients the middle steps to the doctors. As the crowd grew, a second nurse was needed to keep up with the demand for blood pressure screening. With two nurses triaging, the number of patients ready to be seen exceeded the number of doctors. Five chairs were placed in the parking lot area next to the triage nurses to allow the patients to sit and wait their turn to be seen by the next available doctor. However, without the third American nurse, the flow of the patients was interrupted when no one was available to bring the next patient to the next available doctor.
For a short while, Jane Burke, RN, was going back and forth between obtaining blood pressures and acting as a “flow nurse” by bringing the patients to the doctors. One of the Chinese nurses was not busy during this time. Michelle Kobayashi, RN, invited her to take blood pressures, and then took over the function of “flow nurse”. By this time, there was an orderly process of moving the patients through the system: (1) obtain and document name, (2) obtain and document blood pressure and pulse, (3) place the patient in queue for the next available doctor, (4) have the patient see the doctor and obtain a prescription if appropriate, (5) have the patient obtain prescribed medications from the pharmacy.
This system was the most efficient way to provide care to a large group of people. It was able to handle surges in volume without disrupting the process, and the patients and staff seemed equally satisfied, with approximately 300 patients being seen over the course of 5 hours. As the day progressed, the nurse administrator and the owner of the hospital also participated in the role of “flow nurse”. They were able to help the patients move efficiently from the queue to the next available doctor.
Overall, the two separate teams started to blend together to better serve the local villagers.
CLINICAL DAY 5: Marketplace, Tuanjie, Yunlong County
Now that both the American and Chinese teams were comfortable and satisfied with the patient flow process, the day began in a much more organized fashion. With all three American nurses present, the desks and chairs were arranged to provide space for taking names, obtaining blood pressures, queuing for the next available doctor and for the doctors to interview the patients. The pharmacy was set up to the side near a point of egress to allow for a logical flow of patients from one area to the next.
Again, the teams arrived to the village on market day, and large amounts of villagers arrived to seek care. Prepared to handle surges in volume, triage nurses got immediately to work and began moving patients through the system. During this clinic, the teams began to refine their processes. The local government was able to provide additional translators, which allowed Dr. Monica Hernandez and Dr. Michael Kane to work independently instead of sharing the same translator. Due to the prevalence of local dialects and minority languages, a third translator was provided for Dr. Chiang.
The surges in volume began to outgrow the two-nurse triage system. At this point, the Chinese nurse administrator and hospital owner took over flow, while all three American nurses performed triage. The volume was such that the nurse administrator moved patients from triage to the queue, and the hospital owner moved patients from the queue to one of the six doctors.
It was truly inspiring to see the Chinese nurse administrator begin to make improvements to the flow process. At one point, she moved the person taking names from between the triage nurses to the side of the triage nurses. This stopped the confusion regarding which lines served which purpose. The person obtaining the patients’ names was now explaining to the villagers where they should go and what to expect. This made the movement on the lines more orderly, and prevented patients without prescriptions from wasting time standing on the wrong line.
Overall, both the Chinese and American teams were beginning to function as one. The process was practical and allowed each team of doctors to practice medicine according to their own customs and training. The joint American-Chinese team saw approximately 600 patients over four hours, making it the largest clinic of the mission, without losing control of the crowd.
The remainder of the trip was spent visiting sites where UMCA had donated funds in the past. A clinic was attempted at a local leper colony, in Eryuan county, but due to cultural superstitions and taboos, only a limited clinic was provided by the American team. It was much more informal and did not employ the patient flow process used on the previous days.
In June 2009, the patient flow process of the Emergency Trauma Department at Hackensack University Medical Center was revised. The medical, nursing and bedside ancillary staff (nursing assistants and technicians) worked together to reallocate resources to optimize patient throughput in the department. By creating a teams approach that optimized the strengths of each role within the department, throughput decreased, which reduced the average length of stay.
These same principles, when applied to the clinic setting in China, had the same effect as when applied to the emergency environment in America. The time spent on each segment of the patient throughput process was minimized, thus reducing the overall length of stay for each patient.
What started out as a loose arrangement of two teams with differing priorities quickly developed into an efficient process that streamlined the movement of patients. The system was flexible enough that it allowed for both Eastern and Western medicine to coexist in the same clinical setting. Without intending to do so, the Hackensack team used their knowledge of patient flow to improve the care of the Chinese patients.
By sharing their experience in patient flow with the Chinese medical team, the American team developed a system that met the needs of the practitioners, allowing the mission to be successful in providing care to as many of the local citizens as possible. In the end, the overall goal of bringing medical care to the mountain villagers of Dali was met, with the benefit of seeing a significantly greater number of people than the team had anticipated.
Farm plots on the side of the mountain. They say the Dali is blessed with fertile soil and cursed by topography.
Medical mission on the stage.
600 people came this day.
Me, Eric and Jack. Without Jack we would have been sunk - he was our translator throughout the trip. Miss you Jack!!