2022 Report

 “They love a surprise” was a phrase used by Michael Dobbie early in the November 2022 (21Nov – 2 Dec) trip to describe the joy some of our Vietnamese colleagues felt when sharing some unexpected change of plan.  

Background and summary:
This was the third visit to Ninh Thuan district general hospital (NTGH). The anaesthetic and surgical project began in 2019 and was interrupted by CoVid for 2020 and 2021. We were able to continue the surgical component on-line using the Zoom platform. 
Whilst anaesthesia and surgery remained the focus, other offshoots evolved during the time we were in NTGH. 

1) Initial aim was to assist in the upskilling of surgeons and anaesthetists to treat infants and small children. Part of this is always random consultations for a variety of conditions – not always surgical. 

2) Offshoots: 
a)    Fitting and optimisation of PTZ camera for intraoperative Zoom sessions between NTGH theatres and us, in Australia
b)    Operating light tensioning to allow fitting of camera and general maintenance of other theatres
c)    Anaesthetic machine vaporisers repair 
d)    Cannulation of children in theatre
e)    Gas and temperature monitoring for long cases in children
f)    Intraoperative warming for babies and children
g)    Anaesthesia and fever (including sepsis) 
h)    Postoperative pain relief
i)    Paediatric intensive care group
j)    Management of intussusception
k)    General Radiography and Ultrasonography
l)    Postoperative feeding
m)    Milk bank
n)    Intraoperative sharps safety
o)    Linen bin 
p)    Introduction to Neurosurgery
q)    Primary trauma care group
r)    ICU Online learning 
s)    Video of imaging in neonatal gut obstruction 

Who has been involved? 
NTGH: 
Clinicians - Dr Hieu and Dr Lam were the main surgeons - with Dr Phat  and Pruyn assisting at times. Dr Hung was the nominated anaesthetist for the entire period. Some of the other anaesthetists, including Dr Thuan (Vice-Director Anaesthetics) and Dr Dung (senior anaesthetist) joined for short periods. 

We had significant interactions with Dr Hai (Director, Neurosurgery). Dr Hung (Director, Paediatric Intensive Care), Dr Tien (Director, Neonatal Intensive Care), Dr Thế (Vice-Director Adult Intensive Care) and Ns Quyet (Nurse Unit Manager Theatre) - detailed below.

Administration - Dr Phien (Director of NTGH), Dr Thau (Department of quality, Vice-Director NTGH), Mrs Tuoi (PA to Dr Phien and Thau), Ns Nguyen (Director of Nursing).

MESCH: 
Au Vu (interpreter and radiographer), Cuong Vu (interpreter and biomedical technician), Giao Chi Nguyen (interpreter), John Cassey (paediatric surgeon), Michael Dobbie (anaesthetist) 

What happened?
Active planning began in 2022 with the anticipated ending of CoVid travel restrictions and a convenient time for both hospital and MESCH members. 

1) Anaesthesia and Surgery
 A young anaesthetic consultant, Dr Hung, was assigned to work with MESCH and Michael for our visit. Dr Hung was interested and developed new skills such as caudal anaesthesia quickly. He became more comfortable with gas inductions and extubation in theatre. 

Considering the “experience of the child” was a focus of discussion. For example, during our stay, children were cannulated in theatre after they’d been anaesthetised (as opposed to the usual practice of cannulation in the ward) and children were woken and extubated in theatre rather than recovery, a much safer and less traumatic experience. Children went to the general recovery room (as opposed to being recovered by a separate nurse in 2019). The usual local approach is to bring them to recovery with an endotracheal tube in place, tie them to the bed and extubate after they start to struggle on the tube. Bringing patients to recovery already awake and ready to be cuddled and fed was a new experience that required some getting used to by the recovery staff. The presence of parents in the recovery room was challenging for some of the recovery staff. 

The purpose of the visit was driven by the surgical department of the hospital. The anaesthetic department were less invested in the project. The hospital has a limited supply of anaesthetic medications and consumables. This meant having to “make do” with the equipment available. This highlighted the challenges faced by the anaesthetic department and some of the limitations they have on what they can provide for the surgeons. 

Since the anaesthetic department had provided their most capable anaesthetic machine for MESCH to use, gas and temperature monitoring was available for most cases during the visit. When this machine was needed elsewhere and a vastly inferior machine was made available without gas monitoring, it again highlighted the difficulties faced by the local anaesthetists and the very real increased risk to patients by having to “make do” with the available equipment.

There were frequent de-briefs and ad-hoc teaching sessions for both anaesthesia and surgery. In addition, there were three formal teaching sessions for the surgeons - 1 of which involved final year medical students.                                                                                                           

We had been running Zoom-based sessions with Drs Hieu and Lam over the last 2 years. In the 2 weeks, we mentored in 18 elective procedures on infants and small children (7 with undescended testes, 3 hernia and 8 hypospadias. The surgeons had pre-selected 30 children, and we did a preliminary check on them on the morning of the first day. 
Surgical competency
This was validated for both undescended testes and inguinal herniotomy. Dr Lam can do 1 and 2 stage hypospadias procedures, fix common complications  and understands the nuances of variations. His confidence will improve with experience.

Dilemma regarding consumables
A decision to operate on children with hypospadias was made without in-country availability of appropriate catheters and sutures. This was a consequence of a current Department of Health moratorium on acquisition of a wide range of medications and consumables. Their ill-considered, blanket response was a solution to widespread corrupt practices by both suppliers and purchasers during CoVid lockdowns. We were faced with the dilemma of cancelling the operations that the surgeons wanted to learn or find consumables in Australia. Thanks to the extraordinary generosity of both John Hunter and Warners Bay Private operating theatres, a last-minute supply of all these items was obtained. 

Steve Threlfo (MESCH) modified a  disused instrument (donated by John Hunter Hospital theatres) so that it could be modified and re-purposed for suprapubic catheter insertion. This will allow NTGH to use readily available latex catheters (not used in Australia for more than 30 years).instead of more expensive silicone or purpose designed systems. 
For those with an interest… the instrument is inserted into the bladder, trocar withdrawn, Foley catheter inserted through cannula, cannula withdrawn, catheter pulled out through slit in the side of the cannula.

A decision to do hypospadias surgery will entail a commitment to disposables and minor upgrades to instrumentation.

2) Consultations
We were consulted on patients in both neonatal (2) and paediatric intensive care units (2) as well as several ad-hoc patients sent in by various staff members 

3) Fitting and optimisation of PTZ camera for intraoperative Zoom sessions. 
The camera can tilt and zoom so that high resolution video can be shared online. We will use it for online teaching of procedures in the operating theatre. It was initially donated in 2020 by John Hunter IT department and was “unable” to be fitted by the biomedical department of NTGH. 
Cuong, along with Dr Lam and Ns Quyet designed and arranged the manufacturing of a stainless-steel fitting for the PTZ camera. This is rugged, easily cleaned and, since it uses the light manufacturer’s existing light handle socket, can be readily attached and removed from the light. Ns Quyet also arranged the heating box (see later) and various other thing.

Cuong then optimised the software, and we had a Zoom session, demonstrating its excellent live performance. 
A low bandwidth message was fixed by hard-wiring the laptop instead of using wireless. 
Currently, the surgeons use the audio of the hospital’s PACS system. This is inadequate and will be unstable when more than one user wants access to the PACS system. We recommended that the Hospital/ Doctors acquire UHF wireless microphone and headsets.

4) Operating light tensioning. 
When the biomedical technicians at NTGH had first tried the camera on the operating light, its weight had pulled the light down. Cuong and Quyet found a way of adjusting the tension on the light arm – and applied this to other problematic lights in the theatre complex. 

5) Anaesthetic machine vaporisers refurbish. 
Several of the anaesthetic machine vaporisers (to deliver anaesthetic gases) were malfunctioning. Cuong repaired them. 

6) Cannulation of children in theatre
The routine preparation of children for theatre in NTGH involves a series of investigations (Chest X-ray, ECG and blood tests). They are also cannulated – principally by the nursing staff. This is traumatic for the child, their families and the staff. As mentioned previously, Michael demonstrated how quickly and easily cannulation could be performed once the child was asleep. 

Our recommendation, that the hospital adopt this change in procedure was strongly supported by the surgeons and Director of Nursing. It was vetoed by the Director of Anaesthesia.

7) Gas and temperature monitoring for long cases in children
Only one anaesthetic monitor had the capacity to monitor end-tidal CO2 and anaesthetic gases (a routine safety measure for over 30years in Australia). Michael donated a pulse oximeter (for monitoring the children’s oxygen concentration). Most of the anaesthetic machines available in the hospital had no end-tidal CO2 or anaesthetic gas monitoring available. This lack of monitoring severely decreased the safety for the patient and even in the most competent hands can lead to patient injury. A temperature probe was found that was compatible with the most advanced anaesthetic machine and monitoring. This enabled the safe use of the heating device that was introduced.

as a blanket and double-sided tape to stick this to the patient. Dr Lam wrote an instruction document in Vietnamese.

Our recommendation, that, at least, CO2 monitoring be used in all cases was supported by the Anaesthetics department.

8) Intraoperative warming 
Along with the above, Dr Lam had previously fabricated a Perspex box based on that used at John Hunter Hospital and Ns Quyet organised the fabrication of a more robust one. The hospital had hired a convection heater for use during our stay and Dr Lam found some plastic for use as a blanket and double-sided tape to stick this to the patient. Dr Lam wrote an instruction document in Vietnamese.

Our recommendation, that the hospital acquire a convective heater,  was supported by the Anaesthetics Department

9) Anaesthesia and fever (including sepsis)
The temporary deferment of an elective case because of unexplained fever, triggered animated discussion between the surgeons and anaesthetists over the timing of operative intervention in septic patients – the surgeons favouring early intervention. Some evidence was provided to the surgeons and the anaesthetic department regarding the most widely accepted management of fever and sepsis in the perioperative period.

At the final heads of department meeting, Dr Thuan (vice-director Anaesthetic Department) agreed that patients would be given Paracetamol & brought to theatre without delay. 

10) Postoperative pain relief
Michael gave a session on this to paediatric intensive care staff. They listened critically and asked many questions. It was surprising to see how many misconceptions (long debunked in Australia) about bioequivalence and safety persist in this environment. Similar views are held by some junior surgical staff - suggesting widespread belief. 

11) Paediatric intensive care group
Following his initial stellar performance, Michael was invited to discuss a wide range of topics – emergency intubation in PICU; emergency resuscitation equipment; care for children on ventilators; central venous catheters; nutrition while ventilated; gastrointestinal haemorrhage; dosing and equipment sizes at various ages/ weights. He sought assistance from his wife (a paediatric Intensivist) on a couple of these and a “Zalo” (Vietnamese-based chat software) group has been set up. 

12) Management of intussusception (where one bit of bowel gets swallowed up into the bit downstream) 
An incidental discussion with Dr Lam revealed that this was a common condition in NTGH. Whilst they used air to reduce it (as we do in Australia), it was done without any imaging (essentially, a “guess”), required a general anaesthetic and was followed by an immediate post procedure ultrasound scan. With the assistance of Au, we demonstrated a safer, easier, quicker and cheaper technique – no general anaesthetic, using screening with the operating theatre’s existing C-arm, no expensive (and useless) US post procedure.

13) General Radiography and Ultrasonography
Two children presented to our first screening session with suspect/ poorly documented sonographic diagnoses. With permission from the surgeons and radiology, Au re-scanned them. This resulted in negating the need for surgery in one of them and more clearly demonstrating the pathology in another. 

Au used the opportunity to arrange further sessions with the sonographers, surgeons and intensive care doctors. In Australia, sonographers are taught how to use new equipment by company representatives who have a string background in sonography. In VietNam, the teaching is by technicians who simply fix the machines. Accordingly, the sonographers know almost nothing about how to change settings to get the best images. Au optimised the machines and demonstrated easier techniques for vascular access, thyroid scanning (their request!) and showed how images could be manipulated/ poorly acquired to show pathology that did not exist.

Some theatre nurses have been assigned to work as proxy radiographers in theatre - using a standard C-arm.  Au showed than how to cone, adjust exposure (use lower radiation dosing) and the correct buttons to use for screening. All staff and patients will now have markedly reduced radiation exposure.

14) Postoperative feeding
Ns Nguyen (Director of Nursing) asked that we participate in a discussion on post-operative feeding in the Neonatal and Paediatric Intensive Care settings. This followed a Zoom session on a similar theme six weeks previously. 

Attended by many nurses and doctors from obstetrics, NICU and PICU, the conversations ranged widely. Although there were clear (background) dissenting agendas (detailed below), there appeared to be an acceptance that, early feeding was both safe and protective against a range of intensive care complications. The addition of dietary salt, it’s appropriate monitoring and new ideas on progression of feeding were considered. It remains unclear what Dr Tien’s wishes are around engagement of MESCH. 

15) Milk bank 
We had early discussions with Dr Lam regarding the administration-supported practice of advising mothers of newborns to buy powdered milk to feed their babies. The hospital stocks a small range of these milks (all of which are quite expensive). The stock includes the one pictured – claiming to be colostrum. The professional and social pressure on vulnerable mothers to buy an unnecessary, and less safe, product is considerable. Additionally, it imposes significant financial burdens on many families and perpetuates myths about breast feeding. 

The financial benefit to individuals within the hospital makes for widely disparate, and politically sensitive agendas. John was asked by Drs Lam and Hieu to speak about both powdered milk and milk banks on several occasions. Despite presenting overwhelming evidence and position statements (eg from the American Association of Paediatrics) regarding timing of maternal milk supply to newborns and the health benefits of maternal milk (particularly in premature infants), monetary interests currently have the upper hand.

As part of these discussions, human milk banks were raised. John spoke about the simplicity of pasteurisation and the existing milk banks in Da Nang, HCMC and HaNoi. Dr Tien presented on milk banks later in our stay. Unfortunately, we missed this. He is clearly wary of them, presenting numerous obstacles and advocating unnecessarily complex procedures – not used in any developing or developed country. Fortunately, Dr Thau (Vice-Director NTGH) and Ns Nguyen (Director of Nursing) appear to have different views and plan to send a group to Da Nang or HCMC to better understand their systems.

When Dr Lam and his wife had their first child, they had been exposed to the powdered milk dogma mentioned above. Confused and frustrated, they found a community group that promoted breastfeeding. Dr Lam introduced John to their coordinator – a nurse working in NTGH. Simple techniques of pasteurisation and storage were discussed as well as workarounds for ensuring bacteriological safety from samples acquired outside the hospital. 

Dr Thau will send a group to Da Nang or HCMC to better understand their systems.   

16) Intraoperative “sharps” safety
Moving sharp instruments and consumables between people in an operating environment carries considerable risk – including transmission of infection. Various techniques are mandated to minimise these in Australian hospitals. The nursing staff in NTGH theatres told us that they frequently experienced “sharps” injuries. 

We recommended changes in technique and the purchase of disposable containers to minimise these incidents.

17) Linen bin 
The practice in NTGH is for all staff to throw their hand towels, gowns and sterile patient cover sheets onto the floor after use. This increases the, already, numerous trip hazards in these theatres and spreads infection. Like so many things in any workspace, we often don’t see what’s right in front of us.

Ns Nguyen will arrange linen bins for theatres.

18) Introduction to Neurosurgery
We were asked to speak with Dr Hai (Director of Neurosurgery) regarding his plans to, both, develop the paediatric component of their workload and introduce interventional neuroradiology. Dr John Christie (recently retired neurosurgeon and previous director of Neurosurgery John Hunter Hospital) kindly participated in a Zoom session with Dr Hai. Dr Hai appears to have minimal insight into the difficulties involved in establishing an interventional neuro-radiology service.

Dr Christie asked for a list of goals from Dr Hai prior to further discussions. 
We emphasised the need for Dr Hai to arrange his own interpreter(s) as Cuong and Au are, already, heavily committed.

 

19) Primary trauma care group
There had been very few PTC courses run in NTGH since our initial one in 2018. On this occasion, it was explained that the responsibility for running all education sessions fell under the authority of the “Quality” department and that this department had not considered PTC an important activity. Dr Thế (Vice-Director ICU and previous presenter PTC) has formed a small group of younger doctors to teach a “first aid” version of the course. His attempts to do this in the community have been blocked and he is currently trying to do it at hospital level.

20) ICU on-line learning 
The moratorium on acquiring various consumables has meant that, even in intensive care, doctors have had no access to respiratory and metabolic status monitoring. In view of that, Dr Thế put a temporary halt to the Zoom sessions with Dr Ed Martinez (ICU John Hunter Hospital). When things open up again, he will re- establish contact. 

21) Video of imaging in neonatal gut obstruction. Following some sessions on the management of neonatal gut obstruction, Dr Lam had asked for some guidelines for performing imaging in this situation. Together, we decided to produce a Vietnamese language video describing presentation and imaging. With the assistance of Paul Craven (Hunter New England Health service) and the generosity of Tom  MacDougall (Paediatric Radiologist, Newcastle), clips and audio for this had been gathered throughout 2022. We obtained additional footage of Vietnamese babies whilst in Ninh Thuan and began the process of video creation with Dr Phat.  

Evaluation 
    The primary purpose of MESCH is to add to the knowledge and skills of overseas partners – to give them a leg up. It was, therefore, a great bonus that Au and Cuong were able to contribute so much more than simply being fantastic interpreters. 
    At our first meetings with the surgeons and management, I made it clear that this was my last in-country visit. I stressed that other MESCH volunteers may continue visits (with Dr Phien’s permission) and that I would love to continue on-line teaching for as long as that was useful to Dr Lam and Hieu. There was a lot more interaction between us and other departments in this trip. It was unclear to us whether this was a result of my news, greater familiarity of staff with us or some combination of both. 
    Local television news ran quite a long feature on the relationship between NTGH and MESCH. In it, Dr Hieu spoke strongly in favour of our approach to teaching. There remains a high degree of trust in MESCH and a desire to continue the relationship. This, despite us making some controversial statements and recommendations during our stay and at the final senior staff meeting. Dr Hieu spoke strongly about several issues. This may reflect his new role as head of Surgery. Perhaps he was emboldened by us? 
    With a high-quality video link, surgical goals can continue to be met online. 
    The Director of Anaesthesia holds strong views with no inclination to alter any of them. Although many of these are unsupported in both mainstream Vietnamese and Australian practice, his practices are unlikely to be moved by either of them.
    Timing – quite wet and stormy for large parts of the trip.

What do we need to advance this?
1) Funding for VN-English interpreters (accommodation and basic wage) ~ 400AUD./week
2) Airfare and accommodation assistance for Australian volunteers 
3) More VN-English interpreters . We had forgotten about Mrs Hoa (Vn Dräger biomedical rep). We will contact her to ascertain her current willingness to assist.

 

New Videos: 

Current organisational memberships: Statutory (ACNC, Dept Liquor, Gaming and Racing); Google not for profits; Giving circle.

Current organisational associations/contacts: MedEarth (medical supplies); Newcastle Global Health; WHO road trauma; AVI; ABV; Application to UN submitted June 2017

 

Presentations
John C to ABC radion October 2022
 

 Fundraising and Support
a) Events
Nil
b) Regular donations