Children's Anaesthesia & Surgery (Ninh Thuan)
Why was it initiated?
NTGH is a relatively new hospital. Dr Phien saw that the sustainable provision of surgical care and anaesthesia required not only investment in resources and infrastructure, but also in training a workforce - and that’s what he invited MESCH to be involved in.
(For more about the previously misunderstood and neglected place of surgery in improving community health, see the bottom of this page)
What are its aims?
The specific aim of this project was to assist in the upskilling of surgeons and anaesthetists to treat the most vulnerable - infants and small children. As the doctors at this hospital had some experience with the care of small children, both parties agreed that the local doctors would do all procedures from the outset - with only instruction from us. In that way, precious time would not be wasted on "showing".
As detailed below, a number of other side-projects sprang up. These are currently in development.
Communication styles, perceptions and decision-making needed to be addressed in order to maximise knowledge and skills transfer.
When did it start?
Active planning for this project began in early 2019 through email and SKYPE sessions. We discussed logistics, some of the anaesthetic and surgical theory, potential issues and communication. MESCH travelled to Ninh Thuan in September 2019.
Who has been involved?
Ninh Thuan General Hospital
Administration: Dr Phien, Dr Thai (Department of Quality) and Mrs Tuoi (PA to Drs Thai and Phien)
Surgeons: Dr Hieu and Dr Lam are the main surgeons - with Dr An, Pruyn and Thang assisting in 2019. Dr Phat joined in 2021.
Anaesthetists: Dr Vi was the nominated anaesthetist for the 2019 training period with Dr Hung in 2022. Some of the other anaesthetists joined for short periods - Dr Dung and Dr Thuan. Michael Dobbie began sessions with Dr Vi after the 2019 visit. These did not continue due to no ongoing interest from Dr Vi.
Cuong Vu (interpreter and biomedical technician), Au Vu (interpreter and radiographer), John Cassey (Paediatric Surgeon), Michael Dobbie (Anaesthetist), Vy An (interpreter and media), Lise Vu (interpreter) , Giao Chi (interpreter
INITIAL PROGRAM 2019:
In the 2 weeks of the initial program, both elective (31) and emergency (4) procedures were undertaken on infants and small children who had been selected by the local surgeons as having conditions for which they wanted to attain procedural competency. There was no specific plan from the anaesthetic department.
In addition, 3 neonates and an older boy were operated on as emergencies and we were consulted on patients in both the neonatal and paediatric intensive care units.
At the end of each day, both the anaesthetic and surgical groups sat for individual debriefs. We also spoke a lot about cultural differences and how that can influence clear communication. We continually emphasised that we were in Ninh Thuan to be "tools" (Chopsticks), to assist and share knowledge to allow the local doctors to achieve their goals. The combination of all those things, the enthusiasm of staff, their pre-existing knowledge and the relationships that developed, has meant the project aims are being met much more quickly than anticipated.
By the beginning of the second week, we were not scrubbing into cases and the level of direction required was significantly reduced.
At completion of the 2 weeks, the hospital staff were doing most of these procedures on their own. BS Hieu and Lam could recognise variations in anatomy and how to select the correct variation in operation to suit that patient. They are doing old procedures faster and safer. We were very impressed that all surgeons asked insightful questions about things such as complications and how to deal with them, future issuesHieu, Lam and John, pre-operative preparation and postop care.
* Surgical competency was achieved in correction of undescended testes and inguinal hernia and is well advanced in a specific congenital penile problem that, untreated, would prevent the child, when grown, from fathering children.
* We were able to see some of the post-surgical results of the first week's children and discuss the management of complications. Of the 8 children with hypospadias procedures, 2 have fistulae to date – a reasonable complication rate in this setting.
* The concept of a "sharps" dish was introduced - to reduce the risk of accidental stab injury by needles and scalpels and therefore reducing the risk of transmission of blood-borne disease such as hepatitis B and C, HIV.
* There was good uptake of intra-operative local anaesthetic blocks
* Although the anaesthetic questions never stopped, they became much more science based - seeking to understand the physiological basis for decisions.Michael and Cuong NTGH 2019
* Permitting parents to come into the operating room while their child is being anaesthetised creates a much less traumatic experience for the child. Although an unfamiliar concept in the hospital, we were permitted to introduce it.
* The use of intraoperative local anaesthesia (including the use of regional anaesthesia) allowed less strong painkillers to be used. The combination of this, associated with less complicated airway management dramatically improved turnaround time between cases and the children were comfortable in recovery. Both the recovery room nurses and surgeons were very clear that they found this approach desirable.
* We were able to do some routine maintenance on some of the anaesthetic machines allowing them to function more accurately and to be used safely for smaller patients.
We'd previously canned virtual meetings as viable teaching options. However, in 2020, CoVid left us and, more importantly, our partners, with no other choice. We explored the option of mentoring and learning virtually - using the Zoom platform. Since May 2020, all the medical activities of MESCH have been conducted online.
The messages, understandings, relationships and developments that have taken place could not have been possible without our interpreters. We are incredibly privileged to have the continued commitment of Au and Cuong Vu, Giao Chi Nguyen and Khang Võ as part of our organisation over many years. They have, recently, been assisted by Anh Nguyen. Apart from the discrete sessions outlined below, they do an enormous amount of background work in keeping relationships going, meetings and logistics. In a very real sense, they are the words of our thoughts and ideas in Vietnam.
In the last 2 years, apart from numerous planning meetings...
* We've had 4 remote mentored operating sessions for infants - saving their families the expense and hardship of travelling to HCMC. We've been fortunate to have the input of Jon Gani (adult general and upper GI surgeon) for a couple of these. Being able to get uninterrupted, high quality audio and video feeds at both ends remains a challenge and the sessions are currently on hold. We are grateful for the recent enthusiastic support from Chris Mitchell (Area director IT Hunter New England Health) in arranging for a PTZ (pan-tilt-zoom) camera to be tested, and subsequently donated, to Ninh Thuan hospital. Chris has also committed to future collaborations in resolving IT issues.
Jon Gani (surgeon)
Chris Mitchell (IT)
Giao Chi Nguyen (interpreter) Khang Võ (interpreter)
Anh Nguyen (interpreter)
* Conjointly created a Vietnamese language video on the management and prevention of stomal complications.
* We recently signed an MOU with HNE health to film the performance of selected upper and lower GI contrast studies in infants. Dr Lam asked for this so that he can oversee and improve the performance of these in NTGH and post it for use in other rural hospitals without expertise in infants.
Integral to those video projects, has been our donation of video editing software and training in its use.
* We provided Dr Lam with the design for a convection heating box to keep neonates and small infants warm under general anaesthesia. He subsequently built this.
* SIX (6) sessions on clinical case discussions
* EIGHT (8) sessions on management (avoidance of and management of stomal complications, neonatal gut obstruction, undescended testes, labial adhesions, neonatal necrotising enterocolitis, umbilical discharge in infancy). All except 1, had a Vietnamese language information document with associated images
* A series of discussions are planned between ourselves, Dr Hieu, Dr Lam and Neonatology NTGH to discuss the management of congenital diaphragmatic hernia. This condition is associated with 100% mortality in NTGH. Improvement in outcomes is a major surgical focus for the hospital director (Dr Phien). These discussions represent a significant upturn in our involvement with NTGH as they involve other departments than surgery and, potentially, professionally vulnerable issues.
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.
Whilst anaesthesia and surgery remained the focus, other offshoots evolved during the time we were in NTGH (see below)
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 quickly and atraumatically cannulated i 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.
Our recommendation that the hospital adopt the change in cannulation practice was strongly supported by the surgeons and Director of Nursing. It was vetoed by the Director of Anaesthesia. It seems likely he has other motives than his espoused one - that “it takes too long”.
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.
In the 2 weeks (21Nov – 2 Dec) 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.
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. A decision to do hypospadias surgery will entail a commitment to disposables and minor upgrades to instrumentation.
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.
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. Cuong then optimised the software, and we had a Zoom session, demonstrating its excellent live performance - as long as it is hardwired, rather than wireless. Hospital/ Doctors will need to acquire UHF wireless microphone and headsets as using the audio of the hospital’s PACS system will be unstable when more than one user wants access to the system.
4) Anaesthetic machine vaporisers refurbish.
Several of the anaesthetic machine vaporisers (to deliver anaesthetic gases) were malfunctioning. Cuong repaired them.
5) 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. The Anaesthetics department supported our recommendation that, at least, CO2 monitoring be used in all cases.
6) 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. The Anaesthetics department supported our recommendation for purchasing a convection heater. Dr Lam wrote an instruction document in Vietnamese.
7) 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 peri-operative period.
8) 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
9) 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 established.
10) 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 .
11) 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.
12) 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.
13) 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 breastfeeding.
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 co-ordinator – a nurse working in NTGH. Simple techniques of pasteurisation and storage were discussed as well as work-arounds for ensuring bacteriological safety from samples acquired outside the hospital.
14) 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. Changes in technique and the purchase of disposable containers to minimise these incidents will fall under, at least, 3 jurisdictions - including anaesthetics. It is unlikely changes will be implemented.
15) 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.
16) 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 be overly optimistic about resolving the difficulties 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.
17) 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 Th¿ (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 tyring 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 Th¿ 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.
The financial and social burdens of poor healthcare are enormous. More equitable access to good, safe and efficient anaesthetic, surgical and medical care will make huge differences to this community.
Dr Phien’s support and Mrs Tuoi’s interventions are critical to the success of this project and it is clear, that there is both a desire and an ability on behalf of both administration and staff to make this happen.
The primary purpose of MESCH is to add to the knowledge and skills of overseas partners – to give them a leg up. In 2022, it was, therefore, a great bonus that Au and Cuong were able to contribute so much more than simply being fantastic interpreters.
The joint goal of NTGH and MESCH, to upskill surgeons and anaesthetists in treating infants and small children for the conditions they had requested, is on track. From a surgical perspective, competency is well advanced, and we anticipate follow-up visits/ Zoom sessions will consolidate those surgical competencies and move to their next requested goals. We see both an immediate and future impact on productivity, reduction in costs, improved safety and enhanced reputation of the hospital in the community. Better equipment, including disposables, will make procedures safer, quicker, easier and reduce complications.
The Director of Anaesthesia does not seee a role for mutual learning and co-operation between his department and MESCH.
Communication and relationship building is continuing without any noticeable issues. It has been made easier by the individual personalities involved, our continued focus on the importance of cross-cultural communication and social functions. When confusion has occurred, it has been aired and resolved quickly.
The MESCH approach is very different to what local staff are accustomed to - from both other foreign aid groups and visiting Vietnamese doctors from Ho Chi Minh City (Saigon).
These groups treat the local doctors as "assistants" rather than "proceduralists" and, hence, do the procedures themselves. They are dismissive of questions and very little learning takes place. This stark contrast became apparent on day1 when Dr Lam performed the surgery for the first case with us assisting. Dr Hieu shared with us that, despite all the SKYPE calls, he did not believe MESCH would actually come.Local television news ran quite a long feature on the relationship between NTGH and MESCH in 2022. In it, Dr Hieu spoke strongly in favour of our approach to teaching.
The opportunity CoVid provided to use more on-line learning continues to be a very positive, experience. With a high-quality video link, surgical goals can continue to be met online.
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.
We would like to continue to assist Dr Phien in upskilling his staff so that the community this hospital serves becomes safer, happier and more productive.
WHAT DO WE NEED TO ADVANCE THIS?
1) Funding for:
VN-English interpreters ~ 400AUD./week
Airfare and accommodation assistance
2) Volunteers with a range of skills to enable this and other projects to run smoothly -see website
3) People with technical expertise in acquiring and transmitting HD AV signals through a zoom platform
28 December 2022
SURGERY AND ANAESTHESIA - THE NEGLECTED GAP
FOR EACH $1 SPENT STRENGTHENING SURGICAL CAPACITY, $10 IS GENERATED THROUGH IMPROVED HEALTH AND PRODUCTIVITY.
Access to safe emergency and essential surgery
* reduces death and disability from surgical diseases and birth defects
* reduces economic and social disparity
* prevents adverse health outcomes arising from the burden of injuries and non-communicable diseases.
Globally, there is a huge discrepancy in access. Africa and Southeast Asia account for over HALF of the of conditions that could, but are not, treated through basic surgical care.
In fact, governments and funding bodies have only just started to understand that investing in surgical care is simple and cost-effective. For each $1 spent strengthening surgical capacity, $10 is generated through improved health and productivity. That is 1/3 the cost of measles vaccinations, and 10-15 times less than the cost of medication for HIV treatment.