Children's Anaesthesia & Surgery (Ninh Thuan)
Why was it initiated?
* 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.
NTDGH 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 each $1 spent strengthening surgical capacity, $10 is generated through improved health and productivity.
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".
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 has joined in 2021.
Anaesthetists: Dr Vi was the nominated anaesthetist for the training period, though many of the other anaesthetists joined for short periods.Michael Dobbie began sessions with Dr Vi and another anaesthetist from NTGH. As there was no ongoing interest from them, the sessions were discontinued. Dr Vi has moved to another hospital though remains keen on contiuing the relationship.
Cuong Vu (interpreter), Au Vu (interpreter), John Cassey (Paediatric Surgeon), Michael Dobbie (Anaesthetist), Vy An (interpreter and media), Lise Vu (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. Elective procedures were performed each weekday from 8am till after 5pm. The children 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.
By the beginning of the second week, we were not scrubbing into cases and the level of direction required was significantly reduced.
* 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.
* 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.
►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 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.
We are excited to be in Ninh Thuan in November this year and will post a report thereafter
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. It will be important in all future interactions with other staff that the MESCH difference is repeatedly addressed.
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
5 July 2022