Children's Anaesthesia & Surgery (Ninh Thuan)

 

anaesthesia and surgery Ninh Thuan image  

Why was it initiated?

Aware of MESCH’s collaborations with Lam Dong Hospital (DaLat, Vietnam), Dr Phien (director of Ninh Thuan District General Hospital - NTDGH) spoke with us in 2016 whilst we were in Da Lat.  He spoke about how treatable surgical conditions are neglected - especially in poor or rural areas. Both of us acknowledged that 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.

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)

PhienTuoi

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.

HieuLamDr Phats
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. 
Vi

MESCH:

Cuong Vu (interpreter), Au Vu (interpreter), John Cassey (Paediatric Surgeon), Michael Dobbie (Anaesthetist), Vy An (interpreter and media), Lise Vu (interpreter) 

Cuong Vu sAuJohnMichaelVyLise​​

What’s happened? 

Parent in inductionInitial 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.

Since we wanted to ensure that both anaesthetic and surgical skills were transferred without omission, and in a calm and controlled manner, the case throughput during week one was relatively slow.
At the end of each day, both the anaesthetic and surgical groups sat for individual debriefs - often lasting over an hour. 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.
Specifically:
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 effectively 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 isHieu, Lam and Johnsues, 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.
 

2020: Telehealth

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 and 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 Nguyễn and Khang Võ as part of our organisation over many years. They have, recently, been assisted by Anh Nguyễn. 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. These sessions are 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 Nguyễn (interpreter)  Khang Võ (interpreter)  Anh Nguyễn (interpreter)
Jon Gani sChris Mitchell sGiao Chi.sJPGKhang sAnh Nguyens
     

 ►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. 

 

2022

We are excited to be in Ninh Thuan in November this year and will post a report thereafter 

Progressive Evaluation?Michael Vi and Cuong NTGH 2019

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 joint goal of NTDGH 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 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. There needs to be wider engagement with the anaesthetic department in order to clarify what desire and capacity exists for changing current practice.
 Ninh Thuan anaesthetic prep
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. It will be important in all future interactions with other staff that the MESCH difference is repeatedly addressed.
 
The opportunity CoVid provided to use more on-line learning continues to be a very positive, experience.
 
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
Zoom
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  

Want to find out more?       Please email
      Ninh Thuan operating 2019

John Cassey
For MESCH
5 July 2022