Teaching anaesthesia, nursing and surgery for children under 5years in Lam Dong General Hospital (LDGH)
Why was it initiated?
In 2008, an in-country contact identified LDGH as having both a need and capacity to become involved with MESCH. LDGH functions as both the major provincial hospital and the community hospital for DaLat, Vietnam and is situated ~300km from HoChiMinh City (HCMC). In 2009 it had no surgeons or anaesthetists trained in the safe care of babies and small children or in the performance of elective or emergency surgery for them. Since some of these families could not afford the cost involved in going to HCMC for treatment, they usually waited until the condition presented as a life/organ threatening emergency. They then had a high risk anaesthetic for a technically difficult operative procedure – especially for surgeons and anaesthetists inadequately skilled to deal with this.
The end result was a high morbidity and mortality for what should have been a low risk, elective procedure.
We chose inguinal herniotomy as the index procedure since it is the most common general surgical issue in babies and young children and, when presenting as a complicated scenario, can be life-threatening, even in a first world environment. Local surgeons and anaesthetists could not be trained in major paediatric centres and there were no plans for paediatric specialists to move to DaLat.
What were its aims?
All surgeons engaged in the project would meet Australian training standards for the procedures taught, including the ability to operate independently
All anaesthetists engaged in the project would be able to anaesthetise children less than 5 years in a safe and child friendly manner.
All nurses would be able to set up and assist in the process of the procedures.
When did it run?
2009-2013
Who has been involved?
LDGH: Dr: Hy (director LDGH), Tam (surgeon), Sinh (anaesthetist),Quang Hung(anaesthetist) as well as trainee anaesthetists, registered nurses and anaesthetic technicians from Lam Dong Hospital
MESCH: Michel Poppinghaus (anaesthetist), Peter Armstrong (anaesthetist), Milton Sales (GP), John Cassey (surgeon) Sandy Graham (theatre nurse), Amelia Ham (theatre nurse), Maureen Sales (community nurse)
What happened?
Resources
MESCH: provided equipment from Australia to boost local capacity for safer outcomes and project accomplishment. It also assisted in identifying appropriate purchases for future development. Most resources came from generous donors (videolaryngoscope, operating magnifying loupes, sutures and other disposable equipment). Consultant level Australian professionals from MESCH (anaesthesia, nursing and surgery) made annual regular visits for 2-3 weeks at a time. Education resources were provided including 3 bi-lingual DVD's of the procedures - filmed and produced in LDGH. We covered the hospital costs for children from disadvantaged families to a maximum of $4000 AU annually for the first 3 years.
LDGH: Provided transport within DaLat, covered their loss of income for the time we were there; facilitated all permissions and provided a bi-lingual co-ordinator.
Teaching
Our responsibility for the screening clinics in the rural hospitals moved from the surgical and anaesthetic group to a community based medical group. Initial teaching was to all interested hospital staff. In the last 2 years, we focussed on 1 surgeon and a small group of anaesthetists and nurses. Two additional procedures (hydrocoele correction and orchiopexy) were added as they were common procedures requiring similar skill sets and with high impact.
The hospital upgrade to new theatres in 2011 coincided with a shortage of local surgeons. To increase the "attractiveness profile" of LDGH to staff, Dr Hy wished us to do more complex cases and its international credentials were increased by 2 live web-links to Australia. Sadly, Dr Tam (chief surgeon we were involved with) died unexpectedly in early 2014.
Other
Several improvements made turnaround times faster - including fixing the steriliser (by MESCH biomedical technicians).
Evaluation?
Overall, the staff of Lam Dong Hospital and the families it serves have benefited enormously by this development partnership. Procedures that would normally have required an overnight bus trip to HCMC and weeks of waiting there are now done safely, efficiently and in a child-friendly manner locally.
There is an excellent understanding of mutual capacity and a desire to move forward into other projects.
As time has gone on there has been an increasing acceptance that our focus is on education. We have opened up the potential for alternate sources of funding through research projects.
Successes
No post-operative deaths in the 40-50 children/year or operated on.
Incidence of post-operative complications entirely consistent with Australian expectations.
A variety of family friendly interventions introduced including parental presence for induction of anaesthesia and parent orientated VN language written information about procedures and post-operative care.
Influence over postoperative care came gradually with greater trust.
Dr Tam’s (surgeon) and Dr Quang Hung's (anaesthetist) complete competency was assessed and documented using respective Australian guidelines (Royal Australasian College of Surgeons and Australian and New Zealand college of anaesthetists).
Theatre logs showed a clear rise in paediatric cases performed by Dr Son from 2011 and Dr Tam from early 2012 onwards.
Forged strong and transparent relationships so that we can explore areas of mutual interest – replacing inadequacies in the local system with internationally recognised solutions with a local orientation.
Shown how to engage with international aid agencies/ organisations in a way that ensures local ownership of development.
Failures
No independent reports from others in the community. This was naive since the timeframe from staff achieving competency to final evaluation was too short for such an assessment.
No formal assessment of the 2 surgeons who had left Lam Dong before the project was complete - although we believed they were at a satisfactory level. This was due to unexpected staff changes.
New junior anaesthetic staff needing training were not clearly identified
Impediments:
Our only major impediments related to staffing in Lam Dong Hospital. This is likely to be an endemic issue. It is hoped that this may improve by increasing the profile (locally and nationally), broader casemix and opportunities for staff development.
Future?
We await the identification of another local surgeon with adequate commitment.to continue this project
We had been largely restricted in our sphere of influence to the operating room - postoperative care at ward level seems a fertile area for improvement.
We would like to Invite Vietnamese anaesthetists, nurses, primary care doctors and surgeons from regional centres to participate in the program
Obtain research funding to understand community of practice and adult education in the Vietnamese health system with a view to modifying established Australian courses accordingly
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