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Anesthesiology

Vietnam

 

As the Vanderbilt International Anesthesia program expands, so do the number of countries that are touched by our physicians. One of our faculty members, Dr. Jane Easdown, has participated in numerous overseas medical missions in the past. In November 2008, she visited Ho Chi Minh City, Vietnam, for the first time as part of a Health Volunteers Overseas trip. 

She was able to work closely with the medical staff at the Centre for Trauma and Orthopaedics (CTO). Read Dr. Easdown’s account of her service in Vietnam below.


 

This was my first trip to Vietnam, and my first trip with Health Volunteers Overseas (HVO). I spent two weeks at the Centre for Trauma and Orthopaedics (CTO). The chair of the Anesthesiology Department, Dr. Nguyen Chung is a delightful and generous host, attentive to every detail and was the reason why I would come back in a shot!

Lecture preparation:

Dr. Chung emailed me topics he thought would be well received, and I prepared these ahead of time. I prepared both advanced and rudimentary material and used a little of both. I adapted my slides once I had an appreciation for the time it took to translate and my audience. A colleague who had given talks in Asia before advised me to do slides with a lot of English since the audience understands the English written word better than spoken word. This I found to be true. I brought with me a laptop, memory USBs with my lectures and other key articles, the newest Longnecker, Anesthesiology textbook and a text on Anesthesiology for Orthopedics. I left all these resources with Dr. Chung.

Although I was worried about phones and email, it turns out that Ho Chi Minh City has free Wi-Fi almost everywhere, sim cards for phones and almost every other technical resource you might need. I did bring an electrical conversion adaptor and used that for my laptop and phone. I arranged for an international long distance program for my iphone, but it is necessary to turn off any data retrieval which might happen automatically - charges for this are very high.

Activities: Each day at 7 am, I gave a talk to a group of 20 anesthesiology nurses, student nurses, MDs and ICU staff. This was held in the preoperative holding area. They had an LCD projector for a laptop hookup and a screen. I would speak, and Dr. Chung, Nhi or Cong would translate. Two other faculty had very good English language skills as well. Two spoke French very well, as they had trained in France. Dr. Chung is very up-to-date and eager to embrace new ideas and technology. With his suggestion, the talks I gave were all to demonstrate issues he wanted to improve in his department. The topics were:

•  Hypothermia in the perioperative setting
•  Spinal cord injury, spinal shock
•  Managing a patient with aortic stenosis
•  Fat emboli-diagnosis and treatment
•  Managing a patient with valvular heart disease
•  Arterial line monitoring
•  The diabetic patient for surgery
•  Pulmonary problems and the smoking patient

I also presented twice at the morning general staff rounds. The audience is all the medical staff of the hospital -- surgeons, anesthesia, nurse managers, rehab people -- about 80 altogether. My topics there were:

•  Update on perioperative management of spinal cord injury
•  DVT prophylaxis

These were well received with many good clinical questions and requests for references, and I exchanged cards with several people, all of whom have followed up with me. I used PowerPoint, and they had a microphone. I spoke English slowly, and this seemed ok.

I was invited to give department rounds (Managing Head Injury) at another hospital, Gia Dinh Peoples’ Hospital for Dr Nguyen Thi Thanh. They are a group of 25 MDs and nurses in the anesthesiology and critical care department. They were very attentive and keen to have regular visits from HVO. The hospital is quite large with several wings. They do everything there -- ENT, OB, neuro, but not cardiac. The head of the department, Dr. Thanh, is an impressive woman who manages a large department with several ORs in different locations. They have an eight-bed ICU with a separate area for infected cases. I saw several head injury patients there, intubated and sedated.

There was a conference for Asian Anesthesiology the weekend I was there, and Dr. Chung kindly registered me for attendance. This is a series of talks related to regional anesthesia and use of propofol. The speakers from Asia and Europe were top notch -- Dr Hendrik Kehlet among others. Dr. Chung moderated one of the sessions. I met many anesthesiologists from other parts of Vietnam and was invited to speak at another hospital in Ho Chi Minh City. They mentioned that in Vietnam there is no one curriculum for anesthesia education of MDs. This may be a good project for HVO to organize!

After the morning talk at CTO, the rest of the day was spent in the ORs observing cases and talking with anesthesia personnel, nurses, surgeons and recovery room nurses. They were all very kind and helpful and pleased to have me there. There were some difficult airways, and I showed them how to use the light wand. I also introduced them to the BURP maneuver, which was a big hit.

Clinical Care: 

Overall, I was very impressed with the level of perioperative care at CTO. The patients are all in-patients and are in the hospital several days before surgery. They are seen before surgery by an anesthesiologist and assessed for difficulty. If there is a problem detected by either the surgeon or the anesthesiologist, Dr. Chung goes to see the patient. I went to examine several patients with him who had difficult airways. He makes a note of them and comes to the OR when the case is done. He teaches a lot in the OR when these cases come. The preoperative patients are seen, have IVs started by student nurses, and one anesthesiology nurse overseas this process. The anesthesia nurse from the room will do the block in the holding room, usually without gloves, with a butterfly cutting needle. This takes about five minutes and always works! Spinals are done by MDs in the rooms. Dr .Chung has stimulating needles and will soon have an ultrasound machine, but the nurses are very skilled at blocks, and with good success, so it will be hard to retrain them with stimulation or ultrasound, I think.

Once the room is ready, they take the patient directly to the OR and start the surgery. Surgery is very fast, and so is turnover. Almost all surgery, except for spines, is done under spinal or regional anesthesia. There was an inadequate block in one room and they induced GA appropriately after trying sedation. They do really big cases: hemipelvectomy/ scoliosis repairs, etc., with one IV, and usual ASA monitors. Patients come from Northern Vietnam for this care. I saw only one patient with a temp monitor. For temp control they place plastic bags over the arms and legs and head. They have one Bair hugger in the recovery room for the elderly patients. They have the IV line pass through warm water bath which works quite well. They transfuse, often performing an additional cross match manually for each unit. They use a lot of crystalloid, gelatin and hetastarch. There was great interest when I used a light wand for intubation -- also demonstrating a bougie.

One thing is sure: the OR nurses and anesthesiologists give total attention to the patient while never more than a few inches away.  No computers, music, distractions. I was so very impressed with the degree of serious vigilance I saw in every case. I observed a very nice, respectful relationship between the surgeons, anesthesia MDs and nurses. I also saw Dr. Chung do postoperative rounds for a patient who had complications after surgery. I left him information on the Vanderbilt healthcare matrix for future M&M rounds. I did not see any formal process for this when I was there.

Assessment:

1.  With Dr. Chung’s help, I introduced topics that were of interest and importance to the learners. Although the lecture format is quite formal to me, it works quite well there and is what is expected. Given the necessity of having a translator, other teaching methods are more difficult. 

2.  The surgeons and general staff are most attentive to talks, so I would plan on several topics of interest to this general group.

3. I would like to do more airway demonstrations in the OR with airway adjuncts since this was very well received.  I suggested that next time I come (or another HVO volunteer), we do daily intubations on normal airways with the FOB, intubating LMA and light wand they have ready to go. They need more experience with these devices and also to prepare the patient for awake airway procedures.

4.  This is an excellent opportunity for a resident or CRNA to observe and teach. I will
recruit one to come next time.

5.  Curriculum development. Should they request help, this would be an excellent project for an
educator to assist with.

Summary: 

This was an extraordinary teaching opportunity. I felt very much appreciated. I only hope that what I taught left them with knowledge and skills for future patients. I am not surprised that many who make the trip to CTO return again. I hope to go again next year.

Dr. Jane Easdown

 

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