Promoting Best Anesthetic Practices in Ho Chi Minh City: Part 2

Today concludes my second and final week in Vietnam (read about Part 1 of my adventure here!). 

Our Monday morning started off with a healthy patient having a significant facial reconstruction procedure for injuries sustained in a motorbike collision.  Using an arterial line and an experimental noninvasive cardiac output monitor from our home institution, we reviewed management of hypotensive anesthesia to control blood loss during procedures on highly vascular areas.  Minimizing blood loss during surgery is of particular concern at Rang Ham Mat hospital, since access to blood products for transfusion can take considerable time.  We were able to see some of our post-operative patients who were still in the hospital and discussed aspects of PACU care, focusing specifically on strategies to reduce airway swelling.

Later that week we were offered the opportunity to visit the Heart Institute in Ho Chi Minh City, hosted by the head of the anesthesia department B.S. Quy.  Roughly half of the surgical cases here are adults having mostly valve procedures, and the other half children undergoing repair of congenital heart lesions.  As a resident in anesthesia who is planning to do fellowship in pediatric cardiac surgery, I jumped at the chance to spend a day with the cardiac anesthesiologists.  The afternoon of our visit I had the fantastic opportunity to participate in the case of a one year-old child undergoing total repair of Tetralogy of Fallot.  In keeping with last week�s theme of the incredible efficiency of the Vietnamese surgical services, the entire case from incision to dressing was less than three hours, with a cardiopulmonary bypass time of only 65 minutes.  The child did extremely well and was extubated uneventfully by the next morning.  This efficiency is coupled with a remarkably low mortality rate: B.S. Quy explained that after reviewing their practices and making careful improvements, their mortality rate for total repair of Tetralogy of Fallot was now less than 1%.

Jamie placing a central line under careful supervision by B.S. Quy.

I concluded my week by giving a talk on one-lung ventilation in pediatric patients at the 2015 Asia Anesthesia Summit.  With an audience of around 300 anesthetists, it was the largest lecture I�ve given as an anesthesia resident.  I was fortunate enough to have the help of a Vietnamese translator, who translated my lecture in real time over hundreds of wireless headsets provided to the audience members.  I had also sent my lecture slides in advance to be translated as well�looking up at my slides and seeing them in Vietnamese with a little disorienting!  My attending Dr. Denman also gave an excellent talk on best practices in perioperative fluid management.  The conference hosts were extremely appreciative of our participation in the conference and delivered us back to the hotel with armloads of flowers and gifts.

Jamie presenting at the 2015 Asia Anesthesia Summit in Ho Chi Minh City.

These two weeks have raced by, and I have had an amazing trip.  I am so grateful to have had this incredible opportunity not just to do interesting cases, but to really participate in a different medical system.  I hope by working with Vietnamese anesthetists and residents that I have taught them as much as they have taught me.

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Because sometimes laughter conveys a message better than fear...

This builds on my smaller page of MERS-CoV themed wannabe memes found here. 

These were all made by me but feel free to use if they suit a purpose (a link/reference would be appreciated though).

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Interns strike at MRRH, Mbarara, Uganda

April 27, 2015

Mondays on the wards here are always a little harried.  No one rounds over the weekend so come Monday morning you often find patients who were admitted over the weekend that little was done for, old patients whose care wasn�t progressed for two days, and beds that used to be filled with sick patients that are now empty.  Often no one knows what happened to these patients.  They either went home or passed away. 

This Monday (today) had the potential to be even more harried.  The interns went on strike at 5pm on Friday because the government has not paid their salary in months. Interestingly, at this government hospital, as with all government hospitals in Uganda, the interns are the only house officers who are paid.  Like in the United States, the interns are the workhorses at MRRH.  They admit patients in the emergency room, are on call overnight, and execute the orders that are written during ward rounds.  Without them, I was not sure how things would run given that even when they are there and working, patient care is often sub-par.

But, this Monday found the upper level residents and medical students rallying to take care of patients.  During post-take this morning, when we review patients admitted through the emergency room over the weekend, a single upper level resident presented the patients and discussed what she alone had done for them without the help of an intern.  She was calm, cool, collected and smiling after what had to have been a very busy weekend.  On the ward rounds, the medical students and nursing students stepped up to hang medications, consent patients for blood, and track down lab results � jobs usually completed by the interns.  Granted, things still fell through the cracks, orders still weren�t carried out over the weekend, and patients had still left the hospital without explanation.  But, this was no different than any other Monday here.  What was different was the pro-activity towards patient care.  Over the last few weeks I have felt that patient care often comes behind education, research, and the residents� and attendings� side jobs that they need to maintain to make ends meet.  But today the majority of residents and students seemed to be motivated self-starters and to be putting their patients first.

 It was refreshing to see.  Today speaks to the underlying devotion that these doctors have for their clinical work and their patients despite being pulled thin by a system that overworks them, doesn�t pay them well (or at all), and makes it difficult to deliver the quality of diagnostics and treatments that they know would be best for their patients.  Given these tremendous pressures, I have my fingers crossed that the clinical care system at MRRH can step up for what might be a months-long intern strike.  Perhaps more importantly, I hope that the attendings, residents, and students can maintain this Monday�s surge of motivation and accountability even when the interns return to work because this would have the potential to greatly improve patient care.  We�ll see what Tuesday holds�

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Promoting Best Anesthetic Practices in Ho Chi Minh City: Part 1

Hello readers!  I�m Jamie, one of the anesthesia residents at Massachusetts General Hospital in my final year of training.  I�m on a two week medical mission to Ho Chi Minh City, Vietnam, accompanied by attending pediatric anesthesiologist Dr. Denman.  We just finished the first week of our visit.  I have spent most of my time at Rang Ham Mat hospital, which specializes in oromaxillofacial surgery and dentistry.  We worked in a very busy two-room, three-bed surgical suite with a team of nurse anesthetists and one or two anesthesia attendings.  In contrast to many other medical missions, our goal for these two weeks was relatively unique: rather than bringing our own medical teams and performing a high volume of cases, we endeavored to make lasting and sustainable improvements to the existing anesthetic practices at Rang Ham Mat Hospital.  Our focus was therefore on educating anesthetists and anesthetists-in-training so that they may apply skills learned during the mission to their entire clinical practice.  We planned to work with the anesthesia teams on their regularly scheduled cases and help them find ways to improve their current processes.

Our first morning the scheduled primary anesthesiologist was suddenly called away to an important meeting, so my attending Dr. Denman and I managed the day�s cases with the help of a pack of anesthesia residents in various stages of training and their residency director B.S. Thanh. Our first patient was a nervous four year-old boy with a repaired ventricular septal defect and residual pulmonary hypertension who presented for a cleft lip repair.  Via translation from young lecturer B.S. Dao, we reviewed the anesthetic management of pulmonary hypertension with the residents and then started the case, which proceeded uneventfully.  Each subsequent patient presented new opportunities for teaching and best practice discussion.  Once we had finished all of the scheduled cases, I gave several lectures to the Vietnamese medical students and residents discussing anesthetic concerns for craniofacial surgery and pediatric thoracic surgery.

Dr. Denman (right, in blue) discusses perioperative fluid management and cardiac output with the Vietnamese anesthesia residents.

Since this was my first exposure to how perioperative medicine is practiced in Vietnam, I was shocked by the efficiency with which care was delivered.  Unlike at my home institution, room turnover time was measured in seconds, rather than minutes---the interval between one patient exiting the OR and the next one walking in was always less than 90 seconds.  No space is wasted either---the operating suites are the size of the smallest rooms at MGH, and some have two beds with patients having procedures simultaneously.  A gentleman I met who was originally from New York told me his experience of having toe surgery in a Vietnamese hospital---he walked into the operating room and lay down next to a woman, already anesthetized, with an open abdomen, surrounded by surgeons busily working to repair her small intestine.  It was interesting to imagine how some of my more anxious American patients would react to such a scenario!  The rapid turnover allows this two-room surgical suite to finish as many as twenty cases before lunchtime.

Two patients in the OR, both awaiting induction of anesthesia.

I was additionally impressed by the ability of the Vietnamese anesthetists to make good use of limited supplies.  One ventilator with a broken bellows chamber had a staff member assigned to manually ventilate patients connected to that machine.  The anesthesia scavenging system was a hose taped to a partially open window.  Medications weren�t consistently available, so the anesthetists are able to adapt their management plans based on what was inexpensive or what had been donated or left over from other medical missions.

Despite these obstacles, anesthetic care is provided safely to patients primarily because of the skilled teaching and breadth of experience of B.S. Kim, who runs the anesthesia department at Rang Ham Mat, and B.S. Thanh, who runs the anesthesia residency program.  B.S. Thanh has trained an excellent group of residents who not only work hard but are also eager to learn.  It has been a pleasure to work with this team over the past few days. 

I�m looking forward to the second half of this wonderful adventure!

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