Sunday, April 26, 2015

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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