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The Society for Education in Anesthesia-Health Volunteers Overseas Fellowship in VietnamMay 3rd, 2016
This past year, I was fortunate enough to be awarded 1 of 8 Society for Education in Anesthesia-Health Volunteers Overseas (SEA-HVO) Traveling Fellowships. The Traveling Fellowship is a joint collaboration between the SEA and HVO to provide opportunities for senior anesthesia residents to travel to a designated HVO site in a developing country to teach anesthesiology to local anesthesia providers. As stated on their website, HVO’s mission is “to improve global health through education of the local health workforce in resource-scarce countries”. The SEA is a non-profit, member-driven organization whose stated mission is to “support, enrich, and advance anesthesia education and those who teach”. The SEA-HVO Traveling Fellowship provides funding via private donations for 8 anesthesiology residents to travel each year to a designated HVO site for a period of 4 weeks to complete a “Traveling Fellowship Rotation”. The overall goal of the SEA-HVO Fellowship is to allow senior residents the chance to travel to a resource-scarce country to improve anesthesia care by teaching and mentoring their counterparts. To apply for the Fellowship, senior anesthesiology residents must complete the Fellowship application, as well as submit several letters of recommendation and a statement of intent (see below for more information for those interested in applying).
Residents not participating in the SEA-HVO Fellowship (or other anesthesia practitioners) may also participate in an HVO assignment, but may be required to provide their own funding. All HVO assignments are a minimum of 2 weeks (or for the SEA-HVO Fellowship, a minimum of 4 weeks). In general, anesthesia volunteers for HVO can be board eligible/certified, retired or in active practice, hold academic appointment or be in private practice. Final year residents in anesthesiology may also be considered for an assignment if paired with a licensed anesthesiologist to accompany them to the site and precept the resident’s activities. The licensed anesthesiologist must complete the volunteer process and be approved by the project director for the assignment. Residents must also submit a letter of support from their residency program director addressing the resident’s suitability for the fellowship and the program’s willingness to request ABA credit from the ABA Credentials Committee and to financially support the resident’s trip to attend the SEA meeting and to accept the award.
I applied for the SEA-HVO Traveling Fellowship in January 2015 and attended the SEA Spring Meeting in Seattle, Washington in the Spring of 2015 to receive the award. While there, I met with 7 other senior anesthesiology residents from around the country who were the other recipients of the award (http://www.seahq.net/index.php/2014-01-21-22-57-40/2014-01-24-15-30-18/international-health-sea-hvo-70865/108-committees/366-2015-sea-hvo-fellowships-announced). I also met with and was able to thank the benefactors who provided the funding for my award.
My assigned HVO project site was The Hospital for Trauma and Orthopedics (HTO) in Ho Chi Minh City (HCMC), Vietnam, a 440-bed orthopedic hospital that serves as a major teaching institution and referral center for orthopedics in Southern Vietnam. A core staff of anesthesiologists and nurse anesthetists provide anesthesia services at HTO. Dr. Nguyen Chung (the former Chair of the Department of Anesthesiology and local HVO Program Director) is in charge of running the daily activities of the Department of Anesthesiology and the 4-bed Intensive Care Unit (ICU). He is assisted by 7 other physicians. There are approximately 8-10 nurse anesthetists who function under the supervision of physicians and about the same number of nurse anesthetist students. All physicians speak English to some extent. The Hospital for Trauma and Orthopedics in Ho Chi Minh City has 15 operating rooms, and the surgical schedule includes 80-100 scheduled cases every weekday. The main operating room is open until 4 or 5 PM on average and on Saturday until about 1 or 2 PM. The ER suite (5 ORs) handles about 30 operations every 24 hours period.
Prior to my assignment, I worked with the HVO Program Director for the HVO Vietnam site (Dr. Daniel Vo, Boston Children’s Hospital) and Dr. Chung to coordinate the specifics of my trip and plan didactic lectures for the month. Throughout my month there, I gave morning didactic lectures on a range of general anesthesia topics, including Post-Operative Nausea and Vomiting (PONV), Post-Anesthesia Care Unit (PACU) discharge criteria, invasive hemodynamic monitoring, blood transfusion reactions, and postoperative delirium. As a group, we also provided hands on demonstration(s) and lectures on the topics of Laryngeal Mask Airway (LMA) use and application and fiberoptic bronchoscopy, and provided a brief refresher course on ultrasound for regional technique. All of the lectures were translated into Vietnamese beforehand. In addition to daily morning lectures, teaching was conducted via the use of clinical demonstration in the OR and the pre-operative area (where the majority of regional block techniques were performed). While there, I observed that the staff at HTO was already using ultrasound technique for regional anesthesia for a range of surgery types and patients (including awake pediatric patients). Per the request of the anesthesia providers there, we provided instruction and demonstration for several regional techniques they were not as familiar with, including adductor canal and popliteal nerve block(s).
The practice in Vietnam was surprisingly similar to ours in the US, despite the age of the equipment and supplies (some machines were over 20 years old). Despite this, there was some newer equipment available for use by the anesthesia providers, including a Draeger machine. Among the 13 ORs (including the 3 OR’s in the ER), there were a number of newer anesthesia machines, including 2 British Blease, 3 Draeger Fabius, 2 Japanese Lander, and (in the ER) 1 Draeger Fabius and 2 Ohmeda Excel. Up-to-date monitors were also available. Oxygen was the only gas used; nitrous oxide was not available. The majority of the general anesthesia performed was done on modified machines dating from the 1970s with high O2 flows and Halothane vaporizers, utilizing a basic Jackson-Rees circuit. There were closed circuit machines available, but without soda lime, they have been converted to open circuit. Regional anesthesia (including spinal anesthetic) is done with reusable trays.
Most regional anesthesia blocks were performed in the pre-operative area. Prior to receiving regional anesthesia, most patients received sedation with small amounts of midazolam and fentanyl, and occasionally ketamine (especially for pediatric patients). Fentanyl and morphine were the only narcotics available in the OR. Midazolam was the only sedative. Most inductions were done with propofol (rarely with pentothal or ketamine). The most common muscle relaxant used was pancuronium or pipecuronium, and occasionally with vecuronium. Half of the general anesthesia was done under halothane and the other half under isoflurane.
My month in Vietnam was one of the highlights of my residency education. It was a time of reflection, personal education, teaching, and renewed excitement for my chosen profession. In addition to honing my teaching skills, I also learned more about the local surgical pathologies in HCMC, medical illnesses, and anesthesia techniques used at HTO. I improved my ability to be adaptable to local training needs and unique teaching environments. While some might consider it a challenge to provide care in a resource-poor setting, it was inspiring to see how the local providers made the most of the materials and resources they did have available. Furthermore, the experience emphasized the importance of relationship building, collaboration, and the support of local “advocates” for the success of international programs, like the SEA-HVO Traveling Fellowship.
Aside from working at the hospital during the week, I had time in the evenings to explore HCMC, and on the weekends, was able to travel and see the beautiful cities of Dalat and Phu Quoc, and visit the Mekong Delta and Halong Bay (see pictures). Additionally, during the last week I was there, it was the Vietnamese New Year (aka Tet Holiday), which was a cultural experience in its own right.
My experience as a SEA-HVO Traveling Fellow was one I will never forget, and I hope to apply the lessons I’ve learned from my experience in my future global health experience(s) and anesthesia practice. For residents interested in applying for the Fellowship, applications are typically due in February of CA2 year, and require an application form, personal statement, and several letters of recommendation. For more information about the Fellowship and/or applying, please visit http://www.seahq.net/index.php/2014-01-21-22-57-40/2014-01-24-15-30-18/international-health-sea-hvo-70865.
Special thank you to Drs. Judi Turner and Aman Mahajan for their support in my pursuit of the fellowship, and to Dr. Johanna Schwarzenberger for writing me a letter of recommendation.
Other additional resources: https://hvousa.org/.
Rachel Steckelberg, MD, MPH
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