Our afternoon began with mixed emotions, those of nervousness and excitement…how much experience would each group ‘bring to the table’ and what were their expectations? Our expectations were to create a fairly realistic environment by providing airway skill stations such as endotracheal intubation, LMA insertion and surgical airways. The plan was then to slowly introduce them to simulation cases and “go from there”.
As our first group of approximately 10 participants approached the table, I could tell from their eyes that they were nervous as well which put me far more at ease. The initial plan was to divide the groups into 2 where Christian would take half to the surgical airway skills station and I would take half to the intubation, LMA and basic airway adjuncts station. At the same time, we were both feverishly attempting to locate our translators for each skill station…soon we each had translators.
When asking each group who had performed procedures such as intubation, several members of each group would raise their hands.
Both Christian and I agreed that each of our skill station’s goals should be to complete these skills in a safe and efficient manner. We made it our goal to focus on preparation such as positioning, pre-oxygenation, pre-treatment and to perform the actual procedure.
With each passing group, it became apparent that each and every one of them was extremely knowledgeable and the only thing separating us at times was a language barrier. Most members of each group had intubated someone in the past but this also provided an opportunity to hone in on skills as vitally important such as a 2-person bag valve mask, basic oral/nasal airway adjuncts and rescue devices such as the Laryngeal Mask Airway.
We slowly introduced new challenges throughout the afternoon including intubation of the patient in spinal immobilization as well as difficult airways. Each team member also had the opportunity to facilitate intubation with a bougie device that was a new concept for several members as it’s not a tool routinely stocked within their hospital.
Overall, an excellent afternoon with lots of learning and educational opportunities not just for them but also a great opportunity for us to learn new concepts/ideas through their experiences and knowledge.
Ultrasound
By: Anne Sutherland (partnered with Chau Pham)
My normal routine
For the CHKV mission, I was asked to prepare a skills station to teach the use of ultrasound for musculoskeletal procedures. Following my typical approach, I carefully planned a series of exercises meant to move learners from absolute beginners to skilled practitioners who would be able to identify fractures and perform joint injections and arthrocentesis at multiple sites. I was told that there would be a number of healthcare professionals trained in different subspecialties in attendance.
I had taught point of care ultrasonography to small groups before, for individuals at different levels of training. I envisioned a quick progression in skills from the initial image acquisition to the identification of bones from the snowstorm that most beginner ultrasonographers see on the screen. My plan was to give a hands-on demonstration of needle-guided procedures using a surrogate material for the human body, then use a human model to allow participants to scan the knee, ankle, shoulder, and hip joints. After viewing normal anatomy, I would follow with slides of images of pathology, of joint effusions and fractures.
The best laid plans
For the first day of teaching in Long Xuyen, only didactic lectures were scheduled. This allowed us to unpack and set up our individual skills stations, reassembling all of the equipment so carefully bubble-wrapped in Winnipeg. I could feel the excitement and anxiety that I always felt prior to a teaching session coming to the surface. I was unsure about the initial skill levels of the participants- perhaps I was the unskilled practitioner?
For the first day of teaching in Long Xuyen, only didactic lectures were scheduled. This allowed us to unpack and set up our individual skills stations, reassembling all of the equipment so carefully bubble-wrapped in Winnipeg. I could feel the excitement and anxiety that I always felt prior to a teaching session coming to the surface. I was unsure about the initial skill levels of the participants- perhaps I was the unskilled practitioner?
The afternoon of the next day we each gathered by our station as participants milled around our tables, looking for the stations that they wanted. All of our preparation realized, we each began speaking, pausing intermittently to allow our translators to convey our message. Throughout the afternoon, the numbers of participants at each station would swell to what seemed to be 50 people, then down to 3 people, and back up again. As the station progressed, I could see the participants taking on a larger role and correcting their colleague’s hand and probe position without my input. At times my presence felt absolutely integral while at times I felt unneeded.
Over the first few days of the mission, our skills stations seemed to attract more and more participation. I found that the most helpful way to teach was to cater to the specific needs of each individual, depending on their specialty. Each day, I recognized more people, who seemed to want further practice and guidance with our machines. Our ultrasound machines were a curiosity, something different than what they had seen before. Over our first week, I could see improvements in the probe handling and image acquisition. I think my favourite moments were when my translators and their colleagues would teach each other, pointing enthusiastically at the ultrasound, pausing and translating when someone had a question. It was then that I felt that my presence had been effective, and that we had brought knowledge that may persist past our physical presence in the country.
ICU and Ultrasound
By: Aaron Webb (partnered with Dave Easton)
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I never thought that I’d spend two weeks of the last 3 months prior to my Royal College exam flying to South-East Asia to participate in a medical symposium. That being said, Chau did not have to spend much time convincing me that this would be a good idea. It took even less time to convince my wife, Joanna, that it would be a good idea for her to come along with our 18-month old son, Louie. Now that the dust has settled, and the exam is successfully behind us, we couldn’t be happier that we did.
Traveling with an infant is certainly a new experience for us, and we found that experiencing the sights, smells, tastes, and sounds of Vietnam through Louie brought on a special significance. It also helped that we were surrounded by a fantastic team of people who came to feel like family by the end of our time together. Sing-alongs at karaoke bars and on the bus, making immature puns about the name of the Vietnamese dollar (Dong), running through the market in the early morning, and filling our faces with new and delicious food are some of my favourite memories of our down time on the trip.
The medical symposium itself was a fantastic experience. We found extremely gracious hosts in the city of Long Xuyen, and a large group of very intelligent physicians that were eager to learn the new procedures and information that we were teaching.
One of the unique experiences I was able to take part in was with clinical bedside ultrasound teaching. I found a willing accomplice in the ICU director, Dr. Kieu. When I was not delivering lectures or conducting skills stations, a couple of us would pack up one of the ultrasounds and spend a few hours scanning patients in the ICU. We were delighted to see that they had a machine, and several physicians were fairly adept at using them for FAST and aortic aneurysm scans. Although we were often missing a fully fluent translator, we were able to get the point across with body language and clips from the EDE book that we had brought on an iPad. One of the most rewarding moments came after spending much time instructing one of the An Giang physicians on how to perform a proper IVC scan. Later on that morning, we watched as she passed on her newly honed skill to another colleague. This gave us optimism that what we shared with our new Vietnamese friends would be carried forward long after we were gone.
Pediatric Advanced Life Support
By Hareishun Shanmuganathan (partnered with Stasa Veroukis)
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“The Paper Patient Comes First”
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The world of simulation is a daunting one. As physicians, we tend to feel very much on display -our flaws, our gaps in knowledge, and our panic, are all exposed for all to see and judge. However, this exposure is exactly what “sim” is meant to achieve. It focuses an objective lens on our performance, so that when real-life imitates sim, we can deploy the maximum of our honed skills and knowledge in service for our patient. For all physicians, it is the patient who comes first.
In mentoring our superb Vietnamese colleagues, their dedication to their patients was made very obvious! Though we were limited by a very low fidelity model – literally a patient drawn on paper towels, with a plastic airway “head” – our Vietnamese friends eventually approached our model as the real thing. Initially of course, they, like most physicians, were a little apprehensive, and took some time to adjust to the unique learning environment that is sim. However, after a few days, it was readily apparent that they had quickly absorbed the basic principles that sim tries to teach – communication, effective team interactions, how to regulate one’s own panic. They were now enthusiastic participants. I was impressed at how well read the physicians were and, indeed, also how well read the senior ICU nurses were. Though they did not have access to the same resources as we do, in their practice environment they clearly had an idea of what their patients’ care should aspire to.
Moreover, our Vietnamese colleagues care. They, like us, worry about their patients, they agonize over mistakes (even simulated ones), and they want to do better. Perhaps it was this quality that bonded the CHKV Team to our Vietnamese colleagues: the common goal of exercising the full extent of our knowledge and abilities, all in service to our patient. One incident warmly solidified this bond for me.
During one simulation code, Dr. Veroukis and I threw a little wrinkle into our simulation case, and showed our Vietnamese team leader a hand-drawn rhythm strip tracing. It was ventricular fibrillation. In addition to the team leader, the whole team saw it. Within a fraction of second, the whole team sprung into action! The airway physicians immediately started positioning the airway, and began setting up for an intubation. The medication team member reached for the drug syringes. The physician leader, eyes wide with concern, and a bit of healthy fear, immediately pointed to one of her team members to start CPR. Without a moment’s hesitation, that team member interlocked their fingers and placed them on our paper model’s chest, and began the first compression…and then sheepishly smiled. Educators, and mock code team members alike shared a warm little chuckle, but applauded our colleague for how much they “bought in” to the virtual patient. Our dear, oh so vulnerable, paper patient, who had tried to die on us so much that week. For all of us that week, the paper patient came first!
Obstetrics
By: Stephanie Johnston
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When I was asked to participate with this mission in August 2015, I was speechless and the invitation came at a very karmic time. I was in Chicago completing the first of many courses for my Masters of Health Professionals Education (MHPE). Chau’s kind email arrived asking if I would be willing to participate. I was ecstatic as I have wanted to participate in another medical mission, but due to prior experience I only wanted to participate if the mission was education-based. Once I had a chance upon my return to discuss the opportunity with my colleagues at the office, I was fully on board for the mission.
I have to say that this mission has been very different from my two prior missions to Africa. One: the team has been amazing, creating a very supportive environment for troubleshooting and problem solving. Two: being part of an education-based mission has been quite eye opening.
My role for this mission was to provide two obstetrically-related lectures and an associated skills station. From an education perspective, it was quite challenging to decide on the topics and depth of coverage I should provide within the lectures. I did make an attempt to have influence from the OBGYN department in Long Xuyen; however, I feel there may have been a loss of information in translation. The initial request was for a fertility talk and I think this may be due to my name being found on the website for the fertility clinic at home. Considering that fertility is probably not the primary concern in An Giang province, I decided to focus my efforts on the top 2 killers for maternal health: postpartum hemorrhage and preeclampsia. In addition, I decided to add some information about preterm labour. Little did I know, that the information I gave about preterm labour would be the point of interest.
Our first day of the education conference was full of chaos and interest as we tried to sort out the best method for establishing flow within the groups. I was very fortunate to have a translator, Dr. Tho, a practicing Vietnamese OBGYN, helping to facilitate my station. During my planning/development phase, I was informed that labetalol, hydralazine, nifedipine and methyldopa were available in An Giang and I was quite excited to have developed a “pretend uterus” by using hot pink gardening knee pads. When I started my simulation scenario at the hospital, which was based on preeclampsia, I was quite impressed with their answers to the multiple steps I provided during the history and physical exam. They were quite informed and knowledgeable at recognizing gestational hypertension, preeclampsia and HELLP Syndrome. Once we started to try and treat the hypertension, I encountered some new challenges, as the concept of simulation is quite foreign to them. There was some confusion over drug choices, as I provided a bag with multiple “home-labelled syringes” to choose from. They were familiar with labetalol and hydralazine; however, there seemed to be some confusion around which drug to choose. We continued to muddle through the scenario, as they recognized that she needed to be delivered. Delivery of the infant, via the birthing prompt pelvis, was received with reasonable receptivity. When I started to make her bleed, using a long, dark red scarf, the group of obstetricians reacted very quickly, following a similar method/protocol to Canada. I almost felt like I was in the middle of an OSCE at home. Their choice of drug dosings are different, but the same approach is taken. In some ways, I feel as though I was almost useless or causing more harm than good with my teachings, as I am not familiar with their local practices and available treatment options.
It has been a very interesting perspective doing this mission with my new education background. I am finding this mission to be rewarding in some perspectives and challenging or disappointing in other ways. I have had some very cool “Eureka” moments during the past week as I am using the birthing prompt when I don’t have a translator. It is reassuring to say that the process of childbirth is very much the same in Vietnam. Using good ol’ fashion charades and hand gestures, a great deal can be taught. Learning to think on the fly, I ended up spending an afternoon practicing shoulder dystocia and breech deliveries with some keen district “rural” doctors. As an educator it was really cool to have students apply the “See one, Do one, Teach one” philosophy. As we worked through different techniques for shoulders including Woods corkscrew, delivery of the posterior arm and J-maneuver, the students were keen to have me show them and for them to try. We were able to rename them with hand signals using “1, 2 or 3 fingers”. My favourite moments would be when a new member would join the group and their colleagues would start the scenario/delivery for the new member and teach them how to do the different techniques or how they would correct each others’ techniques. It is one of those moments that inspires me to continue pursuing my education training.
From another perspective, I feel as though I was significantly underprepared for my presentations. The obstetrical staff are very well read about the literature and seemed aware of current practices. I started my first lecture talking about preterm labour trying to cover antenatal corticosteroids, magnesium sulfate and indomethacin. I was privileged at seeing their knowledge base during a thorough pimping question period as my practice method significantly differed from their approach. The biggest challenge came when I did not address the drugs they use for tocolysis as they asked questions about several drugs I had never even heard of before. By the end of the presentation, I felt like I had just finished a high risk rounds presentation at home and not performed to my full ability. It has been a lesson to me to be better prepared in the future and to complete some background research about the health care system. After the presentation, one of the OBs, Dr. Hieng, approached me to discuss some of my clinical recommendations. The conversation revealed that they do not have access to IV hydralazine or labetalol to manage hypertension in preeclampsia. Additionally, I seemed to have caused quite a stir by not using nifedipine or betamimetics for tocolysis. It has highlighted another aspect for me to ensure one is aware of the current, local clinical climate. Feeling guilty for my poor performance and ensuing confusion that I caused, I offered to create a third presentation to address the shortcomings of my earlier presentation.
My second presentation and my simulation scenario addressed postpartum hemorrhage and preeclampsia. These topics highlighted another area of confusion, namely their local practice consists of giving oxytocin 10 IU IM and misoprostol 600 to 1000mcg SL as a prophylactic treatment to actively manage the third stage. It appears from the stories I am told that about 5 years ago a patient received a 5 IU bolus of oxytocin IV which resulted in profound hypotension, prompting a change in practice within the hospital. I am quite surprised by this change in practice and was shocked that they are looking towards me to provide an answer and almost endorse that a 5 IU IV bolus is OK, or that if they mix the 5 IU in 5mL of NS and give it slowly, that is… an adequate dose. These brief conversations that are parsed together with broken, simple English have started to show me that there can be a distinct difference between academic/book knowledge and practical or actual practice. Unfortunately, I have had very little opportunity to see or experience their clinical practice.
Gyne Skills Station
By: Joanna Webb
I am a family physician with an interest in women’s health so it seemed a natural fit to run a gynecologic skills station at the CHKV symposium. My main teaching tool was a “pelvic trainer” which consists of a silicone model vagina, cervix and uterus. Lucky we didn’t get too many questions or comments as we passed through customs!
My skills station primarily focused on the insertion of IUD contraceptive devices. With limited access to translators teaching was done primarily through watching and hands on training. Although initially shy at times it was amazing watching the rotating groups warm up, and by the end of the session, participants were eagerly inserting sample IUDs and teaching each other various tips and tricks.
Although not yet widely available, I am hopeful IUDs will become more prevalent in Vietnam. With any luck, the gynecologists will remember the pelvic trainer and feel more confident with their IUD insertions.
CPR/ACLS
By: Lisa Bryski (partnered with Sarah Painter)
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The teaching goes both ways, though. We’ve been humbled by the hospital staff’s willingness to include us in their rounds about patients they are managing. Despite our obvious language barriers as Canadians, we have been treated with great respect when we try to understand or join in a medical discussion. It has taught us the true meaning of collegial professionalism and hosting.
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It’s Week 2 of the CHKV Medical Mission to Vietnam. It’s been an intense but fun trip. The CHKV crew returns well rested from a weekend off and are ready for more teaching and learning. The staff here is a dedicated crew, and have thrown themselves wholeheartedly into any teaching moments we’ve provided.
The hospital staff have a wide range of cases. Their beds are full and their workload busy. Their resources must be doled out carefully to where the need is greatest and the greatest good can be achieved. It is a difficult job they do, much more difficult than what we are used to in Canada. They do it with great grace, however. Each family we have come across in our patient discussions is treated with respect and dignity despite the limited space and resources.
In our conference teaching sessions, it’s been a great privilege to watch the participants grow in both knowledge and in confidence. The first day was full of timid interactions by teachers and students alike. We’ve encouraged each other and have found how much fun it is to be together while we learn. It’s a true joy to see the students now run through resuscitation tasks and codes with confidence. They are also teaching each other as they continue to practice. It’s a great sign that the knowledge has taken, and they will continue to grow once we are gone.
We have only a couple days left to continue to share learning with the conference participants. We’ve come to know them as individuals with great senses of humour and a strong thirst for knowledge. It will be tough to say goodbye on the final day. We hope to return some day for another conference. We’ve made so many connections and friends within this hospital.
Team Simulation Codes (ATLS, ACLS, PALS)
By: Sarah Painter
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Perhaps one of the most valuable and rewarding exercises was our demonstrations. In contemporary medical practice, we have recently experienced a shift in focus. When providing care for an acute patient requiring resuscitation, having an organized team approach with a team leader and assignments for key roles with two way communication is most effective. This more modern approach, often referred to as ‘resusctiationist theory’ is a critical to deliver safe and effective patient care.
In medicine, this is learned and extremely different from the traditional approach. In Canada, we have the benefit of robust resources and access to education allowing for the uptake of this type of practice. During a demonstration of CPR, we had inquired as to the normal approach from the hospital and were informed that they follow these standards and use a team approach. Lisa and I were assigned to the Advanced Cardiac Life Support station – which takes CPR/defibrillation and introduces advanced functions such as airway management and medications.
What we quickly discovered in the skill station, was that there was an opportunity to improve this area. We often enter these situations with a preconceived notion of what we can anticipate. I had expected a team approach that we have become accustomed in tertiary centres at home. But even introducing this structure at our own hospitals at home has been difficult. It takes time and focus to implement this practice. Teams do not practice this way by accident. You have to learn. So once we realized that this would be a great area of focus, we found a way to incorporate it into our symposium.
Everyday after lunch, we would gather the participants (including those video-conferenced in) at the front of the room and focus on a new area. First, the CHKV team members did a demonstration of an ACLS code. The next day, we focused on a trauma patient. The next day, we did a pediatric case. All of the cases included a team leader and team members modelling good communication strategies and an organized systematic approach.
Once participants were more aware and comfortable, we encouraged them to participate in supported way and provided feedback as the cases progressed. By the end of the week, we could see the participants developing new skills that they could incorporate in their practice. As with every new approach, it takes time for practice to evolve in the complex world of in-hospital care. However, we were able to give them essential building blocks and introduce the concept of effective team strategies.