Mission Trip 2

Mission trip #2 to Nhi Dong 1 Children’s Hospital of HCM City, April 10-17, 2009

The members of the team for this trip included Drs. Mike Chen, Elizabeth Beierle from the University of Florida at Gainesville, Allen Browne from Nationwide Children’s Hospital of Columbus, Mark and Ai-Xuan Holterman from RUSH University Medical Center in Chicago, our pediatric surgery nurse practitioner Nancy Browne and neonatal intensive care nurse Erin Hederman, our local representative Joseph Dao.

Of note, following our last visit, the Chicago team hosted Nhi Dong 1 surgeon-in-chief, Dr. Dao Trung Hieu and his young colleagues, Dr. Nguyen Bang for a week in Chicago in November 2008. They visited the medical facilities and observed our clinical activities at RUSH Children’s Hospital at RUSH University Medical Center, U of Illinois Medical Center, Loyola University Medical Center and University of Chicago Comer’s Children Hospital. We also discussed the details of the Memorandum of Understanding.

Joseph Dao and Drs. Hieu and Bang warmly welcomed us back to HCM at the airport.

Day 1. Friday

We joined Nhi Dong 1 surgical staff for a repeat tour of the hospital to introduce Dr. Browne to Nhi Dong 1. We also saw the new hospital library, equipped with two computer terminals with online access and partly stocked bookshelves. We rounded with the surgeons and neonatologists to share management approaches on patients including patients with Epidermolysis bullosa, VACTERL syndrome with gastric perforation, TEF/Duodenal atresia/imperforate anus, sacrococcygeal teratoma, gastroschisis. We also performed preoperative consultations for patients with choledochal cysts and Hirschsprung’s disease. We next operated along with our colleagues in the main pediatric and neonatal operating room.

Our nurses, Nancy and Erin, rounded with the NICU head nurse and met with the Chief Nurse (Ms. Le) to finalize the plans for a joint Nursing Conference for 4/14 & 4/15.

Day 2. We joined Dr. Hieu and his family, Dr. Bang, the surgical residents on a day sightseeing trip to Can Gio with a fabulous lunch by the seaside to renew our friendship.

Day 3: Our team met for an organizational meeting to discuss our mission statement, how to pursue a non-profit organization status and planned for our future visits.

Days 4-7: We returned to do joint surgeries for complex surgical cases such as repair of a cloacal malformation, laparoscopic choledochal and ovarian cyst excision, resection of a hepatic hemangioma, several cases of Hirschsprungs’ disease, some urological reconstructions and many neonatal cases including repair of gastrochisis, tracheoesophageal fistula, resection of a sacrococcygeal teratoma.

Since our team was smaller this time, we accepted Nhi Dong 1’s gracious offer to provide us with transportation. The hospital ambulance would meet out team at 8AM every day in front of our hotel at the center of town and drive us back at the end of our work days.

The focal points of this 2^nd visit are the academic workshops. Each of the US surgeons and Dr. Hieu presented talks with the educational theme of how to manage complex congenital malformations and how to apply laparoscopic techniques to day surgical conditions to an intimate audience of about 20 regional surgeons.

The nursing symposium had an audience of about 100 local and regional attendees. The main topics were retinopathy of prematurity, prevention of medication errors and pain management.

We met with the surgeons from University Hospital and provided suggestions on participations in upcoming international pediatric surgical meetings, abstract and article submissions to pediatric surgical journals.

We presented Nhi Dong 1 surgeons with Bentec silo bags which can be used toward the management of abdominal wall defects (au lieu of makeshift silos from IV bag) and indwelling silastic central venous catheters and provided instructions on their use.

Our official visit concluded with a meeting with Dr. Hieu to discuss our next steps for collaboration. We agreed to delay our initial plan to sign the Memorandum of Understanding until our group obtains formal non-profit status. Acquiring 501 (c ) 3 status is our most urgent priority. We may not have a formal working relationship but will continue to proceed with our collaboration on an informal basis.

Plans are underway for us to participate in a November international surgical symposium hosted by Nhi Dong 1 as well as for nursing educational conference on our return trip.

The nurses agreed to collaborate on academic poster to be presented at American Pediatric Surgical Nurses Association in May 2009 to describe our educational exchange.

Some of our thoughts about this visit:

1. We initiated academic support to the HCM surgeons to our range of mission activities. Filling in the empty shelves in the library bookshelves with more textbooks is also our next priority.
2. Since our workshops are well received, they can be expanded to a wider audience to meet the needs of the local and regional surgeons.
3. We sensed high levels of interests on the part of Nhi Dong 1 intensivists and anesthesiologists to establish the same educational/clinical exchanges being provided through surgeon-surgeon collaboration. Our future visit can be more inclusive in involving non-surgical specialists with surgical-enhancing expertises to improve the overall outcome of the pediatric surgical patients.
4. Our team can continue to support Nhi Dong 1 by providing education materials such as textbooks, access to professional journals, transfer of surgical materials. Once we attained tax-exempt status to allow fundraising, we will have more resources to meet the needs of Nhi Dong 1 and especially the children of VN.
5. Since the work capacity of the current hospital system has not been exploited to its fullest, the elective surgical needs of many children, especially those from far away and without financial means could not be met. One of the goals would be an assessment of how we can find ways within the system to help with Nhi Dong 1 with its clinical overload, especially for elective outpatient surgeries.
6. Our educational efforts should involve not only the surgical attending staff but also the surgical residents in formal and informal teaching sessions since they truly represent the future of pediatric surgery in VN.

Mission Trip 1

Mission trip #1 to Nhi Dong 1 Children’s Hospital of Ho Chi Minh City, July 2008

Day 1: The surgical team was composed of four board certified pediatric surgeons (Dr. Micheal Chen, Elizabeth Beierle, Mark Holterman and Ai-Xuan Holterman), three board certified pediatric anesthesiologists (Larry Berman, Snow White, Erica Cook), a pediatric nurse practitioner (Nancy Browne), an intensive care unit nurse (Kevin Rice), a nurse anesthetist, several medical students, a surgical resident and several administrative support personnel including interpreters, headed by our local representative Vu Dao. Dr. Ai-Xuan Holterman, and Joseph Dao started our week with an informal meeting with the Chief for Pediatric Surgery, Dr. Nguyen Hieu at Nhi Dong 1 for advance directions regarding the activities for the upcoming week.

We participated in the organizational meeting with our sister organization Medical Aid for Vietnam.

The surgical team arrived at a decision cross road and discussed the many options of how to best approach this mission trip. We opted away from establishing off-site independent makeshift locations to offer outreach surgical procedures. Instead, we will remain in Nhi Dong 1 in Ho Chi Minh City to engage in a week of professional exchange with our Vietnamese colleagues to understand their system of care and better inform ourselves of their needs. This information will help guide how to best define our future mission goals and strategic planning.

Day 2:

The team met with Nhi Dong 1 administrative and medical staff for a formal presentation about the hospital, a tour of the entire facility including the outpatient clinics, radiology suites, emergency room, clinical laboratories, intensive care units and clinical wards. We were astonished that this is a 1,000 bed-pediatric hospital, with a surgical volume nearing 30,000 cases/year. Following the tour, our team was divided into 2 surgical units for the remaining week, one unit with the Holterman’s in the main pediatric operating room and the 2^nd unit with Drs. Beierle and Chen for the neonatal operating room. Our pediatric nurse practitioner Nancy was hosted by the nursing leadership and had an independent assessment of the children’s needs from the nursing standpoint. The remaining team volunteers joined Medical Aid for Vietnam for off site mission work.

Day 3-6:

Our surgeons and anesthesiologists worked hand in hand with our Vietnamese professionals, exchanging our experiences in patient management, providing anesthesia care and performing surgical procedures in the inpatient and outpatient operating room facilities. Inpatient procedures are elective complex head and neck and abdominal surgeries, all “index” cases in pediatric surgery, ranging from newborn surgeries such as intestinal atresias, tracheoesophageal fistula, hepatic cysts to laparoscopic and open repair of choledochal cysts, esophageal strictures, total colonic and rectosigmoidal Hirschsprungs’ disease, tumor excision such as retroperitoneal teratoma, esophageal fibrosarcoma, as well emergency procedures such as appendectomy, non operative reduction of intussusception. The clinical experience was incredibly rich, not counting other major cases, we easily participated in over 5 Hirschsprung’s pullthrough, 4-5 choledochal cysts for the short week. We rotated to the highly efficient outpatient day surgery surgical facilities (30 patient procedures in 3 hours!!) for procedures such as inguinal and umbilical hernia repair, circumcision…. Our other activities included clinical rounds on the surgical patients, delivering didactic lectures to the surgical residents. The level of interest on the management of abdominal wall defects is very high, with a lot of good questions from the surgeons and surgical residents, especially regarding the use of the spring-loaded Silo bag.

The team also made our first donations to Nhi Dong 1’s representatives Ms Sa, Head of Nursing and Dr. Hieu, Chief of Pediatric Surgery of pediatric surgical, nursing textbooks and operative materials.

The U.S. consular general and his staff made a special visit to Nhi Dong 1, were given a tour of the hospital facility and were introduced into our group’s effort.

The evening before our last day of work, we shared a dinner event with our Vietnamese surgical hosts including the surgical residents, surgical faculty and surgical nursing staff.

Our formal visit concluded with an official parting ceremony in the conference room, where we exchanged gifts and also discussed ways in which the needs of Nhi Dong 1 could be met. We agreed to establish formal collaborations via a Memorandum of Understanding in preparation for future return visits to continue our exchange program and deliver surgical workshops. We offer to host our Vietnamese surgical colleagues in US medical centers in order to provide them an opportunity to understand US approach to patient care delivery and surgical training, and a broader perspective on what their needs are.

We spent a half-day excursion to the seaside resort Vung Tau before heading back to the US.

Some of our thoughts:

1. The technical skills of our surgical colleagues’ are outstanding, in part through the benefits of the high volume afforded by a centralized system of care. We are so impressed with the surgical residents’ inquisitiveness and learning initiatives. There is so much to teach in a such short time.
2. The physical and work capacity of the hospital system is only partially meeting the overwhelming surgical workload. Despite their best use of and adaptation to current available resources, the health care personnel are constrained in their ability to meet the surgical needs of the children.
3. Potential clinical areas to target their surgical needs are surgical nutrition and infectious disease to enhance the pre and perioperative care and therefore surgical outcome of the surgical patients.
4. From an educational standpoint, our team can enhance our surgical colleagues’ basic fund of knowledge in disease pathophysiology and patient management in the forms of formal lecture series and bedside teachings, providing education materials such as textbooks, access to professional journals and to offer support for academic activities such as clinical publications and presentations at international conferences.