Regional Anesthesia Experience in Ho Chi Minh City

Anthony R. Plunkett, M.D.

esident anesthesiologists at Walter Reed Army Medical Center are fortunate to have the opportunity to participate in medical humanitarian missions as part of their training. Attending anesthesiologists have taken residents to a wide variety of countries, including Ecuador, Peru, Honduras, Eritrea and El Salvadore. These missions are intended to train military residents “austere environment” anesthetic techniques in medically underserved areas of the world. Furthermore these missions expose our trainees to the realities of field medicine and educate the resident on how to provide safe anesthetic care regardless of the surroundings. These environments are not dissimilar to those encountered on the modern battlefield or in times of national disaster, where the luxuries of state-of-the-art technology and ample supplies are not always available.

This year I had the pleasure of participating in a mission to Ho Chi Minh City (formerly Saigon), Vietnam. The purpose of the mission was to educate Vietnamese anesthetists in the use of neurostimulation and ultrasound for peripheral nerve blocks and continuous peripheral nerve blocks.

The funding for this mission was provided through our department and the John P. Murtha Neuroscience and Pain Institute. The project was coordinated through the private nonprofit organization Health Volunteers Overseas (HVO). HVO promotes health care through training and education in 11 specialty areas: anesthesiology, burn management, dentistry, dermatology, hand surgery, internal medicine, nursing, oral and maxillo-facial surgery, orthopedics, pediatrics and physical therapy. HVO specifically supports anesthesia missions in Eritrea, India, Peru, South Africa, St. Lucia, Tanzania and Vietnam.

Ho Chi Minh City is located in the southern part of Vietnam near the Mekong Delta. It is the largest city in Vietnam with an estimated 9 million people in 809 square miles. There are approximately 80 publicly owned hospitals/medical centers and dozens of privately owned clinics. We worked in the Center for Traumatology and Orthopaedics (CTO).

CTO is the main referral center for all orthopedic injuries in Saigon and its outlying areas. It is a 440-bed hospital with seven operating rooms. The operating rooms are divided into upper-extremity, lower-extremity, spine, pediatrics and trauma. There are approximately 1,000 clinic visits daily. Ten nurse anesthetists and an equal number of attending anesthesiologists support an average case load ranging from 100-140 cases per week.

The anesthesia providers are very skilled at the paresthesia technique for administering regional anesthesia. They most commonly perform interscalene, axillary and femoral blocks. They use little to no sedation during block procedures. All patients are placed on standard monitors for block procedures. One of the main reasons for the continued use of the paresthesia technique is the cost and unavailability of nerve stimulators and insulated needles. This is rapidly changing as major regional anesthesia supply companies are taking interest in Vietnam’s emerging economy.

Our educational mission was divided into two one-week training sessions. During the first week, we provided group discussions centered on a cadaver workshop in a local medical school anatomy laboratory. The cadaver workshop consisted of five cadaver stations/dissections: brachial plexus, femoral nerve, sciatic nerve, paravertebral and ultrasound (live models served as the models for the ultrasound laboratory). We spent the second week in the postanesthesia care unit supervising regional anesthetics on various orthopedic patients using a nerve stimulator (B Braun Stimuplex® HNS 12 Nerve Stimulator) and ultrasound (Micromaxx™, Sonosite). We did not emphasize the ultrasound component, however, as it was unlikely the hospital would be able to afford its own machine. We did use the ultrasound to confirm anatomical relationships and to build confidence in trainees in the use of external anatomy for stimulation blocks. There were, on average, 10-12 trainees and staff observing each block performed (and sometimes as many as 20 surrounding one patient).

By the week’s end, we performed 60 nerve blocks, including four lumbar plexus continuous peripheral nerve blocks (which they had never experienced previously). We demonstrated each of the following blocks: interscalene, supraclavicular, infraclavicular, femoral, lumbar plexus, sciatic and lateral sciatic. The staff and trainees were extremely enthusiastic, quick learners and eager to perform the blocks themselves. By the third to fourth day, they were preparing the patients themselves and performing the blocks with our minimal guidance.

I would highly recommend that my resident colleagues pursue and participate in these opportunities. The Society for Education in Anesthesia (SEA) offers the SEA-HVO Traveling Fellowship, which allows senior residents and fellows to participate in a three- to four-week anesthesia mission in a developing country. Although we were invited to the hospital to teach, by the end of my experience, I felt that I was the one who gained a tremendous amount of knowledge. Before the end of the mission, our hosts had acquired two B Braun Stimuplex® HNS 12 nerve stimulators along with 50 nerve block needles. We had no doubt they would be put to good use. Presently we are planning a second visit in 2008.

Anthony R. Plunkett, M.D., is a CA-2 resident at Walter Reed Army Medical Center, Washington, D.C.