FEATURE : IN THE FIELD
Article in the Australian and New Zealand College of Anaesthetists (The ANZCA Bulletin October 2008)

IN JUNE THIS YEAR, Dr Jenny Carden arrived at a hospital in provincial Vietnam where hundreds of people were waiting for her as part of the Vietnam Vision Project (VVP) team.  They unpacked, set to work and in six days at three hospitals in Central and South Vietnam and in Cambodia, the VVP group performed just under 500 cataract operations.

"The days were long, it was extremely hot and humid, there was inadequate or no air conditioning and the hospitals lacked resources.  The group had to provide all the drugs, instruments and disposable equipment, sterilisers, microscopes and phaeco machines," Dr Carden said.  "I've never worked so hard in my life".

The VVP was established in 2003 when a number of members of the Vietnamese Health Professionals Association in NSW, many of whom arrived in Australia as refugees, wanted to raise funds to help poor people living in Vietnam.  Rotary became involved with both fundraising and with trip volunteers and the money raised allow the group to make the trip to Vietnam each year to perform cataract surgery.  Cataract blindness is a widespread problem in Vietnam and it is estimated that approximately 800,000 people currently live with the condition, with another 82,000 new cases developing each year.  The massive backlog exists because of the limited access to free health care with people relying on charity programs such as VVP.  The project prefers to treat peole in the provinces close to where they live.

"It was suggested we bus people from the provinces to the city for treatment, however patients were hesitant about leaving their families, their homes and their rice paddies even for a short time.  Travel within Vietnam is not easy for poor people in remote areas.  While we were there it was the wet season and they had planting to do and families could not spare anyone.  People cannot travel for health care so we went to the provinces and convinced people to come to us locally," Dr Carden said.

The VVP group from Australia consisted of optometrists, GPs, one anaethetist, surgeons, pharmacists, a dentist (who ran the steriliser and assisted with interpreting), nurses and administrative staff as well as three Rotary volunteers.  They also worked in conjuction with, and funded doctors and nurses from, the Saigon Eye Hospital who traveled with them. "We'd arrive at the hospital late in the afternoon to set up the operating theatres - we never knew what to expect when we got there and we were literally operating on the run and making do where we could.  Often we had to find tables, trolleys and equipment and if the hospital didn't have it, then too bad," Dr Carden said.

"We'd return the next morning to begin work and often we had up to six operating tables running at the same time."

First, the administrative staff processed the patients and allocated them an ID number.  The optometrist then assessed patients' eyes and the GPs conducted general health checks, particularly looking for diabetes and hypertension, which are very common and not well treated.  Due to the very high incidence of diabetes, malnutrition and hypertension, the group had to make on-the-spot decisions about whether surgery was advisable because of the risk of complications.  The VVP doctors treated the conditions but they had to keep in mind that medication wasn't going to help patients in the long term as VVP could only give them a limited supply.  The patients then had their eye marked either left or right, drops were put in to dilate the pupil and then they would jump on one of the six beds lined up in the corridor where Dr Carden performed the block.  The patients then walked into theatre for the surgery.

Many of the team visiting from Australia spoke Vietnamese so they could talk to the patients about what was going to happen early in the procedure and get consent.  There were also Vietnamese-speaking nurses explaining and answering questions throughout the day.  The situation in Cambodia was more difficult and the group relied heavily on local staff for communication with patients.

The risk of postoperative infection was extremely high due to the heat, humidity and poor water quality which posed special problems and was overcome with antibiotic prophylaxis.  The VVP group also had to be very frugal with medicines and supplies. "Anything we didn't bring was not guaranteed and we were forced to try and anticipate everything when we were packing for the trip in Australia.  Fortunately, VVP's prior experience working in Vietnam made planning easier," Dr Carden said.

"At the beginning of the trip we had potentially 600 cases to do and I had to make sure my supplies would last so I was very careful with waste.  Unfortunately I ran out of betadine in Cambodia, our last stop, and the hospital was unable to supply any. We had to send someone out to purchase it locally."

The cataracts were much denser than those seen in Australia and so the patients' vision was very poor.  The aim of VVP was to perform a blindness-curing procedure and so this usually meant only performing surgery on one eye.  Surgery for these denser cataracts was technically more difficult, especially with the portable equipment and instruments and unfamiliar environment.  Dr. Carden said another challenge was that many of the Vietnamese patients have very small orbits so the blocks were technically difficult.  She learnt a lot from the Vietnamese eye team and they exchanged ideas on techniques.  Dr Carden said it was an excellent learning experience for all concerned, however, she points out the trip wasn't a teaching exercise and the group was there purely to perform surgery.

"At one point I was also asked about the feasibility of performing a general anaesthetic on a small child with cataracts.  The facilities equipment and drugs for general anaesthesia were rudimentary and there were also concerns about assitance and communication.  We decided that the brief for the trip was to do as many cataracts as possible in the allocated time, so we thought it would be better to take a photo of the girl, return to Australia and organise some fundraising for her surgery to be done in Saigon.  In this situation, it was preferable to treat a number of people in the period of time rather than spend potentially a whole morning giving one person a general anaesthetic in trying conditions," Dr Carden said.

"Doing the ward round at the end of the day was fantastic - it was very rewarding to see the number of people whose lives had been dramatically changed with sight.  VVP restores independence as the patients can now return to work and participate in family activites."

There was extraordinary teamwork between everyone involved with the project.  All members of the group pitched in to help whether it was setting up, carrying equipment, running the steriliser, moving patients or helping with their eye drops, translating and packing.

Since returning to Australia, Dr Carden and the VVP group have been collecting equipment and sending it to Vietnam.  The anaesthetic departments at the hospitals they visited particularly need laryngeal masks and laryngoscopes.  Everything is sent through the Poor Peoples Association of Vietnam, a government organisation, to ensure what is donated actually reaches the hospitals and patients in need.

Dr Carden said she will be involved with the VVP trip again next year because it was such a fulfilling experience culturally, professionally and personally.  In the mean time, the VVP group will continue to fundraise and plan for 2009.  Volunteers for VVP are welcome including people interested in fundraising, making a donation or the trips.  The group is particularly seeking volunteers who speak Vietnamese or Cambodian.  Enquiries can be made via the VVP website at www.vvp.org.au
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Dr Jenny Carden works in private practice with the Victorian Anaesthetic Group.