Trauma course Vietnam (Ninh Thuan)

Why was it initiated?

In a nationwide survey sponsored by the World Bank, road trauma was second only to earning a living as a priority by Vietnamese people. Preventative strategies, including compulsory wearing of helmets and drink-driving legislation have been effective - though the legislation is not enforced. 
Stabilisation and urgent treatment of victims reduces fatalities from serious traffic accidents and disasters, particularly in circumstances with limited medical equipment. 
Acknowledging there was inadequate clinical trauma training for front-line staff, Dr Phien (director Ninh Thuan general hospital - NTGH) invited us to work with them to develop a trauma course appropriate for their resource poor environment. This was September 2017.

Our principal roles have been in mentoring, arbitration of clinical decisions and, initially, to give “western” credibility to the course. We all agreed to maintain local ownership from the outset.

What are its aims?

1) Train community, medical and nursing staff in skills and uniform procedures and embed those into practice

2) Build confidence that

• an acceptable standard of care can be achieved with a minimum of technology
• these courses could be run in the South and in a regional rather than a major city hospital. 

3) Find local solutions for early deaths and morbidity following major and minor trauma in Ninh Thuan province.
4) Strengthen ongoing knowledge sharing and exchange to spread these skills to other hospitals and medical centres in the province

When did it start?

The first course was September 2018

Who has been involved?

NTGH: Dr Phien, Dr Hong (director emergency department NTGH and lecturer), Dr Thế (lecturer), Dr Thai (department of quality), Ms Tuoi (course coordinator from NTGH) 

MESCH: Cuong Vu (lecturer and interpreter), John Cassey (paediatric surgeon, lecturer)

Other: Au Vu (lecturer and interpreter), Võ Xuân Khang (interpreter), Truong Bao Khuê (lecturer and interpreter) 

What’s happened? 

First course 2018

It is critically important to thank, encourage and support the new lecturers and interpreters. These courses require considerable time, mental input and loss of income for everyone involved. 

The slide sets with associated videos that were used in Lam Dong hospital were modified as a result of SKYPE and face-to-face discussion with the local lecturers. This provided the added benefit of education in content and style. 
A locally produced training video on airway management was added as a result of the video teaching session in the instructors' course 2018. More locally produced videos of “how to” were added by Dr Hong and The in 2019.  
Practical sessions have been extended with a focus on airway management throughout the course.  
The 2018 addition of a "discussion group" session early in the course resulted in more effective and earlier interaction amongst the group.

The course has only been run 3 times since it's initiation - all by Dr Hong and Thế with assistance from "graduates" of the previous courses.

It lasts 2.5 days and there has been no Australian input since the first course.There were 15 attendees (doctors and nurses) at the PTC course in 2018 - coming from various hospitals and medical centres in Ninh Thuan province.

An instructor ("train-the-trainer") course of 1.5days duration follows the PTC. Unfortunately, not all the attendees (10) for the 2018 course had attended the PTC.

In 2018, a 1-day community first aid course (along with its own 1 day "train-the-trainer" course) was delivered by Cuong, Au and Bao Khuê - largely to Red Cross members (20). As no government organisation sees itself as having responsibility of community health education, there is no immediate future in this course. Although the executive management staff at NTGH suggested that smaller medical centres might deliver it to their communities, there is no requirement for them to do so.

Dr Thế has been refused permission by the people's committee to run a first-aid course in the community, despite having volunteers from a group of young doctors with similar mindsets. He is currently attempting to get this supported through the Ninh Thuan Hospital administration to run inside the hospital itself.

Evaluation?

Having regard to the track record of previous PTC courses in Vietnam, particularly Lam Dong and the national hospital in Ha Noi, what was achieved in this first year was very encouraging. It is a great initiative by Ninh Thuan Hospital with a very positive future. With the appointment of more staff to the emergency department in 2019, Dr Hong has less clinical workload and remains committed to course development and delivery.

The broad aims described above were subdivided into more specific and, at this point, achievable ones described in the table below. 
 

Aim	Status	Responsible 2019
Initiate Community first aid & instructors courses at NTGH	Achieved but will not be   continued	NTGH
Initiate PTC and instructors courses at NTGH	Achieved	NTGH
Acquisition of knowledge and skills in PTC	Achieved (direct observation and MCQ)	NTGH
Build confidence that care can be achieved with a minimum of technology	Achieved (Resources and course evaluation forms by participants)	NTGH
Increased awareness of the need for training and for this to be driven from the senior staff	Achieved. MOU to continue	NTGH
Introduce a new style of course delivery & determine participant's perceptions of this	Well received (course evaluation forms & direct feedback)	NTGH and MESCH
Understand what impediments might need to be resolved to improve trauma care in Ninh Thuan Province	In progress	NTGH and MESCH
Understand the structure and processes behind trauma care in Ninh Thuan province	In progress	NTGH and MESCH
Modifications to the PTC course	In progress	NTGH and MESCH*
Establish NTGH ownership of the course	Achieved	NTGH**

* Attempt at getting Vn language version of a free interactive (team building) game called “Space-team”. Positive replies from developer. Need volunteers with bilingual fluency.
** Video of simple jaw thrust airway management completed during the course by participants with assistance by Cuong, Au and John 

Participants:
Attendees come from institutions with markedly different capabilities and backgrounds. Exchange of ideas and understanding the capacities and needs of the participant's individual hospitals will take time.

An interesting finding (noted also in Lam Dong) is that, after the course, 25% of participants felt they needed less equipment and more training. This new style of course delivery is rewarding with strong uptake by all participants. 

Some of the difficulties we all (Vietnamese and Australian) experience with participant interaction, engagement and learning are a consequence of participant's unmet and unknown expectations. Some may improve with insights by participants over time (perception) and some will always be insoluble. 

Processes:
Transition from Australian input to completely Vietnamese has been achieved.  
Debriefs in 2018 were mostly at lunch and a little at the end of each day. They were very honest and constructive with tangible differences being made to content and delivery    

The inability to positively expand into community first aid at this time is unfortunate. We will continue to explore options.

Building community confidence in trauma care and hospital staff. Quite apart from improvements in patient outcomes, this course has the potential to improve the reputation of NTGH, other hospitals and medical centres and Ninh Thuan province as a whole. The flow on will positively impact on:

• staff morale - aligned with the hospital’s current quality improvement research and initiatives 
• the community – trusting and using the hospitals more improves income, results in a lower probability of litigation for bad outcomes and less likelihood of abuse and threatening behaviours to staff. This is aligned with new funding arrangements due to commence late 2107.

Evaluation of these and the ability of other hospitals/ medical centres to assess and deal with serious trauma requires a joint decision by provincial health and MESCH.

We would like to continue to assist in making these communities safer and lessen the financial and social burdens of trauma.