Thursday, 29 March 2012

Accommodation assigned

I am very proud of myself, as I have been good. Up until today, we did not know where we would be staying in Addis, but I did not bug anyone about that, not even once! I just waited until, at the last minute, Addis Ababa University (AAU), gently nudged by the Canadian organizers, made up its mind and assigned us our rooms.

We are staying in apartments owned by AAU in Sar Bet, an area southwest of downtown near the old airport, a golf club (?!) and the Canadian Embassy. We don’t have an exact address, because Ethiopia does not work that way. Even street names are a bit vague and inconsistent. Taxi drivers need to be given directions to the nearest square, tourist hotel, or other large building.

On the whole this is good news. Sharing a couple of apartments with the rest of the anesthesia team is more friendly than each of us having our own hotel room, and means we can cook some meals together and work together on our talks, plan our trips etc.                                                                            

There are several downsides. We don’t have free WiFi, we have to use a USB “Rocket Stick” and pay to charge it up from time to time. The water supply can be a bit erratic, so a local health club membership is advised to ensure access to showers. We get a driver to take us to work in the morning, but getting back home we may be on our own, depending on what time we finish.

There are two hotels within walking distance of the hospital which are sometimes used. One of them has free WiFi. That would be nice, but living in a hotel room for four weeks is a bit tough, anywhere in the world.

Spent a while looking at Addis in Google Maps, and in particular at the pictures people have posted. (Street View has not got there yet!). It looks cleaner and more civilized than I expected. Lots of large buildings, sidewalks with a few well-dressed people on them, four-lane highways, public spaces with rather odd looking concrete art on them. At least, those are the things Google users choose to post photos of. 

Wednesday, 28 March 2012

Thoughts on Teaching Anaesthesia in Africa

While teaching anesthesia in Rwanda, I gained an increased respect for my colleagues in the teaching hospitals.

It is very hard, as a physician, to watch someone else performing a medical procedure on a real patient, and not doing it as well as you would. Doctors have to learn somehow, and the first few times they do a procedure, they will do it less well than a more experienced person. There seems to be a short steep learning curve where the learner is just trying to do the proper steps in the correct order, then a longer flatter curve as they become more expert. I figured out that it took me about 400 epidurals before I had got to be as good as I will ever be.

You have to let the learners do things themselves, and keep out of the way, but remain alert to what they are doing. If things start to go wrong, you have to decide how much time to allow the learners to realize they have a problem and correct it themselves. You then have to decide if you can explain what the problem is and have the learner correct it, or if you have to take over the care of the patient and complete the procedure yourself.

A basic anaesthesia skill is keeping the patient’s airway open so he can breathe freely. If I am doing the case, I will often recognise a problem before the level of oxygen in the blood decreases at all, or when the oxygen level falls slightly, say from 99% to 96%. A learner may not recognize there is a problem until the alarm goes off at 90%.

Once the problem is recognized, there are about a dozen things which can be done, ranging from simple manoeuvres such as lifting the patient’s chin, escalating through a variety of airway devices, to slashing a hole in the neck to gain direct access to the windpipe.  The sooner the problem is recognized, the more time is available to find the least invasive solution, before the oxygen level gets so low that it leads to cardiac arrest, permanent brain damage or death.

It’s a very difficult judgement call, to decide how long to allow a resident to ignore a problem, or struggle ineffectively, and when to intervene. You have to be supremely confident that you can bail the resident out and fix the problem.

If you add in the problems of working in an unfamiliar location, with different equipment, when you don’t know how to get the things you might need, and you don’t know who you can trust to be helpful in an emergency, it gets even more difficult.

Finally, if you are working with people who do not have English as a first language, you can dial the stress up one more notch.

There are a few more stressful things to do in this world, but most of them involve dealing with bad guys who have guns, or with the possibility of dying in some other way.

So why do it, why subject myself to this stress? Well, most of the time I don’t; that’s one of the reasons why I left the downtown teaching hospitals and moved out into the community.

Teaching is incredibly important, and someone has to do it. It can be very gratifying to pass on the tricks and tips learned over a lifetime to a new generation, and I feel there is a moral obligation to do so.

The inequalities between a country like Ethiopia and a country like Canada are so huge as to be daunting. What is the best thing I can do to help? Would it be better if I stayed in Canada for the next month and donated my earnings to a charity which built wells or toilets in Ethiopia? (That’s not a rhetorical question; if you have an informed opinion please share it with me.)

I did not really enjoy teaching in the operating rooms in Rwanda; I found it too stressful to be fun.  The only case that I really enjoyed doing was one where, after the resident had made three potentially fatal errors in managing a three year old child, I moved him aside and took over the case myself. This time, I am going as part of a team, which may make things better. Also, I am not sure how I would think about someone who said that they did not find it stressful to teach anesthesia in Africa.

I summed up my Rwanda experience like this:
Maybe in this imperfect world I am doing the best I can, making the most useful contribution possible, and the stress that comes with that just means I am trying to do my job to the best of my abilities. Yeah, I like that idea...” Feb 26, 2010,

 Or to quote my son’s much more famous blog, :

Anybody can change the world, but it’s difficult. And you should do it anyway.”

Flight !!!

Woke up this morning and immediately checked my phone.
I have a ticket made out in my correct name, flying to Ethiopia on Sunday afternoon!
It felt like Christmas, coming downstairs to find Santa had left presents by the chimney!

It’s been hard, the last four days, to stay interested in packing, reading tourist information, and working on my lectures, when my trip was “in jeopardy” according to the Toronto organizers.

It’s difficult to deal with people you don’t know well by e-mail, especially when there are language and cultural issues. I don’t respond well to blasé comments like “It will all work out in the end, you are not out of pocket here, don’t worry”.

I don’t like being powerless, so I did not really mind the initial situation, which amounted to “We made a mistake, you have to fix it”. If I could have fixed it I would have been happy to do so, but it turned out that I could not.

Once I realized I had to leave the solution of the problem to the same people who had the attributes necessary to create the problem, I was unhappy. The difficult issue was how strongly to express that displeasure, and to whom. By my standards, I was very calm and restrained, but by Ethiopian standards I may have come across as rude and pushy. At that stage, my goal was not to make friends, but to express exactly the right amount of frustration, anger and indignation to motivate the maximum degree of effort to fix the problem as soon as possible.

It seems to have worked and I have my ticket.

Would I have it by now if I had not made a bit of a fuss? There is no way I will ever be able to find out.
Now I can book my internal Ethiopian flight to Lalibela and get the discount for passengers arriving on the national airline except … oh dear, my travel agent has today off! Guess it will have to wait one more day…

Monday, 26 March 2012

No flight!

Just spent an interesting 45 minutes with a very kind travel agent (shout out to Romina at the Bayview Ave Flight Centre!).

Even though the booking was nothing to do with her, she looked through the documentation and called Ethiopian Airlines on my behalf. She got through to a gentleman called Boris in India. He said that the flight was still booked  under the last name "Loa", first name "Oystons". He said that there was nothing I could do about that, as it's not my ticket! I did not pay for it, and it's not got my name on it!

He said that the people who issued the ticket could cancel it and buy a new one in the correct name, for a $300 penalty.

I have let the people in Ethiopia know it is their responsibility to fix this.

I was going to spend tonight going over my packing, but my heart is not in it when I don't have a ticket to go!

Saturday, 24 March 2012


For the last week or so I have been checking my email frequently as I have been expecting news that my flight has been booked by the University of Addis Ababa.

Not only is it less than ten days before I fly, but also there have been a flurry of emails confirming where I was leaving from, when I wanted to leave, and when I wanted to fly back, and the correct spelling of my name. This was information I had supplied about two months ago. In one email I was referred to as Petre,a miss-spelling of my middle name, but eventually my full name was written out by the Toronto organisers, with the notation that "Oyston" is my last name,

 Finally got the details on Friday.There are two interesting things about my flight. For one,it will arrive late Monday night, when I am supposed to start work on Monday morning. The other is that my name is written as Dr OYSTONS\LOA.

There are a few good things: For one, I get to go to curling next Saturday, which I thought I was going to miss. I was expecting to be over the Atlantic by Saturday night. They have the correct date for me to fly back to Canada. Also, I prefer the flight they have given me, via Frankfurt, to the one I was expecting, as it divides the flight up into roughly equal parts, instead of a short hop to Washington and a 13 hour flight to Addis.

But the name thing seems to be an issue, Customs are a bit picky about the passport and the ticket matching up these days. I was pleased to wake up this morning to an email, I think from the airline, saying that they are fixing the issue. Then I got a worrying email from Addis, saying I had to contact the "Ticket Office" to confirm my details, without telling me how to do that. On the Ethiopian Airlines web site I eventually found an American 1-800 number, which worked from Canada. They said the issue had not been fixed, but that they were hoping my name would be right by in their system by Monday or Tuesday.

I still cannot buy internal flights at the reduced rate for international Ethiopian customers until the glitch is sorted out.

I know I can be a bit obsessive compulsive, and that I don't have a great tolerance for people who mess up doing simple tasks, but honestly, these are character traits you really want in an anesthesiologist. If I was like the guy in the local car dealership who only installed three of the four floor mats we ordered for our new car, I would leave a trail of dead bodies behind me at work......

Thursday, 22 March 2012


Packing for five weeks away in a country where one cannot assume it will be possible to buy things that you might have forgotten is difficult. Add a few ideological arguments and you can make it almost impossible.

Let’s begin with clothes. Need to dress for comfort. Daytime temperatures are about  22-24oC, and nights about 7 oC, with it being colder when hiking at altitude. Culturally conservative country, visiting churches and monasteries, so mostly long pants. No sandals or “jiggers” get into your feet.

When we lecture the residents we are supposed to dress formally: Dress shoes, long-sleeved shirt and tie. That’s a bit of a pain, but I sort of get the point and in a way I respect it; we can be rather sloppy in our dress in North America. Sloppy clothes can lead to sloppy manners and sloppy thinking. I will be speaking at the annual national meeting of the Ethiopian Anesthesiologists, so I am reluctantly packing a jacket, tie and dark pants for that, as that is what I would wear to present at a similar meeting in Canada.

On the other hand, when we get laundry done, it is done by hand. Apparently they are very thorough, but also very rough. So maybe I need to pack second or third best items.

Should we be packing clothes with the idea that we would leave them behind, donating them to some worthy cause? It is tempting, and if I can find the right cause, I may do so. However, I have heard that its difficult to set up a clothing business in Africa, because you have to compete against free stuff donated by charities and dumped on the market.

Medical supplies are a more difficult issue. They have some basic drugs and equipment, enough for them to use when we are not there. Should we be teaching them to use what they have, or should we be bringing drugs we think they ought to have, or drugs that we are more comfortable using? For example, they do not have any anti-emetics. If you have an anesthetic, you have pain and you will vomit. Get over it, you are lucky to have had surgery and survived! Is that an acceptable cultural norm that we should let pass, or should we be bringing anti-emetics and showing them that something better is possible, at not very great cost?

Other groups have gone to African countries in the past and said: “Our advice is that you should do things this way and use these drugs”. When they come back a few months later and nothing has changed, they get annoyed and say: “Why are we coming if you don’t want and act on our advice?”

We seem to be taking almost exactly the opposite approach. We are there to provide what the Ethiopians ask for, it is their country and we are only there to provide what they tell us they want. If they want a lecture on Paediatric ICUs on April 28h we will provide one, even if no-one we are sending to Ethiopia that month has ever worked in a paediatric ICU.

So at the moment I am packing a bit of everything into two large bags and hoping the weight limit really is two 23 kg bags!

Sunday, 18 March 2012


Nothing like a couple of good acronyms to make things difficult.

TAAAC is the Toronto Addis Ababa Academic Collaboration, the group I will be travelling with in April. TAAAC is an arrangement between the two universities which began with psychiatry and has now extended to other disciplines, including family medicine, emergency medicine and, of course, anesthesiology. The main aim is to support the teaching of Ethiopian residents by sending physicians from the University of Toronto to the University of Addis Ababa three times a year, in February, April and October, to assist with both clinical and classroom teaching. The buzzword is "capacity building". Instead of just going as a service commitment, doing a few cases and helping a few people, we are aiming to increase Ethiopia's ability to train its own physicians and so be more able to treat its own citizens. It has worked for psychiatry, which has helped complete the training of several psychiatrists who now work in Addis and elsewhere in Ethiopia.

CASIEF is the Canadian Anesthesiologists Society International Educational Foundation. It has the same goal of assisting in the education of residents in their own country. It only deals with anesthesia. CASIEF worked in Nepal for many years and set up a self-sustaining training program there. It now works in Rwanda, which only had one medically qualified anesthesiologist left after the genocide. I worked for them in January 2010 (See

The main difference is that CASIEF tries to have one foreign teacher (and perhaps one Canadian resident) in the country at all times, while TAAAC tries to have a small group of three or four anesthesiologists go together three times a year, along with similar sized groups of other medical specialists. They argue that this is less stressful for the visiting professors. In theory, the local staff should continue teaching between our visits, we are just there to help and support them. In Rwanda, it sometimes seemed that the Rwandan staff felt that we were the only ones responsible for teaching. However, we did have the advantage of an apartment which was always reserved for our use,so we could leave local phones, textbooks, and OR supplies locked up in a safe. On this visit TAAAC is getting the use of an office, but I am doubtful that things left there in April will still be around when we go back in October.

Another difference is that for TAAAC I will only be working in one hospital, Black Lion. CASIEF works at the University Hospitals in Kigali and Butare, as well as the partly-private King Faisal Hospital in Kigali. On the one hand, it was interesting to see three hospitals, and the trip between Kigali and Butare is very scenic, on the other hand its nice only to have to learn my way around one site.

TAAAC seems better organized, as there have been several face to face meetings of the team and of the leadership for briefings. The University has policies and procedures in place for foreign trips. One TAAAC leader always goes to ensure each group is orientated and safely set up in Addis. CASIEF recruits teachers from across Canada and the USA, so a lot of preparation and briefing gets done by email.

Both organizations are trying hard to make a difference in Africa, it will be interesting to compare the two approaches.

Saturday, 17 March 2012

What I know about Ethiopia

About six months ago, this would be a very short post, as until I heard that the U of T goes there to teach, I knew almost nothing. I had heard of the Rift Valley, where the earliest human remains were found, but did not know that was in Ethiopia. I did not realize that the name coffee comes from an area in Ethiopia. I did not realize that much of the country is 3,000 m above sea level, so that, even though it is near the equator, it gets cold at night.

Ethiopia has a very strong culture, with its own way of telling the time. Each day starts at dawn, which is the first hour of the day. 12 o'clock in the day is dusk, then there is the first hour of the night.

The main language is Amharic, which is written in a script which allows for combinations of any one of about 34 consonants with any one of seven vowel sounds to make a single written character.

The calendar has thirteen months, most with 30 days but one with only five days, except on leap years, when it has six. In Ethiopia its the year 2004, not 2012, as they don't keep to the same calendar as we do.

They are a proud people. Ethiopia and Liberia were the only African countries which were never colonized., but Ethiopia were occupied by the Italians for a few years (1936-1941) around the time of the second world war.

I hope to see some of the tourist sites, including hiking to Imet Gogo, which one site lists as the fifth best hike on the whole African continent. The churches at Lalibela. deserve to be much better known. They are carved out of the ground, in some cases out of a single rock, so that the whole church is below grade. They have their own ancient branch of Christianity, with many ancient churches and monasteries. They also claim to have the Ark of the Covenant.

The food is unusual too. The staple is injera, a large pancake made of a flour called teff. This is put on a big plate in the middle of the table, then various vegetarian and meat curries are poured onto it, and eaten communally using more bits of injera to pick the food up The things they put on the injera are quite tasty, but the injera itself looks and tastes like corrugated cardboard soaked in warm water. Maybe its an acquired taste, or maybe I will be heading to the pizzerias, coffee shops and bakeries the Italians left behind!

First post!

In two weeks time, I will  be heading to Addis Ababa for five weeks to teach anesthesia at the University of Addis Ababa and at the Black Lion Hospital. I am going as part of TAAAC, an academic collaboration between the University of Toronto and the University of Addis Ababa.

It is similar to a trip I did two years ago to Rwanda ( The main aim is to teach anesthesia residents in their own country with the hope that they will stay there, rather than use their qualification to get work in a more developed country.

At present, I don't know when I will be leaving, or where I will be staying in Addis. Both these issues are arranged and paid for by the University of Addis Ababa, and tend to be left until the last minute. It's not the way I like to do things, but I have no say in the matter.

Enough for now, I have to get on with some packing and arranging the lectures I need to give. We will be teaching in the operating room most days, but Wed and Fri afternoons we have to give lectures according to a pre-planned schedule. I am assigned anatomy and nerve block of the arm. Not topics I would choose for myself, but again its not my decision.