In a way I
was looking forward to this conference, as in Ethiopia I am more comfortable
delivering a prepared speech than giving anesthetics, but my expectations were
fairly low, especially as the schedule was not finalized until the afternoon of
the day before.
The three
of us dressed smartly, and a driver came to take us to the Desalgne Hotel just
off Bole Road. This is a spacious and glitzy hotel. We went up to the fifth
floor conference rooms, where there was the usual sign-in sheet, free notebook
and pens, and a couple of snappily-dressed drug reps selling halothane (?!) and
haemacell. Had a chat to them about bringing drugs into Ethiopia. The
government maintains a national drug list, and they need the support of the
anesthesiologists if they want to get anesthesia drugs in. If the pharmaceuticals
are manufactured in India or China there has to be a government on-site
inspection of the manufacturing plant, which may be a wise precaution.
After a
coffee, there was the usual welcome speech, and an apology that the Ministry of
Health was unable to send a delegate.
There were
75 people in attendance, including all our residents, anesthesiologists from
the police hospital, army and various private hospitals in Addis, and some from other
cities like Jimma. There seemed to be a few anesthesia nurses there, too.
Dr A gave a
talk on nosocomial (hospital-acquired) infections in ICU. I was not surprised
when she said they were three times more common in developing countries. Just
looking at the Black Lion ICUs, with limited water supplies, no clean towels,
few gowns, and patients close together it’s not surprising. She offered some
cheap suggestions (like nursing patients 30 degrees head up, and feeding as
soon as possible), some more expensive ideas (like total body draping, gowning
and gloves for central lines), and some thoughts about designing the new ICUs
which are apparently in the works in various hospitals including Black Lion, to
reduce spread of infection. It was a good talk and well received.
At the
coffee break they served delicious small chocolate covered donuts, and we could
get some fresh air on the fourth floor balcony.
A local
anesthesiologist presented a case of tonsillectomy in a four year old with
undiagnosed laryngeal stenosis. After several attempts he got a 3.0 tube in,
and the surgery and extubation were uneventful. This led to a good discussion.
I suggested that nebulised epinephrine would have been useful if the kid had
developed stridor. We talked about using the LMA as a rescue airway or even for
the procedure, and I was surprised to find that even in a private hospital they
did not have a suitable LMA for a four year old child. We discussed surgical
airways and I referred to a British review which said that emergency surgical
airways in kids have a poor success rate. Finally, there was a discussion of
how to ensure that subsequent anesthesiologists knew about the problem.
A drug rep
was then given ten minutes to talk about his company and the products they had
in the pipeline, which was interesting but would not have been allowed in
Canada.
There was
an excellent buffet lunch. National food – injera and wot – supplemented by an array of salads, some
pasta, a couple of stews, some bits of chicken, followed by small bits of cake
and fresh fruit.
Dr D then
gave his paediatric talk, covering recent controversy in fluid management, the
assessment of the ill child, and recent changes to ACLS protocols for
paediatric cardiac arrest. It was all good stuff, but he needed more time to
cover it, and the program was kept strictly to schedule.
I then talked
about Day Surgery, which seems to be a new idea in Ethiopia, where many
patients wait a long time for minor procedures because of the lack of surgical
beds, when they do not need to be admitted.
I went over the logistics of running a Day Surgery unit in detail, then
showed what we do at The Scarborough Hospital Eye Centre as an example. People
seemed interested in the idea, but unsure how to get the ball rolling. There
were specific and valid concerns about how to set up a system so that patients who
had problems after they had gone home could contact the hospital and be
re-assessed and possibly admitted. Black Lion can be a crazy busy place and you
can’t just assume that patients would be able to telephone someone and get seen
promptly.
I had some
interesting conversations in the coffee breaks. I met one of the two medical
anesthesiologists from Jimma, a university city about 200 km from Addis. They
are opening a new surgical suite with 12 ORs, and starting a residency training
program with six residents! OK, he has a large group of nurse anesthetists to
help out, but every other night they will be calling him for telephone advice
or to come in for difficult cases. Not surprisingly, he is looking for outside
help! Unfortunately I think TAAAC will be very busy serving Addis, especially
as they will be getting six new residents next year, and CASIEF has recently
added a project in Palestine to its ongoing work in Rwanda, so I can’t see
either organization being able to offer much more than moral support.
There was a
members-only business meeting of the association so we read papers in the lobby
and hung around until that was finished, then went with the residents in a
hospital van to an Italian restaurant in a local art gallery for dinner.
It was a
very good day’s work. As we had been in Addis between two and four weeks, we
were seen as professional colleagues, not just a bunch of western dudes flying
into Africa to teach the natives how to do things. Overall they have a
realistic model of anesthesia care, with nurses providing most of the routine
care, under the supervision of medical anesthesiologists, and physicians doing
the more complicated cases. Hopefully, the surgeons will come to appreciate
that for the more difficult cases, physician anesthesiologists can provide
better preoperative assessment, better intra-operative management, better
postoperative pain relief, and, if necessary, high quality intensive care, and
that all these will result in better outcomes for their patients.
The Professional
Association has a lot of work to do, getting the message across to the Health
Ministry that high quality anesthesia is an essential part of health care, and
that they need the drugs and equipment to do the job they have been trained
for. I hope that eventually they will be able to write guidelines for
anesthesia in Ethiopia. For example, if they develop the standard that every
intubated patient should have a sterile single-use endotracheal tube rather
than a washed and recycled one it will be easier for anesthesiologists across
the country to insist that their hospitals supply them.
It will be
a long and had struggle, but I think that it is very worthwhile, and I am proud
that I have been able to play my small part in supporting Ethiopia’s anesthesiologists.
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