Friday, 6 April 2012

Work in Addis

(If you are not an anesthesiologist you may struggle with this long post, sorry).

How basic are things at the Black Lion in Addis?

They have old Ohmeda Anesthesia machines with built in ECG and O2 Sat monitoring that work of a big tank of oxygen (with no back up cylinder on the machine). No nitrous, no CO2 monitoring, no agent monitoring, one art line transducer in the hospital, no dantrolene, no intralipid for local anesthesia toxicity (no TPN of any kind, come to that), one ventilator in the six bed ICU.

If I was there as an inspector for the Ontario College of Physicians and Surgeons, there would be about a dozen infractions of standards they would have to fix very quickly.

And despite this they do major cases. Whipple’s, Oesophogastrectomies, neurosurgery, neonates, pneumonectomies (without a bronchoscope to check for tube position). There is no shortage of pathology in Ethiopia, and a lot of it ends up at Black Lion.

The first case I saw was a 12 day old baby having surgery for a trachea-oesophageal fistula. The visiting anesthesiologist, fresh from a year at Sick Kids, had done two previous cases. The local staff anesthesiologist does about one a month. At HSC, the kid would have had a cardiac echo to rule out associated congenital heart lesions. Not in Addis. At HSC he had provided total intravenous anesthesia with remifentanyl for a rigid bronch to locate the lesion before placing the endotracheal tube. In Addis, we just inserted the tube beyond the carina then pulled back until we could just hear bilateral air entry. The surgeon could not have been more pleasant or helpful, stopping surgery several times so we could sort out problems. At the end of the case everyone left and we were not sure where the patient was supposed to go. It took almost an hour before someone brought a bed to the OR reception area and we then took the baby out into the hall and waited for the elevator to take the kid up to ICU.

The need for good surgical care is enormous, as there is a vast amount of pathology. The local physicians are almost all smart, well educated, knowledgeable in theory, and pleasant to deal with. They try hard to do good work in almost impossible circumstances.

I am doing OB anesthesia, so one of my issues is to make sure the OB operating room is set up for an emergency CSection at any time. We’d usually use a spinal anesthetic, so we can get a kidney basin with a bunch of assorted re-used spinal needles, some prep and a fabric drape. Drugs? For about a dozen years, the only drug I have used for spinals is 0.75% heavy bupivacaine. We have none. We have 5% heavy lidocaine, which I have never used. Also 0.5% isobaric bupivacaine marked “Not for Spinal use”, which is what I am currently using, as it only expired in November last year. (I asked the resident who said that they use stuff that’s less than one year past expiry, but sometimes give an extra 10%). The local physicians have to be so much smarter than I am, because they need to be able to do cases with whatever drugs they can find.

The first couple of CSections I did without ECG monitoring because I could not figure out the system. We don’t have any of the little circular paper and jelly ECG stickers, so we wet the ECG clip with KY jelly and then tape it directly onto the patient. This actually works!

They don’t have any ephedrine if the patient becomes hypotensive. I found this out only after the patient’s BP was 57/40. One of the other Toronto anaesthesiologists had given me an ampoule of ephedrine, but I had left it in my pack, two floors down, locked in an office to which I did not have the key. The patient was lying so quietly that I thought she was unconscious – or worse – but the patients here are just stoical and lie still and accept whatever happens.

“What do you have for hypotension?” I asked while squeezing the IV bag. “Adrenaline”. At this stage anything seemed good. “How much do you usually give?” I asked, pretending to be testing her, but in fact I had little clue. “5-10 mcg, should I dilute some for you?” Great, thanks, it’s good to be working with a smart resident!

In Canada I would add the 1 mg of adrenaline to 100 cc bag of saline to get 10 mcg/ml, but small IV bags don’t exist. Even a 2.8 kg neonates gets attached to a 1000ml IV bag with a regular adult IV set. The resident diluted the drug in two stages, so we had one 10 ml syringe with 100mcg/ml from which she took 1 ml and diluted it to get to 10 mcg/ml. Although she carefully labelled the syringes, I lived in fear that one of us would use the wrong syringe and give a 10x overdose. In Canada I would have discarded the higher concentration to avoid errors, but here nothing is wasted. One 2 ml ampoule of fentanyl is kept all day and may be divided between several patients, but being careful not to use the same syringe on different patients.

I am supposed to be helping set up an epidural analgesia service for obstetrics. They use 10 ml luer-lock glass syringes for the epidural, which are washed, sterilised, and put into an aluminium dish which is folded over them. There is no way they remain sterile. They have a supply of the very nice Arrow epidural catheters I love, but the only epidural needles they fit through are twice as long as necessary. They have decent epidural needles which are the right length, but one size smaller than I usually use, and only some rather horrid rigid plastic catheters fit through them. We provide an epidural service for whatever hours I feel like working, maybe 8 am – 4 pm. After that the resident makes up a punch of syringes with 0.25% bupivacaine in them and I write orders for the OB resident to do top ups. The first case I did I got a bloody tap and then a CSF leak. The epidural ended up working OK, but at 6 pm, as I was leaving, they said they would do a CSection at 9pm, and could I write orders for the nurse anesthesiologist who works nights to top up the epidural for CSection? Not very happy about that idea, given the problems I had had. I wrote a suggested dose should the anes nurse feel comfortable, but I was not surprised to find the patient got a GA.

Today there were two pre-eclamptic patients who would benefit from epidurals. I saw them with my resident about 10 am, and she was keen to get the practice in. The first patient had had blood sent for a platelet count, but it was not back yet, so we waited. By 4 pm it was still not back. Found out the usual turn-around time is 12 hours. The only practical approach will be to assume the platelets are OK unless the patient shows signs of bleeding or bruising.

We went to get consent from the second patient, who refused, so went to have coffee with the resident and discuss ethics. Is it a universal rule that patients have to be informed and give consent to the things doctors do to them? Or is that some fancy white man idea? The patient was apparently puzzled that she was being asked. They are used to accepting whatever treatment they are given, often without explanation, never mind consent. Do I accept that as the African norm, which will make it really easy for my resident to do epidurals on everyone, and will be good for her education?

Even within the Toronto group there are marked divisions in ideas. I was asked to help another resident put an epidural into a patient having abdominal surgery. As far as I could see, that was a fairly good idea, as he was an older patient having moderately major surgery, but not essential. However, he would get limited benefit from it as they can only run epidurals in ICU, not on the floor, so the epidural would likely be topped up and then removed at the end of surgery. Just as we were getting set up the surgeon came in and said he did not want the patient to have an epidural, apparently mainly on the grounds we were running late and he did not want the case delayed, rather than any patient care issue. The resident and I suggested it would be good for postoperative pain relief, but the surgeon was adamant, so I backed down. The other Toronto anesthesiologists felt that I was wrong, that the anesthetic technique should be decided only by the anesthesiologist, and I should have said that we would not do the case without the epidural. I would have stood my ground more firmly if the patient was sicker, but in this case I felt the epidural was optional and I preferred not to fight the surgeon over the issue. Does that make me a polite and diplomatic person or a wimp?

In the end I did no clinical work today, but did listen to a couple of talks given by the other visiting physicians. I am learning more than I am teaching!

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