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,  johninrwanda.blogspot.ca/

 Or to quote my son’s much more famous blog, visiblechildren.tumblr.com :

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

TAAAC and CASIEF

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 www.johninrwanda.blogspot.com).

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.