Friday, 18 October 2013

Anaesthesia trainee in Zambia - A volunteer perspective.

Dr Lowri Bowen is currently in a 6 month volunteer post with the Zambian Anaesthetic Development Project (ZADP) working at University Teaching Hospital, Lusaka. She will enter her final year of anaesthetic training on her return to the UK in February.

The MMed programme has currently taken its third intake of trainees destined to complete the four year course and become Zambian trained Physician Anaesthetists, which is very exciting. The ZADP mandate has many different guises so I am frequently seen changing my hats of responsibilities! It incorporates teaching on the MMed programme as well as clinical officers (which I’ll touch on later) mixed in with trying to coordinate the department’s patient safety initiatives, resources, and equipment and governance issues.  I know this already sounds hectic – I’ll try and just give a flavor of the supervision, clinical and teaching aspects in this installment!

Monday morning. The day starts as usual with the 20 minute bicycle ride in to work alongside Dr. David Snell, the in-country lead, which is pleasant due to the temperature being cool at 7am (in contrast to the 32C in some theatres by midday). It’s a chance for some exercise and also a great time to plan the day ahead and to debrief on the way home.

I was supervising a second year trainee with a very interesting (to anaesthetists) maxillofacial case who had a HUGE swelling (most likely tumour) over his jaw extending right up to his cheekbone and slightly to the side of his eye (parotid/maxillo/temporal) area. Looked like he had mumps! Anyway he managed to open his mouth a mere 2cm and then I could see that the whole back half of the right side of his mouth was also involved so there was barely any room for doing anything there - never mind the potential bleeding risk. His jaw movements were also pretty non-existent. So goodness knows how he was eating anything solid. So, although I was the supervisor, it was time to phone a friend and off I went to find David. The three of us, Dave, the trainee and I, concocted a pretty robust plan, which included further plans B, C and D to cover all eventualities and scurried around to locate all sorts of equipment that may have been helpful. In the UK this case would have had a specialized fibreoptic guided intubation with the patient awake or a few other more complex options, which are not available to us here. So we had settled on using an inhalational induction (breathing the anaesthetic) to get him off to sleep and then placing the laryngoscope in the left side of the mouth; usually we place the blade in the right side of the mouth – but this was physically an impossibility. We had also insisted the maxillofacial surgeon to be ready for action with his knife to place a tracheostomy if all the plans failed.

Meanwhile the maxillofacial surgeon had clearly got bored of our detailed planning and decided to cut out the middle men (i.e. us) and put in a tracheostomy under local anaesthesia! So there we were - a functioning airway without the stress for us! Once he had secured the tracheostomy we could begin the anaesthetic, which was then thankfully uneventful. Once he was asleep I looked in his mouth with the laryngoscope to see what would have happened had we not placed the tracheostomy in him and actually had a pretty good view of his vocal cords - grade 2a. However, the whole planning and preparation for a difficult airway was something the trainee remarked on being a great learning experience for her (me too I thought as thinking of all eventualities out here isn’t always easy!)

I have been up and back to Ndola in the Copperbelt with another of the trainees a weekend or so ago. That was an interesting ride at night. Amazing amount of trucks and lorries. Some with and some without lights, some dangerous and some not. Some cars in ditches and some not, some pot holes and some speed bumps and some dusty off road bits but a rich pattern of life along the Great North Road. I can now easily comprehend why so many of the emergencies and resulting fatalities in UTH are road traffic accidents.

We are due to teach a Primary Trauma Course aimed at managing trauma in low resource settings – and is pertinent as it is one of the highest – if not the highest cause of deaths in Zambia. Running these courses is great as it will increase the numbers of doctors from all sorts of specialty backgrounds to be able to deal with trauma in a safe and uniform way but it also encourages Zambians to take ownership of teaching on their own courses. After a successful first course last year in Lusaka this will be the second course to be held in Zambia and will have newly trained Zambian instructors teaching on it. A particular delight to me is that one of the anaesthetic MMed trainees is one of the leads in the organization of the course. This is incredibly encouraging for the future of the course and will have further far-reaching benefits for further course developments in Zambia in the future. So as we had lots to do in Ndola and ran out of time, we came back in the dark again - via a wrong turn that almost took us to the Congo, which even I agree probably would have been dangerous!

My Monday afternoons have been devoted to teaching the MMed's alongside David. This is my favorite teaching job as it is the day where we teach our newly started ZEST sessions - Zambian Emergency Simulation Training! Zest as in lime - refreshing and new, a twist on the conventional teaching methods. The sessions are run in the nearby medical School skills lab, which has a few basic resuscitation dummies, which enable a good range of clinical scenarios to be practiced.  We usually run a few scenarios using an ipad bluetoothed to the iPhone as a remote control monitor to show observations that change according to the interventions done – so it’s as life like as possible. The origin for it came after one of the trainee’s asked if we could do a session on defibrillation (electric shock to the heart) as none of them had ever defibrillated a live patient (or dummy for that matter). This in itself is an interesting and eye-opening fact however when thought of in the context that there are no monitors or defibrillators on any wards except Intensive care (and obviously theatres) I guess most cardiac arrests are not identified as those that can be shocked or not. I do think the Vinnie Jones basic life support ‘Staying alive’ video has a role to play out here! The trainees seem to enjoy it though and are now feeling more confident to tackle any such eventuality! Anaphylaxis up next week….  

I have also got a slot teaching the clinical nurse anaesthetists every other Friday. These guys are not linked to the MMed programme and are not medical doctors. They do a basic physician helper training course and then that is topped up by a two year training in anaesthesia before potentially travelling all over Zambia to deliver anaesthesia. So far I have delivered two sessions and it has been well received and enjoyable to me. In fact I am humbled by their thirst for knowledge. I was worried in the first session as they are all required to attend teaching in their shirts and ties and wear their clinical white coats fully buttoned up. Combining this and the midday heat after a few of them have come straight from a night shift I was totally amazed that the attendance has been 100% and that only one person has exhibited heavy eyelids for a few minutes!

I have found working in Zambia fantastic so far. Yes there are frustrations but the overwhelming positivity stems from the hope for the future and the current batch of MMed trainees (as well as the small interaction I have had with the clinical officers) are certainly giving me plenty of hope for this end.  The staff at the hospital have been very accommodating and friendly, and my Nyanja is coming on leaps and bounds! It is truly a wonderful part of the world to live in and I am very grateful for the opportunity to be here and would like to thank not only the MMed trainees but also the local anaesthetic consultant faculty, the theatre and ICU staff as well as THET for allowing me to transition to life in Lusaka so smoothly. I am looking forwards to an interesting few months and hope to continue with a few further blogs of the programme in due course.

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