Friday, June 26, 2015

Teaching Anesthesiology to Rwandan Medical Students: Focus on ABC’s and Oxygen

Standing in front of the 10 medical students starting their 5-week anesthesia rotation, I realized that there is one primary objective I need to achieve: teaching resuscitation skills. This is their last clinical rotation; in 5 weeks, they will be disbursed as general practitioners to the district medical centers where they may be the one doctor available to both hold the scalpel and provide the anesthesia care for a C-section. “ABC’s and vitals” is the mantra I keep repeating to them. Ensure that the trauma patient who just comes into the emergency room has a patent Airway, is Breathing, and has Circulation, then check their vital signs to gage whether their heart or lungs may imminently collapse before tending to the specific injuries. These are the skills in recognizing respiratory or hemodynamic instability and the expertise in resuscitation that we cultivate in anesthesiology and are transferable to keeping a patient alive in any setting, not just the operating theater. Teaching medical students in Rwanda, I realize that these are the most important lessons to get across, not the more self-serving desire to show them “how cool anesthesiology is” and to entice them to follow my career choice.
The reality is, likely none of these students will choose anesthesiology as a specialty, at least not as their first, second, or even third choice. The popularity of anesthesiology as a career choice in Rwanda is similar to how it was like in the U.S. twenty years ago. High patient mortality leading to high stress, low pay, over-burdensome clinical duties due to lack of personnel, and limited respect are some of the top deterrents medical students listed on a survey I helped conduct this month on choice of specialty.

This perspective forms part of the context for designing lessons and case scenarios. The other key component is tailoring to their knowledge base. Speaking with anesthesiologists from the U.S. who have been teaching the medical students for almost a year, I learned that the medical students have received only very rudimentary lessons about the complex physiology of the respiratory system. Thus, we started our first lesson by explaining the fundamentals of why oxygen is crucial for survival and how oxygen enters the body. When a patient cannot take in sufficient oxygen (either due to anesthesia or medical condition), anesthesiologists step in as the “Oxygen-Providing Service.” This paring down to the core of what anesthesiologists provide removes the distractions arising from the technical aspects of anesthesiology, and focuses their attention on assessing a patient’s clinical status and intervening expeditiously.

Thus, the case scenario that I designed is set in the emergency room rather than the operating theater. It emphasizes vigilance, reassessment of a patient’s condition, stabilization of a patient’s cardiopulmonary status, refinement of their differential diagnoses, and anticipating next steps –skills that are important in any clinical setting. Faced with the challenge of managing an unstable patient, the students were very engaged, volunteered answers, and asked questions. In an education system where students were expected to simply absorb information and not encouraged to speak in class, this active involvement from the students was very encouraging.

The final class took place in the SimLab, where the students were able to put the theory and skills into practice by working as a team to resuscitate and ventilate the mannequins. Though most if not all of them will not become anesthesiologists, as practitioners in a country where there is 0.6 physician for every 10,000 people, they will likely encounter situations when they would be called upon to oxygenate and stabilize a patient. I hope they will remember the ABC’s from the Oxygen-Providing Service.

Sunday, June 21, 2015

Cancer Care in Botswana Continued

So the meeting with the ministry personnel never actually came to fruition, we were unable to connect due to certain time constraints and obligations I was however able to meet directly with her nurse coordinator to share ideas. I got a sense from her that although cancer was had not been a major priority, the ministry of health is not recognizes how important and how significant of an impact it is having on the population.
We discussed the strategies to empower the local clinics and health providers. The hierarchy of health care goes from health post, local clinics, primary hospital, 2nd hospital, and tertiary hospitals.   So the plan is to map the countries health clinic and posts, identify the numbers of health provides to create an appropriate strategy to educate them. We discussed the most effect mechanisms for educating health workers and her thoughts were that from the HIV and TB initiatives, workshops had been very successful.  I will have to continue to follow from afar.

I want to focus a little bit of my time in the different hospitals.

I spent majority of my 1st week in Bots at the oncology department of the Gaborone private hospital (GPH). Here the government funded and private patient receive radiation.  So a lot of patients I saw were government funded patients, whom I would have some continuity with at the public hospital. I spent a lot of time assessing the different areas of need.  So I’ll start with that.  GPH is the only radiation facility in the country.  There is only one linear accelerator and a handful (2-3) of radiation oncologists. Because of the volume of patients, there is no room for specialization. They radiation specialist saw patients with cancer of different primary sites, very unlike the U.S, where you really focus on 2-3 disease sites.  There were of course problems such that the scanners were not always functional, which meant patient had to go the radiology department to have their scans. The biggest problem I noted was the lack of human resources, and human capacity. The issues of occasional machine malfunctions were present, but the major issue was the lack of support. For example, in the clinic, the patients generally come in and sit in a cue and they are given a number and they are seen one after another without any form of triage, they are no set appointments, so it is not uncommon for a patient to come into the hospital and sit there for hours waiting for their appointment. There are very few oncologists in Botswana; many of the ones here are expatriates. (A lot of this has to do with the relatively nascent medical school and a handful of residencies that are also relatively new). The government sponsors training of their physicians abroad with the hopes that they will return. However they are presented with better opportunities and incentives and a good portion do not return (but this is an entirely different topic for a different day). Given all the potential problems, there is a lot of hope and room for improvement.   Some physicians are choosing to come back and work in their home country. For a low resources setting, the facility was functioning adequately. Of course there were challenges, but there were a lot of positives. There is a dosimetrist who assists with the radiation plans for patients. There is also one physicist who assisted with QA.  The software that was used for patients’ treatment with pretty updated and comparable to the software used at large academic centers in the US.

The sign for oncology ward
The experience at the private hospital was great because I could immediately juxtapose it with my experience at the public hospital. Besides the fact that the facility was a little nicer, the government hospital experience was not very different. The same needs I saw at the private hospital were also very prevalent at the public hospital. The was a lack of triage such that there is no support for the physicians, for example, a patient came in for a follow-up visit while on chemo and mentioned to the physician that she thought her blood pressure might be elevated.  There was no way to adequately record this, a functioning blood pressure cuff was not available in that office space and the patient was tasked to return to a primary health physician. Another noticeable problem at Princess Marina was the space restraints. Because this hospital is a referral center, patients typically travel long distances from their local health posts and primary hospitals. This means that a patient who is coming in with a potential new diagnosis of cancer is sitting in a waiting area that is adjacent to patients in the ward. So as you seat in the oncology cue waiting to be seen by the oncologist, you can see patients who are undergoing treatment for cancer.  The immense psychosocial havoc that could have on a patient is incomprehensible. The question that would have crept up in my mind, “is my fate similar to the fate of the people lying in the beds next to the waiting area? Now I don’t know if this is what the patients thought, but I can only imagine.

The chairs and patients are waiting areas for patients and just beyond the blue cart is the open ward

Wednesday, June 17, 2015

Cancer Care in Botswana

Hello from Gabarone,

I am now half way into my trip and I thought this might be a good time to sit and reflect on the things I have learned/experienced so far.  The major lesson I learned is that more questions arise than there were answers.  The choice to come Botswana stemmed from an already established collaboration between the Oncology department at MGH and two hospitals in the city of Gaborone (one public/government run) and one private which services government insured patients for certain aspects of care mainly with regards to oncology. The objectives were a few fold help establish breast cancer guidelines in hopes of standardizing treatment of breast cancer patients. Additionally, I hoped to assist with setting up a multi disciplinary breast clinic to make the transition for patient much easier.

Both have come with challenges as well as some progress. In trying to adapt the breast cancer guidelines used in the US, I had to get input from physicians who practice here in Botswana. Immediately you realize that cancer in the US is very different from Cancer in Botswana. For example where as we have screening guidelines and yearly mammography to detect early and occult malignancies, one of the physician’s quotes that 99% of breast cancer patients that they encounter self palpated a mass.  This essentially means that the breast cancer is locally advanced and diagnosed at a much later stage. This also means that things like breast conserving surgeries which is a viable option in the US is not an option in Botswana i.e women who come to attention for management of breast cancer, get mastectomies. So the questions: why are women diagnosed so late?  Why is there no capacity for screening, is it an acceptable fact young women are dying of potentially curable malignancies? In a country where breast are associated with femininity, is late stage disease resulting in mastectomies the best that can be done? There are so many questions…

Back to the guidelines, even though currently the guidelines are a skeleton compared to the one used in the US, it leaves a lot of room for improvement, which is a major positive. Also all the physicians were on board that these guidelines were in deed important and were mostly willing to contribute from their perspectives so that care can be standardized.  

With regard to the multi disciplinary clinic, the major limitation currently is finding an adequate space that would allow all the participating physicians to evaluate the patients’ together.   Also hiring a nurse that could staff that clinic full time has been a challenge. Even though the government has the capacity, I have learned is that cancer is not quite as high a priority as infectious disease for example. The nation wide campaign against HIV and TB has been remarkable partly because the percentages of both are so high and there were enough interested parties to highlight the toll these diseases were taking on the population. Being an optimist though, I think there are enough interested parties that want to change the thinking about cancer; I believe the break through is just around the corner, at least I hope.   

In terms of helping the to stream line the process for patients, I am setting up a meeting with a physician who works with the ministry of health to discuss efforts to educate local providers and health care workers to recognize warning signs and symptoms and also to focus on age appropriate screening as part of their general check up, stayed tuned for the results of that meeting on the next post.