Moving Anesthesia and Critical Care Forward in Botswana

Devan Bartels, MD, MPH

Resident in the Department of Anesthesiology, Critical Care and Pain Medicine at Massachusetts General Hospital

PGY4

Moving Anesthesia and Critical Care Forward in Botswana

 

Our trip to Botswana is winding down, and we return to the United States this week. It has been an incredible month of new experiences, constant learning, and meeting inspiring people. David and I have many people to thank for helping make this experience possible, including, but we are sure not limited to, the Department of Anesthesiology, Critical Care and Pain Medicine at MGH (especially Drs. Paul Firth and Lena Dohlman), the University of Botswana Department of Anaesthesia and Critical Care (especially Dr. Neguisse Bekele), the wonderful staff at Princess Marina Hospital, the Partners COE program, and MGH Global Health.

Drs. David Bartels, Lena Dohlman, and Devan Bartels in front of the new teaching hospital.

After a month of striving to achieve our mission of education and capacity assessment, we are heartened that we were able to provide significant supplementary medical student and staff anesthetist education, and we are encouraged by the potential we see for developing anesthesia and critical care capacity in Botswana. A major goal of ours was to convey our enthusiasm for the field of anesthesia and the unique skillset it provides the healthcare system. We have been happy to hear several students express to us that they are now considering becoming anesthesiologists! This is great news and is exactly what is needed. Anesthesia and critical care are vital aspects to a health system, and capacity for anesthesia and critical care is needed in Botswana.

During this last week, we have continued to help teach medical students in the operating rooms and during tutorials. A major theme for our teaching has been safety in obstetric anesthesia, and topics have included postpartum hemorrhage, airway management in the parturient, and appropriate selection of anesthetic technique. In the tutorial sessions, we have discussed monitoring, acid/base status, and vasoactive medications. We have also participated in several case presentations. These sessions are a lot of fun and are perhaps good oral board exam preparation! A student will present a case (e.g. 25 yo female for emergent ex lap…) and then the staff UBSOM anesthesiologist will ask the presenter and her colleagues about appropriate management of the patient. Most often, this discussion starts with the question, “How would you anesthetize this patient?” From this starting point, an organic conversation emerges with students and staff asking questions, offering opinions, and arriving at management consensus. Finally, in addition to our educational work, we have had the chance to learn more about the Botswana-Harvard Partnership and the University of Botswana School of Medicine. This has been invaluable as we learn how to improve future efforts and coordinate with existing programs.

As our time in Botswana draws to a close (for now!), the major question that we now ask ourselves is: What is the path forward for anesthesia and critical care capacity in this remarkable country, especially as the morbidity and mortality of non-communicable disease (especially preventable surgical disease) increase? We have witnessed firsthand the hard work that is already happening and can see the future potential. We know that future development will likely be slow because it requires development of the most precious asset – human capital. This will require real investments in existing staff, recruitment of new (likely foreign) anesthesiologists, and of course, development of the next generation of Batswana anesthesiologists and critical care specialists. It will not be easy, but whatever the path, we have been honored to help at this stage and hope to participate in the future to help create sustainable Botswana anesthesia and critical care capacity. We are eager to return to Boston and further share our experiences and lessons learned. Ke a leboga and thank you!

A Gaborone morning from the top of Kgale (KAA-ley) Hill. Kgale Hill is south of the city and near where the set for “The No. 1 Ladies’ Detective Agency” TV series, based on the Alexander McCall Smith books, was located. This has earned the area the nickname “Kgalewood."

Medellin: Adapting to Life at the Intersection of the Hospital and the Language Classroom

Alister Martin

Resident MGH/Brigham - Harvard Affiliated Emergency Medicine Residency

PGY-2

Medellin: Adapting to Life at the Intersection of the Hospital and the Language Classroom 

It’s been three weeks now and I think I’ve found my rhythm here in Medellin. Since my last post was focused on the study details, and the data collection process is coming along well (we’ve successfully arranged data capture at both of the target sites) I figured I’d zoom out a bit and show you what life is like for me here during rest of my time. When I landed a few weeks back I signed up for a month-long full immersion Spanish language course in the mornings through a wonderful school called Colombia Immersion which was set in the picturesque Colombian town of Envigado. My daily schedule has been to go to these immersion classes from about 9A until 3P. I then make the long hike out to Hospital Pablo Tobon Uribe in another barrio on the opposite side of the city called Robledo. I usually take an uber and this provides a fantastic time to practice my Spanish with the locals. We talk about all sorts of things, the weather, the Colombian peace process, the food(Bandeja Paisa has been a weekly treat), and US politics. Mostly though, we talk about how proud they are to have Pablo Tobon Uribe hospital in the city. They tell me stories of mothers who were saved there, of accidents on ‘motos’(motorcycles – which are very popular in the city) that Hospital Pablo Tobon Uribe helped them through, of diseases that were misdiagnosed at other hospitals but were correctly treated there. One driver told me that he thought it was the best in the country. It was very clear to me that the people of Medellin love this hospital for the care it provides. After spending most weekday nights in the halls of that hospital and experiencing the gratitude the patients have for the care we provided I am also, in some small but tangible way, left with that same pride. This hospital, much like the city of Medellin, has left its mark on me.

The emergency room at Pablo Tobon Uribe has been like a home away from home for me here. Perhaps that's because when you're in a foreign city for an extended period of time with a different culture, you grasp at that which resembles the familiar, that which feels like home. Maybe in these foreign places home beckons even at the same time as it pushes you away and towards this new place you've found yourself in. For me that was the emergency department. Whether it was scurrying for the ultrasound to evaluate for pericardial effusion or doing a late night snack run with co-residents on an overnight to the pastelleria(cafeteria) downstairs there were so many things that felt like my job back home stateside. In those first few days, when the culture shock was most palpable, and I was just learning how to balance in this beautiful, big, scary city, these tiny creature comforts reminded me that not all was different, that some things were the same. 

Even here in this home away from home there were still stark differences, particularly in the patient mix. The volume of trauma here was higher than at my home institution and the nature of the trauma varied. One patient I had, a mid thirties male had been arguing with a "friend" and was struck with a machete directly in the middle of the face. I later saw him as he was being wheeled up to the OR, calmly watching a music video of J. Balvin(an international reggaeton artist and Medellin native), tapping his fingers to the beat, as if he were waiting for the metro. I can't count the number of motorcycle vs MVCs we've had. The number of motorcycles on the road here is astounding.

The Spanish immersion school was a pleasant surprise on this trip. I had not been expecting to grow so close with the people there. The coaches, the other students, and the professors were all fantastic and the school accommodated my having to leave early to make it to the hospital. The classrooms were small and modest and free of distractions. You sat on these soft padded wooden grates and the professor used a large whiteboard. In the afternoons I’d have private coaching sessions where my coaches and I would practice “escenas” which were essentially mock patient-doctor interviews. Overall, I think I have built a solid foundation upon which to continue building my medical Spanish fluency.

Ultrasound Use Among Colombian Emergency Medicine Residents and Leveraging Behavioral Economics Insights

Alister Martin

Resident MGH/Brigham - Harvard Affiliated Emergency Medicine Residency

PGY-2

 

Ultrasound Use Among Colombian Emergency Medicine Residents and Leveraging Behavioral Economics Insights

I landed in Colombia intent on accomplishing three things: doing shifts in the emergency department at a local hospital here, executing our research project on the utilization of point of care ultrasound with the goal of investigating potential behavioral economics interventions to increase its use among emergency department residents, and taking full immersion Spanish classes. How was I going to fit all that into four short weeks? I had no idea. I jumped in and prioritized getting the study off the ground first. Our nationwide resident ultrasound survey project began in Cali, Colombia where a member of our team organized the residents of the emergency medicine program in that city. Our next city was Medellin, Colombia where I was based out of and that's where my story begins.

My first job in Medellin was to understand who the stakeholders were and what defined success for my time with regard to accomplishing the goals of our data collection process. Briefly, the question we were trying to answer was what was the current state of bedside ultrasound(BSUS) use among emergency medicine residents in Colombia and what, if any, were the current barriers to its use? This was a follow up from a study done in 2012 that found that while many residents had an interest in BSUS, and had been informally taught about its use, overall there was a limited use of ultrasound among emergency medicine residents. Since we already had the data from Cali, I was free to focus on organizing the data collection process in the Medellin based programs.

Prior to leaving I had predicted that there would be logistical challenges, I am a firm believer in Muphy’s Law after all. What I didn’t know was what the nature of those challenges would be. 48 hours into my trip I learned that my predictions were accurate, if not a bit underestimated. Those first few days were challenging. My Spanish was still pretty basic, I had only just begun my full immersion Spanish courses, and I experienced my fair share of the normal “we’re not in Kansas anymore” moments. I also came to find that I had overestimated my understanding of how the resident training process here worked and that I was operating from some critical misassumptions. I had initially thought that the administration that I would be working with to administer the study was the same as the hospital I was rotating at. After hearing from another member of the team who was also based out of Medellin, I came to learn that the administration of our ED rotation hospital had no idea that we intended to do a survey of the resident programs. It was here that I learned a crucial difference in the resident training process in Colombia as compared to the US. In Colombia, the residents are not at all affiliated with the hospital – they are only affiliated with the University they are part of. For example, they rotate at many of the hospitals in Medellin but are affiliated to one of the two universities in town. What this would look like in Boston would be a system where residents would either be from, say, Boston University or Harvard Medical School but would rotate at all the hospitals in Boston. For example, Boston University internal medicine residents would rotate at MGH, Brigham, Mount Auburn, BMC etc.

 

On the second night in Medellin I met up with a super helpful young attending who had rotated in Boston prior and had connections to my principal investigator back stateside. We met and he helped me revise my understanding of how things worked at the two programs here in Medellin; Universidad de Antioquia and CES. After this I began to draw a more accurate mental map of who the stakeholders were and how I would begin to rethink our approach. The residents of both programs had semi regular didactic conferences and these settings would prove to be the best for survey administration. 

It’s been a week since I’ve touched down now and after an initial hiccup with the Visa process, I started at the hospital mid-week last week. I was surprised by many things that first week in the hospital but three things jumped out at me immediately. The first was that there was a Sonosite ultrasound that belonged specifically to the Emergency Department here. Coming in I had guessed that maybe the ultrasound would be difficult to find or that, perhaps, it would belong to another department on some other floor in the hospital. Crucially, while the ultrasound was accessible, unlike our department where ultrasound is in sight providing a visual trigger, it was not easily visible here in this ED. Here it lives tucked away in a closet. This has consequences on behavioral change around ultrasound use and provides, perhaps, the first behavioral economics lever to investigate potential interventions. The concept of choice architecture, a term coined by Thaler and Sunstein, reflects the fact that there are many ways to present a choice to the decision-maker, and that what is chosen often depends upon how the choice is presented. Perhaps the current set up works against the use of BSUS, and increases the barrier to its use slightly, almost like out of sight out of mind. As my Spanish Professor likes to say, “Ya veremos(we’ll see). Second, was that I did not see any residents using the ultrasound on their own. I did however, see attendings use the ultrasound occasionally. The third was the most interesting finding. When I used the ultrasound to evaluate patients the residents who helped me translate and who were watching knew almost all of the most important images and structures. For example, I think the first patient I evaluated had SOB. The residents were easily able to identify B-lines, the pleural lines, and could identify lung sliding. They were also able to re-create images on their own when I passed them the probe. That pattern continued for most of the common uses of bedside ultrasound (evaluations of FAST, bedside echo, RUSH, gallbladder, renal US, etc). I was impressed and intrigued. If residents had access to the ultrasound, they were very knowledgeable on its use, and there were patients who could benefit from its use, why didn’t they use it? I had to learn more.