Wednesday, March 22, 2017

Perioperative Anesthesia Education in Gaborone, Botswana

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

Perioperative Anesthesia Education in Gaborone, Botswana

Dumela from Botswana! One of the major reasons for being invited as a visiting physician educator at the University of Botswana School of Medicine (UBSoM) was to assist in developing the medical student curriculum and help with both intra-operative and classroom-based instruction. This task, however, is fraught with challenges and questions. What do medical students learn in Botswana medical school? How are students evaluated? How do students expect to be taught and how do they learn best? How are topics best communicated? How can we teach in a culturally competent fashion?

The UBSoM is located on the University of Botswana campus, an expansive stretch of academic and administrative buildings on the eastern side of Gaborone, the capital of Botswana. Our first day, we met with our host and mentor, Dr. Neguisse Bekele, chair of the Dept. of Anesthesia at UBSOM, to better understand the structure of the medical student curriculum and to learn how we could be most effective as educators. We learned that medical students at UBSOM have limited exposure to anesthesia. They have dedicated anesthesiology teaching blocks for a total of a month -- 2 weeks each in 3rd and 5th year. This is not much time, and a common lament among the students is that they feel there is not enough time to learn everything. As such, the curriculum for 3rd and 5th years must be high yield and focused on critical information that will benefit the students whether they later train to be anesthesiologists or pursue another field of medicine. The 3rd year curriculum is focused on pharmacology, physiology, monitoring, fluid management, and airway management. The 5th year focuses on neuraxial anesthesia, ventilator management, emergencies, and anesthesia for patients at the extremes of age. Themes that run across both curricula are patient assessment, anesthetic plan generation, and understating the complications, indications and contra-indications of any procedure. Covering all of this material is a tall order, and the medical students work hard! Teaching occurs in the main and obstetric operating theaters of Princess Marina Hospital and at the medical school in tutorial rooms and skills labs.

While keeping within the curricular goals already in existence, we have tailored our educational to focus on mastery of key pharmacologic and physiologic concepts as appropriate to the medical student education levels. Much of this education occurs in the operating theater area and is related the clinical aspects of the days cases, and as such, we sometimes also find ourselves teaching nurse anesthetists or medical officers (physicians who have completed an internship year but have no specialty training).  Regional anesthetic techniques are widely used, so recently, we discussed the causes, diagnosis and management of local anesthetic toxicity.

Devan discussing local anesthetic toxicity with UBSOM medical students and Princess Marina Hospital medical officers.

Princess Marina Hospital is one of the major trauma centers in Gaborone, which has prompted discussions about anesthesia in the trauma patient, including the role of rapid sequence intubation.

Devan after a successful discussion about rapid sequence intubation during a teaching session with a group of 5th year University of Botswana Medical students in the induction area of the main operating theater.
In addition, we have implemented practical, hands-on knowledge and skills sessions. Since the airway management session, we have offered monitoring, ventilator, vascular access, and neuraxial anesthesia workshops. During the monitoring session, we discussed basic and advanced monitors – indications, interpretation and trouble shooting. Most cases at Princess Marina are conducted with basic ASA monitors, but temperature management is limited by scarcity of temperature probes.

David discussing 3 lead telemetry with several 5th year University of Botswana medical students in one of the operating rooms at Princess Marina Hospital.
During the ventilator session, the students learned the basic “knobology” of the anesthesia machines in the main ORs (mainly Drägers and MindRay vents) and had a chance to discover the different ventilation modes available. This practical session was tied to a review of the classic New England Journal of Medicine ARDSNet article about the benefit of low tidal volume ventilation. In this way, we were able to introduce further discussion about evidence-based medical practice. During the ventilator and neuraxial anesthesia workshops, students had a chance to really get hands on and practice IV and central line placement on mannequins and both spinal and epidural techniques.

Overall, we’ve tried to convey our enthusiasm for the field of anesthesia and the power of anesthesia knowledge and skills across medical specialties. We have done this by hosting several hands-on medical student workshops that allow medical students to practice skills and ask questions in a less formal yet structured setting, by providing additional teaching resources, and by supplementing intra-operative teaching. It is our hope that much of this teaching can carry over into the anesthesia MMed program at UBSOM once it is started. Of course, sustainability in any educational effort is a challenge, but we are optimistic that a combination of telemedicine education and further advancement of the path that we have forged for future resident educators will help promote continued anesthesia education and enthusiasm at UBSOM.

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