Friday, March 24, 2017

Ultrasound in the Operating Theater - Botswana


David Bartels, MD
Resident in the Department of Anesthesiology, Critical Care and Pain Medicine at Massachusetts General Hospital
PGY4


Ultrasound in the Operating Theater - Botswana
 
Arriving in Botswana, Devan and I were excited to see peripheral nerve blocks and central access procedures performed under landmark technique. After a certain generation of trainees, these landmark-based techniques are a lost art among American anesthesia residents, as we have “grown up” in the age of ultrasound. That being said, ultrasound use in the USA is considered standard of care for many good reasons, and the potential for ultrasound use in the developing setting is huge. Ultrasound is safe, non-invasive, and fast to use. It serves as a diagnostic and procedural aid.  It is performed by the clinician at the patient’s bedside in real time. It is recommended for use in high-risk vascular access procedures (e.g internal jugular central line placement) and is beneficial for regional blocks by reducing risk of local anesthetic systemic toxicity, increasing regional block success, reducing time to complete the block, and reducing the effective dose of medication. Performing regional nerve blocks and vascular access procedures under ultrasound guidance requires two components: (1) availability of an ultrasound machine and (2) training on how to use ultrasound. Princess Marina Hospital is fortunate to have a modern ultrasound machine that is shared among departments and is housed in the intensive care unit. Yet, many of the staff have not been trained in ultrasound use.

During our time in Botswana, we have provided ultrasound training to medical students, medical officers, and staff using the ultrasound from Princess Marina Hospital.  This training has spanned the spectrum from learning the basics of ultrasound physics to visualizing anatomy on volunteers. In addition, we have covered the basic “knobology” and handling of the Princess Marina Hospital ultrasound such that staff anesthetists are more comfortable in procuring and optimizing images. We have also discussed the vocabulary used to describe ultrasound images (e.g. “hyperechoic”), such that we are able to communicate clearly with each other. It is our hope that with this foundation, further education can occur either via self-practice, further workshops, and guidance via telemedicine.

Devan teaching basic ultrasound use to staff and students at Princess Marina Hospital.
In addition to this training, we have trialed the use of the Accuro ultrasound device, which was generously loaned to us for the month by Rivanna. The device is designed to obtain neuraxial ultrasound images for spinal and epidural placement and estimates the distance to the epidural space. While the device was not used clinically, we did use it as a teaching tool on volunteers to demonstrate neuraxial anatomy, which was an incredible aid.

Two medical officers practice using the Accuro neuraxial ultrasound device.

This past week, we provided a dedicated ultrasound workshop to Princess Marina Hospital operating room staff during their weekly academic rounds. After Devan and I reviewed ultrasound basics and answered questions, we assisted staff anesthetists in practicing with the ultrasound and provided an “in-service” training session throughout the morning. This practice consisted of the basics on how to handle the probe and operate the machine. More advanced staff practiced needle visualization using expired needles donated by MGH colleagues and hunks of polony (a compressed meat similar to bologna). This practical session was a huge success and a lot of fun. More importantly, our Princess Marina Hospital colleagues recognized the value of ultrasound use in their practice and are eager to learn more. This will be the next challenge – to ensure that our training is part of a sustainable educational endeavor.

David listens while leading a Friday morning departmental discussion about basics of ultrasound. A portrait of Botswana’s president, Ian Khama, hangs in the background.

Princess Marina Hospital staff anesthesiologists and medical officers practicing ultrasound visualization of the internal jugular vein on a colleague during our ultrasound workshop.

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
PGY4


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.

Anesthesia at the University of Botswana School of Medicine and Princess Marina Hospital – Gaborone, Botswana

David Bartels, MD
Resident in the Department of Anesthesiology, Critical Care and Pain Medicine at Massachusetts General Hospital
PGY4

Anesthesia at the University of Botswana School of Medicine and Princess Marina Hospital – Gaborone, Botswana

Botswana is often cited as one of the success stories of southern Africa. Responsible management of its diamond wealth and democratic leadership has fueled economic growth in this country of 2 million since independence in 1966. From one of the poorest countries in the world, Botswana has developed into a middle-income country; however, many challenges remain, including in the health sector despite a successful antiretroviral program to combat HIV/AIDS which has increased the life expectancy in Botswana from 47.8 years for both sexes in 2000 to 65.7 years for both sexes in 2015.  As treatment for HIV/AIDS has succeeded in largely transforming the disease into a chronic, manageable condition, other health problems, including non-communicable disease and surgical disease have increased in importance. To help address this, in 2009, the University of Botswana School of Medicine was founded, which has expanded to include 250 students, 50 students per class. (Medical school in Botswana is a 5-year undergraduate program yielding an MBBS degree.) These students rotate at various facilities, but much of their clinical time is spent at Princess Marina Hospital, which is the public national referral hospital in Gaborone.

Devan Bartels, MD MPH and I arrived in Botswana at the beginning of March, under the supervision of our mentors from MGH, Drs. Paul Firth and Lena Dohlman, and our UBSOM mentor, Dr. Neguisse Bekele, with a threefold mission: (1) assist the medical student education efforts of the Department of Anesthesia and Critical Care at the newly founded University of Botswana Medical School (UBSOM), (2) offer stake-holder driven workshops to UBSOM staff and Princess Marina Staff, and (3) assess the capacity at UBSOM and Princess Marina Hospital for the MMed program (residency) in anesthesiology and critical care that UBSOM staff hope to initiate.

Although efforts in anesthesia are relatively new, we are fortunate in that Harvard has had a long and robust presence in Botswana for over 20 years, as part of the Botswana-Harvard Partnership (BHP). A variety of incredible Harvard groups are active in Botswana, including BOTSOGO (Botswana Oncology Global Outreach) and the BIDMC-Harvard Program.

David and Devan in front of the BHP building, adjacent to Princess Marina Hospital in Gaborone
Since arriving, we have been busy working to achieve this threefold mission. Our days are generally divided between the operating room, the UBSOM tutorial and skills rooms, and meetings with UBSOM and PMH anesthetists.  Medical students rotate on anesthesia for 2 weeks in their 3rd year and 2 weeks their 5th year. As such, we have tried to make our teaching as clinically oriented and high-yield as possible, considering the fact that many (despite our best efforts at persuasion!) will likely not train to be anesthesiologists. With this in mind, we are trying to teach basic skills and knowledge that will serve the students well regardless of the specialty they eventually pursue. Topics that we have and will cover include airway management, IV fluid management, contraindications/indications for regional vs general anesthetic techniques, and basic pharmacology.

Recently, we designed and implemented a basic airway workshop using materials generously donated from colleagues at MGH. We started the session with an informal discussion of why a patient might need their airway managed. From this point, we discussed basic airway anatomy, basic respiratory physiology, and the different types of airway management (e.g. mask vs LMA vs ETT). Throughout this discussion, we tried to elicit answers from the medical students based on what they had observed so far during their operating room experiences.

David teaching about direct laryngoscopy, bougie use, and intubation. Here he supervises a University of Botswana School of Medicine student intubate an airway model.
Many questions bubbled over from what they had observed in the ORs. What is an LMA? How do you size an endotracheal tube? What in the world is a bougie? In the OR, due to patient care concerns, procedures happen quickly – IVs are placed, patients are mask ventilated, tracheas are intubated. In our workshop, we were able to slow things down and pass around examples of LMAs, ETTs, oral airway, nasal airways, bougies, laryngoscopes, etc. Students were then able to examine the design of this equipment in detail and, through guiding questions, understand the underlying reasons we use this equipment – for example, why a Miller blade is advantageous in an infant and why an LMA is not a good idea if the patient is an aspiration risk. As the culmination of the course, students attempted LMA placement and intubation on an airway model.  In discussion with students afterwards, it was clear that they felt more comfortable handling basic airway equipment and could apply this understanding to clinical situations. We were rewarded over the next few days, when we overheard students talking to each other during a case about the attending anesthesiologist’s choice of endotracheal tube size, correctly identifying airway equipment, correctly placing LMAs, and, in one case, accurately diagnosing a main stem intubation. It is our hope to continue to assist in helping UBSOM students bridge their pre-clinical education to clinical application.

Wednesday, March 15, 2017

Cardiac Surgery in Africa: the Rwanda Experience

Jeff McLaren
Resident in Anesthesiology at Brigham and Women’s Hospital
PGY 4

Posting #2: Last week and Summary

My last entry was Saturday 3/4, it is now 3/8 and we are leaving today for the states. We have completed 20 surgeries in total on 16 patients.  Of these cases 16 were cardiac cases with 2 washouts and 2 pacemaker placements for post op issues. Everyone has been doing great and recovering well though no one has gone home yet. If you recall I spoke of a patient we did last Wednesday 3/1 who have a very complicated post op course. She was finally extubated today. It was amazing to see how happy her father was to see her awake without an endotracheal tube in. All week he continued to ask why his daughter had not recovered like the others and he spent most days and every night with her. One of the more amazing things I have seen is the way the patients themselves help each other. They talk to each other about their experiences and they feel better knowing others are feeling the same way. Language barriers are so huge here and you feel at time helpless as a clinician when you can’t even explain the simplest things to your patients. Even with the translators you don’t know if what you want to convey is really getting through. Overall the mission was a success and so far all of our patients are well. What happens from here is a mystery. Many of them will remain on chronic heart failure medications to manage symptoms and all of them will be on Coumadin with follow up INR draws. This doesn’t always happen as you can imagine in a developing country where many people walk miles to get anywhere and have limited resources to pay for all this. Despite these obstacles the patients tend to do well and from what I have heard the success of this mission has very much established a strong relationship with the people of Rwanda. Last night the Minister of Health held a dinner for all of us to thank us for our efforts.



Matt and I said goodbye to our Rwandan counterparts Gerald and Cervant. Their efforts the past 10 days has been extraordinary and they have continued to work hard despite the long hours. Its hard to measure the success of such a short intervention without testing or simulation but overall Cervant and Gerald have really improved. They have become much more confident in their technical skills and their overall management has improved. The hope is that they take the lessons we have taught them and continue to practice this in their careers. Fortunately for both of them they will have the opportunity to spend some time in the US next year. Gerald will be visiting Stanford while Cervant will visit Penn State and Cornell. I think given the differences in pace between Rwanda and the US this will be a great experience for both of them. They will continue to grow and learn from top institutions that will help them become extremely valuable members of their communities in Rwanda.

Our last day in Rwanda was spent visiting some of the memorial sites from the 1994 genocide. This was an incredibly powerful and moving tribute to one of too many horrible events in the history of mankind. It is even more difficult to see this and to think that many I have worked with and spent time with over the past 2 weeks had been alive and affected by such horrible tragedy. Though almost no one speaks of the events of 1994, it is hard to imagine that they aren’t affected by it. Despite the events of 1994, the country itself is growing. Kigali itself is growing more every day with new construction and infrastructure that will help millions of people. Despite the stark contrast in medical care between the US and Rwanda the healthcare industry is growing. As Danny, one of our attendings pointed out, even though its not what we are used to, it is better than what Rwanda used to have. Any care is better than no care and the care here will get better every year. It is inspiring that the amazing people of this country are so resilient and that their government is dedicated to improving life for all Rwandans. This experience for me has been one I will never forget. The care I was able to provide in such a beautiful place with such wonderful people continues to fuel my desire to work internationally and help expand quality healthcare around the globe.

Cardiac Surgery in Africa: the Rwanda Experience

Jeff McLaren
Resident in Anesthesiology at Brigham and Women’s Hospital
PGY 4

Posting #1: 2/24-3/4

Friday 2/24: First thing you notice about Rwanda is the smiles.  “The land of a thousand hills and a million smiles” is what our driver tells us as he picks us up from the airport in Kigali. When we arrive it is dark and we can only see the lights of the city scattered across the landscape but it is clear he wasn’t joking when he said a thousand hills.

Sunday 2/26: Today was the patient selection meeting. A group of 50+ people including cardiologist from both the US and Rwanda, Surgeons, Anesthesiologists, nurses and care coordinators sat in a room and reviewed ~40 patients for 16 surgery slots. The goal of this meeting is to select the best candidates; sick enough to need surgery now, but not too sick to be too high risk.  This decision was not one taken lightly by any in the room and I left feeling guilt that we had to choose who would be sent away. Danny, one of my anesthesia attendings did remind us that choosing was better than no choice, which is what most patients suffering from rheumatic heart disease are faced with.  We finished the day by setting up our ORs. An entire cardiac OR and ICU packed up and shipped to King Faisal Hospital in Kigali. Overall the operation is impressive and despite the location, the hospital is reasonably well equipped to supply us with the things we couldn’t bring. My co-resident Matt and I went to preop our patients before leaving. I still am astounded by the trust that the patients and their families have shown in all of us. As our translators explains the plan for the following day they ask questions appropriate to what will happen but you can’t help but feel like they don’t fully grasp what tomorrow will be like for them.

Monday 2/27:
First cases are completed. Our first two cases are straightforward without issue and the first case had already been extubated prior to leaving the hospital for the night. Matt and I met one of the two residents we will be working with over the next 10 days. Gerald, originally from Uganda is a 2nd year anesthesia resident and has been assigned to work with us over the week with his co-resident Cervant. Today Gerald mostly just watched and helped as we talked him through what was going to happen during the procedures. They have no experience in cardiac surgery except in what they have read. There is no actual cardiac surgery in Rwanda, as the only cardiac surgery done is from medical missions that visit,. Formerly there were 3 a year but now we are down to 1. There is only one cardiac anesthesiologist out of the 20 anesthesia attendings in the ENTIRE country. Mind you there are 11 million people in Rwanda. King Faisal is a private hospital owned by a Spanish company, but it is the best hospital in the country and the Ministry of Health has worked out some arrangement with them to give us OR time and space for an ICU. The hospital is like a tropical hotel in that the interior is all open to air and as I was transferring my patient to the ICU after the first case I couldn’t help but look out over the rolling hills in the distance and smile. Today was great, everyone did well and we are all excited to work. Tomorrow the patients are more sick, and will be much more challenging.

Tuesday 2/28:
My patient today was an 18 year old girl weighing 66 pounds. She looks younger than the 11 year old we operated on yesterday. She had horrible mitral stenosis and aortic regurgitation that has stunted her growth. She now has two new mechanical valves and will likely never be able to have children due to the dangerous clot risks encountered during pregnancy with mechanical valves. This is something many women here face apparently after their surgery. The inability to bear children is a scarlet letter to most women here and our group has told stories of husbands leaving because of this. She is one of the sickest patients I have ever cared for but she did very well and will be extubated soon. Today was our first real day teaching the residents. Despite being in their second year it is very clear that the learning curve during our 10 days will be steep. It was our intention to use the 10 days to have a cardiac anesthesia tutorial but based on what we have seen, Matt and I will likely focus more on more basic patient care knowledge and use cardiac anesthesia to focus on communication skills. Their knowledge base is good but their clinical experience overall is lower than those in the US at a similar stage. This is likely due to the lack of health care available. Our attendings mentioned to us that the knowledge we pass on to these trainees is likely to help hundreds to thousands as they will use this knowledge to care for many other Rwandans. Tomorrow we have some of the sickest patients we will operate on all week.

Wednesday 3/1:
Technically it is 3/2… I just got back from a washout of our first case. A very sick 15 year old girl with systolic PA pressures and bad mitral stenosis. She too looks like an 8 year old and she was diuresed aggressively over the last two days just to get her to surgery. She was already showing signs of liver dysfunction and her INR was on the rise. The case was initially complicated by a rocky return to bypass after attempting to just repair her tricuspid valve, which turned out to be futile. She instead needed a full replacement. When we dropped off at the ICU her chest tube had put out 1000ml of blood, which given her weight was just under half her blood volume. The blood bank is Rwanda is across town so as we waited for the cab to return with the blood products she was in need of, we started by autotransfusing the blood coming from her chest tube(after filtering). I have worked in one of the nations top hospitals and despite our location and lack of resources I can honestly say that better care couldn’t have been given in the US. The team here is incredible and the focus is only one thing, caring for the patient. There are no administrative hurdles to jump, only the limitations of a developing country. Eventually the decision was made to go back and look for bleeding sources. We didn’t find much… but when we got back to the ICU the bleeding had decreased. Hopefully she will be doing ok by the AM.

Saturday 3/4:
Been a couple days since writing but today was my birthday, and my first Rwandan birthday. Someone found an amazing French bakery and I had an amazing chocolate moose cake with everyone. Definitely one of my more memorable birthdays. My friend from Tuesday night is still intubated but is stable. Our concern now is will she be extubated before we leave next Wednesday. Officially our ICU team leaves next Thursday so if its not by then she will be transitioned to the King Faisal team, something that has been done before but none of us want that to happen.  We have had nothing but success over the remainder of the week and our patients continue to do well.  You can’t help but think the reason these patients are doing so well despite their illness is their young age. Our oldest patient is 37, youngest is 11. Thought their bodies have been ravaged by disease they recover so quickly. Well kinda…

Teaching Cardiac Anesthesia in Rwanda



Matthew Swisher
Resident in anesthesiology at BWH
PGY4


During our mission trip to Rwanda, a large emphasis was placed on the sustainability of our work and educating the Rwandan healthcare providers.  We had the added benefit of always working alongside two anesthesia residents for each case.  Since cardiac anesthesia is not available in Rwanda, we were able to impart the basic fundamentals of cardiac surgery, monitoring, and procedures.  Arterial catheters and central lines are not placed for anesthesia in Rwanda, so we were able to educate them on placement, monitoring, and troubleshooting.  To some surprise, they use ultrasound for nerve blocks and were very interested in applying what they have learned to vascular access.  Part of our effectiveness was strengthened by having one of our BWH anesthesiologists there for the past year working exclusively on improving resident education.  We were very impressed by their eagerness to learn and master new techniques (despite having never been exposed to cardiac surgery).
One of the Rwandan anesthesia residents, Gerald, mask ventilating a patient prior to intubation

One of the most important tenets of anesthetic care we wanted to impart was vigilance.  Rwandan anesthetic care can be very different to what we are accustomed to.  Cases are frequently staffed by non-anesthesiologist technicians, and there is not always a member of the anesthesia team in the operating room at all times monitoring patients during surgery.  Cardiac anesthesia requires a high degree of vigilance, so we hope our emphasis on vigilance can be applied to their other cases and further education.
Jeff, the other BWH anesthesia resident, supervising Gerald placing a central line

By the end of our two weeks, we noticed Gerald and Servant, the two King Faisal anesthesia residents, applying our teaching to their patient care and becoming more comfortable with cardiac anesthesia.