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 3^rd year and 2 weeks their 5^th 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.