Prince George BC welcomes the first Canadian VAST Course

Thank you to all involved in the most recent VAST Course in Prince George, British Columbia. This is a fantastic moment for the team behind VAST, seeing it delivered in a drastically different setting. Please read Dr Patty Livingston’s reflections on the course.

Prince George in November: crisp air, snow-covered ground crunching underfoot, evergreens, bright red berries and unique light – soft, almost mystical, with dramatic pinks and blues in the late afternoon. Nighttime moose encounters are a threat to drivers, who choose robust high-set trucks for safety.

Prince George is a hub for northern British Columbia. Fourteen years ago, the University of British Columbia established the Prince George medical school campus with the goal of preparing future doctors to serve in rural and northern communities. Previously, students trained in Vancouver and accustom to the big city context they rarely returned to the north. Now they learn in a setting that reflects the local needs. Trainees are often placed for extended periods in communities further afield, in small family practices in the interior and north. It was a rare and pleasant surprise to hear learners say their career aspiration is rural family medicine. We have come to Prince George to teach the Vital Anesthesia Simulation Training (VAST) Course.

Simulation-based health professional education is widespread in high-resource settings, but it typically requires expensive mannequins, a simulation laboratory and technical expertise to run the equipment. The innovation of VAST is to create high quality, authentic clinical scenarios with simple technology, minimal equipment and human actors. The scenarios feel quite real and require learners to respond accordingly. Course participants manage commonly encountered clinical situations (e.g., urgent laparotomy, obstetrics, pediatrics, trauma, pain management) and learn non-technical skills for effective team working. Through simple portable methods, VAST creates an immersive, emotionally charged environment where participants have good “buy in” or credibility. The course is designed to be inter-professional and scalable to learners through fundamental, intermediate and advance levels of many scenarios. After running four VAST Courses in both rural and urban Rwanda, we were eager to explore a completely different context.

Our teaching group comprises Angela (an anesthesiologist and expert who has taught multiple courses around the world, including the recent VAST Course in Nyagatare, Rwanda), Lisa (global health coordinator), Julian (Prince George anesthesiologist and lead for the CASIEF Ethiopia program) and me (Patty, VAST co-author, teacher of VAST in Rwanda and former CASIEF Rwanda program lead). Our goal in offering VAST in Prince George is two-fold: to test VAST in a semi-rural Canadian context and to prepare Julian for facilitating the VAST Course in Addis Abba, Ethiopia in January.

The simulation centre in Prince George is well equipped and the staff are helpful. We had brought the core printed materials: course manuals, handbooks for participants, scenario role-play instruction cards, patient documentation (e.g., vital sign observation charts, anesthesia records, progress notes) and photographs of pathology to be discovered during patient examination. The Prince George simulation centre provided the remainder of the materials and a few simple mannequins. We spent the first two days setting up our workspace and running through scenarios to help Julian become familiar with VAST Course facilitation. This was useful for all of us and essentially offered a dress rehearsal before the learners arrived.

Angela and I had previously experienced VAST in a remote district hospital in Rwanda where the challenges were many: participants had to travel hours in the rain to arrive, people had little capacity in English, a hotel venue with abundant ambient noise and learners with no prior simulation experience. In contrast, Prince George was easy. The attendees included one anesthesiologist, one anesthesia assistant and four medical students. They arrived on time, fluent in English, with previous simulation experience and a high level of training. We quickly discovered that we could offer the intermediate and advanced levels of many scenarios. Because of everyone’s schedules, we condensed the course to two days rather than the usual three-day course. Despite this, we needed to omit little because the learning was smooth and efficient.

The course was received with great enthusiasm and appreciation. Indeed, the learners commented that interacting with simulated patients created much more buy in than they had previously experienced with expensive plastic mannequins. Credibility was such that we nearly had to stop one of them from intubating a colleague!

At the post-course dinner, kindly hosted by Julian and his wife, the learners asked to be involved in future VAST Courses and suggested specific communities they thought would be ideal. One medical student from Yukon thought there would be great value for the course in northern Canada. Others thought the course should be included widely in training programs and run for general practitioners. Our team left Prince George inspired by the value of this course in Canada and keen to implement it widely in both teaching hospitals and more remote settings.

 

Accompaniment by the anesthesiologist

Alan Chu, MSc MD FRCPC

Sustainability, capacity-building, and buy-in.  Integration with the public health system.  Education, interprofessional collaboration, and government support for anesthesia infrastructure.  Although I was disappointed to learn that CASIEF’s legacy-worthy Rwanda project was winding down, its latest pickup in Guyana has great promise!

I have participated in many overseas missions, always small standalone projects, predominantly focused on care provision.  Care provision in Bolivia, Kenya, Haiti post-2010 quake; high-needs settings with minimal infrastructure and, in the case of Haiti, almost complete lack of government capacity.  With training in global health delivery focused on upstream and systemic solutions, I could not help feeling frustrated by organizations with great ideas but impatience with follow-through.

CASIEF’s current project in Guyana is a partnership with the University of Guyana in its capital city of Georgetown, at the country’s lone tertiary care hospital and sole academic centre for postgraduate training.  This is a vibrant community of physicians with training from all parts of the world and where many of the consultant educators are from Canada’s own McMaster University.  Indeed, McMaster has been instrumental in the development of nearly all residency training programs in Guyana, including general surgery, orthopedic surgery, pediatrics, psychiatry, and of course anesthesia.

Are you a senior anesthetist who has developed some wisdom in professional relationship-building and have a few good teaching scripts?  This is the project for you.  Most physicians doing this type of work fit this demographic: practicing physician, married with no children at home, late-career, with a good income.[1]

That being said, a refreshing aspect of the medical community at the Georgetown Public is that it is a youthful group.  The overseas volunteers were mostly early- and mid-career physicians, all with lots of energy.  The thoracic surgeon was a young fellow who hoped to develop a local thoracics training program using his recent residency and fellowship experience in North America and the UK.

These people are fascinating and inspiring.  I met not one but two ex-pat Guyanese who grew up in my own hometown of Toronto, and have returned to contribute to their country.  One precocious young office manager speaks only in inspirational sayings; his bumper sticker reads “Your attitude determines your altitude!”.  There are also several Canadian and U.S. physicians who maintain adjunct positions with the University of Guyana, some of whom leave the comfort of their homes to return frequently or stay for long stretches.

The anesthesia staff are an eclectic group, mostly mid-career, and clearly engaged in the ongoing development of this residency program.  They also contribute to the training of medical students and nurse anesthetists.  Dr. Alex Harvey is both Program Director for the anesthesia program and Head of the Institute of Health Sciences Education (akin to our PGME department).  She is a Jamaican-trained anesthesiologist and the only staff who provides cardiac anesthesia care for the open-heart team that visits every few months.  The sound of Spanish flows throughout the ORs as four were trained in Cuba, similar to a good portion of their surgical colleagues.  Some are not particularly academically inclined, having thrived in their environments because of their pragmatism, but they all are both engaged and engaging.  Hearing their varied and worldly stories is humbling and inspiring, a balance of acceptance of the realities of life and the empowerment that comes from taking it by the horns.

Accompaniment

“Safe Anesthesia & Surgery Saves Lives” is CASIEF’s motto[2] and while this may seem a daunting political task, there is much that individuals can contribute!  The single greatest task for Canadian anesthesiologists is to build relationships with Guyanese physicians and staff.  It is this accompaniment that is the backbone support for the development of contemporary anesthesia professionalism, with its focus on patient safety and the relief of pain and suffering.

There's an element of mystery, of openness, in accompaniment: I'll go with you and support you on your journey wherever it leads. I'll keep you company and share your fate for a while. And by ‘a while,’ I don't mean a little while.” – Paul Farmer, 2011 Harvard commencement address

The role of bilateral partnership became evident one day quite early in my stay.  It was an important national holiday and I had plans to attend the Diwali parade with some friends.  What unfolded however was far from a celebration, it was catastrophic.  We found our Guyanese friend’s father unresponsive at the bottom of his stairs and, after learning there was no ambulance available, proceeded to perform forty-five minutes of basic life support in the back of his vehicle as he raced to the hospital, dodging countless potholes, struggling to understand what was happening on this most holy of days.  Back at the visitors’ residence an hour later, far away from my usual debrief supports and quite shaken, I was surprised when Dr. Harvey appeared at my doorstep.  We sat and chatted for a good while and I felt more at home than I have on any other mission.  What a display of accompaniment, and of partnership.  I can no longer assume that the privileged are accompanying the poor for when I needed support it was quite the opposite.  Despite the heavy workload and trying circumstances of Georgetown, here was yet another case in which Dr. Harvey did not hesitate to simply do what was required given the situation before her, much as each of us do in our daily work.  In many ways, we are the same, and we walk this journey together while building the relationships that are the foundation of all global health work.

With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.”  -- Paul Farmer, 2013, To Repair the World.

How is your emotional intelligence?  Are you able to reflect on your role, privilege, and power, and recognize how and why you are reacting to circumstances as they unfold?  It is often the same people who do not get thrown by countertransference from challenging patients who are well-suited to this work, clinicians who can take a step back while still showing up.

The hidden costs of help

The most commonly cited reason for doing overseas work is “to help” or “to do something good”[3], but some missions exhibit a much higher help-to-harm ratio!  Consider that the average physician cost for each short-term mission is $11,000[4].  What could local governments do with the annual spending by visiting physicians alone?  Think of the local costs of visiting missions: garbage, local resource use/waste, even lost employment time in some cases.  Think too of the potential for harm: inappropriate management in the presence of undetected comorbidities; postoperative complication management out of scope or beyond the resources of local personnel; psychological impact of exposure to colonial approaches or views; and Canadian medical trainees providing care beyond their level of training.  It is reasonable to admit that much overseas work suffers from physicians’ “pursuit of self-efficacy”, from various forms of medical tourism, and from other suboptimal motivations that perhaps may not justify its high price tag.[5],[6],[7]

It cannot be understated that the risk of harm remains of paramount importance to all overseas work.  A comment like “What?!  You don’t have that here?!  Well, how can you even do this work??  That is not safe!” will certainly make it harder for the subsequent CASIEF volunteer to achieve the goals of this collaborative project.  In fact, much subtler comments have ended relationships.

Thinking about bringing a resident with you?  Do it!  But be smart and cautious, please.

It requires a lot of interpersonal work for you and for them, especially if you believe some of what I have highlighted about the risk of harm and the importance of relationship-building.  Think of all your possible reservations and anxieties about your upcoming work.  Then imagine a sleep-deprived, always multi-tasking, relatively inexperienced resident contemplating these issues!

In my experience, the best way to incorporate a learner into the mission is to begin with pre-departure training that requires them to reflect on what aspects will be the most challenging for them personally and professionally.  Some description of the historical context of overseas work might help them develop a sense of privilege at being involved in this work; at being a guest of colleagues who are allowing themselves to be vulnerable.  There is literature on what should go into such pre-departure training, but in my view working through the ethics is vital[8].  Precepted missions (in which a Canadian anesthesiologist accompanies a Canadian trainee) are most appropriate for inexperienced residents or students, and the Guyana project is perfectly structured for this.  Plan ahead for your post-return debriefing and do not skimp, schedule multiple follow-up meetings.

I tell my residents something akin to: “This is hard work.  I’ve done this a lot and it is still hard for me.  But incredibly rewarding and a ton of fun.  You will be using all of your senses in overdrive, all day every day, and this is exhausting.  Strive to achieve the same principles as you would at home – patient safety, alleviate suffering, optimize patient outcomes.  Assessing your patients for disease severity and stability will require curiosity and thoughtfulness.  When developing anesthetic plans, consider how our context might affect patient outcomes.  Finally, contemplate what kind of global citizen you would like to be, and when you talk to anybody chose each word carefully to reflect that ideal.”

The doctor, not yet thirty, had been schooled for scarcity and failure, even as I’d been schooled for plenty and success … Working in that clinic had lowered his expectations about what was possible when it came to providing health care to those living in poverty … I’ve since learned that the great majority of global public health experts and others who seek to attack poverty are hostages to similar failures of imagination … How does this story relate to you? First, try to counter failures of imagination … Second point: as you seek to imagine or reimagine solutions to the greatest problems of our time, harness the power of partnership.”  – Paul Farmer, 2013, To Repair the World.

The CASIEF Guyana project is a great place for creative relationship-building.  I made a clinical blunder early on that resulted in a patient requiring a bedside chest tube; as I made the rounds apologizing and discussing the case with various staff, the intensivist roundly congratulated me for inadvertently unmasking the patient’s moderate-sized hemothorax and securing definitive care!  Early in the second week, after treading lightly and getting to know our colleagues and context, we routinely had a large audience of staff and residents in the regional block area looking on and getting involved.  In fact, I might even have imagined that surgeons were thankful that some cases at risk of being canceled could be deemed safe with the use of regional anesthesia or after surface ultrasound assessment.  I learned from my colleagues here that relationships can withstand clinical hiccups and that you never know how things will turn out.

I also had the opportunity to attend M&M rounds, which occurs about once monthly and is attended by all members and residents of the combined Department of Anesthesia and Intensive Care.  The case discussed was a patient who was incompletely optimized and delayed by an anesthesia trainee but subsequently approved by the staff consultant.  This was only after the surgical team had sequentially contacted progressively higher rungs on the ladder until somebody finally acquiesced.  The patient proceeded to arrest on the OR table under the care of the most junior anesthesia care provider on service (a nurse anesthetist) after a code run by the general surgeon.  With some rudimentary understanding of cultural and professional norms, I had some sense of the main issues at play and whispered some thoughts into the ear of the department head, who nodded in agreement.  To my astonishment, he then stood and asked me to address the department – what a heart-racing and humbling invitation that was!  This was what leadership courses call a “crucial conversation”.  The department head nodded supportively throughout, but this was also my last day, so my sincere apologies to subsequent volunteers if they have had to deal with any fallout I may have caused!

One day I was approach by a Guyanese colleague who asked, “So, how do our residents compare to yours?”  Awkward conversation ensued as I had not anticipated this question and I imagined completing an EPA assessment for a resident here.  In retrospect, I wish I had said that our residents are trained for our context and yours must be for yours.  The principles remain the same – safe patient care that also alleviates suffering and optimizes patient outcomes.  Our residents would struggle to accomplish that here.  My hope is that Dr. Harvey and the rest of our colleagues in Guyana, do not receive this message first from reading this newsletter, but rather from a collegial dinner on the balcony overlooking some mango trees, taking in the warm air and faint sounds of bhangra music.  And that those future conversations are replete with imagination.

[1] Caldron PHImpens APavlova MGroot W. 2016. BMC Health Serv Res. Dec 7;16(1):682. Demographic profile of physician participants in short-term medical missions.

[2] https://casief.ca

[3] Caldron PHImpens APavlova MGroot W. 2017. Int J Health Plann Manage. Jan 12. Why do they care? Narratives of physician volunteers on motivations for participation in short-term medical missions abroad.

[4] Caldron PHImpens APavlova MGroot W. 2016. Global Health. Aug 22;12(1):45.Economic assessment of US physician participation in short-term medical missions.

[5] Farmer, Paul. Personal communication, October 4, 2014.

[6] Philpott, J. 2010. Training for a Global State of Mind. Virtual Mentor American Medical Association Journal of Ethics March, Volume 12, Number 3: 231-236.

[7] Arya AN & Evert J. 2018. Global Health Experiential Education: From Theory to Practice. Routledge, New York.

[8] Pinto AD & Upshur REG. 2013. An Introduction to Global Health Ethics. Routledge, New York.

U of T Anesthesia Sports & BBQ Day

On Saturday September 8th, 2018 the University of Toronto held their 2nd Annual Department of Anesthesia Sports & BBQ Day. The event works to bring together staff and trainees and their families for some fun, friendly competition. This year we were honoured to be chosen as the selected charity and we were delighted that together the members of the Toronto anesthesia community raised $5,500 for CASIEF to support the development of anesthesia training programs in low resource countries.

total of 195 staff, fellows, residents, and administrative staff from the Department of Anesthesia and their respective families attended the event. We had fantastic weather and it a true pleasure to see everyone in matching hospital team t-shirts, cheer their teams, compete in fun games, laugh, and enjoy the comeradery.

There was representation from Toronto General, Toronto Western, Mount Sinai, SickKids, Sunnybrook, St. Michael's, Michael Garron, and St. Joseph's. Congratulations to the Toronto General team for winning the sports tournament and fundraising competition - they took home the champion’s trophy (named 'The Laryngoscope') this year. 

Thank you, University of Toronto, for all of your kind support!

Event Organizers

Team Pic – Michael Garron

Team Pic – Sinai

Team Pic – St. Michael’s

Team Pic – Sunnybrook

Team Pic – TGH

Shalini’s Guyana Blog – Guyana wrap-up

Guyana wrap-up-part 1 – Sept. 10th

My 5 weeks volunteering trip with CASIEF has come to an end. I will be wrapping up the trip in 3 parts. I have met many new people, made many new friends and seen a different way of life. I came here with a notion of poverty and suffering. It just goes to show how wrong one can be when one makes an opinion without actually experiencing it.

I found out that the perinatal and under-5 mortality is high, much higher than most countries of the world (shocking numbers: perinatal: 2.8%, under-5: 3.6%). Obstetric analgesia is a rare occurrence, the C-section rate is high. SAO providers (surgeons, anesthesiologists, obstetricians) are stuck in the 20th century with minimal CME possibilities/desire/both. None of the patients speak Spanish but the majority of doctors have been educated in the Spanish language in Latin America and therefore communication with patients is not their forte! Postoperative pain management is limited to IV morphine for all patients in the recovery room. The patients appear very sensitive to opioids and do not seem to need much. However, the Wong-Baker pain scales posted at each bay in the PACU by my predecessor are just posters on the wall, still there. Over and over again, I heard patients tell me “pain is life“.

External partnership programs for post-graduate anesthesia training are being implemented so hopefully there will be changes. Perhaps the success of the CASIEF endeavour will be defined by not the number of people who go to Guyana but the strength of the partnership programs and the effect it will have on the residents. Residents are very keen. I would say they are hungry for knowledge and try and do their best with the limited opportunities for learning. I felt sad when I was teaching ‘massive transfusion’ to a group of residents who have very limited access to blood and none to blood products.

I think I learnt more than I taught! I learnt how to provide anesthesia when supplies are irregular; sometimes drugs and equipment were available and at other times, not. Choosing between absolute sterility and reusing the sparingly available supplies was a hard task, probably the hardest during this journey. Here in Canada, we take disposable single-use equipment and drug availability for granted. When local anesthesia shortage happened in North America (a few months ago), I remember how disturbed everyone was. This is a common occurrence in Guyana! During my stay, the supply for bupivacaine came and it was called ‘Numbicaine‘. The pediatric tylenol is called ‘babygesic‘. How appropriate!

The best part of the trip was teaching regional anesthesia to a bunch of very enthusiastic residents who couldn’t wait to practice their skills (sometimes on a patient and at other times on a pumpkin). The nadir of the trip, however, was not in Guyana but when I returned. With new eyes, I saw the absolute waste of drugs and equipment in Canada whereas ORs in Guyana (and I am sure in many parts of the world) are cancelled due to lack of equipment, drugs, sterile gowns; absolutely anything!

Guyana wrap-up part 2 – Sept. 10th

What I learnt in Guyana was the ability to have a sensible judgement without judging. Safety is an issue in Guyana, this is a known fact. However, that did not mean that we did not go out or socialize. Like anywhere else in the world, there were good people and there were bad people. To be able to survive in a place considered risky/corrupt is a valuable skill that I needed to bring back with me, after 5 weeks in Guyana.

This was a poster on one of the streets of Georgetown.

The other thing I learnt was to stop seeing Guyanese healthcare with a Canadian eye. These healthcare providers work with extremely limited resources so who am I to judge? In similar circumstances, would contemporary healthcare providers be able to provide the same level of care?

I carried an ultrasound machine that Sonosite had loaned me for the purpose, specifically. I wonder if I should have collected donations to buy the machine from them for the purpose of teaching. Guyanese anesthesia and ICU residents would have benefited so much. Though the whole ensemble fitted in a backpack, it did give me a bit of trouble during the check-in process at the airports (it was 14 kg and had 2 lithium batteries) but overall, it was an excellent idea and worked well. I am attaching a picture for you, Lina Lee!

For most of our days in Guyana, we stayed at a wonderful place, Project Dawn, a brainchild of Sister Carmen who was a nun and later became a doctor to help Guyanese people. After her passing, the place is being maintained by Marcie Gravensande. The place was wonderful, safe, spacious, with 24 h security and air-conditioning, had an excellent kitchen and lounging space. Each person was given a loaf of bread, a jar of peanut butter, a bag of ground coffee and a litre of milk that was good to give us a headstart. Each group marked their own food supplies and we did as well! Marcie told me that though many doctors come, only a few come back.

Guyana wrap-up part 3 – Sept. 10th

When I landed in Guyana, I crossed the threshold into a completely novel environment, spiked temperatures, intense greenery and an overwhelming sense of a placid way of life. My first exploration of the country was an extraordinary trip to the heart of the rainforests to see the famous Kaieteur falls. The Orninduik falls were fascinating, separating the country of Brazil from Guyana.

I was also introduced to “chutney music“. Has anyone heard about it? Believe it or not, it is a mixture of rural Indian ‘Bhojpuri‘ music that has amalgamated with the local and English tunes and has become very popular in the Caribbean. I also visited a Hindu temple. It was a strange feeling at first. Even though the scriptures were being read in an accented tone of Hindi, no one understood and the priest explained in English. This was a first for me, I mean Hindu temple with the puja (read service) in English! However, after a few minutes, the language of the puja became irrelevant and I could have been in India.

The streets of Georgetown are lined with red flaming gul-mohar trees, coconut, jackfruit and mango trees loaded with fruits, as well as blooming lotus and water lilies. Nature appeared at its best here.

I also came to know about the only musical instrument that was invented in the 20th century. The steel-pan! I could not fathom how the Beethoven’s sonatas could come out of this simple steel drum but they did!

Beth and I had an extraordinary time together. I don’t think residents ever spend 1 whole month with a consultant or vice versa. We came to know about each other’s lives, families, wishes, likes and more importantly, dislikes! I now know that Beth is an excellent teacher and has a lot of patience. Together, we experienced a 7.3 Richter earthquake, watched a Bollywood style dance drama, ate dhal poori and craved for cucumbers! She now knows that I am terrible with board games, love to cook and hate doing dishes. I now know that she loves animals and will pet stray dogs, cats and even donkeys, regardless of their cleanliness and ticks/fleas status!

Thanks to all of you who followed me during this 5 weeks journey! This will be my last blog regarding Guyana. Let us see what happens in 2019.

Bye for now.


Shalini’s entire set of blog postings is at < https://traveldocanesthesia.wordpress.com/ > including her great photos.

Shalini’s Guyana Blog – Finale

Guyanese history – Sept 2

This is a country that was ruled by the French, British and Dutch. To my amazement, there is nothing reminiscent of those times except the names of towns. The only influences that I could see are Indian and African even though neither India nor Africa ever ruled this place.

Both these genetic pools moved to this country between18- 19th century, some as slaves and others as indentured servants and brought their culture, food and religion with them and to this day, this is how they live. The roads are lined by churches, Hindu temples and mosques. People’s names do not depict any religion here. I have met Samantha who is a Hindu, Ravindra who is a Muslim and Indira who is a Christian. So simple and without any religious bias. No one’s religion can be identified by name. Guyanese people have made their lives simpler. How wonderful!

Unfortunately, during this long journey from Africa and India, the language was lost. The English here is spoken in a sing-song way that reminded me of my childhood when West Indian cricketers visited India and the Doordarshan (Indian TV channel and the only one those days) broadcasted Clive Lloyd’s interview. This is how he spoke! I remember Clive Lloyd so well. Only today I came to know that he is Guyanese and lives in Georgetown! I think I may have seen him during the cricket match we had gone to see that day. The cameraman had focussed on someone who did not belong to the Guyana warriors but was sitting in the pavilion and now that I think of it, he was the BIG C!

Heart-breaking stories & St. George’s – Sept 5

There have been other heartbreaking stories, just like Ned’s. The Hansen’s disease patient died the next day. I remember how Beth injected lidocaine in his ear so that perfusion would improve and she was able to record the SPO2, successfully. I remember his vehement refusal for Foley’s and then quietly saying that he takes a size 18F catheter.

Nancy came to the pain clinic for pain management. She had no investigations with her. She had a fracture of the arm that no one had looked at. When a colleague asked her for new investigations, she was very hesitant as it was not affordable and she had to ask her nephew who supported her and lived in the US.

Chronic pain management is unheard of. Acute pain management is not far off. Obstetric patients cry in pain for the lack of analgesia. No families or loved ones are allowed to be with them. Many of them have heard of pain-relief but do not expect it.

On my last day in Georgetown, I visited the St. George’s Anglican Cathedral which was built between 1889-1894 and is the tallest wooden structure in the world. It has an old world charm with a tropical flavour. Large windows at the lower level can be opened to let in the Atlantic breeze! The beautiful stained glass windows higher up depict the life of Christ. The pipe organ is massive. The chandelier in the church is a gift from Queen Victoria. Unfortunately, I could not get a close enough picture as there were preparations for the next day service going on. Like most of Guyana, it needs some TLC!


Follow Shalini’s blog at < https://traveldocanesthesia.wordpress.com/ > and see her great photos with the postings.

Shalini’s Guyana Blog – Week 4.5

Essequibo river trip – Aug 28th

Our weekends here in Guyana have been pretty amazing and I want to share this one with you too.

On Sunday, I took a trip up the Essequibo river that is the largest river in Guyana. It is more than 1000 Km long but does not even make to the list of top 10 of South America! The estuary (the uninformed me had to look up what it meant) is 20 km wide. Can you imagine? All rivers in Guyana (read South America) are either muddy due to silt or black/brown due to the plant tannins. They do not originate from glaciers so the waters are not clear.

I boarded a small bus, crossed the Demerara river and after a short halt in the town of Parika, reached a place called Roed-en-rust. With 30 other people, I boarded a ‘jet boat’ which was a larger version of a speedboat. 15 min of boat ride at 30 km/hr, we reached the Fort island, the house to ruins of Fort Zealandia, the oldest structure in Guyana and a UNESCO heritage site. It was named after Zeeland, a Dutch province. The history of the place is so interesting, the rulers changed from Dutch to French to British with the baton moving back and forth a few times! There is a Court of Policy building where apparently slaves were traded and our guide told us that they were probably beheaded too! Such a shameful part of the past. The island does not have electricity or fresh water, houses about 30 families and believe it or not, there is a medical centre and a school too. I would have loved to get into the medical centre but unfortunately, it was closed.

There are many islands (364 to be exact) in the river Essequibo, some of them larger than the country of Barbados. One entire island is owned by Eddy Grant, the founding member of the British pop group ‘Equals’. It is rumoured that it was sold a few years ago but no one can be sure.

The country’s maximum security male prison is where the Mazaruni river joins the Essequibo. Though it is on the mainland, one needs to access it via the Essequibo river so even local Guyanese are surprised when they learn that it is not on an island. I was told that jail-time may not be a deterrent but rather an attractive option to desperately poor people as they get free meals, paid work and a roof over their heads.

The flora and fauna of the area are wonderful. The country has a raw beauty that the tourism industry has not messed up, at least not yet. There is a variety of fish including monster fish Piraiba, the newly discovered air-breathing fish Arapaima and crocodiles in the river so I heaved a sigh of relief when my feet touched the ground and the bus had returned to Georgetown. Back to work, last week in Guyana.

Last week in Georgetown – Aug 29th

This is my 5th and last week here in Guyana. I am having mixed feelings as I have got used to the 7.30 pick up by the hospital driver Noel, on the way to the OR, buy lunch of roti and either chicken or pumpkin curry (Beth’s favourite and mine too) and then go and change into scrubs. I am usually lugging the Sonosite on my shoulders so the first stop is the Anesthesia room to park the machine and put it for charging. Morning 8 am is usually still early so there is enough time to peek in all ORs and check the list. The list almost always changes so there is no point in checking it the afternoon prior.

OR matron Sister Gill asked when I will come back and I was surprised when I heard myself saying ‘next year’! The nurse in charge of the OR is called matron and when I had asked her name, she very clearly had articulated ‘SISTER GILL’ with emphasis on the ‘sister’.

Today I cleaned the anesthesia cupboards that had supplies brought in by various visiting teams over the years and the sterility date was long past (10-12 years past!). Dr Martin, nurse Debra and I sorted out the stuff so that the supplies can be accessed. This was such an accomplishment. Even though I am not OCD, today I felt like one.

Tuesdays are the days that I looked forward to. It is the pain clinic afternoon and patients are so thankful for us seeing them and hearing their story. They are usually non-complaining, God-fearing and just there to know if we could help them. Most of them have chronic health issues, hypertension, diabetes, coronary artery disease. None of them is on any opioids. So different from the typical chronic pain patient of North America! Today I felt sad when the physiotherapist brought Ned (not his real name) who was shot in the spine in 2009 and has used a walker since then. His pain was more of diabetic neuropathy type but he wanted to know if I could help him walk though he has not walked since 2009. He had heard that I have done epidural steroids and wondered if that could help him walk. I am not sure who was more disappointed, he or I? He just said, ‘don’t worry Doc. This is life’.

Not all was sad this Tuesday. Epidural steroid patients from the past weeks came for a followup visit. Daisy (not her real name) has been coming every Tuesday since her epidural steroid just to tell me that it was ‘night and day’. This Tuesday she came to say goodbye as she knew I was leaving. Don (again not real name) came as a followup. He had an inadvertent dural puncture during the epidural teaching process. He was walking better and smiling. He said he could do their physiotherapy much better and promised me to that he will take his blood pressure pills and statins. Thank God, no PDPH! AnnDee has had a good response to gabapentin and acetaminophen and that is wonderful news as there is nothing else available.

I will miss the Tuesdays clinics.


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Shalini’s Guyana Blog – Week 4

End of work week 4 – August 24th

It is unbelievable that 4 weeks have gone by, so quickly. Beth will be leaving this Sunday and I am staying for another week.

Work week was very good, we had so many things to do, learn and teach. The showpiece of the entire teaching month was the first journal club that we organized this Thursday. The 4 final year residents presented 2 papers that we had selected for them, early in August. The residents were excited albeit a bit apprehensive and I must say, appeared scared, initially. They had never spoken to an audience or presented an article. Beth is a great teacher and together, we helped them refine their presentations and finally, they pulled it off, and wonderfully so. Well done Maxine, Tiffany, Shellon and Smolana, we are proud of you! There was good discussion and all residents participated, asking relevant questions. They also arranged for a little pizza party during the half time break between the presentations. Well planned and executed! I hope the oncoming visiting team keeps up this journal club activity.

Cases during this week were very interesting as well. We had a 92 year old patient with Hansen’s disease for fracture femur. Beth had never seen a case of Hansen’s disease so that was a learning experience for her. There was another very elderly woman who supposedly had a hip fracture but Xray could not be done due to pain. A femoral block (planned and guided by me, supervised by Beth and done by the Guyanese resident) allowed the C-arm to be used and it turned out that there was no fracture! I have been going around with the US machine demonstrating its uses wherever needed; a-lines, peripheral lines in kids, blocks in adults/kids, teaching spinal scanning. It has been a useful thing to bring, I must say.

We have been going to the pain clinic every Tuesday. We have done 2 epidural steroids. One patient returned, very happy. The second one will return next Tuesday, hopefully with good results.

Today was the last day for Beth with the residents. They gathered together and organized a little farewell speech and a going away present for both of us. Such a lovely and thoughtful gesture!

I bought a pumpkin for teaching epidural needle and catheter insertion as there is no other way residents could experience the ‘loss of resistance’ feeling especially as there are not many occasions to do an epidural. This turned out to be an excellent idea and residents practiced their LOR to air as well as saline and catheter threading skills in the pumpkin. Necessity is indeed, the mother of invention. I plan to bake the pumpkin next week, before returning home!

Demerara and the Eldorado rum – August 25th

Did you know that Demerara sugar comes from the sugarcanes in Guyana?

I have always enjoyed the golden yellow/brown crystals of the sugar in my coffee but did not know that it came from the molasses of the sugarcanes that are grown in the Demerara region of Guyana! We are staying in the Demerara-Mahaica region here in Guyana and the big bridge that connects Georgetown to rest of the country is also called Demerara so the sugar in my coffee back home becomes more important. Does it not? The remarkable Eldorado rum also comes from Guyana and is considered one of the best rums in the world and since 1992, it has repeatedly won awards in its category. It is called the true gold of Guyana. I can personally vouch for its smoothness and velvety taste. Though I am a wine drinker, I think Eldorado has the power to convert me!

Shawn, an Guyanese doctor who was an ENT fellow in London, Ontario took us over the Demerara bridge one night. It is the 4th longest pontoon bridge in the world and is 1.8 km long. Pontoon bridge is a floating bridge and barges/boats/pontoons support the bridge deck. Pretty neat, isn’t it? The deck moved a lot when we drove over it and then when we were on the walkway, it shook a lot when cars/trucks went by. A passing car slowed down to enquire if we were planning to jump in the (crocodile and snake infested) river! The river is also called Demerara, is nearly 350 km long, has powerful current and drains in the Atlantic ocean. The bridge opens at scheduled times to allow ships (5000 tons) to go through! There is a network of large rivers all over Guyana that are the drainage basins for this very fertile land. No wonder the fruits taste so good here.


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Shalini’s Guyana Blog – Week 3.5

Timeless Sunday! August 19th

Today was a timeless Sunday. We visited a place where time has stood still and seems to have no meaning. There are no clocks, no supplied electricity and no locks at the wonderful 20-acre oasis of the winemaker Warren and his artist wife Tracy.

The place is called PANDAMA, named after the Pandama palms that grow wild here. Actually, everything grows wild at the retreat and nothing is planted. Water is from a nearby creek, the lights are solar and the only fan is the breeze from the forest. The two Macaws have to be kept in the cage because of the ‘Wild-woman’ (the residential cat who has a month old un-named kitten). The other residents include Onynx, Moonlight and Spice (all dogs). Warren (an ex-US Navy veteran) makes fruit wines and I tasted beautiful whites and reds made from starfruit, soursop, rose, lime, cherry and jamoon. Jamoon is an Indian berry that brought back childhood memories of stained black lips and tongue giving our (my sister and me) secret away that we had eaten it despite being told not to. This fruit also grows in Guyana and its botanical name is Syzygium cumini (thanks to my botanist mom who taught me to look for the botanical name of each plant/tree as it did not change whichever country one lived in). The pièce de résistance was the pineapple wine with a dash of the hot pepper wine! I ended up buying both.

We had heard a lot about the black creek that is on the property. I had gone there with the firm idea that come what may, I was not getting in the black water. Period. Beth, on the other hand, is an adventurous sort and supported by Kristen, went right in! Finally, I could not see them enjoying so much so had to get in. It was totally not what I had expected. The water was cool, clean and coffee coloured due to the tannins from the leaves and finally, Tajh (the other OB/gyn resident) also had to give in! We spent a long time in the creek and once we got out, the dogs too came in to cool off.

We returned to Project Dawn, pleasantly tired, relaxed and happy. Was this the effect of the creek water? Tracy had mentioned that it makes one young and allows the soul to breathe. Will time be the augur???

And there was latte! August 22nd

I had an amazing cup of latte in a small coffee shop that came highly recommended. Addicted to the Starbucks latte, I was so grateful for the wonderful coffee at ‘Oasis’. It is a shame the place closes at 6.30 pm but I should be thankful for small mercies! The walk to Oasis was via Promenade gardens that had unusual trees and flowers and also a statue of our very own Mahatma Gandhi, with real eyeglasses!

Mid-week post: great invention! August 23

Great inventions have always been made in emergency situations, so I have been told. Though it will never turn out into a great invention, kudos to the presence of mind of the caregiver who came up with this quick and indeed very clever way of modifying a broken wheelchair to make it functional!


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Shalini’s Guyana Blog – Week 3

Work week 3 – August 18, 2018

Another week has gone by. Things have not been smooth, to say the least. There are so many things that are not right, in so many ways.

Patient communication is such an issue here. It is not considered important to inform the patient about his/her progress, the reason for surgery or its cancellation or results of surgery, let alone anyone from his/her family. The mother of a child who underwent surgery a few hours ago asked me what surgery was done and who did it. I cannot imagine this in the world where I work. It takes such little time and does not cost anything so I cannot understand why it is not done.

While the inside of my head was buzzing with thoughts and opinions that wanted to get out regarding this, the local newspaper published a letter to the editor about poor communication from Guyanese physicians. The writer writes about the play of the power struggle between patients and doctors with patients who have moved to the 21st century of health care delivery and doctors who are stuck in the 20th century with the view that they are the bosses and should not be questioned. He mentions poor communication as an endemic disease that is prevalent here. You may need to cut and paste the link. https://www.kaieteurnewsonline.com/2018/08/13/poor-communication-by-doctors-in-guyana/

All is not bad in the health care here. Whatever drugs are available, they are free for the patient. Perhaps, the west needs to look at this!

Timeless Sunday! – August 19, 2018

Today was a timeless Sunday. We visited a place where time has stood still and seems to have no meaning. There are no clocks, no supplied electricity and no locks at the wonderful 20-acre oasis of the winemaker Warren and his artist wife Tracy.

The place is called PANDAMA, named after the Pandama palms that grow wild here. Actually, everything grows wild at the retreat and nothing is planted. Water is from a nearby creek, the lights are solar and the only fan is the breeze from the forest. The two Macaws have to be kept in the cage because of the ‘Wild-woman’ (the residential cat who has a month old un-named kitten). The other residents include Onynx, Moonlight and Spice (all dogs). Warren (an ex-US Navy veteran) makes fruit wines and I tasted beautiful whites and reds made from starfruit, soursop, rose, lime, cherry and jamoon. Jamoon is an Indian berry that brought back childhood memories of stained black lips and tongue giving our (my sister and me) secret away that we had eaten it despite being told not to. This fruit also grows in Guyana and its botanical name is Syzygium cumini (thanks to my botanist mom who taught me to look for the botanical name of each plant/tree as it did not change whichever country one lived in). The pièce de résistance was the pineapple wine with a dash of the hot pepper wine! I ended up buying both.

We had heard a lot about the black creek that is on the property. I had gone there with the firm idea that come what may, I was not getting in the black water. Period. Beth, on the other hand, is an adventurous sort and supported by Kristen, went right in! Finally, I could not see them enjoying so much so had to get in. It was totally not what I had expected. The water was cool, clean and coffee coloured due to the tannins from the leaves and finally, Tajh (the other OB/gyn resident) also had to give in! We spent a long time in the creek and once we got out, the dogs too came in to cool off.

We returned to Project Dawn, pleasantly tired, relaxed and happy. Was this the effect of the creek water? Tracy had mentioned that it makes one young and allows the soul to breathe. Will time be the augur???


Follow Shalini’s blog at < https://traveldocanesthesia.wordpress.com/ > and see her great photos with the postings.

Shalini’s Guyana Blog – Week 2

Work Week 2 – Aug 13

This has been a busy week, a week of interesting cases and unusual conversations. Many things considered mandatory in London, Ontario seem almost frivolous here. Things like a sheet to cover the patient’s exposed body, blankets, bedsheets on the patient’s bed, pillows, alcohol wipes, paper towels, labour epidurals, screens to keep patients’ privacy, informed consents, safe sharps management, anaesthesia machine checks, the help of an RT, availability of blood for transfusion. Oh, I could go on forever!

Beth and I have decided that we are going to kiss our anaesthesia machine and glidescope when we return! She has also said that she is looking forward to her OB call. This one I am not too sure about and I will have to see if she changes her mind!!!

Here is a patient who very kindly allowed us to photograph her for teaching purposes. She came in for a mandibular tumour excision. We did promise her that her face would have a black stripe over her eyes. A very pleasant woman who lives in a remote area of Guyana and came in for surgery as she could not eat anymore.

Kaieteur falls weekend trip – Aug 13

We had an amazing weekend. We were invited to a Guyanese wedding on Saturday. An anaesthesia resident was getting married (to an OB resident!) and we were last minute invitees. What an opportunity to see a local wedding! Despite both the groom and the bride being of different faiths, the ceremonies did not take too long and then it was food and dancing. We all had fun!

We had been negotiating with various travel agents for a weekend trip to Kaieteur and Orninduik falls. Finally, after finding the right price, on Sunday morning we were at the Ogle airport to take the small 12-seater Cessna 208B to the Kaieteur Falls. It was raining heavily and the trip cancellation was looming on the horizon. However, 2 hrs of waiting was rewarded by a sudden clearing of skies and takeoff

There are no roads to this protected national park and the only other way is to hike for 7 days through dangerous rainforests (that many still do, believe it or not). Neither were we brave nor did we have the time so we flew over miles and miles of dense Amazon rainforest for about 50 minutes and then the falls suddenly appeared.

The Kaieteur Falls are about 4 times higher than our own at Niagara so one can imagine the absolute perpendicular drop of the coffee coloured water. I believe that they are the world’s largest single drop waterfall by volume. There is sheer isolation without any touristy stuff here. The 12 people on our flight, one pilot and one guide were the only souls (apart from the 2 park rangers and one local guide stationed there). Not even mosquitoes! There are carnivorous plants in the jungle that eat all the small insects. I was fortunate enough to see the little golden frog that was discovered in the jungles of Amazon in 2008 and had made the news. It did hide but not before I had taken its picture!

Orninduik falls were another 25 min flight away and as the falls are not deep, we enjoyed bathing in them. It then started to rain just as our time to return was drawing near. Our pilot was very experienced and he brought all of us safely back to Georgetown in the evening. A lovely end to an eventful week about which I will tell in my next post.

Cricket Stories – Aug 10

Today I will share with you a West Indies cricket experience. For those of you who are uninformed, cricket is a sport, not an insect! It is widely played throughout the world except for North America! Countries have their own teams (e.g. England, Australia, NewZealand, India, Sri Lanka, South Africa, Pakistan to name a few). As the Caribbean countries are small, they play as one team: West Indies and it is one of the powerful teams in the world.

Created in 2013, the Caribbean Premier League is an annual Twenty20 cricket tournament held in the Caribbean and most Caribbean teams participate individually, with each other. The matches are much sought after and we were lucky to have one in Georgetown where Guyana Amazon warriors were playing St. Kitts & Nevis patriots.

With our new found OB/Gyn friends Jennifer and Kristen, we went to the Providence stadium to see the colourful and noisy carnival last night. Remind you, Jenn and Kristen along with Beth are (or at least were) cricket naive. All three of them had a crash course in cricket, thanks to aunty ‘Google’ and uncle ‘Wikipedia’. And then it was a blast. Yours truly tried a hand at taking selfies and after many miserable failed attempts, nailed it and the proof is here for all to see!!!!

 


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