Shalini’s Guyana Blog – Week 2

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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!!!!

 


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

Shalini’s Guyana Blog – Two more from Week 1

Block room in Georgetown!

There were a fair bit of medical students hanging around, it was their last day and they did not know what do so we started teaching them. They were delighted to practice their BMV, LMA insertion and intubation skills on a mannequin. We did make a make-shift block room in the PACU but there was no patient for us! Perhaps in the coming week?

Guyana end of week 1!

Today is the end of week 1. We have been in Guyana for 7 days now. This was a very eventful week and I will report the interesting events.

Clinical work is interesting in the Georgetown public hospital corporation. We had a teaching session with the residents (at various levels of training) on Thursday and got to know them as well. Now I can tell a few names and I am sure I will get better, as the days go by. Maxine is the senior most and will be visiting Hamilton, Ontario in a few months time. She is waiting for her CPSO license. The PGY4s (this is a 4-year program) visit Hamilton for 3 months, regularly. This is such a wonderful opportunity for the Guyanese residents as they get to see things that they have only read about.

We visited the OB suite. It is a relatively new building that was finished in 2017. There were 4 C-sections planned for the day. The place is run by nurse-anesthetists who do all spinals/GAs. Attendings are available in the building across the street in case of problems. It was Deja Vu for me and it seemed that I had stepped back in time, at least 35 years! There is minimal OB analgesia service and lack of equipment/personnel may be partially to blame. Also, the residents/attending stay in the main ORs.

Just as we were getting the hang of the Project Dawn, we had to move out on Friday as the place was needed for a larger orthopedic group. Now, we are in a hotel in the town. This is a reasonably comfortable place and we both have our own rooms but we have to eat out every night. I am worried about restaurant food for 12 nights. I have not hand-washed clothes for more than 2 decades and this is not something I am looking forward to!

On Saturday, we walked to the botanical gardens and the attached zoo. This was a nice trip and we saw some strange animals. We met one of the anesthesia consultants who was also there with his daughter. On our way back, Beth bought coconut water and we did some grocery shopping. Beth cannot stop trying to pet stray animals and I cannot stop telling her not to. Let us see who wins.

We went out with the two OB/gyn residents from USA and had a nice evening. Today, we walked to the local Bourda market and bought some fruits and vegetables. We are both craving fresh greens and fruits! No to mention “LATTE”!!!


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

Shalini’s Guyana Blog – Guyana Day 3

We arrived on Monday, uneventfully. I was surprised that my ultrasound machine did not create any problems! Our pickup was there, waiting patiently for us.

We are staying at a place called “Project Dawn”. It is a fascinating place that was the brainchild of a nun Dr Cameron Gannon who started it as a medical centre in 2002. It is not a medical centre anymore but houses almost all of the medical/educational teams that come to Guyana for voluntary work. There is a common kitchen, the place is airconditioned and is guarded 24/7.

We were picked up by the hospital van on Tuesday and spent a very eventful day at the GPH (Georgetown public hospital). We met consultants Drs Fernando, Shankar, Acosta and Feng (?Du). There were many residents at various levels of training and I am sure I will remember their names as the weeks go by. There are 5 operating rooms for ortho, general surgery, ophthalmology, ENT, urology, gyne and some thoracic work. Cardiac teams visit off and on and do cardiac surgery as well. They tell me that there is a fair bit of trauma. The residents are all very keen to learn! Most drugs are available. Today we did a laparotomy for perforated viscus and Beth was thrilled to use halothane. Though everyone here wants to use propofol, I think I will use thiopentone on Thursday for Beth’s benefit! We are also preparing for our first teaching session tomorrow.

Like most operating rooms world over, there are no lunch breaks. An ex-nurse delivers food for a small price and many doctors buy from her. I think Beth and I will do the same. The meal is about CAD 2. Today we tried a typical Guyanese lunch of chicken wrapped in ‘roti’ that she had brought over.

Today (Wednesday) is a national holiday here so we are staying in. We went for a long walk with our bottle of water and an umbrella. The sidewalks are full of lotus and lily plants, all in full bloom. Did I mention that it rains every day?


Shalini’s blog is at < https://traveldocanesthesia.wordpress.com/ >.

Shalini’s Guyana Blog – Pre-Departure Entries

We will be following the postings of Dr. Shalini Dhir during her time in Guyana. Her blog is < https://traveldocanesthesia.wordpress.com/ >. This first set of postings leads up to her departure.


Anticipation – July 15, 2018

The time to leave for Guyana is approaching. All paperwork and permissions have been obtained and Beth and I leave in 2 weeks time as part of CASIEF (Canadian Anesthesia Society International Educational Foundation) partnership with the Georgetown Public Corporation.  We will be in Georgetown, Guyana and be teaching the residents there.

I think while teaching, I would be learning at the same time. This is a 4-week mission. Let us see. Hopefully, I will be able to keep the blog updated.

Week 2 of preparations – July 21, 2018

This is the last week before I leave for Guyana. The anxiety is brewing, just like the coffee at Starbucks, that I love and the flat white that I will not get for a month!

There a lot of firsts for me, first time volunteering, first time away from home for such a long time (35 days to be exact) and first time going to a place I know nothing about. I have never packed for a month, ever. Let us see what all I forget.

There is some medical equipment that I plan to carry with me. Let us see if the airlines will allow it. I have written to the airlines Toronto manager but am yet to hear from him. Soon, I will assemble the presentations and cases for teaching.

Day of departure+3 – July 26, 2018

Today is DOD+3. The ultrasound machine arrived today. I had written to the company in a faint hope, not expecting a response. However, I was pleasantly surprised and after filling one form, the application was accepted and the machine arrived (along with 5 probes: 2 linear, 2 curvilinear and one phased array) in my office! It is quite compact and fits in a backpack, supplied by them. Now, the challenge is to carry it. I will keep you all posted on the progress. The only caveat is that I have to bring it back and send it by FedEx to them on my return! Leslie, my physio was suggesting that I should have collected money and paid the company so that the machine could be left in Guyana. It is a bit too late for that now, I think.

Beth and I are collecting teaching material and taking printouts of almost everything. We plan to meet at the airport and keep our fingers crossed because of excess baggage! Ciao for now.

DOD – July 29, 2018

Today is the DOD (day of departure). Suitcases are packed, all phone calls have been made, paperwork is completed (hopefully) and flight has been checked in. The only thing left is the journey to Toronto airport that may probably be the largest hassle during the entire trip (considering the traffic and 401 delays)!

A small hiccup has come in regarding the accommodation. The accommodation plan has fallen apart so it is uncertain where we will stay. This trip is going to be an adventure, I can tell. As long as it is not in the jungle and not a tent, I suppose Beth and I will be fine!

Rest from Guyana!

Anesthesia in Rwanda – a learner’s perspective

A month in Kigali has flown by, and I am already thinking about when I can go back. Through my transitional internship program, I had the chance to observe the practice of anesthesia in Rwanda and see the educational collaboration of CASIEF & HRH with the University of Rwanda first hand. There are 4 referral-level, teaching hospitals of Rwanda, 3 in Kigali, and another in Huye (Butare) in the southern part of the country, a 3.5 hour drive from Kigali. While most of my time was spent at CHUK – the largest public hospital in the country, I also visited King Faisal – a private hospital, and the Rwandan Military Hospital, each with its unique atmospheres.

The affiliated medical school at The University of Rwanda has its own residency program, which started in the mid 2000’s. Enrollment has been steadily increasing, more exponentially since about 2011, and today there are 30 residents total divided among the 3 years. In Rwanda, after graduating medical school (which is 6 years, immediately after high school), one is required to do 1-2 years of general practice, working as a family medicine physician in a rural district hospital, often as the sole provider. Only after completing this can one then apply for specialty training. For anesthesia, this consists of 3 clinical anesthesia years, much like in the States. (Next year, the training program will be extended to 4 years; concurrently, there is some talk of doing away with the mandatory service prior to specialty training.)

Each Monday all the residents from all 4 hospital sites convene at CHUK for didactics, led by the CASIEF & HRH volunteer anesthesiologists. The residents are split into Foundations (CA-1’s) and Core (CA-2’s and CA-3’s) for small group sessions in the morning, followed by a case presentation and other interactive lessons in the afternoon, often related to simulation or ultrasound. When I was there, the residents were prepping for their end of the year exams, so they were all eager to hone down core concepts. For me, this month was an excellent introduction to anesthesia and I found it very helpful learning with the Foundations group. The rest of the week, I would spend time in the operating rooms and the intensive care unit, where I was paired with a CA-3 Rwandan resident. At CHUK, there is one attending, with one to two senior residents (but usually only one) overseeing the 6 main operating rooms, each of which has a CA-1 or non-physician anesthetist (NPA, equivalent of a CRNA in the US) assigned. There was a separate team of residents for the 2 operating rooms in the maternity ward.

 

The breadth of cases in the main OR was quite impressive: all kinds of pediatrics (and only one peds surgeon), neurosurgery and orthopedics (mostly trauma, including late presenting trauma), urology, gastrointestinal/general, and ENT. While I had visited district and referral hospitals in other sub-Saharan countries, these in Kigali were much more advanced and well-equipped. It was a refreshing experience seeing the successful delivery of a relatively higher level of medical care. There were a several interesting and difficult airway cases, including a child with a large laryngeal papilloma, who ultimately needed an emergent tracheostomy after multiple failed intubations; luckily, communication was excellent among all the teams, and the ENT surgeon was already scrubbed and standing by while we were trying to get the airway.

There is one communal tea room, where everyone (nurses, doctors, technicians, cleaning staff, etc.) can mingle and grab a cup of tea or snack when there is down time. The next case would start…whenever it would start. That could range from 15 minutes to 1hr+ depending on the presence of the proper personnel, equipment, or the patient.

At King Faisal, I spent most of my time in the ICU. This hospital is well-equipped and privately funded. You talk to any non-medical expatriate living in Kigali and this is the hospital they will know. Many of the doctors are foreign-trained. I happened to be there the day of multidisciplinary ICU grand rounds. We all stood in a large circle in the ICU – about 30 people including anesthesia, surgery, internal medicine, and ENT residents (that particular day’s case was about a goiter). It was led by a neurosurgery attending, so his residents were there as well. There was even a cardiology attending (one of twelve cardiologists in the country!). The neurosurgeon posed clinical questions about the case and went around the circle asking each of the residents. No powerpoint slideshow or paper handouts, just good old fashioned verbal communication.

During my last week, I also visited the Rwandan Military Hospital, and was struck by their military-speed efficiency. While the first case began an hour after its designated start time (not uncommon in Rwanda), the room turnover for the subsequent cases was done with lightning speed. Just when the first patient settled and stabilized in the PACU, it was time to bring in the next one. I was also expecting the patients to be mostly older men, but this hospital actually serves the general public as well, and they do all kinds of cases including pediatrics and OB.

Being a PGY-1 was a challenging yet exciting experience. Most foreign residents visiting Rwanda were there to teach and offer their clinical expertise. There’s a bit of an expectation of any ‘mzungu’ at the hospital that you are there to impart your wisdom and help improve current practices. While I was comfortable adjusting an insulin regimen or diuresing someone with CHF after 10 months doing mostly internal medicine rotations, I had very little experience as an anesthesia provider. It was a preview of all the exciting things ahead, and a humbling reminder that I was about to embark on ‘intern year 2.0’. Still, some interesting differences in practice have stuck with me, like the regular use of halothane or just funny semantics like calling it propoket rather than ketofol. Overall, this month got me super pumped to know that I am finally about to start learning and practicing my chosen specialty.

Another thing I was impressed by was the strength and organization of the residency program and the collaboration with CASIEF/HRH. Each year, two Rwandan residents are chosen to rotate at hospitals in the US and Canada, all with the support (including financial) of the University of Rwanda and the Ministry of Health. Anesthesiology is becoming a more and more popular specialty choice in Rwanda, I think in part due to this strong partnership. The profession grew from only one anesthesiologist in the entire country after the genocide in 1994 to over ten new anesthesiologists minted each year, with many pursuing subspecialty training as well. The current group of residents are part of the new wave of anesthesiologists, and have the insight and numbers to direct what their field will look like. They are bright and see the unique position they are in. Down the line, the plan is to wind down foreign support so there can be a permanently self-sustaining training program in Rwanda. I am optimistic it will be a success.

Yuanting Zha
Incoming CA-1 resident at Brigham and Women’s Hospital in July 2018

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