Bethune Round Table 2019 Call for Abstracts

CNIS Bethune Round Table in Global Surgery
June 6 – 9, 2019
Edmonton, Alberta, Canada

The call for abstracts is now open!

The 2019 theme is Ethics in Global Surgery. As the field of global surgery develops, it is important that ethical concerns remain at the forefront of its advancement. We encourage abstracts pertaining to the theme, but abstracts covering all topics in global surgery are welcome for submission.

Scholarship for Selected Abstracts

If your abstract is accepted, you may qualify for a scholarship to cover travel costs if you are clinician practicing in a low or middle-income country.

Deadlines:

January 31, 2019: Abstract deadline if applying for travel scholarship
February 28, 2019: Final abstract deadline

For full abstract submission details and to submit your abstract, visit: https://bethuneroundtable.com/.

To submit your abstract, click here.

To register for the conference, click here.

Dr. Livingston returns to Rwanda (2nd edition)

VAST Refresher Course 1 – Wednesday, January 9, 2019

We have been running the Vital Anesthesia Simulation Training (VAST) Course, a 3 day course that focusses on clinical practices and non-technical skills (e.g., team working, task coordination, prioritization) to improve peri-operative safety (https://vastcourse.org). The course was developed and implemented last year. We have been studying the impact of the course on non-technical skills. The initial measurements were made in August and September during the first four VAST Courses. Yesterday, we invited half of the course participants back for a refresher course and to complete the final performance measurements. The remaining participants will return on Jan 18.

I won’t comment too much on the details of the study other than to say we have been looking at performance of non-technical skills in short simulated scenarios before, immediately after and 5 months after the course. It was delightful to see the course participants again and to hear about their experiences and changes they have been able to make after returning to their home hospitals. It gives one hope that the VAST Course is a valuable direction for our efforts.

After a busy day of testing and hearing stories from the participants, we had a relaxing swim at the Serena Hotel and a lovely dinner at one of my favourite restaurants (Khana Khazana). Dave, Chris and Stephen are great companions. They work hard and are always keen to jump into whatever tasks need to be done. All of them have a delightful sense of humour (although too darn many puns from Stephen) so we’ve had plenty of light moments as well.

We will be getting away soon for our first weekend adventure. The guys are going gorilla trekking in Uganda on Friday. I will finish a few meetings in Kigali on Friday and meet them Friday evening at the Africa Rising Cycling Centre on Friday evening. We have a bike ride planned for Saturday before going to Lake Kivu on Saturday evening. Then back to Kigali on Sunday to get ready for another busy work week.

We send our best wishes from Rwanda, where it is green, fragrant, moist and warm. My companions have promised to post a few messages as well.

Cycling in the hills of Rwanda – Sunday, January 13, 2019 (from Stephen)

We are now one week into our visit to Rwanda and as I consider possible topics for my first reflection, I am stunned at the volume of experiences I have enjoyed in even this short time. Saturday morning, I awoke to find myself in the Africa Rising Cycling Club. We had ahead of us a 44km cycling trip that Patty promised us wouldn’t be too arduous. Knowing the cycling accomplishments of Patty and the CASIEF volunteers before me, I was nonetheless nervous. In my fretting, I was amazed to discover the many ways this trip itself represents the progression of a cycle.

For myself, this Rwandan visit represents the expression of what drew me to medicine in the first place. In my first week of medical school, with Patty as my case tutor, I recall her prodding us to consider what we could contribute to the global work of medicine. I now find myself in Kigali taking my first, imperfect attempts at teaching fellow residents. I have so much farther to go in my own learning, but I couldn’t escape the feeling that the arc of my own cycle is turning.

Setting out from Africa Rising, likewise palpable was the sense that this place represented the changing of a season for Rwanda too. I wouldn’t claim to understand the nuance of history, but the optimism of this cycle centre was inspiring. As we prepared for our own modest cycling trip, the Rwandan national cycling team played host to the Nigerian national team and trained with a goal no less ambitious than winning the Africa Cup. Having previously captured bronze and silver, their sights were set squarely on the gold for 2019. The momentum of the Rwandan cycling team truly captured something of the spirit of Rwanda itself. Indeed, the Rwandan team finished their +200km race from Ruhengeri to Kigali and back before we finished our own modest trip.

In its own way, CASIEF’s sustained partnership in Rwanda is witnessing the completion of its cycle. The accomplishments and talent on display every day in our interactions with the Rwandan residents speaks to their dedication as well as the coordinated work of many, many CASIEF volunteers before me. From the Simulation Centre, to curriculum renewal, and to the many relationships I myself have built with visiting Rwandan residents in Halifax, the work of this programme runs deep. As CASIEF ponders its next steps in Rwanda, the sentiment that CASIEF’s own cycle is turning is unmistakable.

Like my visit to Rwanda itself, our own cycling trip exceeded all expectations. Flanked by small crowds of curious children, we cycled the beautiful volcanic terrain to a waiting lunch on Ruhondo Island. The pictures below fail to do the vistas justice. As we finally settle back into our apartment in Kigali, I’m excited to consider what our next week has in store.

Gorillas in the Mist – Sunday, January 13, 2019 (from Chris)

Growing up, “Gorillas in the Mist” played in our household on a near bi-weekly basis. I know the plot (and most of the dialogue!) by hear, and my first inkling that I might one day spend my life travelling from country to country, continent to continent came from imagining myself in Dian’s shoes, immersing myself in a new land and culture while in pursuit of a greater cause. Mountain Gorillas have always had such a incredible appeal – so like us: intelligent, playful, family-oriented. When I first committed to spending a month volunteering with CASEIF, I knew that I just simply had to make time (and money!) to make the dream come true.

And so this past weekend I was giddy with excitement when I, along with Dave and Stephen, hopped in a car and began the trek to Mgahinga National Park in Uganda to sit in silence with a family of 9 gorillas for a single hour. We chose to visit the gorillas in Uganda, rather than our adopted home for the month, primarily because of the (significantly) reduced cost and the increased availability of permits – Uganda being only a burgeoning spot to visit these majestic apes. Mgahinga, at just 13 square kilometres is the smallest national park in Uganda, and one of two parks in the country where the Mountain Gorilla can be viewed.

After a relatively painless border crossing near Kisoro, Uganda, we spent a sleepless night in an expectantly dingy border town hotel before embarking on our journey. Early the next morning, we drove up a steep, winding and badly pot-holed road to the park entrance, where we would begin the 2.5 hour trek up the mountain. Or journey through vines, thickets, and patches of sting nettles was worth the sweat and sore muscles.

The first thing you notice when visiting gorillas is the sound – grunting, chewing, vines and leaves falling as the gorillas grab hold of their favourite plants. The next thing you notice, the smell: musty, dank, earthy, mixed with a sweaty pungency and a hint of excrement. Never mind all of the that, my first site of a wild, adolescent male silverback was one that I will never forget. Laying in a pile of crushed leaves, almost gingerly lifting his head to observe his observers, before flopping backwards to get comfy again. Of course, the photos do no justice.

Over the next hour my fellow trekkers and I had the sublime experience of watching this small family, 9 of the mere 900 or so Mountain Gorillas left on this planet. I watched as the babies of the group (two 2-year olds) play, eat and cling to their mothers as they roamed the forest in search of food and entertainment. More than once I scurried back as one of the four silverbacks pushed their way past us, gently but intimidatingly so. And perhaps most emotionally, I watched the 8-year-old female who was suffering from a hand injury after recently being caught in a poacher’s trap – it’s unclear at this time if the damage will be temporary or not, only time will tell.

In the early 1980’s the population of Mountain Gorillas was nearly extinct – found in just three countries that have had more than a fair share of political and civil turmoil, it’s amazing that a population of just 254 (in 1981) has now exceeded 900. It has been no easy task, and the work of countless conservationists, including the venerable Dr. Fossey, are to be thanked. While it is not an easy nor particularly affordable activity, the money that is raised continues to ensure the protection of these beautiful creatures, and for me that makes it worth it.

The work that CASIEF does here in Rwanda, while incredibly valuable, places volunteers in challenging situations with long hours, but the opportunity to take a few moments to fulfil a childhood dream adds so much to the overall experience. The Mountain Gorillas are so much a part of the country’s national identity, and I’m so thankful to have had the opportunity to experience them firsthand – and you should too!


Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Dr. Livingston returns to Rwanda

Returning to my second home – Thursday, January 3, 2019

In the wee hours tomorrow morning, I will begin the long journey back to Rwanda. This will be my last month-long visit as a CASIEF volunteer, although no doubt I will return for shorter visits and to help with specific programs.

The CASIEF-Rwanda program started in 2006, when there were only a few anesthesiologists in the the country. There are now 18 anesthesiologists and another 40 residents in training. With collaboration among partners in Rwanda, Canada, the USA, Australia, New Zealand and Scotland, great strides have been made in the past 12 years. This has included building an anesthesia training curriculum, establishing a multi-disciplinary simulation centre, training over 150 non-physician anesthetists (who provide most anesthesia care away from the urban centres) in SAFE Obstetric anesthesia, implementing a pain management program in Butare (the vast majority of this done by Dr Gaston, who has received international recognition for his accomplishments) and development of the Vital Anesthesia Simulation Training (VAST) Course (a 3-day course of essential anesthesia practices and non-technical skills designed for low-resource settings: https://vastcourse.org). This has come from the hard work of many dedicated individuals; it has been a pleasure to collaborate with all of them. Anesthesia in Rwanda has gone from being one of the least desired specialties to one where the best applicants are selected. The residents are well-qualified and committed to building an excellent anesthesia department. Former residents are now the leaders. I feel fortunate to have been involved in this work.

As usual, I have a big team coming and a long “to do” list. The team this year will be Dave (Dal global health fellow), Stephen (Dal anesthesia resident), Chris (Toronto anesthesia resident and the Lucky Iron Fish developer https://www.youtube.com/watch?v=0Lf6glgKt3Q), Mary (pain specialist who will come for a week for a pain conference) and Jon (Dal regional anesthesia fellow who has made a few previous teaching visits to Rwanda). In addition to the Monday academic program and OR teaching, we will follow up on a research evaluation of the VAST Course and present at the first pain management conference to be held in Rwanda (organized by Gaston). After three weeks in Rwanda, we will travel to Addis Abba, Ethiopia, where CASIEF has started a new partnership for anesthesia resident education. In Ethiopia, we will run a VAST Facilitator Course, so that Ethiopian anesthesiologists can teach VAST in the future, and also teach a VAST Course. I’ve never been anywhere in Africa other than Rwanda (not counting Nairobi airport) so it will be interesting to visit Addis Abba.

I won’t be arriving in Kigali until late Saturday afternoon and it always takes a while to get up and running. Please look for the next blog post early next week. I am grateful to all of you who follow the blog and offer your support.

 

Somewhere over the Atlantic Ocean – Sunday, January 6, 2019

Chris was the only member of my team on the same flights to Rwanda, although we met just departing Toronto.

Somewhere over the Atlantic Ocean a few hours into the flight, an overhead call was made seeking medical assistance. I have been on many flights where these calls are made and typically someone is a bit lightheaded or has had too much to drink. This one was different. Chris, two other health care providers and I (with help from the flight attendants) ran a full code for about 45 minutes, using as much as we found in the meager medical kit and the defibrillator. Unfortunately, the patient did not survive. It was a very sad situation and for many reasons the conditions for the resuscitation attempt were poor.

The travel this time had a connection in Addis Abba, Ethiopia. Since we will spend our final week there, this routing made sense. My previous flights over Africa have been nighttime so it was great to see the landscape from the air, as we flew in the afternoon from Addis Abba to Kigali (via Bujumbura, Burundi). Addis appears relatively flat with some surrounding hills. As we flew further south over the Great Rift Valley, the terrain changed from dry brown to lush green hills. We flew over Lake Victoria – it’s huge! Burundi and Rwanda have similar landscape but Burundi is sparsely populated and has few roads. Rwanda is one of the most densely populated countries in the world at 230 people per sq. km. It is quite apparent from the air.

We arrived in Kigali Saturday afternoon with enough time and energy to get phones working, change money and have dinner on a leafy terrace

Stephen arrived at 2:00 AM today (Sunday) minus luggage…

We’ve spent the day getting ready for academic day tomorrow. There are 11 new PGYs but we won’t meet them tomorrow. We will have a group of about 20 residents and have made some lively teaching plans. Good night, stay tuned.

 

Lively teaching day – Monday, January 7, 2019

Academic day. The residents received questions to be answered from their preparation reading the week before. They sent their answers to us in advance so we can look for areas of misunderstanding. Each week, one Rwandan resident is assigned to be the resident teacher so I prepared the program for yesterday along with her. This helps the residents build teaching skills.

The topic for yesterday was obstetric anesthesia and analgesia. We had an action packed day. The morning session included a review of the homework questions with emphasis on clear, concise answers. Then we had a pro-con debate on establishing a labour epidural service in their hospital. This encouraged the residents to move beyond book knowledge and to think critically about their working environment. After that, we broke the residents into four teams to sequence cards of all the anesthesia actions required from receiving a call for an emergency general cesarean section to delivery of the neonate (thanks for the idea, Amélie). We regrouped to critique and refine the sequencing and then our teaching team ran a demonstration scenario of exactly these events. We let the residents know they would be be asked to role-play this same scenario in simulation in the afternoon. Our morning session ended with a lively game of Jeopardy (always popular) complete with prizes.

In the afternoon, we ran three stations and broke the residents into small groups to rotate through the stations. This included the cesarean general anesthesia induction from the morning, an epidural station and spinal station.

The day was utterly satisfying. One cannot imagine a keener group of learners. They remained enthusiastic and engaged throughout the day.

I have been coming to Rwanda for ten years. When I started there were 8 residents and no designated teaching space. We had to move from one borrowed teaching area to another, often to be displaced by another group. There were no materials for teaching and certainly there was no simulation. Teaching was with powerpoint lectures. The residents struggled with English, so communication was challenging. The curriculum was four page topic list with volunteers choosing a topic to teach from the list.

Today there are 40 residents who have a full academic day each week in a simulation centre with a classroom and sim lab. There is a one year curriculum for foundations (first year residents) and a two year curriculum for core (second and third year residents). Fourth year residents are involved in teaching. We are currently working on a one-year simulation-based curriculum for the first year residents to supplement the academic curriculum. Teaching methods have moved from passive to active. The residents communicate well in English.

The graduates of the CASIEF-Rwanda program are now in leadership positions (university head of anesthesia, hospital anesthesia heads, program director). Reflecting on the situation, I believe CASIEF has now accomplished its original goal of building a sustainable anesthesia training program in Rwanda. There is still a need for support, particularly for subspecialty areas (e.g., pain management, regional anesthesia) but the core elements are in place and anesthesia is thriving.

It has been a pleasure to share this experience with Dave, Chris and Stephen. They have promised to write a few posts as well.

 


Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

CASIEF Featured in CAS Anesthesia News

DEAR CAS MEMBERS AND CASIEF SUPPORTERS:

CAS_AnesthesiaNews_2018-12-33-4_CASIEFIt has been an incredible year for CASIEF with great success in all our respective programs. CASIEF runs through the amazing generosity of Canadian anesthesiologists and we would like to thank you for your donations that allow us to work on improving the capacity for safe anesthesia care in some of the poorest countries in the world.

In previous years, we have had very successful fundraising drives, including for Lifebox, and in 2019 we would like to set a new target for our goals in Ethiopia. Ethiopia is at a crossroads for anesthesia. The government seems committed to increasing the numbers of residents and residency programs, and there is a huge number of learners, probably 100 residents in Addis Ababa alone next year. There are, however, very few local teachers. We feel that if we can provide support to scale up anesthesia training in Ethiopia, there can be a big change over the next five to six years. We plan to collaborate with partners in the US to work together on scaling up anesthesia training in Ethiopia. We want to send more volunteers, and we would like to fund some volunteers for longer (6 – 12 month) visits. We would like to get Ethiopian residents and fellows to Canada for training that they can’t get in-country. We would also like to provide administrative support in scaling up the residency program nationally and supporting local leaders in achieving this. Our fundraising goal is to raise $100,000 by June 2019. Many of you already give generously, and we would like to ask you to consider giving more to this particular cause. Many anesthesiologists prefer to make larger donations in the form of securities or stocks and, if you are considering this, please contact us at info@casief.ca.

We would like to apply the successful model we have used in Rwanda to Ethiopia, but the training gap in Ethiopia is on a completely different scale. Please help us to work with our partners in Ethiopia and the US to make the same impact on Ethiopian anesthesia that we have made in Rwanda. If you are thinking of volunteering, please contact Julian.Barnbrook@casief.ca for further information, or sign up here.

Lastly, we are excited to announce the annual CASIEF dinner will be located at an interesting venue in Calgary. More information to come in the new year — we hope to see you there.

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.


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