An anesthesiology resident in Ethiopia: My experience at Tikur Anbessa (Black Lion) Hospital
Karim Mohamed PGY5
In April 2017, I departed on a 4-week teaching elective with the Toronto Addis Ababa Academic Collaboration (TAAAC) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF). In this report, I hope to describe my time in this beautiful country, the impact it had on my life, and what I hope for the future of the collaboration.
About CAS IEF
Since its inception in 1996 CAS IEF has been active in improving and making available safe anesthesia in low and middle-income countries (LMIC). The philosophy of the organization has been to develop self-sustaining programs that are suitable to a country’s needs. Through collaborations with educational institutions, governmental agencies, and anesthesia providers, the organization has been successful in supporting anesthesia initiatives in Guyana, Rwanda, Zambia, Burkina Faso, and Ethiopia.
The fact of the matter is that five billion (yes, five BILLION!) people lack access to safe surgical care. This results in more people succumbing to surgical disease annually than HIV, TB, and malaria combined! CAS IEF realizes the need for safe and appropriate anesthesia services in the provision of these surgeries. CAS IEF has put together a skilled, and experienced board of trustees working to meet the organization’s objective.
Ethiopia is a country with a fascinating history and proud people. Land-locked, nestled in the Horn of Africa, Ethiopia has some incredible archeological, historical, and cultural sights. With a population of nearly 100 million, it is the most populous land-locked country in the world, and second most populous in Africa. Many archeologists believe that some of the first modern humans originated in Ethiopia, before making their way to the Middle east.
The country has a complex religious history with approximately two-thirds of its inhabitants being Christian and a large proportion of remainder being Muslim. Religious influences can be seen throughout the country and generally people of both faiths live in peace.
Ethiopia has largely been a monarchy for most of it’s history. Ethiopian’s are proud to announce that it is the only African nation to defeat a colonial power during the 19th-century, and some claim it has never truly been under outside control. In 1974, the government fell to a military communist group backed by the Soviet Union. They remained in power until the revolution of 1991 when the current governmental party took control, and has maintained it’s position since.
Ethiopia’s economy is largely supported by agricultural exports, the most important of which is coffee. The coffee bean originates from Ethiopia, and it is an important part of the country’s culture, and economic identity. The next time you are enjoying that brew in the lounge, remember that Ethiopia is responsible for introducing the world to this delicious drink!
I was lucky enough to share my experience in Ethiopia with Dr. Sophia Lane, a fourth-year anesthesiology resident at the University of Toronto. There were two attending physicians who were part of the teaching mission, Dr. Neil Adhikari, a staff critical care physician at Sunnybrook Hospital in Toronto; and Dr. Jason McVicar, a staff Anesthesiologist at The Ottawa Hospital.
Having spent some time in Africa before, I thought I knew what to expect when I first arrived in Addis, however I was in for quite a surprise. The city itself was extremely busy, there were people everywhere, and the air pollution was bordering on intolerable. I remember thinking that the building architecture clearly had a Soviet influence, likely from the communist era of the 70s. It was warm, but not hot. Addis is quite high in elevation, and as there are no large bodies of water around, humidity was not really an issue. Addis Ababa University had put us up at a government hotel called The Ghion in the heart of downtown Addis. The hotel has a very prominent place in local culture, with many weddings being held there in the summer.
The hospital was a brisk, pick-pocket ridden, 20-minute walk away. Attempting to weave around morning traffic, avoiding the random 10-foot holes in the ground; appropriately named “death-holes” by Sophia, and protecting any valuables was our morning routine. The hospital itself was associated with the University and was quite large with at least three different buildings. A quick tour revealed that there was an MRI, CT, a very busy ER, OB ward, a rehab centre, and a separate building for administration and lecture halls. Every morning the anesthesiology group would meet for Morning Report. Here we would hear about any cases performed overnight, pre-anesthetic evaluations for the cases of the day, and a brief handover of the ICU. There were many rotating residents from orthopedics, general surgery, and neurosurgery. After Morning Report, the residents would disperse to their respective assignments (OR or ICU), and then return after rounds for teaching 3 days of the week.
Our first two weeks were in the ICU with Dr. Adhikari. The ICU was split into medical and surgical. The anesthesiologists are in charge of the surgical ICU as well as performing any invasive lines, or airway management on the medical side. For most of the two weeks, there were approximately 8 patients admitted to the surgical ICU, with 6 or them being ventilated. It became immediately apparent that resources were going to be an issue, as we expected. Some examples of resource deficiencies that were first encountered in the ICU include: little to no opioid or sedation options available in the hospital, suction machines were shared among patients and catheters were often hard to come by, ventilators did not have humified circuits, IV cannulas were in short supply, and there were no infusion pumps. With all that being said, I must say that the medical staff were very good at working with what they had. Providing care in a setting with an abundance of resources is something we take for granted back here in Canada. The residents were very creative in how they allocated resources, while still providing the best patient care possible.
The patient population in Ethiopia was vastly different from what we normally see in Canada. Admitting a patient over 55 was extremely rare, probably because the life expectancy is 58 years. Unfortunately, by the time patients presented to hospital, they were usually extremely unwell. A large number of obstetric patients were admitted with severe eclampsia or post-partum hemorrhage due to the lack of ante-natal care. During our time in ICU we observed cases that we only read about in Canada; and the distribution of chronic disease to acute was excessively biased to the later. Overall during our time in the ICU, there were many areas of improvement that we identified and attempted to address during our academic lecture sessions. Some of the teaching topics included: appropriate ventilation weaning strategies, sedation and analgesia in the ICU, oxygen delivery devices, a review of research methodology in the ICU, and a brief guide on the use of ultrasound for central line insertion.
After the two weeks in the ICU, we were joined by Dr. Jason McVicar, and we transitioned from the ICU to the OR. There were 6 ORs in the main building, and an additional three in a separate building that were dedicated to orthopedic surgery. The ORs and ICU were staffed by 4 staff anesthesiologists, and so they were spread very thin. Most of the anesthesia care was provided by nurse anesthetists, along with the occasional junior resident assigned to their room. Junior residents received clinical teaching from the nurse anesthetists; while the academic classroom sessions were run by other residents and moderated by a staff anesthesiologist.
The academic teaching sessions that were scheduled ranged in topics from basic airway management, to the peri-operative use of beta-blockers in patients. Many of the lectures utilized Powerpoint, and were sourced from reference texts including Miller and Barash. Additional resources included the WFSA tutorials of the week, and other online lecture presentations. During our stay, we supplemented many of the already scheduled talks with presentations that we felt would be relevant and beneficial to the practice we witnessed. The residents were very keen to learn, their knowledge base in medicine was very impressive.
The residents were very shy the first few sessions, and contrary to what we observe in Ottawa, they were very reluctant to participate in any interactive dialogue during lectures. I suspect this is because they were comfortable with a didactic style of teaching, and it came to them as a little bit of a surprise that we wanted them involved. A few days in, that had changed and they were eager to provide answers to any discussion questions. Some of the topics that we discussed included: acid-base analysis, anesthesia machine check, basics of the anesthesia machine, ATLS in hemorrhagic shock, basic ECG interpretation, comparison of general and regional anesthesia, a primer on opioids, spinal anesthesia, and a number of oral-exam style trouble rounds targeted to the senior residents.
What I learnt from the academic sessions was that the residents were eager for knowledge, and often what they lacked was an expert being able to prepare complex material into a format that is understandable and engaging. As hard as it was to prepare all the lectures in the evenings, it was well worth the look on the residents faces when they truly learned something. An example of this was during our anesthesia machine talk, the residents were surprised to hear that the APL valve did not need to be closed once the machine was switched to the mechanical ventilator. They were truly convinced through dogma that it needed to be closed for the ventilator to work. When we explained the circuit diagrams to them, and it became clear that the APL had no impact on the ventilator, the residents were keen to show the anesthetists in the OR the next day. Something that is not easy to read about in a textbook, that becomes routine practice, really does need an expert to dispel the dogma.
The time that we were not in academic teaching sessions in the classroom, we spent observing and teaching in the OR. Often Sophia and I would go into a room each and provide teaching to junior residents as well as to the anesthetists during cases. Anesthesia practice varied greatly in the ORs. Many times, patients were genuinely in danger of serious complications due to the practice of the anesthetist, or anesthesiologist, and it was very difficult to not step in immediately and assume care. We really had to try to orient the provider to fix the situation and offer some teaching. Many of the surgeries were performed under neuraxial technique, although the failure rate of spinals was quite high. The most striking area for improvement was summed up well by Dr. McVicar during our many debriefs with the residents. Despite the lack of resources, the largest improvement that could be made in their practice was being prepared for unanticipated events. Anesthetic machine checks were never completed, and suction was not available during a couple of aspiration episodes. Oxygen to the anesthesia machine was provided via large pressurized tank, and once during the OR, the oxygen tank depleted and it took 10 minutes to have it changed. During that time, there was no way to provide volatile anesthesia or mechanically ventilate the patient, IV boluses of ketamine and propofol were used until the tank could be changed. Simply checking the tank in the morning would have eliminated this potentially dangerous event.
The surgical safety checklist was treated as a chore, and something that just needed to be completed; it was not used as a conversation between the entire team. Often a nurse would just pull a resident to the side and complete it between each other in the corner without anyone else listening. One consequence of this was a spinal anesthetic being administered for a hip surgery, only to later discover that the surgery was planned for 6 hours. Despite all this, the residents were very open to listening to our feedback and were engaged in debrief sessions that we had after each case. I was happy to see that the first-year residents had checked their machines everyday after we had given the machine check lecture.
On call, there was no staff coverage and second and third year residents were often expected to manage the 6-week-old infant with ischemic gut going for a laparotomy. Inevitably a number of these cases did not go well, resulting in patient mortality or morbidity. There was little to no realization that staff should be available for complex cases such as this overnight.
Overall, I must say that the experience in Ethiopia was eye-opening and very humbling. The people were incredibly welcoming, and appreciative of any teaching that we were willing to provide. I do hope that we left some knowledge with the residents that will shape their future practice. The fact of the matter is that there is a lot of room for improvement. Patient safety initiatives, quality improvement, medical education, and communication are all terms that we take for granted here in Canada; but my short time there made me realise how very important these are to the practice of anesthesiology. CAS IEF will need a strong continued presence to develop a core of well trained anesthesiologists in Ethiopia.
I went to Ethiopia hoping to determine if a future in Global Health was indeed for me. My time there confirmed that it is. I additionally wanted to leave an impression on some of the residents there, and to become a contact with who they could communicate. Overall my time in Ethiopia will forever change my outlook on medical education. I have come to realise that not having a new endotracheal tube for every patient, or sevoflurane, or even opioids, usually is not the cause of a poor outcome. However, not having a competent, well trained anesthesia care provider often is. This is what I hope future CAS IEF missions continue to focus on, and I hope to be there when I can to support this lofty, but ever important goal.
Figure 1: The food was plentiful and delicious. The flatbread, called Injera is used to pick up the variety of vegetarian and meat thick curries. Remember to only use your right hand while eating!
Figure 2: Dr. Jason McVicar pointing out relevant anatomy for an ultrasound guided supraclavicular block with the first year residents, this picture was taken just minutes before the power went out!
Figure 3: Lalibela is a town in northern Ethiopia, best known for its distinctive rock-cut churches. The pictured church here dates back to the 12th century.
Figure 4: A stunning view from a-top a hill in Lalibela.
Figure 5: The first year residents with Dr. Jason McVicar and Dr. Sophia Lane on our last day.