No matter how much international experience under your belt the initial days in a low-income country are a medical seismic shock with potential register on the Richter scale. Call it medical jet lag. A recalibration is required that necessitates a reconsideration of what you take for granted at home. My approach is to listen and simply absorb. The surgical cases are very much the same but disease processes also very different. Medical presentations are more advanced as access to definitive treatment are more limited.

A well-trodden medical maxim states that when you hear hoof beats think horses rather than zebras. It is used to illustrate the point that uncommon presentations of common diseases occur with greater frequency than rare conditions. In Abyssinia the zebras are the horses.

Anesthesiologists were in the bathroom or asleep at the wheel when job titles were being handed out. Most people can’t pronounce it, no one can agree on how to spell it and even other physicians don’t really understand what we do. We are the witches and warlocks of the medical world. “Life guard” would be more appropriate but instead that moniker was coopted by teenage babysitters in speedos. All the credit to them and the marketing firm that locked down the term. It stands to reason. The anesthesiologist’s role is to suspend consciousness, maintaining normal physiology and guard life while the barbaric acts are performed, which under any other circumstance would constitute torture. Needless to say that the invention of anesthesia is one of the greatest human achievements of all time, right up there with the domestication of fire and the printing press. I say we go toe to toe with the pool kids and let the chips fall where they may.

There is a ying and yang between surgeons and anesthesia colleagues; an interdependence that takes place through the mutual care of our patients. One requires the other and alone they serve no functional purpose. We are partners in an elaborate dance where the patient sets the tune, surgeon decides the steps, and the gas passer sets the dance floor. In high-income countries the symbiotic surgeon-anesthesia relationship has an equal power dynamic and modern medicine has finally recognized that the patient is the one ultimately in charge. In Canada, surgeons and anesthesiologists require five-year training programs alike for a sum total of 13 years of post-secondary education. We stand on equal footing in the operating theatre and frequently collaborate on choosing the best approach for a surgical journey for the patient.

The shortage of anesthesiologists and surgical load in low-income countries has resulted in a shift to use non-physician anesthesia providers with less training to fill the gap. Today the mainstay anesthesia providers in Ethiopia are anesthetists. They provide very good care and are technically quite skilled within their scope of practice. Some surgeons may prefer the anesthetists as they may be more willing to take direction without protest. Pesky anesthesiologists have a tendency to voice concerns and suggest elective surgical procedures be coordinated with the overall health of the patient to ensure optimal conditions and a reduction in postoperative complications. We often insist pain management strategies such as an epidural, which can be perceived to consume precious operating time and threaten case cancellations, all in the best interest of the patient.

Part of our role is to encourage collaborative decision making in concert with our surgical colleagues while demonstrating techniques and providing advice on anesthetic plans to ensure a safe surgical course. The first few days require acclimatization to the patients, their conditions, the surgeries and the flow of the hospital. Once you know where to find the bathroom with running water and remember to bring your toilet paper you can focus on clinical care.

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Jason McVicar, February 25 2019

How’s that for the next summer blockbuster? Who am I kidding, in film anesthesiologists are akin to wardens: a plot device reserved for wallflowers or villains.

I’m back in Addis on the garden terrace of the Ghion Hotel. From this little government sponsored oasis, combined with jet lag, and a St. George premium lager I could convince myself I’m almost anywhere. Except Ottawa. The polar vortex and snow squalls clearly don’t reach the northern ridge of the Great Rift Valley.

It is exciting to be back at the Black Lion Hospital and Addis Ababa University in the Ethiopian capital.  I’m working again with the Canadian Anesthesiologists’ Society International Foundation or CASIEF for short. It’s not a sexy name like Save the Children or World Vision but this charity does great work. CASIEF is a scrappy little organization built on the vision of benevolent anesthesiologists 50 years ago. The charity’s first date was in Nepal and evolved with a successful courtship in Rwanda built on the dedication of a few very dedicated souls such as Drs. Jeanne, Angela Enright, Franco Carli and Patty Livingston. Today relationships also exist with the  anesthesia programs in Guyana, Burkina Faso and here in Ethiopia.

The CASIEF model is one built on relationships: Education Development would best characterize the mission. The model primarily consists of a visiting professor program from Canadian institutions where teachers travel to assist with clinical teaching in the operating theatre and deliver lectures with a partnership to assist with curriculum and professional development.  Teach a friend to fish type thing but the learning is truly bidirectional. As trust is built the scope spreads across a variety of domains such as leadership, professionalism and research.  The mandate is to collaborate with partners to build capacity for safe, sustainable anesthesia and perioperative care through education, knowledge translation, and advocacy.  Like any engagement there are fits and starts but the long term evolution of growing yesterday’s students into today’s professional leaders is remarkable.

I didn’t forget my laptop this time. On the last visit in 2017, I managed this same trek only to leave the lifeline to all my educational materials in the seat pocket of the commuter flight in Toronto- a teacher without tools.  The residents on the trip, Sophia and Karim, came through with resources and expertise.  Having that pesky final Royal College exam at the end of 13 years of training on the immediate horizon has wide-ranging benefits both at home and abroad.  We provided operating room table-side instruction by day and crammed lessons together by night at the hotel. Often the teaching topics were requested the day before.  Our routine most evenings would consist of huddling in the hotel lobby scouring resources and cobbling to together lessons while making small beer sacrifices to Etherna, the undisputed God of Wi-Fi as she teased us with broken links to pearls of pharmacology and physiology.  It was the best of times, it was the worst of times.

Humanitarian parlance has an old adage, “This isn’t our first rodeo.”  This is my third visit to Addis Ababa. There is something special about returning to a place you have visited before. You never really go back to the same place. Change is inevitable. Development and progress relentlessly march forward.  Roads are paved, buildings fall and get put up, mostly by the Chinese in these parts. There is a growing familiarity but I am not exactly the same person on each subsequent visit.  Traveling as a wide-eyed medical student or first time faculty carry an innocence that fades with each return.  Small quotidian familiarities appear in subtle ways. The warm blast of the first breath of sub-Saharan air on the tarmac, the texture of enjera and kitfo cuisine and the thousand yard stare of a grizzled wanderer to ward off touts comes more naturally with each arrival.

There is a personal cost to being away from family. I’ll be honest, dread creeps into the last day before any overseas work travel now.  It hasn’t always been this way but every trip since we started our little family has an element of regret.  Kids change things.

Humanitarian work, if that is what I am going to call this, is rather incongruent to family life.  The demographics of the volunteers or aid workers are very bi-modal: pre and post children.  The challenges of leaving a family with household kids at any age are a significant barrier. You often have to call in supports from friends and extended family. I am certainly grateful to those in our lives who have helped us get through these strained times.  I just video called home and my 4-year-old son refused to acknowledge me. The two year old was genuinely happy to see me and had the inquisitive instinct to ask again where Ethiopia was. The debts incurred will have to be repaid.

Back into the theatre tomorrow.  All the world’s a stage…

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Jason McVicar, February 15 2019

Final Reflection – Saturday, February 2, 2019 (from Patty)

Our team is dispersing: most of us are returning to Canada but Dave will stay on with Emma for a few weeks in Addis Ababa before going back to Rwanda to help with the foundations simulation curriculum.

Although I am tired after the long flight from Addis Ababa (as I wait for the final flight to Halifax), I can’t help reflect that our last month has been enormously productive, energetic and rewarding. We’ve had great teaching moments, watched learners blossom, seen trainee facilitators become confident teachers, contributed to sustainable simulation-based teaching in Rwanda and Ethiopia and had fun doing so. Our team has shared many laughs and lighthearted moments as well as serious discussions. We resolved challenges creatively and with care.

I am grateful to all the learners and colleagues in Rwanda and Ethiopia who have been so generous. Thank you to the members of the Jan 2019 team (Dave, Stephen, Chris, Jon, Mary, Julian and Emma). Although I will miss you, I hope our paths will continue to cross as the caring anesthesia network around the world grows richer and richer.

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

Nyamirambo – Saturday, January 26, 2019 (from Patty)

I brought the team to Nyamirambo last night to walk down memory lane. We took Christophe and headed to the Green Corner for delicious fish (tilapia from Lake Victoria) that is eaten using one’s fingers.

This came with Rwandan french fries, so possibly the best fish and chips ever. We wandered down the main street of Nyamirambo – full of people, shops, bars, music and joie de vivre. It had not reached full 2:00 AM fortissimo levels of noise yet, being too early. We stopped at the door of the Guma Guma bar to check that the chairs were all lined up in front of the TV (like church) for the next Premier League game. Indeed, life is unchanged in Nyamirambo. The old apartment building was dark and rather ghost like. Enough of that, we returned to the new apartment and chatted late into the night exploring Stephen’s vast knowledge of esoterica.

We are at another transition point. Tomorrow we fly to Addis Abba, Ethiopia to run a VAST Course. CASIEF has a new program in Ethiopia and we look forward to learning more. Chris is the only one of us who has been to Addis before (outside of airport transfers).

As our time in Rwanda comes to a close, I reflect on the visit. It has been productive in so many ways. There is a hunger for our continued involvement, yet at the same time there is a sense of enormous progress. The anesthesia program is well launched and able to function without us. Many people around the country have received extra training and plans are underway to embed the VAST Course as a frequent offering for continuous professional development.

On a more personal note, I reflect on time. Life is always too short but it is possible to have a rich life where time is enjoyable, meaningful and memorable. That is the gift that Rwanda has given me. Even though we have only been here a few weeks, it seems ages ago that Chris and I were wandering around for our first lunch, we cycled the dirt roads in the northern province, our first Jeopardy game with the residents, watching the fishing boats on Lake Kivu. All marvellous, all rich experiences.

My future involvement in Rwanda is an open question. I will no longer come as a CASIEF volunteer (too old and no longer practicing anesthesia at home) but I suspect I will return in some other capacity, perhaps a family visit with all the people who consider me their Canadian mum.

On to Ethiopia – Monday, January 28, 2019 (from Patty)

Our final night in Kigali, we were invited to the home of Francoise, anesthesia program director and a good friend. It was a warm gathering with family and friends. Francoise gave us a lesson in the African method for carrying a child. Chris and I both made the effort but clearly Francoise is the only one of us who looks perfectly at home with a baby on her back.

The journey to Ethiopia had a prolonged detour in Bujumbura, Burundi, long delays in the visa line, and what felt like an interminable wait for the shuttle to the hotel. We rolled in around midnight last night, tired and punchy.

First impressions of Addis – fewer trees, busy, fast paced, lots of concrete, tall buildings, enormous hospital complex, people wearing traditional clothing. We jumped right into a VAST facilitator course today with 3 staff anesthesiologists and a senior resident. Our team expanded to include Emma, an Ottawa resident, and Julian, the CASIEF-Ethiopia lead. Our Ethiopian hosts had arranged a bright airy teaching space and assembled the course materials. We quickly began rolling out the scenarios and were delighted at how well the group picked up the key ideas.

We finished the evening with a traditional Ethiopian meal – communal meal on injera eaten with fingers. We have one more day of facilitator training tomorrow before welcoming 14 participants to the VAST Course on Wednesday.

A VAST success – Wednesday, January 30, 2019 (from Patty)

Day one of the VAST Course in Addis. The participants are on time, the space is bright and cheery, the food is more or less on time, the day is bright and sunny. My concerns about people being too quiet during the first session were quickly put to rest – by mid-day people were jumping in with comments and insights and we had to curtail discussion to keep on time. We have a mixed group of anesthesia residents, NPAs, nurses and surgeons. The four facilitators we trained on Monday and Tuesday have exceeded expectations by a huge margin. They are now running and debriefing scenarios with some prompting from our team. It is a huge luxury to have a big team (to say nothing of the talent!). Dave is now a VAST Course pro. An additional bonus is the the level of English is strong and where needed our local facilitators quickly translate into Amharic. Other great moments: Laurence, the sim coordinator from Rwanda, coaching Haben, the anesthesia admin assist. My heart melted to see them sharing a chair and chatting away. I truly hope this is the beginning of a journey of simulation in Ethiopia.

Strong Women – Thursday, January 31, 2019 (from Patty)

Many of the leaders in the anesthesia department are strong, talented women. How great! The head of department and the head of the Ethiopian Society of Anesthesiologists are both female. Three of these skilled women are helping to facilitate the VAST Course. Watching them engage with participants and pull out the best performance, is inspiring. Day two of VAST is scenario heavy with 7 challenging OB anesthesia scenarios. We are tired but smiling.

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