Join us at an upcoming event to network with colleagues, learn more about CASIEF, and get inspired about how you can get involved in global health.
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.
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.
“Safe Anesthesia & Surgery Saves Lives” is CASIEF’s motto 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”, 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. 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.,,
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. 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.
 Caldron PH, Impens A, Pavlova M, Groot 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.
 Farmer, Paul. Personal communication, October 4, 2014.
 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.
 Arya AN & Evert J. 2018. Global Health Experiential Education: From Theory to Practice. Routledge, New York.
 Pinto AD & Upshur REG. 2013. An Introduction to Global Health Ethics. Routledge, New York.
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.
A 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.
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.
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.
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2018 CASIEF Gala Dinner
Sunday, June 17, 2018.
Auberge Saint-Gabriel, 426 Rue Saint-Gabriel, Montreal
Reception 18:30, Dinner & Speaker 19:00 – 22:00
Tickets available during your CAS Annual Meeting (registration www.casconference.ca).
Dr. Dan Poenaru – Guest Speaker
Dr. Poenaru is a Canadian pediatric surgeon who has dedicated his life to treating needy children throughout eastern Africa. Motivated “by the enormous needs of African children,” not only those of Kenya, but also the numerous Somali refugees entering the country, Dr Poenaru opened a surgical practice in Kijabe, Kenya. Throughout his career, he has treated patients through civil war
and in refugee camps, exposing himself to tremendous personal risk. Dr Poenaru is the recipient of the 2014 Teasdale-Corti Humanitarian Award of the Royal College of Physicians and Surgeons of Canada and the 2015 ACS/Pfizer Surgical Humanitarianism Award of the American College of Surgeons.
To learn more about our speaker:
To view our dinner venue:
- (In English) http://aubergesaint-gabriel.com/en/rooms/grenier-hall/
- (In French) http://aubergesaint-gabriel.com/rooms/la-grenier/
View the Gala Brochure for more information.
ANESTHESIA GLOBAL OUTREACH COURSE
Anesthesia is an essential component of every health system. Despite its pivotal role in routine surgical care, it has not been prioritized globally. This is undoubtedly partially due to a global health human resources shortage and disparities in distribution of personnel globally. Beyond this, at the level of many district hospitals in low-income countries, there are simply few resources to institute physician-led anesthetic care models that are commonplace in high resource settings. Given the scope of the surgical burden of disease, attempts to remedy the situation have included equipment donations, trainee exchanges, or even assisting patients to obtain care abroad. Their sustainability and effectiveness remains uncertain.
The Anesthesia for Global Outreach Course is focused on providing anesthesia providers with the skills and knowledge to work both safely and responsibly in the low-resource setting. The target audience for this course is medical professionals planning to deliver anesthesia, peri-operative, and critical care in the low-resource settings. It is designed primarily for anesthesiologists, certified registered nurse anesthetists, and anesthesiologist assistants, however it may also include nursing, pain management, and respiratory care.
Upcoming Course Details:
BETHUNE ROUND TABLE 2017
The Bethune Round Table (BRT) is an annual interdisciplinary scientific meeting hosted at a Canadian academic centre to discuss challenges and solutions to improving surgical care to under-serviced and marginalized populations in low- and middle-income countries. The objective of the BRT is to bring together health professionals from a variety of disciplines including surgeons, anesthesiologists, obstetricians, and nurses to share their research and experiences in the delivery of surgery in low-resource settings.
Upcoming Course Details
Dates: June 1-3, 2017
Host: University of Ottawa
WORLD CONGRESS OF ANAESTHESIOLOGISTS
Upcoming Course Details
Dates: Aug 28-Sept 2, 2016
Venue: Hong Kong Convention and Exhibition Centre