news World Anaesthesia In this issue: Meet the WAS Ugandan Fellow Report on PTC in China Anaesthesia in Zambia (cover picture)

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1 Volume 12 Number 2 April 2011 ISSN World Anaesthesia news In this issue: Meet the WAS Ugandan Fellow Report on PTC in China Anaesthesia in Zambia (cover picture) How to use drawover anaesthesia WAS Seminars WA WORLD ANAESTHESIA Profile of Berend Mets

2 WA WORLD ANAESTHESIA World Anaesthesia Society Travel Grant The World Anaesthesia Society is offering a grant of up to 1000 for trainee anaesthetists wishing to work or teach in a developing country Application and award of these grants will be through the travel grant system run by the International Relations Committee of the AAGBI with two grants awarded each year. Further information and application forms available at

3 Welcome to my first issue of World Anaesthesia News (WAN) as editor. It is an issue of firsts. We are introducing the first World Anaesthesia Society (WAS) Ugandan fellow and advertising the first WAS travel grant. In addition we have a report of the first primary trauma care courses in China and the first in a series of How to articles covering draw-over anaesthetic machines. More ideas for how to articles are welcome. I would like to thank my predecessor Bill Casey for his dedication during the 10 years he edited this publication. We wanted to feature him in the profiles section and say a proper thank you, but modest man that he is, he refused. I am a consultant anaesthetist at Stoke Mandeville and Wycombe Hospitals in Buckinghamshire and my specialist interests are developing world anaesthesia and obstetric anaesthesia. My world anaesthesia qualifications are based on 14 months spent working and teaching in the Queen Elizabeth Central Hospital in Blantyre, Malawi in the school of anaesthesia. Whilst I was trying to organize my work in Malawi, WAN and the contacts I made from reading it were invaluable so I hope to continue Bill s good work and help more readers to get involved in supporting our colleges in the developing world. The WAS had its 2011 AGM after the very well attended WAS Seminar (see page 16). Discussions revolved around how the Society should develop and we would like your input. The Society will be contacting you soon to ask your views on what projects it funds and the future format of WAN. If we don t have an address for you please supply one to the specialist society coordinator Busola Adesanya- Yusuf at busola@aagbi.org. As this issue goes to print the new WAS website is being designed. The WAS site will sit within the International Relations Committee of the Association of Anaesthetists of Great Britain and Ireland site at In the meantime you can keep in touch via facebook on our new page. Please search for World Anaesthesia, take a look and like the page. On that note, this is your magazine and I d like as many people to contribute as possible. Get in touch with me at worldanaesthesianews@ gmail.com with articles, letters or ideas. Contents Editorial 3 Education The World Anaesthesia Ugandan Fellow 4 How to article number 1: draw-over anaesthesia 5 Primary Trauma Care Teaching Programme for China 10 Teaching Anaesthesia in Developing Countries 14 Report of World Anaesthesia Seminar (January 2011) 16 Anaesthesia around the world Report on volunteer mission with Mercy Flyers: Mukinge Hospital, Zambia, 19 The Glostavent in Ghana 22 Zambia Newsletter 24 Profiles Berend Mets 25 Letter to the Editor 27 News and Information Useful information 28 WAS application form 31 worldanaesthesianews@gmail.com

4 Education 4 The World Anaesthesia Society Ugandan Fellowship Programme Mary Nabukenya is a doctor in Uganda who wants to become an anaesthetist. Before the World Anaesthesia Society Ugandan Fellowship programme she would have had to have worked and saved for at least two years before starting her anaesthetic training. After that she probably would have had to moonlight in private hospitals to continue to fund her studies. Because of the World Anaesthesia Fellowship Mary has been able start her studies and is currently studying for her MMed in Anaesthesia. Uganda is a low-income country with a severe anaesthetic workforce crisis. Physician salaries are low and many postgraduate trainees leave the country or are attracted into externally supported specialities such as public health or HIV. Anaesthesia has not attracted postgraduate doctors into the speciality in recent years and there are now fewer than 20 physician anaesthetists (350 nonphysician anaesthetic officers) for a population of 30 million. In 2006 there was only one physician training in anaesthesia in Uganda. The AAGBI/GPAS Uganda Anaesthesia Fellowship has been established as a collaborative project between the Association of Anaesthetists of Great Britain and Ireland and the University of San Francisco California Global Partnerships in Anesthesia and Surgery. The aim of the project is to increase the number of physician anaesthetists in Uganda necessary for the development of the specialty and to train the physician and nonphysician workforce of the future. Postgraduate training in anaesthesia in Uganda There are two three-year MMed programmes in anaesthesia in Uganda at present, one at Mulago Hospital in the capital Kampala, the other at Mbarara University Hospital in the West of the country. Postgraduate trainees in Uganda are required to pay university fees, and most do not receive a salary whilst they are training. The aim of the AAGBI/GPAS Fellowship programme is to provide trainees with an income to pay their university fees and to provide moderate support for living costs when the trainee does not receive a salary from the employing hospital. The Fellowship funds trainees to a maximum of 3000 per annum for each year of training. Trainees are appointed by interview after their internship year. They have regular assessments, annual written and oral examinations, and are required to complete a research project in their final year. They have an annual appraisal with a member of the AAGBI or GPAS. When accepting a fellowship, trainees sign an agreement to work following training in sub-saharan Africa for the period of time that they receive funding from AAGBI/GPAS. Outcome of the Fellowship training programme The first trainee Arthur Kwizera graduated in 2009 and is now employed in Mulago hospital. He has actively recruited trainees into the programme and there are now 12 postgraduate trainees in anaesthesia, seven fully funded and four partially funded by the Fellowship programme. The aim of the Ugandan Society of Anaesthesia is to recruit ten trainee anaesthetists per year over the next five years, and the World Anaesthesia Society would like to support them in this aim. The World Anaesthesia Society has agreed to join forces with the AAGBI/GPAS programme and fund an anaesthetic fellow, Mary Nambukenya, for the next three years. She has written a short piece to introduce herself below and will be updating us on her progress on our facebook page and via World Anaesthesia News. Your subscriptions to the World Anaesthesia Society provide Mary Mary Nabukenya with this funding and help secure the future of anaesthesia in Uganda. Dr Nambukenya introduces herself: I m called Mary Theresa Nabukenya, born and bred in Uganda. I did my MBChB program in Makerere University College of Health Sciences and graduated in January I did my internship in Mulago Hospital for a year and then joined the MMed program to study Anaesthesiology. Currently, I m a full-time student in the Department of Anaesthesia, Makerere University, based in Mulago Hospital. As students in this department, we have a hands-on experience right from the start of the programme. So we spend a lot of time in the operating theatres working and learning. Getting the World Anaesthesia sponsorship means more than a lot to me. Being straight out of my internship, I didn t have enough money saved up to study my masters immediately, so I d have had to work for at least 2 years before joining the program. It therefore enabled me to join a postgraduate program sooner than later. It means less financial stress and more time dedicated to studies. During the course of the year, we get many visiting anaesthesiologists coming to the department. The experiences are priceless - we learn a huge amount from them, and it opens our minds to what is happening elsewhere. Deciding to study anaesthesiology is one of the best decisions I have ever made! I have no regrets whatsoever! Thank you for making it happen. Thank you. Mary

5 How to article number 1: draw-over anaesthesia A Pearson¹ and R Eltringham² ¹Speciality Trainee, ²Consultant, Department of Anaesthesia, Gloucestershire Royal Hospital, Gloucester, UK Introduction Draw-over anaesthesia is simple, in both its concept and delivery. The equipment is straightforward to use and maintain, and is relatively inexpensive to purchase [1]. However to many modern anaesthetists, draw-over anaesthesia is seen as an old fashioned practice which has no place in the high-tech world of today. Many have never used it or even seen it in action; some even go so far as to suggest it should be banned. As today s anaesthetic machines become more complex, sophisticated and expensive they also become more vulnerable to external influences. They have become dependent on an uninterrupted supply of oxygen and electricity and require regular maintenance and servicing by highly trained technicians. However, at present these facilities are not available in the less affluent parts of the world, where the majority of people live and there is currently little prospect of this situation changing. Attempts to introduce modern sophisticated machines to poorly resourced hospitals have been universally unsuccessful [2]. In situations where compressed gases are unavailable, continuous flow machines cannot function and draw-over anaesthesia represents a viable alternative. With the appropriate apparatus, training and monitoring, it is easily performed and safe. Theory of Vaporisation For a volatile agent to be administered a carrier gas must pass through a vaporising chamber. It can either be pushed through under positive pressure, as in continuous flow anaesthesia; or drawn through by negative pressure, as in draw-over anaesthesia. The carrier gas can be drawn over by the negative pressure of the patient s inspiration, a selfinflating bag or by a ventilator. A one-way valve placed downstream from the vaporiser prevents reversal of flow in the circuit. Components of a draw-over system There are several components essential to a draw-over breathing system (fig. 1). These are: 1. Reservoir - In its simplest form this is a length of corrugated tubing with a side-arm for supplementary oxygen. When the patient exhales the oxygen flows into the reservoir tube to be included in the next breath. In modern draw-over machines, such as the portable version of the Glostavent (fig. 2), Education Fig. 1 Components of a draw-over system, courtesy of Diamedica Ltd (numbers correspond to text) 5

6 Education a more efficient type of reservoir is used. A valve at the air entry port prevents spillage of oxygen, a 2 litre bag increases the volume of the reservoir and a pressure relief valve prevents over distension of the bag. 2. Vaporiser - The standard plenum vaporisers are unsuitable for draw-over anaesthesia as the resistance to breathing is too high. A draw-over vaporiser must have minimal resistance to allow spontaneous respiration. 3. Self-inflating bag -There must be a self inflating bag for controlled or assisted ventilation and a valve to direct the anaesthetic mixture towards the patient when it is compressed. 4. Non-rebreathing valve - This is situated as close to the patient as possible in order to reduce the dead space. Several varieties of nonrebreathing valve have been used including Laerdal, Ruben and Ambu valves. All valves are designed to ensure inhaled gases come entirely from the anaesthetic machine and are not diluted by room air. They direct all expired gases to the atmosphere and not back towards the anaesthetic machine which would result in rebreathing. 5. Scavenging tube - This can be connected to the expiratory limb of the non-rebreathing valve if scavenging facilities are available. Pre-use checks As with all anaesthetic machines, it is the responsibility of the anaesthetist to ensure that the anaesthetic machine is in good working order and that they are capable of using it. The equipment is first checked to ensure all components are in place and functioning correctly. The anaesthetist should then: Check the available oxygen source, either from the oxygen concentrator or cylinder, and test the flow rate over the entire range Check the integrity of the circuit by compressing the self-inflating bag and ensuring that positive pressure can be generated at the patient s airway and that the bag on the reservoir unit moves in time with compressions 6 Fig. 2 Photograph of the portable Glostavent (courtesy of Diamedica Ltd). Confirm that the vaporiser contains volatile agent and test movements of the dial over the whole scale. Modes of operation The modern draw-over anaesthetic machine can function in both drawover and continuous flow modes. If the patient`s minute volume exceeds the oxygen flow rate entering the reservoir, the pressure in the reservoir becomes sub atmospheric; air is then drawn into the system and it functions in draw-over mode. If the oxygen flow rate

7 is increased until it exceeds the patient`s minute volume then the pressure in the reservoir rises and the system automatically transfers to continuous flow mode. In continuous flow mode any of the standard anaesthetic circuits can be used by substituting them for the draw-over system at the outlet of the vaporiser, inserting a non-rebreathing valve and using the fresh gas flow recommended for the system in use. Pre-oxygenation For efficient pre-oxygenation it is important to eliminate dilution with atmospheric air. This is best achieved by ensuring an airtight seal at the facemask and using a sufficiently high flow rate to distend the reservoir bag and provide continuous flow. Type of respiration Draw-over apparatus can be used with either spontaneous or controlled ventilation. If ventilation has to be controlled or assisted during an anaesthetic this is achieved by compression of the self-inflating bag on the respiratory tubing. It is important to appreciate that compression of the bag on the reservoir unit does not deliver positive pressure ventilation due to the presence of the pressure relief valve. If long-term ventilation is needed a ventilator can be used in combination with the drawover system. Induction of anaesthesia Induction can be by intravenous administration or inhalation. If inhalational induction is selected, a closefitting facemask is required to ensure an airtight seal so that negative pressure can be generated. In some patients, such as children and uncooperative adults, or those with facial injuries, an airtight seal may be impossible to achieve. In this situation, the draw-over mode can be converted to continuous flow mode as described above. Flushing the circuit In an emergency situation, the system can be flushed with oxygen. To achieve this rapidly the anaesthetist should: Turn the vaporiser off Disconnect the respiratory tubing from the patient Set the oxygen flow meter to deliver the maximum flow rate Compress the selfinflating bag several times to purge the breathing system of the anaesthetic mixture Reconnect the respiratory tubing and ventilate the lungs with oxygen. Use in the absence of oxygen The source of oxygen can be a cylinder, central supply or oxygen concentrator. If no oxygen is available, atmospheric air is used as the carrier gas. In this situation assisted ventilation may be required if there is respiratory depression due to opiates or volatile anaesthetic agents. Use in infants A 500ml self-inflating bag is available for paediatric patients. Small children breathing spontaneously may have difficulty generating enough negative pressure in the vaporiser to deliver adequate anaesthetic agent in draw-over mode. In patients weighing less than 10kg it may be preferable to use the system in continuous flow mode or with controlled ventilation. Alternatively the draw-over breathing system can be replaced with a Mapleson `F` System as described above. Monitoring in the absence of monitors When sophisticated electronic monitoring equipment is unavailable, draw-over becomes a safer mode of anaesthesia [3]. In spontaneous breathing patients, movement of the bag on the reservoir unit provides the anaesthetist with an indication of respiratory rate and depth. Alternatively a fenestrated Education 7

8 Education reservoir bag can be attached to expiratory tubing and its movements observed. Providing these are adequate, rebreathing and hypercarbia should not occur with the draw-over system as the expired gases are completely directed away from the circuit by the non-rebreathing valve at the patient s airway. Similarly, carbon dioxide levels are not affected by additional factors, such as the condition of soda lime or fresh gas flow rates, as with other anaesthetic circuits. The concentration of the volatile agent inspired by the patient in draw-over mode is identical to the concentration delivered by the vaporiser. It is not diluted by an unknown concentration as in lowflow anaesthesia where continuous agent monitoring is recommended. is designed to prevent expired gases re-entering the anaesthetic tubing. Bacterial filters should be used if available. If there are no filters used, it is recommended that the valve be washed in warm soapy water between patients [4] and autoclaved if there has been a high risk of infection. The vaporiser is designed to require minimal maintenance. Due to the presence of thymol in halothane, the movements of the dial lever can become stiff. In this case, the shuttle casing should be cleaned. A small quantity of halothane is poured into the vaporiser chamber which is then inverted and shaken several times to remove the thymol deposit. The halothane used to clear the thymol should then be discarded. oxygen [5] and transfer to continuous flow mode Vaporiser - Newer draw-over vaporisers are reliable over a wider range of conditions, give higher concentrations of volatile agents and can now be used with Sevoflurane Non-rebreathing valve - A new non-rebreathing valve is now available which is situated on the anaesthetic machine well away from the patient [6]. This eliminates the need for a bulky valve in the region of the patient s airway and facilitates scavenging. More sophisticated drawover anaesthetic machines, such as the Glostavent and the Universal Anaesthetic Machine, are now available which incorporate an oxygen concentrator and in the case of the Glostavent a gas driven ventilator [5]. The system is designed to be used without nitrous oxide. Air is the principal carrier gas supplemented by additional oxygen, when available, so that it is impossible to deliver a hypoxic mixture to the patient. Care and Maintenance The breathing system is at reduced risk from contamination due to the non-rebreathing valve which Recent developments In the last few years there has been an upsurge of interest in draw-over anaesthesia as recent innovations have been introduced which have dramatically improved performance. These include: Reservoir - The design of the modified reservoir, as described above, has facilitated conservation of Conclusion In the developing world, provision of safe and reliable anaesthesia can be a challenging undertaking [5]. Draw-over anaesthesia represents a simple and safe alternative for delivering an anaesthetic in areas where resources are poor. It offers distinct advantages of safety where monitoring is absent and electricity and oxygen sources are limited. For these 8 Footnote: Practical training in draw over anaesthesia is available at the Gloucestershire Royal Hospital. Anyone planning to work overseas who would like to familiarize themselves with this form of anaesthesia before their departure should apply to Dr Eltringham at reltringham@btinternet.com.

9 and many other reasons, it has been used successfully in field and military anaesthesia for several years. Recent developments in draw-over anaesthesia hope to increase the interest in its use and highlight its potential to the modern-day anaesthetist. References 1. S Simpson, I Wilson Draw over Anaesthesia Review Update in Anaesthesia Article 6 2. Ezi-Ashi TI, Papworth DP, Nunn JF Inhalational anaesthesia in developing countries Part I. The problems and a proposed solution. Anaesthesia 1983; 38: R Tully, R Eltringham, I Walker, A Bartlett The portable Glostavent : a new anaesthetic machine for use in difficult situations Anaesthesia and Intensive Care November 2010; 38: 6 4. Diamedica Ltd. Glostavent Users Manual. Bratton Fleming, Devon: Diamedica Ltd, R M Beringer, R J Eltringham The Glostavent : evolution of an anaesthetic machine for developing countries Anaesthesia and Intensive Care 2008; 36:3 7. S Payne, R Tully, R Eltringham A new valve for draw-over anaesthesia Anaesthesia 2010; 65: Education Declaration of interests: Dr Eltringham has been involved as an advisor throughout the development of the Glostavent, although neither author has any financial involvement in any of the products described. Keep up-to-date with the World Anaesthesia Society via its facebook page. Search World Anaesthesia at 9

10 Education Primary Trauma Care Teaching Programme for China Dr Amaia Arana Medical Coordinator. PTC China project The country China is the third largest country in the world, with a total estimated area of over 9 million square kilometres, including vast areas of inhospitable terrain. With just over 1.3 billion people it is the world s most populous country, representing a full 20 percent of the world s population. 10 The current pace of economic, socio-cultural and political change in China is stunning. On the back of increasing industrial output, the economy has grown at eight to ten percent a year for more than two decades. However much of China still lives in poverty with about one-fifth of the population living in urban areas and the rest in undeveloped rural regions. Background With the rapid development of the Chinese economy there are an increasing number of casualties due to road traffic accidents, adding to those from natural disasters such as earthquakes and floods. Some of these casualties may not die or suffer disabilities if sufficient rescue and treatment endeavours could be made in time. One of the main problems facing healthcare providers in China is the low level of trauma care teaching. There is no systematic training for trauma care procedures or methods and many medical staff working at the front line lack the knowledge of correct rescue and treatment strategies. With the cooperation of the Hong Kong Kadoorie Charitable Foundation, the National Institute of Health Administration (NIHA) and the Ministry of Health China (MOH) the Primary Trauma Care Foundation has built an appropriate Primary Trauma Care (PTC) training model for the Chinese context and hopes to establish PTC as the National Chinese Trauma Programme. The program will also include the establishment of the Primary Trauma database and Trauma register in the country. The main objective was to begin the foundation of a PTC training network that was initially concentrated in four National Training Centres (NTC). The four NTC are located in: Wuhan in Hu Bei province, Zhengzhou in He Nan province, Nanning in Guang Xi province, and Shenyang in Liao Ning province. During September 2010 medics from the four NTC met for training in Wuhan (phase one). Between October and November 2010 training took place in the four NTC (phase two), which will then be responsible for the teaching and training of further doctors from over 50 hospitals throughout China in 2011 (phase three). By the end of the first year we expect to train almost 2000 Chinese professionals. The cascade model of teaching of this program will enable this course to rapidly move to district and rural areas throughout the provinces in years two and three During phase one the instructors on the courses were experienced PTC instructors from other parts of the world. In phase two the newly qualified Chinese PTC instructors led the courses supervised by two foreign instructors. During phase three foreign instructors will occasionally supervise the courses to ensure project progression and quality assurance of the programme.

11 Continuous medical education points and exams The Chinese MOH decided to award 3 continuous medical education points for this course, and requested for the course to have an objective pass/fail assessment. This is something new to the PTC program, and in order to set an objective marking system an examination committee has been created. The committee consists of six members, all of who have been instructors in the courses of phase one of the project and have been able to appraise the practicalities of the exam process in practice. The exam of the two-day PTC basic course consists of a MCQ paper and a ten point assessment practical scenario on the primary survey. Those students who pass the PTC basic course and have shown attendance to 100% of the course are invited to the one-day PTC instructor course. PHASE ONE Details of activities During phase one, two groups of experienced foreign PTC instructors travelled to Wuhan to teach the courses. Each group taught four basic PTC courses and four instructor courses over two weeks. Each course was attended by 20 to 22 students. A total of 167 medics were trained in phase one. The specialities distribution was 81 anaesthetists, 79 emergency doctors and seven doctors belonging to other specialties, mainly surgeons and gynaecologists. Facilities The facilities were good. The course was held in the skills centre at Wuhan Union Hospital it had a small lecture theatre that was well laid out with PowerPoint facilities for the slides to be seen simultaneously in English and Chinese, and a bigger lecture theatre that was utilised when courses overlapped. Attached was a facility with many trolleys and dummies for skill stations and scenarios. We were a bit short of equipment (laryngoscopes, cervical collars etc.) particularly during the weekend when we had a double amount of students. There was a black board and a white board. A slaughtered goat was produced for each course for chest drains insertion practice, and the larynx was used for surgical cricothyroidotomy. This worked very well. Contents of the PTC course There were between five and six foreign instructors in any of the groups at any one time. During the first group, the courses were initially delivered exclusively by the foreign instructors. The basic PTC course was followed for the first course, whilst the foreign instructors noted any adaptations that were needed. As the foreign instructors had to work entirely with translators, effectively doubling the time needed, they had little time to elaborate on the basic slides. However, in subsequent courses when some of the Chinese doctors were starting to act as instructors, we encouraged them to expand on the basic information. The opening session of the course, a local trauma perspective, was delivered by a local doctor on all courses. Education 11

12 Education At the end of each day, the foreign instructors together with the new Chinese instructors had a meeting to provide feedback, evaluate how the day went and to allocate the teaching sessions and workshops for the following day. The input from the Chinese instructors during these sessions was most valuable. By the end of the courses several of the new Chinese instructors from all the NTCs had experienced all the aspects of the delivery of the courses The exam An arbitrary pass rate for the MCQ s and the scenario were decided. The scenario was the same for all the candidates in any one group in order to standardise the assessment All the candidates passed the MCQ and assessment scenario, although some candidates had to repeat the exam in order to pass and all proceeded to the instructor course. leaders of the City Level Training Centre. Speeches were given by representatives of various parties. Media coverage Over 10 newspapers and news websites reported the open ceremony and the launching of PTC training program in China, including xinhuanet.com. news. china.com.cn, Science and Technology Daily newspaper and the Chu Tian Du Shi newspaper. The foreign instructors had the opportunity to visit the Accident and Emergency Department and the Cardiac Intensive Care Unit at Wuhan Union Hospital, a 32-bed facility in a hospital for 2700 people. Most nights the PTC instructors were taken to banquets arranged by the PTC students and by the Wuhan Training Centres staff. In the Yangtze River Harbour we lit lanterns in honour of the long life and success of PTC China, and we ended the night in a Chinese Tea House tasting different types of teas. A most interesting cultural experience. Evaluation of the courses Overall everything went well considering we were working in a new environment, with translators and introducing new assessment procedure. We finished all the courses with a feedback session from the students to the instructors. These sessions were carried out in a brainstorming mode where the students had the opportunity to comment on what they liked about the courses and what could be improved. They were very happy with the teaching methods, especially the discussion groups and the scenarios. The systematic approach and the practical aspects of the courses were also very well liked. On things Subsidiary activities Opening Ceremony An Open Ceremony of the PTC China Training Program was held on the 5th of September in the Union Hospital, Wuhan. Around 700 people attended the Ceremony, including representatives from PTC Foundation, officials of MOH and NIHA, representatives of the Kadoorie Charity Foundation, officials and staff from the Union Hospital of Wuhan, leaders of the four NTC, PTC students to be and 12

13 to be improved, the lack of time to practice the scenarios and teaching skills was reiterated on several occasions. No pictures were added during the lectures, and this as well as the use of videos was mentioned as desirable by the students. It was recommended that these would be appropriately added later when the local instructors were adapting their own course to the local environment. Everyone acknowledged the cultural, and particularly the language limitations on the delivery of the courses; this should be easily overcome when the Chinese take over the programme. Overall, the students as well as the instructors enjoyed the courses and considered them a very interesting experience. The introduction of the exam required some changes in the program and might still need some evolution. Perhaps in the future it might be desirable to consider a different mark for passing the course and for becoming an instructor. Only about half of the students had teaching commitments as part of their usual jobs. Even to those with teaching commitments the ideas about interaction during lectures, scenario teaching, discussion groups and feedback were new to them. They showed a great interest and excitement for these new methods, but they felt the length of the course was not enough to make good teachers of them. They though it was a bit unfair that the first time they had to practice as teachers was the time that they got evaluated. The Chinese instructors should take this into account during the process of adapting the courses to their needs. On the whole they were quite impressed with these new concepts, and from that point of view the PTC course was a success. On a personal note it was fascinating, and certainly challenging, for the instructors to teach the PTC course in a setting with so many cultural differences, particularly the language and the scripture. Education Acknowledgements PTC Foundation would like to thanks to all the people who have contributed to make these courses in China a reality. 13

14 Teaching anaesthesia in Education 14 developing countries Introduction Teaching in developing countries can be very different from teaching in the west. Trainee and graduate anaesthetists around the world share an enthusiasm and eagerness to learn, no matter what their clinical setting and resources. However, many (for example the nurse anaesthetists I taught in Tanzania in 2008) are used to a very different style of teaching. The style was dictatorial, and cultural differences meant that many students did not want to speak up in class. In addition, I had to overcome some degree of language barrier and learn to use a blackboard and chalk to teach. There are many books written on different teaching techniques and styles for adult learners. 1,2 However, few of these are appropriate in resource poor countries. Further, there may well be a mismatch between theoretical knowledge that is taught and learnt, and actual clinical practice. This article aims to consider the differences and difficulties that may exist when teaching in the developing world. WHO TO TEACH In many countries, anaesthesia is a profession not just of doctors, but also of nurses and assistant medical officers. It is important that the level of teaching should be appropriate to the audience. Many nurse anaesthetists will have had standard school education followed by their nurse training. This may lead them to become very competent clinicians, but without the detailed knowledge of physiology and pharmacology that would be expected from those with a medical degree. In order to provide safe anaesthesia, some scientific knowledge is required, but it is a critical to pitch a teaching session at the correct level. One approach when working with a new group is to spend the first five minutes of each session ascertaining their basic level of knowledge, and then have various options planned for the session depending on that initial assessment. A mixed ability group is a particular challenge. In this setting, asking those with higher training to act as mentors to the other students will not only help the class to function, but will also ensure that the more able students consolidate their knowledge. PREPARATION Students who look through or read about a subject prior to the official class are more likely to retain information. It is therefore the duty of the teacher to provide a timetable for the teaching so that the students know which subjects to prepare. Similarly, thorough preparation by the teacher is essential for a successful teaching session. STUDENT PARTICIPATION Students are frequently asked to prepare a topic to present to the rest of the class. This is an ideal opportunity for the student to impart knowledge on a certain subject, but also to practice their own teaching technique. This does not come naturally to everyone. Remembered that the students we teach today can and will become the teachers of the future. A teacher should be a role model as the students will often copy the styles that they see - this also applies to a teacher s behaviour in a clinical setting. Teaching a student to teach is beyond the scope of this article. However, students need to concentrate not only on the material knowledge they are trying to impart, but also on engaging the other students, asking and receiving questions. TEACHING METHODS Resources It may often be difficult to obtain resources to aid teaching. Libraries may not be present, and those libraries that do Naomi Goodwin Consultant Anaesthetist, Cardiff exist may be under-stocked, or stocked with out-of-date literature. The internet is an excellent source of up-to-date information, but is often hard to use in environments where either the internet connection or the electricity supply is erratic. For those that do have access, Hinari ( is a WHO project which provides free or low cost access to over 6200 journals from major publishers. This interface is available in English, French, Spanish and, Portuguese, and covers journals in thirty different languages. Another resource for printed material and material on CD Rom is www. talcuk.org (Teaching Aids at Low Cost). This website provides many standard medical textbooks, as well as books written especially for those working in developing countries, at very low prices, and will ship around the world. Examples of interest include the free CD Rom produced by the Association of Anaesthetists of Great Britain and Ireland which contains the back dated issues of Update in Anaesthesia, the Primary Trauma Care manual, a video of the glass spine, extracts from the Oxford Handbook of Anaesthesia, and the very useful Tutorial of the week and Uganda Update. Teachers need to be innovative, adapting their teaching to the resources that they have available to them. It may be that you rely heavily a blackboard and chalk. If this is the case, it is well worth considering before any teaching session what you will write. For an hour s class, it is useful to have a list of key words and perhaps 3-4 diagrams, in mind that you can draw or write rapidly on the board. Although a common style, writing detailed information on the board rather than interacting with the class may not be beneficial to the students.

15 Overhead projectors with transparencies may be available. These need preparing in advance, and in a similar fashion to PowerPoint presentations, operating a less is more attitude to the amount written on each transparency is a good technique. Students have the tendency to copy down everything that they see and so if you write a lot so will they. You may find that they are too busy writing to play a full interactive part in your class. It is of course much easier if it is possible to use a PowerPoint or equivalent medium, but again, you must know your teaching material well enough to be able to transfer back to chalk and board if you are working in an environment where electricity is likely to fail. It is also very easy to become distracted by PowerPoint and all of the features that it offers. Newer technological innovations include battery powered LED projectors and low cost small, but powerful computers. TEACHING STYLES The students may well have been taught in schools in large classes, where it is disrespectful to question a teacher. This can be intimidating for a teacher from the West to understand why the class may be less interactive than they are used to. There may well also be language difficulties, with students all being taught in one common language which may not be their mother tongue. TEACHING TECHNIQUES Teaching must change according to the environment. You must consider what information you are trying to impart to your students. It may well be that large lectures are the style of choice, but although this may impart a lot of information to a lot of people at once, it is easy for the quiet or shy student not to take part in this learning experience. Small groups or one-to-one situations are often more productive. Many students when asked will express a preference for a more interactive and dynamic style of teaching, and yet feel uncomfortable in interacting themselves in class. It will always be a challenge to introduce a new teaching style to adult learners. TEACHING AIDS Some of the most useful teaching aids can be very simple. For example, simple felt-tip pens can be used to draw the anatomy of nerves and vessels onto each other. Students can take it in turns to feel anatomical landmarks on each other and draw these in position. It may be important to divide the students into same sex groups for this exercise and to always make sure that issues of modesty are maintained. A toy doll may be used in a similar fashion, but is not so anatomically accurate! THEATRE TEACHING As anaesthetists we spend much time working in theatre, and this can be an ideal place to teach. However, it must always be remembered that the patient comes first, and the person conducting the anaesthetic must be able to do so safely and without distraction. It is helpful to have a variety of different topics ready to teach on an impromptu basis. This is often a one-to-one situation, but if you are teaching a group of students, it is important to make sure that everyone can see and hear. The importance of language difficulties in this situation can be critical, as a facemask can prevent students and teachers alike from lip reading and reading of facial expressions to work out what is being said. CONCLUSION There are many challenges to teaching anaesthesia, and these can be compounded when teaching in developing countries. Lack of resources and cultural and language barriers need to be overcome. However, the benefits are rewarding, enormous and can last a lifetime. REFERENCES The theory and practice of teaching. Jarvis P (Ed) Routledge publication. Learning to teach in higher education second edition. Ramsden P RoutledgeFarmer publication. Landauer, T. K., & Bjork, R. A. (1978). Optimum rehearsal patterns and name learning. In M. Gruneberg, P. E. Morris, & R. N. Sykes (Eds.), Practical aspects of memory (pp ). London: Academic Press. Education 15

16 Education 16 Report of the World Anaesthesia Society Seminar at the Winter Scientific meeting of the AAGBI Lake Tana This years Winter World Anaestheisa Symposia was again held as a satellite meeting at the Winter Scientific Meeting of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) at the Westminster Conference Centre, London. It was well attended with over 200 delegates taking time in their lunch break to attend and hear our two excellent speakers. Dr Ben Silverman presented his experiences working in Gondar in the Ethiopian Highlands and Dr Rachael Craven spoke about her experiences working for Medicine Sans Frontieres (MSF) after the earthquake in Haiti. Ben and his wife took a year out from their anaesthetic training to set up a Masters course for the anaesthetic practitioners in Gondar. Gondar is located in the mountainous highlands of Northern Ethiopia at an altitude of 2100m, with the stunning Simien Mountains to the north and Lake Tana the source of the Blue Nile - to the south. The hospital is a university teaching hospital with a catchment population of over 3 million. From the beginning they were keen to ensure that the curriculum was clinically relevant and theatre-based and thanks to their work the Masters course 19 January 2011 started in September To succeed, the Masters course will need tutors, for periods of three months to a year from May 2011 until at least November Senior trainees, consultants or retired anaesthetists in the UK would be ideal tutors. There will be a salary of $1200 (US) pcm, paid locally. The work of Ben and the local staff in setting up the course will enable an interested anaesthetist to settle in rapidly, so that their time is productive and rewarding. For anyone considering working in a developing country, this is somewhere you could have a very beneficial role. Anyone interested in helping out should contact Ben Silverman at B.silverman@doctors.org.uk. Aftermath of earthquake in the remains of the original MSF hospital, Port au Prince

17 Education Operating theatre, Gondar Dr Rachael Craven discussed her work with MSF in Haiti both before and immediately after the devastating earthquake of MSF have had a presence in Haiti for a number of years and had been running a hospital within the capital Port au Prince with a large number of local staff. This building was destroyed in the earthquake and Rachael s talk detailed the enormous efforts to set up a new tented hospital to serve the hundreds of injured patients from the earthquake. Her talk and pictures brought home to the audience the difficult conditions before the earthquake and the devastating effect and huge scale of the disaster. She also detailed the amazing efforts of the MSF volunteers to get the field hospital up and running with all its associated infrastructure in such a short time and the help and care provided to earthquake victims. Dr Craven is again visiting Haiti with MSF one year on and we wish her well. Aerial view of the tented hospital set up in the aftermath of the earthquake Wards in the new tented hospital Operating within the new tented hospital The old MSF hospital. Note the first floor operating theatre, now on the ground floor and missing a wall The next WAS seminar will be on Thursday 9th June at the AAGBI in London and will cover a range of topics including reports from Uganda and Zanzibar, discussions on sustainable support and a forum to discuss networks and contacts for anaesthetists wishing to work overseas. 17

18 Education WA WORLD ANAESTHESIA World Anaesthesia Society Seminar AAGBI, Portland Place - Thursday 9th June, 9am to 4.30pm Developing World Anaesthesia - The way forward This year s seminar will be a forum for anaesthetists of all grades to learn from the recent experiences of anaesthetists and other specialists providing support for colleagues working overseas. This day is also an excellent opportunity to meet and mix with anaesthetists who share this area of interest. The day will be divided into three sessions: The Front Line will feature talks on topics such as: The state of obstetric anaesthesia in Uganda Supporting a government hospital in Zanzibar Delivery of military anaesthesia in Afghanistan and MSF missions in the wake of the Indonesian Tsunami and the Haitian earthquake. Sustainable Support focuses on strategies for providing support for colleagues working in settings where resources are severely limited. Our speakers include Pia MacRae, Chief executive of THET, and Professor John Kinnear, Director of Medical Education at Southend University. Networks and Connections will provide a forum to present and discuss several schemes that are being developed to provide web-based information and contact networks for specialists who currently or plan to work overseas. Apply to attend this seminar via the AAGBI website: 18

19 Report on a volunteer mission with Mercy Flyers: Mukinge Hospital, Zambia How do you summarise the impact of a visit like this in 1500 words? One thing I know: the effects on me were greater than I had anticipated. When I reflect on the three weeks or so I spent in Mukinge Hospital, I think principally of individuals. Patients who had nowhere else to go (no choose and book policy here) and who came to the hospital desperate for help - seemed to make it so simple. Relatives providing food, basic nursing to their loved ones, sweeping the floor, translating for us muzungu - and listening avidly to all the consultations on the Nightingale-style wards. Nurses and student nurses on wards and in theatre - with ready smiles, more translations and time taken to explain things to the visitor. The stretched medical staff giving endless time to hospital clincial care, responding to whatever comes, prepared to act outside their comfort zone in the absence of specialists, intensive care and referral options. Expat teachers and nurses who have been there for decades, looking The Cessna after short term volunteers like me with as much welcome and care as if I were the first one. I ended up at Mukinge Hospital via a contact made on the Anaesthesia in Developing Countries Course (ADC). Craig Oranmore-Brown had been a faculty member for ADC and ed to let us know of a need for anaesthetists at Mukinge arising from the absence of their normal anaesthetist on furlough. Conveniently enough, Craig Hilary Edgcombe Mukinge Hospital runs a charity called Mercy Flyers 1 (MF), which specalises in flying specialist doctors out on short term outreach projects within Zambia. I was able to become a Mercy Flyers volunteer in order to go to Mukinge. MF sorted out the paperwork and registration with the Health Professions Council of Zambia, advised on visas and accommodated me at the start and end of my visit in Lusaka. Craig also accompanied me to Mukinge and worked with me for the first couple of days to help me get settled in. Mukinge is a district hospital in a fairly remote corner of the North Western province of Zambia. A mission hospital with a firm Christian ethos, it is funded partially from government grant and partially from donors. I found it to be well set up from an anaesthetic point of view: there are two theatres (one major, one minor) and oxygen concentrators and monitors in each. 19 Anaesthesia around the world

20 Anaesthesia around the world 20 The majors theatre has a Glostavent machine which was in good working order and has its own concentrator in addition. A good thing to combine with oxygen concentrators is a reasonably reliable power supply and the theatre complex has a backup battery system which supports power when the hospital system fails. Sadly this cannot cover the whole hospital and one man did die on the ward from concentrator failure during a brief power cut. Equipment was available to give a safe spinal and general anaesthetic, and to provide safe obstetric anaesthesia, as defined by Sarah Hodges in her Uganda study of Some data: Mukinge is a 200-bed hospital with acute wards (male, female, maternity and paediatric) and chronic wards (TB ward and a second paediatric ward mainly managing malnutrition). It is a referral centre for rural health clinics and for smaller hospitals and enjoys a good reputation, meaning patients often come from some distance. During my time there I anaesthetised 71 patients, about half of whom were children. Cases included Caesarean sections, elective and emergency hysterectomies, tubal ligations, destructive delivery, hernia repairs, laparotomies for intestinal obstruction, prostatectomies, skin-grafting, placement of traction pins and K-wires for trauma. In addition I provided procedural sedation for children having dressing changes, MUA and similar small procedures. During the last few days of my stay we had a visiting plastic surgeon from Lusaka fly out to conduct a routine outreach visit during which we operated on patients who had been accumulating since his last outreach; the predominant surgery was for burns-related contractures in children although we did do some cleft lip and palate work as well. A wise colleague of mine describes the spectrum of differences in developing vs developed world anaesthesia: the drugs, kit, patients and surgeons may all be quite different from those we are used to. All applied in this case. I have learned to love ketamine, particularly in procedural sedation for children. As a consequence I have also more fully appreciated the benefits of atropine (and longed for glycopyrrolate). I have been reminded to check ampoules with great diligence (thiopentone: 1g vial, Traction - still an effective treatment ephedrine 50mg/ml, naloxone 40mcg vials). I have realised that without propofol, or reliable fasting protocols, the LMA becomes less attractive (though there are boxes and boxes of donated LMAs in the store room). The importance of really sticky sticky tape has imprinted itself on my brain. There are differences in stock management too: many consumables become less consumable and more re-usable than the packaging suggests. A limited supply of donated equipment means some hard decisions about who it gets used for; it s tempting not to use it all but only to stockpile it for the ultimate deserving candidate who doesn t exist. I have seen patients sicker and more stoical than I would have believed possible and seen more recover more surprisingly than I could have hoped. I ve been struck by the

21 The patient at the front was the one to be anaesthetised. effectiveness of traction as a fracture management strategy, and saddened by the need for skills in destructive delivery. I ve regretted not being able to communicate directly with most under my care, and laughed at my own attempts to gain informed consent ( But Doctor, I am here for you to make me OK: why would I have questions? ). I have had to explain to confused nurses that I am a doctor, but only in one speciality. I cannot do a Caesarean or deliver a footling breech myself. But I am a doctor, honestly. And I have worked with doctors who can do...pretty much everything. I ve enjoyed working with a surgeon who knows how to give an anaesthetic, who positions our patients perfectly for spinals and who forgives me for the occasional ketamineinduced muscle spasm, who commiserates over the dose of pancuronium given 10 minutes before unexpectedly closing, and understand my rejoicing when the pancuronium - date-expired - turns out to be minimally effective. While I learned far more than I gave during the trip, I was also glad to try and offer some training. The student nurses in theatre had a compulsory fast-track introduction to recovery nursing and rose to the challenge impressively. The paediatric nurse (and, effectively the paediatrician and neonatologist) at Mukinge and interim hospital administrator among many other roles, is also the person delivering anaesthetic services there whilst they are between anaesthetists; we learned from each other as I tried to recall general paediatrics and she picked up some anaesthesia tips in theatre. Memorable and considerately, she did not laugh unduly when, in the middle of an impromptu lecture about waiting to extubate children until they were really, really ready, the child in question flipped himself prone and started to crawl off the table. We decided he was probably ready to extubate... A short time somewhere like this raises more questions than it answers: professionally I found myself constantly working out whether a difference between practices there and here was deliberate, desirable or disastrous. Almost always there was a good reason for the unfamiliar practice and I learned (a bit) to wait and listen before leaping in with UKstyle advice. Frequent surprises taught me to take nothing for granted and ask questions about every aspect of patient management. There are bigger questions to ask - why are conditions as they are? Why so much discrepancy between rich and poor in this country? What is the long-term role of the overseas doctor in a country like this? - I did not get very far with these on a month s acquaintance. As far as the personal question goes, though - would I return to more of the same? - You bet. Acknowledgements and grateful thanks are due to: The International Relations Committee of the AAGBI for generous funding. Craig Oranmore-Brown of Mercy Flyers for inspiration, training and support. The Flying Mission pilots who got me from Lusaka to Mukinge in a tiny Cessna. Robert Neighbour and Roger Eltringham for making sure I could work the Glostavent before I went. Michelle Proctor, David Friend and all those at Mukinge for all the support and help provided in clinical and non-clinical ways. Mike Dobson, whose fault it all is really. 1 : 2 : Anaesthesia services in developing countries: defining the problems. Hodges et al, Anaesthesia (1): 4-11 Anaesthesia around the world 21

22 The Glostavent in Ghana Anaesthesia around the world Rosie Utton When I arrived at Korle Bu Teaching Hospital in Ghana s capital Accra, in the sweltering African sun, it was a while before I found the anaesthetic department of the hospital, let alone the very machines I had come all this way to see in action. It proved difficult to trace the Gloucester made anaesthetic machines, five of which were donated to Korle Bu s anaesthetic department back in My elective project s aim was to witness how these simple machines, with their oxygen concentrator, Manley Multivent Ventilator and draw-over anaesthetic circuit, were utilised at Korle Bu. Unfortunately, when I arrived I could only find three of the five first generation machines, two of which had missing parts. It quickly became evident that the machines most often in use at Korle Bu were the more sophisticated continuous flow German Dräger machines. I decided to ask the staff at Korle Bu what they liked and disliked about the Glostavent and what they wanted from their anaesthetic machines in the form of an anonymous questionnaire. suggest that the machines were falling out of use and were only being used by a small number of anaesthetic staff. This conclusion was backed up by the fact that most of the newer members of staff felt that they had had no training on the use of draw-over anaesthesia. This finding would not have been particularly surprising, except for the fact that the supply of electricity, compressed gases and maintenance, essential for the safe use of the more sophisticated machines was not always available. For example, the oxygen concentrator on the Glostavent was considered very useful by almost all of the staff and it was used on several occasions during my visit when the oxygen supply to the main theatres was interrupted. So why was the Glostavent falling out of use? The positive Korle Bu Teaching Hospital comments made about the Glostavent included that it was convenient, efficient, easy to use, basic, robust and affordable. However, the negative comments were that it was less user-friendly than other machines in the department and that it was bulky and inflexible. The features of the Glostavent which were favoured included its good oxygen provision and efficient oxygen consumption, a good battery back-up, the lack of maintenance required to keep it working and that ventilation continues in the absence of electricity. The issues that made the Glostavent less favourable to use were that the vaporiser was small and that there was no breathing bag in the circuit. There were also complaints that the valves on the anaesthetic circuit were flimsy and the circuit was challenging to assemble. The machine was Sixteen members of staff completed the questionnaire; fourteen out of the sixteen members of staff had seen the Glostavent in use. However, only three had hands on experience of using drawover anaesthesia. This would 22

23 Isaac Ayree considered difficult to use in paediatrics and neonates. The minimal choice of ventilator modes (IPPV only) and a lack of monitoring options (no FiO 2 or I:E ratio) were also criticised. The aesthetics of the machine were also considered outdated and the insulator foam used to protect the oxygen concentrator perished with time. felt the Glostavent didn t fulfil the criteria they considered to be necessary in an anaesthetic machine. It should be noted that the first generation Glostavents are very basic and some of these factors have been tackled in newer generations of the machine. Maintenance of an anaesthetic machine is an integral part of how successful a machine will be in the long term. A key selling point of the Glostavent is that it is very easily taken apart and repaired and this was echoed by Isaac Ayree the anaesthetic engineer I met while in Korle Bu. Self-taught, he very much favoured servicing the Glostavent as it was far easier to resolve its problems than any of the other machines in the hospital. However, this in itself appeared to be a double-edged sword, as parts often went missing from the Glostavent, either found on other machines or never recovered. It was quite clear during my visit that the that the staff at Korle Bu had to overcome huge challenges on a day to day basis loss of electricity and oxygen supply, sweltering temperatures, machines that are difficult to repair with expensive parts and a demand for anaesthesia that far outstrips provision. Yet despite all this they still favoured the more complex continuous flow machines. With little or no funding available for new machines I hope that the staff in Korle Bu Hospital are able to maintain good anaesthetic provision for their patients in the future. Anaesthesia around the world Suggestions for improvement included a more substantial valve system and to include a gas scavenging system. The most repeated suggestions were to improve the aesthetics of the machine and to increase the choice of monitoring and ventilatory modes. The control and assessment of respiration and the depth of anaesthesia reached are more precisely measured in some machines than others and this is clearly a significant factor for the anaesthetists at Korle Bu. In this respect a high proportion of the anaesthetists Servicing the Glostavent 23

24 Zambia Newsletter Anaesthesia around the world 24 Naomi Phiri Clinical Officer Anaesthetist University Teaching Hospital, Lusaka, Zambia As a regular reader of WAN for many years I am pleased to contribute. It seems to be one of the few publications that are aimed at the needs of anaesthetists working in the developing world. We sometimes feel very isolated so it is re-assuring for us to read what is happening in other hospitals and to discover how they cope with problems similar to our own. In the past you have featured reports from various countries around the world but nothing recently from Zambia. I am therefore submitting this report in the hope that you will publish it to let readers know of the progress we are making here and how our specialty is seen through the eyes of a typical anaesthetic clinical officer. A question I am frequently asked is Why did you take up the specialty of anaesthesia? I always tell them that I first became interested in anaesthesia after seeing the calm way in which a patient was successfully resuscitated in the casualty department by an anaesthetist. I was so impressed that I immediately applied to become a clinical officer anaesthetist at the University Teaching Hospital (UTH) in Lusaka and have now been working here for six years. UTH is the main teaching hospital in Zambia. It has 1100 beds and 17 operating theatres where operations are carried out each year. All branches of surgery including open heart surgery are represented. There is also an obstetric unit where deliveries are performed each year. Pain relief for obstetric patients is provided by pethidine, there is no epidural service. There is a ten - bedded ICU to which the clinical officer anaesthetists are frequently called to help with the day to day management of a wide variety of patients. The anaesthetic staff consists of six consultants and nine clinical officer anaesthetists. Each day there are two clinical officers and one consultant on call for emergencies and one on call for the ICU. The anaesthetic machines we use are Boyles machines, Glostavents and various Chinese machines whose names are unpronounceable. All my colleagues love the Glostavents because they are very easy to use and keep going if the power fails and when the oxygen is cut off. We also use Glostavents in Intensive Care when all the other ventilators are occupied. The anaesthetic agents we use are ketamine, thiopentone, halothane, pancuronium, pethidine, fentanyl, and diazepam. We don t perform many regional blocks except spinals for caesarean sections. We have teaching from the consultants but would like more to improve our knowledge. In October 2010 we had a WFSA refresher course consisting of lectures, discussions and demonstrations over 3 days. More than 100 anaesthetic officers attended from all over Zambia. The lecturers were mainly from the UK but some of our own consultants also took part. All lectures were very good and relevant to our practice but we liked especially the case presentations where we could ask questions and take an active part in the discussions. We want more of these with audience participation in future courses. We also like to know how problems are tackled in other countries so we can improve our own performance. The highlight of the meeting was the speech of Lord Crisp who is promising help from the UK government and from the Tropical Health Education Trust (THET).They are hoping to set up an MMed course at the hospital for physician anaesthetists and we are all very excited at this prospect as we feel that the specialty of anaesthesia has been neglected for too long here. However, things are definitely improving and I would like to request that the WFSA and the AAGBI continue to support our efforts to improve the anaesthesia service in Zambia and the developing world. Refresher Course

25 Berend Mets Roger Eltringham As members of the World Federation of Societies of Anaesthesiologists (WFSA) choir took their places on the podium I felt a nudge from the chorister standing next to me. Berend s leg is bleeding he whispered. Bad luck I replied as I tried frantically to memorize the words of the forthcoming solo I had been allocated. No, I mean it is bleeding badly he hissed with a hint of desperation in his voice. We ll sort it out later I said out of the corner of my mouth as our musical conductor, the formidable Rob McDougall of Australia, pointed his baton in my direction. As I struggled through my verse of Waltzing Matilda I became aware of a disturbance on the stage and spilling into the crowd. At the end of my number, as the booing was beginning to die down, I followed a trail of blood across the stage which led to the prostrate body of Professor Mets. Although weakened by haemorrhage from a recent leg wound, he seemed his usual cheerful self as he lay beside the stage staring blankly into the night sky and surrounded by anxious attendants. Why did you take part when you were in this state? demanded one of the bystanders. Berend seemed genuinely puzzled by the question. Because I didn t want to let anyone down he replied. This bizarre incident took place at the farewell concert following the Annual Meeting of the Vietnamese Society of Anaesthetists in Hanoi in I recall it in some detail because, if any one incident encapsulates the character of Berend Mets, it is this. The idea of letting down his colleagues is a complete anathema to him and this is what has made him such a valuable colleague and friend to fellow anaesthetists from all parts of the world. Born in Indonesia of Dutch parents he later moved to South Africa to study medicine at Stellenbosch University from where he graduated in After completing an internship at Edendale Hospital in South Africa he moved to Canada for a brief spell as a General Practitioner. His next move was to the U.K. where he was initiated into the mysteries of anaesthesia at the Gloucestershire Royal Hospital. So impressed was he with the specialty of anaesthesia that he returned to South Africa to join the anaesthesia residency program at the Groote Schuur hospital in Cape Town and completed the course in Berend Mets Not satisfied with one postgraduate degree, he then transferred to the department of Pharmacology and was awarded a PhD. After spending the next few years as a consultant anaesthetist at the University of Cape Town Medical School he moved to the United States in 1992 and became assistant professor and later associate professor at Columbia University in New York. In 2002 his exceptional talents were recognised by Penn State University where he was appointed to his present position of Eric A. Walker Professor and Chair at the Dept of Anesthesiology. The list of his achievements includes so many awards, publications, presentations and honours that it is impossible to list them here. Suffice it to say that he has been actively engaged in a wide variety of research projects for many years resulting in over sixty publications, to date, in peer reviewed journals and fifteen book chapters. He has also edited several publications including Current Opinions Profiles 25