OOPT report Zambia Anaesthesia Development Project Feb-Aug 2017 Introduction The Zambia Anaesthesia Development Project (ZADP) commenced in 2012 to support the training of Zambian anaesthetists on a four-year Master of Medicine (MMed) programme. A third of all disease will require some form of surgical intervention but there can be no safe surgery without safe anaesthesia. Zambia has an extreme shortage of anaesthetic doctors. A population of sixteen million is served by only thirty, with much of the workload undertaken by clinical officer and nurse anaesthetists. I have completed a six-month OOPT as a Visiting Lecturer in Anaesthesia with ZADP at the University Teaching Hospital (UTH) in Lusaka. UTH is the only tertiary referral centre in Zambia. It has over 1600 beds and performs 18,000 surgeries and 20,000 deliveries annually. The anaesthetic department consists of 5 consultants, 24 MMed trainees and a varying number of clinical officer anaesthetists. Anaesthetic services are provided for a wide variety of surgical specialities and additionally critical care. On arrival at UTH my educational supervisor, consultant anaesthetist Dr. Dylan Bould who was in country for a three-week period, gave me a comprehensive induction. I also received a hand over from previous ZADP registrars on the ongoing project work.
Clinical practice During my placement in Zambia the working week was split into three clinical days and two non-clinical days, and consisted of approximately 40 hours work per week. There was no on-call commitment. All my clinical sessions were teaching lists where I was accompanied by an MMed anaesthetic trainee to whom I provided hands on teaching in theatre. For one month of the six I also had 2-3 trainee nurse and clinical officer anaesthetists allocated to each of my lists, this sometimes provided a challenging environment for teaching. The rota was coordinated by one of the senior MMed trainees and I was allocated to a variety of elective and emergency lists, as well as critical care. I do however have a particular interest in paediatric ophthalmic anaesthesia, so undertook this list on a regular basis. Other subspecialities included general surgery, gynaecology, orthopaedics, obstetrics and neurosurgery. Theatres are split into several locations within the hospital. Phase 5 for emergencies, phase 3 for elective work, D block for paediatrics and C block for obstetrics and gynaecology.
All patients are admitted prior to surgery and are reviewed by an anaesthetist the day before the list. There is no specific clinic based pre-assessment service. I undertook a total of 140 cases in theatre, 67 of which were paediatric. The caseload was 90% ASA 1 or 2 patients. There was a good mix of general and regional anaesthesia. The caseload in ophthalmics was of particular interest, with a high proportion of patients undergoing destructive eye surgery including exenteration, enucleation and evisceration. Patients often presented very late, in paediatrics with retinoblastoma and in adults with squamous cell carcinoma secondary to HIV. The set-up for anaesthesia at UTH is adequate to provide a safe service for the majority of the time. However, there are frequently significant challenges with regard to equipment and drugs. There are no anaesthetic rooms but each theatre is furnished with a modern machine with a circle circuit. Oxygen is available from cylinders but there is no air or nitrous. Basic airway equipment is available but endotracheal tubes and laryngeal masks are cleaned and re-used. There is no video laryngoscope or fibre-optic scope. Basic monitoring ECG, saturations, non-invasive blood pressure is available, but there are no arterial lines. Central lines are not readily available nor are infusion pumps. There is one nerve stimulator, but no ultrasound and peripheral blocks are rarely performed. Spinal needles are often unavailable and 22G venflons are used in their absence. There are no epidural sets. With regard to drugs, the volatile anaesthetic halothane is consistently available, as is propofol. Analgesia is in intermittent supply, with
fentanyl and paracetamol particularly sporadic. Ketamine and morphine are usually present. The only inotrope is adrenaline, which is used peripherally and there are no pressors such as phenylephrine or metaraminol. The muscle relaxants available are suxamethonium and pancuronium. Unfortunately heavy marcain is also in short supply, and it has been common practice for anaesthetic clinical officers to mix dextrose with plain bupivacaine for use in spinals. Clear protocols are in place for the ordering and supply of blood products at UTH (largely as a result of the recent major haemorrhage project). However, it remains very difficult to obtain emergency blood in the event of unanticipated haemorrhage. The group and save is a largely redundant test, and in elective cases where blood loss is expected to be high surgery will not commence until cross-matched whole blood is present in the theatre complex. As a result there is a tendency to over order blood for elective work just in case. Other products such as platelets and fresh frozen plasma are even less readily available. The recovery areas normally have a pulse oximeter and suction available and are staffed by nurses. However, the nursing staff have not received formal recovery training in many cases. Patients are therefore only taken to recovery when they are awake and maintaining their own airway. Another problematic area is the availability of investigations perioperatively. Following the major haemorrhage project, there is now point of care testing for haemoglobin. However, the turnaround time for laboratory investigations is such that formal blood results are hardly ever available for emergency cases. Is it particularly difficult to obtain clotting results. X-rays are readily available but the CT and MRI scanners are frequently out of service and this presents a significant problem for the large number of head injury patients. Access to critical care beds post-operatively is challenging. There are only 10 beds and poly-trauma victims from road traffic accidents frequently occupy these. Cultural differences mean that withdrawal of care is not practiced in end of life cases. There is no access to haemofiltration but dialysis can be provided off the unit by the renal team. MMed trainees provide the core clinical cover on the unit with ward rounds from anaesthetic consultants or senior ZADP anaesthetists approximately twice weekly. This is an area where significant improvements could be made, as consistent leadership is lacking. One of the recent MMed graduates has a specific interest in critical care and there is hope that if appointed to a consultant post she would take the unit forwards.
My supervisor Dr. Dylan Bould (based in Canada) was on hand for Skype conversations to discuss challenging cases and project work. He was able to undertake work-placed based assessments with me whilst in country. The Head of Department at UTH, Dr. Christopher Chanda was present for more immediate advice on a day-to-day basis. I was also able to consult with my ZADP colleagues who consisted of two other senior trainees and two junior trainees. We additionally had several visiting ZADP consultants from the UK and Australia who attended UTH for 1-2 week periods. There were regular ZADP group skype meetings to discuss any difficulties. I felt well supported at all times. Outreach trips During my six-month placement I undertook two outreach trips. At present all of the anaesthetic MMed training in Zambia is focused in the capital, Lusaka. Other towns and in particular the rural areas are under even greater strain. In March I visited the Copperbelt together with the eye charity Orbis. The aim of this visit was to assess the suitability of hospitals in Kitwe as locations for anaesthetic MMed training. I spent a day at the Kitwe Eye Annex and also visited two of the mining hospitals in the area. Although there is a hope that training placements could commence in these areas in the future, my findings were that consultant supervision is currently too limited. On a second outreach visit I was invited to Zimba mission eye hospital to provide a day of paediatric anaesthesia for an eye camp visiting from Lusaka. Zimba is a small village 250km south of Lusaka. Visiting teams provide surgical operating weeks approximately 4 times a year.
There is no permanent anaesthetic support and although paediatric anaesthesia has been undertaken at this hospital previously, the normal caseload is adults under regional eye blocks. The trip required considerable preparation and planning, as I had to amass all the necessary anaesthetic equipment and drugs in Lusaka and transport them in the car to Zimba. Together with one of my fellow ZADP colleagues we undertook a rewarding day of remote site paediatric anaesthesia providing eye care for children living in abject poverty, many of whom had travelled hundreds of miles to reach the clinic. Education Education is a major focus of the ZADP project at UTH. As well as providing clinical teaching in theatre I facilitated weekly classroom based teaching sessions with the senior MMed trainees (year 3 and 4). I also provided viva practice in preparation for their examinations. I additionally provided teaching sessions for 6 th year medical students who rotated to anaesthesia for two-week placements. Other educational sessions included teaching intern doctors airway skills and advanced life support via simulation in Livingstone, and hosting a basic life support training afternoon in the community for staff at the local Honda garage. I had also been due to teach on the Safer Anaesthesia From Education (SAFE) Obstetrics and Lifebox courses in Ndola. Unfortunately although we spent time preparing our lectures and workshops for these courses they were cancelled twice at short notice due to funds not being available from the Zambian Ministry of Health. We were however, able to put on an abbreviated form of the Lifebox course locally in Lusaka for our MMed trainees.
In June I acted as one of the examiners for the final year anaesthetic MMed Objective Structured Clinical Examination (OSCE). This was an excellent opportunity to build upon my previous UK experience of examining medical student OSCEs. Major haemorrhage project The major haemorrhage project has been a core focus of ZADP for the last 2 years. As I commenced my placement the project was in its final three months. My role in project consisted of data collection and analysis for the four core project outcome indicators. These included a major haemorrhage case series, an audit of traceability of crossmatched blood, an audit of haemoglobin documentation and an audit of blood product requests and transfusion triggers. Together with my ZADP colleagues we compiled and submitted the Health Partnership Scheme final grant report to the Tropical Health Education Trust in May. This was a valuable learning experience. Management, quality improvement and leadership With my particular interest in ophthalmic anaesthesia the focus of my quality improvement projects was in ophthalmology department. My first project was undertaken with the assistance of one of the 1 st year MMed anaesthesia trainees, and formed the basis of a leadership project for him. I noted early on that both the eye clinic and the local anaesthesia ophthalmic theatre (both remote sites) had an absence of emergency equipment and protocols. We identified an emergency contact, created an emergency box and laminated emergency protocols for both areas. We also provided a morning training session for the ophthalmology department on basic life support and managing relevant emergencies such as bradycardia and anaphylaxis. The training was very well received.
The next project I undertook was to write guidelines for the provision of anaesthetic services in ophthalmology, pre-assessment services in ophthalmology and also sedation services in ophthalmology. As part of this work I developed a new pre-assessment pro-forma for local anaesthesia cases. I presented this work to the ophthalmology department and provided training on pre-assessment. I recognised the need for improved pre-assessment guidance after conducting a short audit of on the day cancellations in the unit, which demonstrated a high rate of avoidable cancellations for uncontrolled hypertension and diabetes. The protocols have been approved by the Senior Medical Superintendent (SMS) for the eye annex and the anaesthetic Head of Department. The development of a sedation protocol for ophthalmology forms part of a wider remote site sedation project which is ongoing at UTH. A pilot of remote site sedation in the local anaesthesia ophthalmic theatre is underway. Another quality improvement project evolved in ophthalmology after I recognised a significant patient safety issue relating to local anaesthesia blocks. All regional eye blocks were sharp needle (retro or peri-bulbar) and being undertaken by surgeons in the remote site local anaesthesia theatre, with no monitoring, intravenous access or anaesthetist present. I discussed this with the SMS and agreed that I would run two training days in theatre to teach Subtenon s blocks,
which have a better safety profile and for which intravenous access is not mandatory. Subtenon s cannulae were not available at the hospital, but I circumvented this with a technique I learnt at Moorfields using a 22G venflon sheath instead. Despite initial scepticism and concerns over intraocular pressure rises, many of the surgeons have now adopted this technique. I also secured a Lifebox for the department such that high-risk patients can have pulse oximetry and heart rate monitoring intra-op. Liaising with the eye charity Orbis, I was able to secure funding for one of the ophthalmology MMed trainees to attend a Lifebox course. As a result of this training we worked together to produce and implement a World Health Organisation checklist specific to ophthalmology at UTH. Courses Whilst in Zambia I attended two courses. The first was a three-day leadership and management course in February. Topics included project management, team building and self-awareness, and people and performance management. The second was a four-day clinical teaching course in May. Topics included clinical teaching, small and large group teaching and simulation. Study leave I was fortunate to be able to take one week of study leave during my placement and accepted an invitation to join an Orbis Flying Eye
Hospital (FEH) programme in Quy Nhon, Bihn Dihn province, Vietnam as an associate anaesthetist. Bihn Dihn province is home to more than 6 million people and is one of the poorest areas in the country, with a high prevalence of blindness. Binh Dinh Eye Hospital (BDEH) was established in 1976 and is now one of the major eye-care facilities in central Vietnam. It has one of the highest cataract surgery rates per capita in the country and since 2016 has begun undertaking paediatric surgery with the support of Orbis. During the week long placement I worked together with a consultant anaesthetist from Moorfields and a US paediatric anaesthesiologist to provide hands on training for local anaesthetists, whilst providing anaesthesia for cataract, strabismus and glaucoma surgery. Monday was a dedicated pre-assessment day where cases were screened and optimised. Tuesday to Friday were designated operating days. I spent three days within the local hospital and one day on board the FEH. Our anaesthetic trainees were unable to speak English and so our teaching was all conducted via translation by a young doctor from Ho Chi Minh City. BDEH was adequately equipped for both local and general anaesthesia. The trainees were incredibly keen to learn. One of the highlights was creating a low fidelity Subtenon s model from sterile gloves and using it for teaching. Working on board the FEH was a fascinating experience. The plane was based at the airport and patients were transferred by bus from the local hospital. The plane was well equipped with a state of the art operating theatre, recovery, screening room and lecture theatre. Surgery was broadcast live to the lecture theatre (and also online via cybersight) with surgeons commentating throughout each operation. I am incredibly grateful to Orbis for this amazing experience and will look forward to joining the team again next year for another FEH programme.
Publications and articles Publications Le Cheminant, M. 2017. Volunteering for Vision in Rural Africa. Ophthalmic Anaesthesia. 7 (1): 12. Newspaper articles In April a newspaper article about ZADP was published in the Guernsey Press based on a skype interview I undertook. Awaiting publication My former college and university are both due to publish pieces about my work with ZADP later this year. Both articles were written by me and one will be published online in Cambridge Alumni Stories and the other in the Newnham College magazine - Changing Lives. Radio BBC radio Guernsey will interview me about my work with ZADP this August. Logistics Travel. There are no direct flights to Zambia from the UK but both Emirates and Kenya airlines fly the route with one stop. Accommodation My accommodation was sourced by ZADP and I was housed in a lovely self-catering cottage 2 miles from UTH.
Transport A car is almost essential in Lusaka as walking is inadvisable after dusk. I was able to hire a car from the local Honda garage but many of my colleagues purchased a vehicle. Cars are very expensive in Zambia due to a large import tax. An international driving permit must be obtained in advance from the AA, a UK license will only be valid for 3 months. Visa It is straightforward to obtain a business visa on arrival. This covers a 30- day period during which you must apply to immigration for a temporary work permit. Health Professions Council Zambia (HPCZ) In order to work as a doctor in Zambia you must obtain HPCZ registration prior to commencing the post. Indemnity and insurance The Medical Defence Union provided my indemnity at no extra cost and for insurance I obtained a postgraduate policy from Wesleyan. Funding My OOPT was funded by the Tropical Health Education Trust, the International Relations Committee and the Beit Trust. As a team we also set up a Just Giving page to support our cause. Travel opportunities There are many travel opportunities both locally and within Africa. I had the pleasure of visiting the lower Zambezi, South Luanga national park, Livingstone and Victoria Falls. I also travelled to Uganda and Zanzibar.
Conclusions My 6-month OOPT with ZADP has been an incredible learning experience. Whilst completing the anaesthesia in developing countries module I have learnt to provide safe anaesthesia with limited resources within challenging environments. I have particularly enhanced my clinical skills in paediatric anaesthesia. I have also broadened my experience in management, service development and education whilst building on core skills of leadership and teamwork. The opportunity to live and work within a different cultural environment has made me more adaptable and helped me to use innovative problem solving approaches. I am looking forward to utilising these new skills as I return to London for my final year of training. Dr. Michelle Le Cheminant