(If you are
not an anesthesiologist you may struggle with this long post, sorry).
How basic
are things at the Black Lion in Addis?
They have
old Ohmeda Anesthesia machines with built in ECG and O2 Sat monitoring that
work of a big tank of oxygen (with no back up cylinder on the machine). No
nitrous, no CO2 monitoring, no agent monitoring, one art line transducer in the
hospital, no dantrolene, no intralipid for local anesthesia toxicity (no TPN of
any kind, come to that), one ventilator in the six bed ICU.
If I was
there as an inspector for the Ontario College of Physicians and Surgeons, there
would be about a dozen infractions of standards they would have to fix very
quickly.
And despite
this they do major cases. Whipple’s, Oesophogastrectomies, neurosurgery,
neonates, pneumonectomies (without a bronchoscope to check for tube position).
There is no shortage of pathology in Ethiopia, and a lot of it ends up at Black
Lion.
The first
case I saw was a 12 day old baby having surgery for a trachea-oesophageal
fistula. The visiting anesthesiologist, fresh from a year at Sick Kids, had
done two previous cases. The local staff anesthesiologist does about one a month.
At HSC, the kid would have had a cardiac echo to rule out associated congenital
heart lesions. Not in Addis. At HSC he had provided total intravenous
anesthesia with remifentanyl for a rigid bronch to locate the lesion before
placing the endotracheal tube. In Addis, we just inserted the tube beyond the
carina then pulled back until we could just hear bilateral air entry. The
surgeon could not have been more pleasant or helpful, stopping surgery several
times so we could sort out problems. At the end of the case everyone left and
we were not sure where the patient was supposed to go. It took almost an hour
before someone brought a bed to the OR reception area and we then took the baby
out into the hall and waited for the elevator to take the kid up to ICU.
The need
for good surgical care is enormous, as there is a vast amount of pathology. The
local physicians are almost all smart, well educated, knowledgeable in theory,
and pleasant to deal with. They try hard to do good work in almost impossible
circumstances.
I am doing
OB anesthesia, so one of my issues is to make sure the OB operating room is set
up for an emergency CSection at any time. We’d usually use a spinal anesthetic,
so we can get a kidney basin with a bunch of assorted re-used spinal needles,
some prep and a fabric drape. Drugs? For about a dozen years, the only drug I
have used for spinals is 0.75% heavy bupivacaine. We have none. We have 5%
heavy lidocaine, which I have never used. Also 0.5% isobaric bupivacaine marked
“Not for Spinal use”, which is what I am currently using, as it only expired in
November last year. (I asked the resident who said that they use stuff that’s
less than one year past expiry, but sometimes give an extra 10%). The local
physicians have to be so much smarter than I am, because they need to be able
to do cases with whatever drugs they can find.
The first
couple of CSections I did without ECG monitoring because I could not figure out
the system. We don’t have any of the little circular paper and jelly ECG
stickers, so we wet the ECG clip with KY jelly and then tape it directly onto
the patient. This actually works!
They don’t
have any ephedrine if the patient becomes hypotensive. I found this out only
after the patient’s BP was 57/40. One of the other Toronto anaesthesiologists
had given me an ampoule of ephedrine, but I had left it in my pack, two floors
down, locked in an office to which I did not have the key. The patient was
lying so quietly that I thought she was unconscious – or worse – but the
patients here are just stoical and lie still and accept whatever happens.
“What do
you have for hypotension?” I asked while squeezing the IV bag. “Adrenaline”. At
this stage anything seemed good. “How much do you usually give?” I asked,
pretending to be testing her, but in fact I had little clue. “5-10 mcg, should
I dilute some for you?” Great, thanks, it’s good to be working with a smart
resident!
In Canada I
would add the 1 mg of adrenaline to 100 cc bag of saline to get 10 mcg/ml, but
small IV bags don’t exist. Even a 2.8 kg neonates gets attached to a 1000ml IV
bag with a regular adult IV set. The resident diluted the drug in two stages,
so we had one 10 ml syringe with 100mcg/ml from which she took 1 ml and diluted
it to get to 10 mcg/ml. Although she carefully labelled the syringes, I lived
in fear that one of us would use the wrong syringe and give a 10x overdose. In
Canada I would have discarded the higher concentration to avoid errors, but
here nothing is wasted. One 2 ml ampoule of fentanyl is kept all day and may be
divided between several patients, but being careful not to use the same syringe
on different patients.
I am
supposed to be helping set up an epidural analgesia service for obstetrics.
They use 10 ml luer-lock glass syringes for the epidural, which are washed,
sterilised, and put into an aluminium dish which is folded over them. There is
no way they remain sterile. They have a supply of the very nice Arrow epidural
catheters I love, but the only epidural needles they fit through are twice as
long as necessary. They have decent epidural needles which are the right
length, but one size smaller than I usually use, and only some rather horrid
rigid plastic catheters fit through them. We provide an epidural service for
whatever hours I feel like working, maybe 8 am – 4 pm. After that the resident
makes up a punch of syringes with 0.25% bupivacaine in them and I write orders
for the OB resident to do top ups. The first case I did I got a bloody tap and
then a CSF leak. The epidural ended up working OK, but at 6 pm, as I was
leaving, they said they would do a CSection at 9pm, and could I write orders
for the nurse anesthesiologist who works nights to top up the epidural for
CSection? Not very happy about that idea, given the problems I had had. I wrote
a suggested dose should the anes nurse feel comfortable, but I was not
surprised to find the patient got a GA.
Today there
were two pre-eclamptic patients who would benefit from epidurals. I saw them
with my resident about 10 am, and she was keen to get the practice in. The
first patient had had blood sent for a platelet count, but it was not back yet,
so we waited. By 4 pm it was still not back. Found out the usual turn-around
time is 12 hours. The only practical approach will be to assume the platelets
are OK unless the patient shows signs of bleeding or bruising.
We went to
get consent from the second patient, who refused, so went to have coffee with
the resident and discuss ethics. Is it a universal rule that patients have to
be informed and give consent to the things doctors do to them? Or is that some
fancy white man idea? The patient was apparently puzzled that she was being
asked. They are used to accepting whatever treatment they are given, often
without explanation, never mind consent. Do I accept that as the African norm,
which will make it really easy for my resident to do epidurals on everyone, and
will be good for her education?
Even within
the Toronto group there are marked divisions in ideas. I was asked to help
another resident put an epidural into a patient having abdominal surgery. As
far as I could see, that was a fairly good idea, as he was an older patient
having moderately major surgery, but not essential. However, he would get
limited benefit from it as they can only run epidurals in ICU, not on the
floor, so the epidural would likely be topped up and then removed at the end of
surgery. Just as we were getting set up the surgeon came in and said he did not
want the patient to have an epidural, apparently mainly on the grounds we were
running late and he did not want the case delayed, rather than any patient care
issue. The resident and I suggested it would be good for postoperative pain
relief, but the surgeon was adamant, so I backed down. The other Toronto
anesthesiologists felt that I was wrong, that the anesthetic technique should
be decided only by the anesthesiologist, and I should have said that we would
not do the case without the epidural. I would have stood my ground more firmly
if the patient was sicker, but in this case I felt the epidural was optional
and I preferred not to fight the surgeon over the issue. Does that make me a
polite and diplomatic person or a wimp?
In the end
I did no clinical work today, but did listen to a couple of talks given by the
other visiting physicians. I am learning more than I am teaching!
