In a way I was looking forward to this conference, as in Ethiopia I am more comfortable delivering a prepared speech than giving anesthetics, but my expectations were fairly low, especially as the schedule was not finalized until the afternoon of the day before.
The three of us dressed smartly, and a driver came to take us to the Desalgne Hotel just off Bole Road. This is a spacious and glitzy hotel. We went up to the fifth floor conference rooms, where there was the usual sign-in sheet, free notebook and pens, and a couple of snappily-dressed drug reps selling halothane (?!) and haemacell. Had a chat to them about bringing drugs into Ethiopia. The government maintains a national drug list, and they need the support of the anesthesiologists if they want to get anesthesia drugs in. If the pharmaceuticals are manufactured in India or China there has to be a government on-site inspection of the manufacturing plant, which may be a wise precaution.
After a coffee, there was the usual welcome speech, and an apology that the Ministry of Health was unable to send a delegate.
There were 75 people in attendance, including all our residents, anesthesiologists from the police hospital, army and various private hospitals in Addis, and some from other cities like Jimma. There seemed to be a few anesthesia nurses there, too.
Dr A gave a talk on nosocomial (hospital-acquired) infections in ICU. I was not surprised when she said they were three times more common in developing countries. Just looking at the Black Lion ICUs, with limited water supplies, no clean towels, few gowns, and patients close together it’s not surprising. She offered some cheap suggestions (like nursing patients 30 degrees head up, and feeding as soon as possible), some more expensive ideas (like total body draping, gowning and gloves for central lines), and some thoughts about designing the new ICUs which are apparently in the works in various hospitals including Black Lion, to reduce spread of infection. It was a good talk and well received.
At the coffee break they served delicious small chocolate covered donuts, and we could get some fresh air on the fourth floor balcony.
A local anesthesiologist presented a case of tonsillectomy in a four year old with undiagnosed laryngeal stenosis. After several attempts he got a 3.0 tube in, and the surgery and extubation were uneventful. This led to a good discussion. I suggested that nebulised epinephrine would have been useful if the kid had developed stridor. We talked about using the LMA as a rescue airway or even for the procedure, and I was surprised to find that even in a private hospital they did not have a suitable LMA for a four year old child. We discussed surgical airways and I referred to a British review which said that emergency surgical airways in kids have a poor success rate. Finally, there was a discussion of how to ensure that subsequent anesthesiologists knew about the problem.
A drug rep was then given ten minutes to talk about his company and the products they had in the pipeline, which was interesting but would not have been allowed in Canada.
There was an excellent buffet lunch. National food – injera and wot – supplemented by an array of salads, some pasta, a couple of stews, some bits of chicken, followed by small bits of cake and fresh fruit.
Dr D then gave his paediatric talk, covering recent controversy in fluid management, the assessment of the ill child, and recent changes to ACLS protocols for paediatric cardiac arrest. It was all good stuff, but he needed more time to cover it, and the program was kept strictly to schedule.
I then talked about Day Surgery, which seems to be a new idea in Ethiopia, where many patients wait a long time for minor procedures because of the lack of surgical beds, when they do not need to be admitted. I went over the logistics of running a Day Surgery unit in detail, then showed what we do at The Scarborough Hospital Eye Centre as an example. People seemed interested in the idea, but unsure how to get the ball rolling. There were specific and valid concerns about how to set up a system so that patients who had problems after they had gone home could contact the hospital and be re-assessed and possibly admitted. Black Lion can be a crazy busy place and you can’t just assume that patients would be able to telephone someone and get seen promptly.
I had some interesting conversations in the coffee breaks. I met one of the two medical anesthesiologists from Jimma, a university city about 200 km from Addis. They are opening a new surgical suite with 12 ORs, and starting a residency training program with six residents! OK, he has a large group of nurse anesthetists to help out, but every other night they will be calling him for telephone advice or to come in for difficult cases. Not surprisingly, he is looking for outside help! Unfortunately I think TAAAC will be very busy serving Addis, especially as they will be getting six new residents next year, and CASIEF has recently added a project in Palestine to its ongoing work in Rwanda, so I can’t see either organization being able to offer much more than moral support.
There was a members-only business meeting of the association so we read papers in the lobby and hung around until that was finished, then went with the residents in a hospital van to an Italian restaurant in a local art gallery for dinner.
It was a very good day’s work. As we had been in Addis between two and four weeks, we were seen as professional colleagues, not just a bunch of western dudes flying into Africa to teach the natives how to do things. Overall they have a realistic model of anesthesia care, with nurses providing most of the routine care, under the supervision of medical anesthesiologists, and physicians doing the more complicated cases. Hopefully, the surgeons will come to appreciate that for the more difficult cases, physician anesthesiologists can provide better preoperative assessment, better intra-operative management, better postoperative pain relief, and, if necessary, high quality intensive care, and that all these will result in better outcomes for their patients.
The Professional Association has a lot of work to do, getting the message across to the Health Ministry that high quality anesthesia is an essential part of health care, and that they need the drugs and equipment to do the job they have been trained for. I hope that eventually they will be able to write guidelines for anesthesia in Ethiopia. For example, if they develop the standard that every intubated patient should have a sterile single-use endotracheal tube rather than a washed and recycled one it will be easier for anesthesiologists across the country to insist that their hospitals supply them.
It will be a long and had struggle, but I think that it is very worthwhile, and I am proud that I have been able to play my small part in supporting Ethiopia’s anesthesiologists.