Read about Arjun Krishna and his time teaching anesthesia residents in Ethiopia

Arjun Krishna, PGY-4 at the University of Toronto, went to teach anesthesia residents in Ethiopia with the Toronto Addis Ababa Academic Collaboration this past April.  Teaching and observing, he was exposed to an interesting case mix and he shares his story here.

Where did you go and how long did you go for?

I was selected accompany a resident teaching trip to Addis Ababa, Ethiopia in April 2013 for one month duration. My time was spent teaching at the Black Lion Hospital (Tikur Anbessa Hospital), the only tertiary care Hospital of Ethiopia and the main clinical facility for Addis Ababa University Medical School.

When did you start planning your trip? Who helped plan it? Did your department support you?

My trip to Ethiopia was part of a collaboration between the University of Toronto and Addis Ababa University –  the collaboration is  known as TAAAC (Toronto Addis Ababa Academic Collaboration). This group originated with a project in the Department of Psychiatry at Addis Ababa University.  The Department, in desiring a residency program in Psychiatry, involved the University of  Toronto in its inception and development in 2003.  The project was so successful that it has subsequently grown to involve a variety of specialties. The basic concept is for small teaching teams to teach graduate students in many faculties of Addis Ababa University.  In the Faculty of Medicine, two consultants and a senior resident from Toronto teach for a one month period in Addis Ababa to supplement a self-sustaining, high quality residency training program for Ethiopia.

The Anesthesia group (TAAAC Anesthesia) began teaching trips in October 2011, and has a trip 3 times per year (February, April, and October).  The first group of residents trained with U of T / AAU colloboration is expected to graduate in 2014.

I was first approached to apply for the senior resident’s position about 1 year in advance (May 2012).  I began my preparations for the trip in November 2012.   My preparations included culturally specific teaching on living in Ethiopia (given by the TAAAC organization), obtaining appropriate vaccinations for the trip and reading around the pharmacology available in Ethiopia (drugs I had only read about until that point). I am the second resident to attend the trip.  Prior to my trip, 2 anesthesia fellows have also participated.

The interest in this trip is growing. TAAAC Anesthesia is sending out applications to the upcoming year of residents during the previous academic year (ie. The PGY3 and PGY4’s will be applying for their spots in PYG4 and PGY5 year respectively).

The 2 leads for TAAAC Anesthesia for the project are Dr. Greg Silverman
(greg.silverman@utoronto.ca) and Dr. Alison Macarthur (alison.macarthur@uhn.ca). http://www.missbdesign.com/clients/TAAAC/

The anesthesia department is very supportive of the project for residents. I am provided a stipend up to 1500$ to cover my travel expenses for the month.  

What kind of cases did you do?

My function as a visitor from University of Toronto was to teach and supervise the PGY1 and PGY2 residents in the OR. I was not directly responsible for patient care, but worked alongside the residents I was assigned with during their clinical duties.  Black Lion (Tikur Anbessa) Hospital is a tertiary care center that is involved in most surgical subspecialties including, General Surgery, Pediatrics, Neurosurgery, Orthopedics, Cardio-Thoracics, ENT, Urology, Trauma, Vascular, and OB/Gynecology.

The anesthesiologists also cover a 6-bed Surgical ICU and a Pre-Admission Unit.

Examples of cases I was involved in included:

• Cardio-Thoracics- Thoracotomy for lobectomy/pneumonectomy. Transhiatal esophagectomy, decortication, pericardiectomy for tuberculous pericarditis.

• Pediatrics- Tracheo-esophageal fistula repair in a 5d old, cranioplasty of an infant for an abnormal bony growth, excision of a large neck mass (neuroblastoma). Rigid bronchoscopy for foreign body removal.

• Obstetrics- mainly high-risk patients including severe pre-eclampsia and eclampsia. I helped with elective and urgent C-Sections, and laboring epidurals.

• General Surgery- Laparotomy for liver resections, hernia repairs, bowel resections

• Vascular- carotid body tumor resection

• Neurosurgery- L1 transection requiring decompression/fusion and pedicle screw, craniotomy for tumor, C1-2 spine fusion unstable fracture.

• Urology- TURP, TURBT, radical prostatectomy, nephrectomy

• Orthopedics- ORIF, K-wire of frequently occurring fractures as motor vehicle-related trauma is a large cause of morbidity / mortality in Ethiopia.

One particularly memorable case for me was a 19 year old pregnant female (G1P0, 27weeks GA) patient who presented with a history of focal seizures and progressive right-sided weakness. She was diagnosed with a left frontal oligodendroma (which was located quite peripherally).

Despite being started on anti-epileptics and steroids she had persisting seizures.  Neurosurgery felt she required a craniotomy and tumor resection, prior to the end of her pregnancy.  She was not felt to have significantly raised ICP.

There were numerous anesthetic considerations. Firstly, the pregnancy was not technically viable in Ethiopia, as the neonatal care has not developed sufficiently for care to the pulmonary mature neonate born before 28 weeks GA.  Secondly, anesthesiologists do not have access to end-tidal monitoring precluded adequate monitoring of maternal arterial CO2 to ensure adequate fetal acid-base balance and gas exchange. These factors were in addition to the usual considerations of pregnancy.

After a long discussion between the Surgeons, Anesthesiologists, and the patient, a plan was formulated to conduct an awake-craniotomy. The surgical department had been taught this technique in their teaching collaboration with a university in Norway, but the anesthesia department had not yet become familiar with this technique and the anesthetic challenges in safely sedating a patient while craniotomy was conducted.  By remaining awake, the patient maintained control of her own ventilation (even with a little sedation). The patient and fetus tolerated the procedure.

How did you enjoy your time outside of the hospital?

Ethiopia is an absolutely gorgeous country. There are many beautiful tourist attractions to visit outside of Addis that can be done over a weekend trip.

The first weekend we went to Gondar and the Simien Mountains. We managed to get 2 days of hiking in and see the spectacular views of this World Heritage location.

The second weekend we travelled to a famous UNESCO heritage site, Lalibela. This town is famous for its rock-hewn churches, which were carved out of stone and made approximately 1000 years ago. They are magnificent with a rich history of the Orthodox Christian religion of Ethiopia. Lalibela is nestled in the mountains of the north, so we enjoyed fantastic views, especially at a wonderful restaurant called Ben Abeba.

During the weekdays, outside of the hospital, we managed to go out for dinner. This turned out to be very social, as we would regularly meet with the other specialties from TAAAC. We would also regularly go out with the Ethiopian residents, which was quite nice.

Overall how was the experience?

If I were to summarize this trip in one word, it would be “incredible”. And I would use this word to describe the trip on so many levels.

First off, it was amazing to be in Ethiopia, experience the culture, travel the sites, meet so many wonderful people, and see their pace of life.

The vision of TAAAC is great- creating a quality, self-sustaining training program in Addis makes a lot of sense. It gives the right balance of providing a service yet you gain back such a remarkable experience. The limited resource environment really challenges your capabilities as an Anesthesiologist. I found I was often going right back to basic principles. It was very educational for me to see Anesthesia being practiced in such a unique way. This will make me stronger for my practice here in Canada.

In the end, I feel that I took just as much from the trip as I gave. I truly appreciate the opportunity and hope to go back again in the future.