The UK manufactured Universal Anesthesia Machine is under testing in Sierra Leone. Credit: http://www.ingmarmed.com/
By Kemo Cham
Imagine you are in surgery involving hacking off of your limb, sewing up of a wound or the removal of a tumor from a part of your body without anything to reduce the pain. What anesthetics dois reduce the pain in the patient.
Anaesthesia is a crucial age old discipline in the medical field, yet it is one of the most poorly developed in Sierra Leone. Those familiar with the department say it is just another casualty of a familiar trend of indifference by a health system barely functioning. Most hospitals across the country do not have enough staff to provide safe anaesthetics, putting many lives at risk, say officials.
Anaesthesia is a surgical discipline that deals with preparing of patients for operation, monitoring the patient throughout the surgery and making sure that they are safe after surgery. In other words, anesthetists or anesthesiologists are responsible to making sure that a patient who is about to undergo surgery is ready for it by administering medications that either put them into a state of unconsciousness or makes part of their body numb so that they do not feel pain.
Sierra Leone currently has five doctor anesthetists. The exact number of nurse anesthetists is not known. But officials say the total available staff is far less than what is required for the country.
Among the five doctor anesthetists, most are foreigners or diaspora-based Sierra Leoneans.
According to World Health Organisation (WHO) standard, any health facility that conducts surgery must have at least two anesthetists to a theatre. The second one serves as a backup. But with many of Sierra Leone’s hospitals running in three shifts, this means every facility with one theatre needs at least six trained anesthetists, said Dr Michael Koroma, head of the anaesthetics department at the Princess Christian Maternity Hospital (PCMH) and coordinator of the National Training of Nurses Anesthetics (NTNA) project.
NTNA is a donor funded initiative designed to build the country’s anesthetics department. Koroma said most of the health facilities that boast of having anesthetists have only one each, and these are at district level, like the Pujehun government hospital. PCMH, which hosts the NTNA programme, has the largest with at least 12 anaesthetists, he said.
Efforts to fix the department began immediately after the civil war, when it was observed that there was only one doctor anaesthetist in the whole country who was in fact a foreign [Dutch] doctor, and six nurse anaesthetists. All of them were based in Freetown, so that surgical operations were unheard of outside the capital city in as late as 2003.
Because of scarcity of trained anaesthetists, a lot of doctors in Sierra Leone have been forced to perform dual role – surgery and anaesthetics – which experts say increases the risk of danger.
“That’s why there were a lot of fatalities…,” Koroma told Politico in an interview. “Doctors can’t perform properly if there are no anaesthetists,” he said.
Lack of concentration
Anesthetics are divided into two main types: Local and General anesthetics. With local anesthetics a small part of the body of the patient is made numb. This is usually for minor procedures. The patient gets a shot of the medicine directly into the surgical area to block pain. The patient may even stay awake during the procedure.
Local anesthetics works in such a way that they block the nerves that connect a particular body part or region to the brain, preventing the nerves from carrying pain signals to the brain. Examples include novocaine shots, which dentists use to numb the nerves in the mouth during dental surgeries. Epidurals are used during caesarean section as they allow for a relatively painless childbirth by blocking the nerves that originate at the base of the spinal cord and serve the pelvic region.
General Anaesthetics, on the other hand, are often employed in serious surgeries that require a patient to be completely unaware. They are used to affect the brain and the rest of the body. The patient gets some anaesthetics through a vein, or they may inhale it. With this type of anaesthesia the patient is unconscious and don't feel pain during the surgery.
But the type of anesthesia used depends on several factors which can be determined by the doctor, hence the need for trained doctor anesthetists.
A well-established anaesthetics department is crucial to solving Sierra Leone’s problem with maternal and infant mortality. The service delivery for a comprehensive emergency obstetric and new-born care includes safe blood transfusion and conduct of caesarean, among others, all of which involve anaesthesia.
“Increasing evidence is beginning to emerge that maternal and infant survival is proportionately correlated to the number of health workers providing obstetric care that includes anaesthesia,” notes a WHO bulletin of 2010. It argues that though the common perception is that anaesthesia services are only required at the level of secondary and tertiary health-care facilities, the availability of basic services at the first referral level facility can contribute significantly to a reduction in death and disability.
At the district and sub-district level, health personnel are expected to provide a range of anaesthesia services (local, intravenous ketamine, spinal and general anaesthesia) for the management of pregnancy-related complications, unsafe abortion, injuries (road traffic accidents, domestic violence, burns, falls, rape), complications of female genital mutilation, congenital anomalies as well as other surgical conditions, the bulletin notes.
Beyond training
Since 2003 on average every 18 months some 20 people have been trained under the NTNA programme, which is funded by UNFPA and other international partners. Over a 100 nurses have gone through it since 2001. The training is 20 percent of lectures and 80 percent practical work.
Graduation for the latest batch of trainees was held in November 2015, involving 27 health workers from across the country.
But the project coordinator said a number of factors combined to frustrate the efforts. For example, recruitment often becomes difficult because trainees are not given study leave, making it hard for them to concentrate. And because of this, said Dr Koroma, they are reluctant to enrol.
Anaesthetics is among the specialist areas been considered for Sierra Leone’s first post-graduate medical college.
Koroma sees a major advantage in this in that in-country training offers the best option. He said presently most training was being done outside the country and that those who benefit from the minimal scholarship awarded most times fail to return after completion.
“We found out that if you do in-country training, the trainers are likely to give their services back to the people. Trainees reduces work load on local staff, and the learning environment is suitable for them. Above all the cost is low,” he said.
Beyond the training there is also the need to address equally crucial issues like shortage of essential equipment and drugs, as well as unavailability of power at hospitals and health centers. Koroma said ensuring adequate staff accommodation is also part of the solution.
Besides the government’s effort, other separate projects have been pursued to help this situation. Example is the John Hopkins Austere Research Group’s 2013/2014 research on the use of the Universal Anesthetics Machine (UAM) through the ‘Safe Anesthesia & Surgery in Sierra Leone Initiative (SASSL)’.
The UAM is an illustration of the advancement in anesthesia in the developed world. But most of these achievements are light years ahead of the situation in developing countries.
The SASSL initiative conducts researches on the possibility of deploying new anesthesia machines like the UAM which are designed for environments where compressed gases are not consistently available and measure the impact that these machines will have on the safety and capacity of surgery in these countries. It also includes donation of thousands of dollars worth of medical equipment relevant to the department.
(C) Politico 10/02/16
