Q: What was the main goal of this year’s American Board of Anesthesiology-accredited, month-long global health residency rotation in Ghana?

A: The goal of the trip to Ghana was to create a project that could show an incremental measurable gain in the delivery of health care. We arrived in Accra, Ghana at a very interesting time. We were working at Ridge Regional Hospital and there were three separate groups of trainees: first-year nursing anesthesia students, certified anesthetist (nurses) doing continuing medical educations (CME), and house officers who were doing a six-month anesthesia rotation.

It became apparent that there was huge deficit in people who would be qualified to lecture at the nurse anesthesia school associated with Ridge Regional Hospital. My project included providing required lectures to the house officers. Given their initial lack of excitement, I decided to pitch the idea to them of ‘flipping the classroom.’ Each day, a separate house officer would take one of the topics and give a 20-30 minute lecture on the topic. After the lectures, I would fill in the gaps for each topic. The house officers were immediately engaged and in a short time it became easy to see their excitement for the field of anesthesiology.

During the month, we were also charged with providing basic life support training for all trainees. The team provided this training for the SRNAs (40), certified anesthetists (30), and the house officers (7). During this time, I was able to locate the only working defibrillator in the hospital. There was a code earlier in the month and no one associated knew where the defibrillator was located.

This was also a month of growth. I participated in my first intraoperative code. The patient was a mother who was referred from an outside hospital due to sickle cell crisis (Hgb of 4 mg/dl) and fetal distress. The mother was rushed to the operating room but coded shortly after induction. Intraoperative ECG is not commonly used due to lack of disposable stickers and working cables. The patient did have a working pulse oximeter which allowed us to track oxygenation and was helpful for determining return of spontaneous circulation (ROSC). Without getting into the clinical specifics of the case, there was no access to non-invasive blood pressure, no stat labs, no defibrillator, no ECG, no intraoperative fetal monitoring, and no functioning post procedure ICU care.

After work, there were opportunities to debrief and see Ghana. We were invited to meet with a group of Americans living in Ghana, many of whom were just granted dual citizenship. Adam Flowe, Derrick King, and Kent Smith joined us for the last week of the mission trip. They helped with teaching and providing many valuable supplies. Kent was able to tour the hospital with the technical support staff and provide insight about ways to improve efficiency.

Overall the trip was a great success. I have grown so much as a global citizen, a human, and a physician. It is safe to say that quality anesthesia care is one of the largest health care disparities in Africa. Dr. Adeyemi Olufolabi (Duke) and Dr. Medge Owen (Wake Forest) are literally saving the lives of women and children around the world. Their work has forever changed Ghana.

Brian Rogers, MD (CA-3)

Stacey HiltonQ: What was the main goal of this year’s American Board of Anesthesiology-accredited, month-long global health residency rotation in Ghana?
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Q: Can you provide an example of the learning takeaways that Duke Anesthesiology residents gain from their global health mission trips?

A: In March, we spent a week in Jacmel, Haiti, providing anesthesia care and helping to improve the education of Haitian doctors and nurses caring for patients in the perioperative period.

Some very advanced equipment (stryker lap tower), some very basic equipment (fly paper) and a very tall Duke Anesthesiology faculty member (Dr. Aaron Sandler).

Some very advanced equipment (stryker lap tower), some very basic equipment (fly paper) and a very tall Duke Anesthesiology faculty member (Dr. Aaron Sandler).

The days were long, mostly pushing 14 hours, but we worked with wonderful folks to take excellent care of very grateful people as they received the surgeries they needed, so time went by quickly.  We found ourselves in a very safe anesthetic environment, with the crucial monitors (including capnography), good availability of necessary medications, and even a videolaryngoscope, but there were a few bells and whistles we have grown used to at Duke that were missing which brought us out of our bubble and challenged us to expand our thinking about delivering a safe anesthetic.

Systems-based process improvement is a central part of Duke Anesthesiology residency training, whether at home or abroad.

Systems-based process improvement is a central part of Duke Anesthesiology residency training, whether at home or abroad.

Anu learned a lot and saw pathology she’d only read about such as thyroid storm, acute hypocalcemia, and the emergency airway management of an expanding neck hematoma!  She also adjusted to using an unfamiliar machine in an unfamiliar environment and relying on spontaneous respiration in our intubated patients (in order to avoid wasting expensive oxygen on driving the ventilator) during some long surgeries for huge parotid tumors, impressive goiters, and the laparoscopic (mostly) removal of the largest gall bladder either of us had ever seen.  The proudest moment of Aaron’s week might have been when Anu, after a ten-hour sevoflurane anesthetic with spontaneous respiration and no end-tidal agent monitor, managed a two-minute wakeup!

There was also the opportunity for improving the education of the Haitian providers, starting with nurses and nursing students, some of whom were caring for postoperative patients for the first time in their careers, and continuing with the Haitian surgeon who will be managing the facility’s two ICU/ventilator beds when they open in June.  He was especially hungry for practical advice on using arterial blood gas measurements to manage ventilator settings, a topic we were happy to talk about.

We both returned to Durham exhausted (as well as desperate for hot showers and a day without bug spray), but also remarkably refreshed.  We felt that we had a made a direct difference in some folks’ lives, both the patients undergoing surgery and the nurses and doctors who ended the week a little bit better educated than they were before.  And, on a personal level, we had been reminded of why we originally wanted to go into medicine.  Overall, not a bad outcome for our week in Haiti.

Aaron Sandler, MD, PhD, and Anushree Doshi, MD (CA-2)

Stacey HiltonQ: Can you provide an example of the learning takeaways that Duke Anesthesiology residents gain from their global health mission trips?
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Q: What role does the Duke Anesthesiology Residency Program play in global health?

Global Health - DARE BlogA: Dr. Brad Taicher takes us on his journey abroad to provide a snapshot of how our department and residency program make a real difference in the lives of others.

It’s March 11th and we’ve safely arrived in Guatemala City, Guatemala for the sixth time in as many years to help evaluate and care for a group children undergoing general and urologic surgeries. This year’s anesthesia team is comprised of Stephanie Jones (CA-3 resident), Dayna Seguin (CRNA) and Becky Motykiewicz (CRNA), as well as three local anesthesia residents who will anesthetize with us throughout the week (Drs. Miguel Gonzales, Amilkar Garcia and Yolanda Castaneda). On our first day, we saw 80 plus children come through the clinic to be evaluated by our surgical team for appropriateness, and by our anesthesia teams to ensure they are medically optimized, and plan for the week ahead.

Why Guatemala? It’s the poorest country in Central America, and one of the poorest in the world. The public health system in Guatemala is well developed, but bankrupt. It lacks sufficient resources to provide care for all in need, creating an enormous backlog of patients, many of whom have no chance of ever receiving the surgeries they need through the public health system. There are about 4.5 million people in and around Guatemala City; more than 90 percent of whom rely on the public system and only two significant public hospitals to handle major surgeries. These two hospitals are only provided enough funding to purchase supplies to do elective operations in the mornings for about half of the year. When they run out of supplies, it’s emergency surgery only. There is no pediatric fellowship training here for those who are interested, so when I’m here, I’m usually the only pediatric anesthesiologist in the country. Pediatrics is an interest for many here, but a job for few. And for perspective, Guatemala is a country of children with greater than 50 percent of the population less than 18 years old.

In the United States, we may encounter patients who lack the skills to cope with the stress of their surgical encounter. In Guatemala, it is the opposite; patients have overdeveloped coping skills secondary to the conditions of their upbringing and the ubiquitous violence. It is often said that Guatemalan children don’t cry because they have long ago run out of tears. Our mission brings hope to these individuals and families while simultaneously seeking a sustainable model by supplementing pediatric training for local providers and collaborating on research and quality improvement endeavors with local institutions.

In addition to Guatemala, Duke teams have traveled to Ghana, Haiti, Philippines, India, and countless other countries. We are grateful for the phenomenal support provided by our department, hospital, and university over the past six years and the opportunity to include our own trainees and CRNAs on our mission trips. We are excited to continue our collaboration here in Guatemala, and look forward to another successful trip!

Brad Taicher, DO, MBA

Guest BloggerQ: What role does the Duke Anesthesiology Residency Program play in global health?
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Q: Why does the Duke Anesthesiology Residency Program believe it’s important to offer trainees “near-peer teaching?”

Little Dr. Ankeet and his older brotherA: During childhood, I would not admit it, but now I am proud to say I learned a lot from my older brother. He is two years older than me and taught me skills such as catching a football, packing my lunch, dealing with bullies and more. Why is it easier to learn certain skills from a sibling compared to parents? Educational theorists give many reasons, probably the most important being the knowledge gap between an expert and a beginner compared to the gap between a beginner and someone with intermediate skill. There is also an intimidation factor in a novice who is asking for assistance from an expert (Melvin 2014).

Inherently, anesthesiology resident education does not provide many opportunities for near-peer teaching, or teaching of CA1 residents by CA2 and CA3 residents. In fact, anesthesiology is one of a few medical specialties that actually pairs novice residents with experts in an operating room environment. It is common for a CA1 resident with less than three months experience to be learning from an anesthesiologist with more than 10 years of experience, daily!

As educators, we need to provide ample opportunities for near-peer teaching. Some examples in our Duke Anesthesiology Residency Program and others around the country include:

  1. Teaching scholars program: CA3 residents interested in education are elected into leadership positions to help with teaching activities for medical students and junior residents using simulation, lecture-based and intraoperative environments.
  2. Advanced clinical rotation: CA3 residents are assigned to coach CA1 and CA2 residents through advanced anesthetic cases.
  3. Social activities: Promote team building between classes (scavenger hunt, retreats, informal and formal dinner gatherings).
  4. Team night float system: Same CA3 and CA1 work together for an entire week on night call.
  5. Simulation activities teaching crisis management while senior residents are working with junior residents on difficult anesthetic cases.

There is a role to train residents and medical students to be effective teachers. Near-peer teaching does not end with residency, it is a lifelong necessity – and not limited to work only. I still learn from my brother.

Melvin, L et al. What makes a great resident teacher? A multi-center survey of medical students attending internal medicine conference. JGME. 2014. Available at: http://www.jgme.org/doi/pdf/10.4300/JGME-D-13-00426

Dr. Ankeet Udani

Dr. Ankeet UdaniQ: Why does the Duke Anesthesiology Residency Program believe it’s important to offer trainees “near-peer teaching?”
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Q: Did you see one, before doing one?

Dr. Udani in the Sim LabA: See one, do one, teach one. This is an age-old phrase in medical education. I can write about the pros and cons of this teaching approach, but here I wanted to primarily write about the importance of seeing one.

A few months ago, I was orienting our newest residents using simulation. We asked our residents to conduct a rapid sequence induction (RSI). The team of CA-1s came up with a plan and proceeded with induction. Despite getting caught up a couple of times, our scenario reached an end and all went well. At the end of the session, we asked learners for their feedback on how effective our teaching strategy was. All of them enjoyed being immersed in the simulator, but more than one stated that it would have been helpful to have seen an expert do a RSI before they did one. They sought a role model.

The feedback resonated with me. I reflected on my teaching practices and discovered that I often ask students to perform a task, with my specifications, under my guidance. However, the student had rarely watched me do it my way. For example, I enjoy teaching ultrasound-guided vascular access. I often coached residents through the steps of placing an ultrasound-guided arterial line; they are doing not seeing. Part of me did not want to take away their opportunity to place the line. However, I have since changed my teaching practices. Now, I demonstrate the procedure myself, describing in detail each step and pausing for questions. The students report that they learn a lot of my nuances by seeing an expert. They then model their behaviors to reflect the entire task from beginning to end. This confirms aspects of Albert Bandura’s social learning theory developed in the 1960s.

As an educator, serving as a role model extends to all aspects of patient care, teamwork, professionalism, and more; it likely extends outside the workplace. Learners are watching and modeling. For this reason, I now stress that students see me do at least one, before doing one.

Dr. Ankeet Udani

Dr. Ankeet UdaniQ: Did you see one, before doing one?
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