Stories From the Field:

BOTSWANA

Anesthesia and Critical Care at the University of Botswana School of Medicine and Princess Marina Hospital – Gaborone, Botswana

David Bartels, MD
Devan Bartels, MD MPH

Massachusetts General Hospital
Department of Anesthesiology, Critical Care, and Pain Medicine
PGY-4 Residents

Botswana is often cited as one of the success stories of southern Africa. Responsible management of its diamond wealth and democratic leadership has fueled economic growth in this country of 2 million since independence in 1966. From one of the poorest countries in the world, Botswana has developed into a middle-income country; however, many challenges remain, including the increasing morbidity and mortality burden of non-communicable disease.

We arrived in Botswana at the beginning of March 2017, under the supervision of our mentors from MGH, Drs. Paul Firth and Lena Dohlman, and our University of Botswana School of Medicine (UBSOM) mentor, Dr. Neguisse Bekele, with a threefold mission: (1) assist the medical student education efforts of the Department of Anesthesia and Critical Care at UBSOM, (2) offer stake-holder driven workshops to UBSOM staff and Princess Marina Hospital staff, and (3) assess the capacity at UBSOM and Princess Marina Hospital for the MMed program (residency) in anesthesiology and critical care that UBSOM staff hope to initiate. Although efforts in anesthesia are relatively new, we are fortunate in that Harvard has had a long and robust presence in Botswana for over 20 years, as part of the Botswana-Harvard Partnership (BHP).

During our time in Botswana, our days were divided between the operating theaters, the UBSOM tutorial and skills rooms, and meetings with various stakeholders.  On our first day, we met with our host and mentor, Dr. Bekele, to better understand the structure of the medical student curriculum and to learn how we could be most effective as educators. We learned that medical students at UBSOM have limited exposure to anesthesia. As such, the curriculum for 3rd and 5th years must be high yield and focused on critical information that will benefit the students regardless of what specialty they pursue. While keeping within the curricular goals already in existence, we focused our educational efforts on mastery of key pharmacologic and physiologic concepts and conveyed our enthusiasm for the field of anesthesia. Much of this education occurred in the operating theaters and was related to the clinical aspects of the day’s cases.  For example, regional anesthetic techniques are widely used, so we discussed the causes, diagnosis, and management of local anesthetic toxicity. Additionally, Princess Marina Hospital is one of the major trauma centers in Gaborone, which prompted discussions about anesthesia in the trauma patient, including the role of rapid sequence intubation.

In addition, we implemented workshops for students and staff that emphasized practical skills, covering airway management, monitoring, ventilator management, vascular access, and neuraxial anesthesia. During the ventilator session, the students learned the basic principles of positive pressure ventilation and had a chance to discover the different ventilation modes available on the anesthesia machines. This practical session was tied to a review of the classic New England Journal of Medicine ARDSNet article about the benefits of lower tidal volume ventilation. In this way, we were able to introduce further discussion about evidence-based medical practice.

At the request of the staff, we organized and facilitated an ultrasound workshop for Princess Marina Hospital operating room staff during their weekly academic rounds. After we reviewed ultrasound basics and “knobology,” we provided an “in-service” training session to staff anesthetists consisting of basic probe handling and machine operation. More advanced staff practiced needle visualization using expired needles donated by MGH colleagues and hunks of meat. This practical session was a huge success and a lot of fun. More importantly, our Princess Marina Hospital colleagues recognized the value of ultrasound use in their practice and are eager to learn more. This will be the next challenge – to ensure that our training is part of a sustainable educational endeavor.

The third part of our trip was to preliminarily assess the capacity at UBSOM and Princess Marina Hospital for the MMed program (residency) in anesthesiology and critical care that UBSOM staff hope to initiate. To accomplish this, we met with various stakeholders and explored the existing medical program ecosystem in Botswana. Underlying this work was the basic question: what is the path forward for building anesthesia and critical care capacity in this remarkable country? During our month in Botswana, we witnessed firsthand the hard work that is already happening and can see the future potential. We formed relationships that make us optimistic that long-term collaboration is possible. Anesthesia and critical care form the backbone of a robust surgical care system, and Botswana desperately needs this capacity. Looking back to the first time we were in Botswana, in 2006, we see how far Botswana has come in the past decade. Looking forward, we see the opportunity to help build anesthesia and critical care capacity and see how much potential remains.