Developing anaesthesia skills in low and middle-income countries through the work of the Future Health Africa Trauma Team
Future Health Africa (FHA) is a UK-based charity that strives for sustainable improvement in the health and wellbeing of people in low and middle-income countries (LMICs). The aim of the charity is to transform lives, relieve suffering and reduce poverty through collaboration with local health providers.
FHA projects currently take place in Kenya. Volunteers have trained in the UK or are Kenyans working in government facilities. All are committed to reducing inequality in healthcare and making a personal contribution to the internationally-agreed UN sustainable development goals [1].
The charity has recently launched a new website and increased its media visibility, with a view to gaining sponsorship and a more predictable income.
The Future Health Africa Trauma Team
Motorbikes are ubiquitous in Kenya, usually ridden with multiple passengers without helmets carrying a heavy cargo. Roads are treacherous, so accidents are frequent. In addition, many people sustain injuries through manual labour, and childhood trauma remains common.
Trauma is a ‘Cinderella’ specialty in Kenya; often patients who suffer fractures go untreated, resulting in long-term disability with deleterious consequences for their dependents.
“Fixing one person will influence a whole family, even a community” [2]
The FHA Trauma Team offers medical aid, but aspires to and achieves so much more. We categorise our work into gold, silver and bronze:
- Bronze is medical aid: treating fractures and making non-functional limbs functional.
- Silver is side-by-side working with our Kenyan colleagues, with education and exchange of ideas.
- Gold is the introduction of a permanent change in practice or service delivery to improve trauma care in the long-term. As one key example, we have successfully introduced the WHO theatre checklist.
Most of the Trauma Team volunteers work in hospitals in the South West of England (Truro, Plymouth, Torbay and Exeter). We take a full theatre team, radiographers, physiotherapists, and an administrator who ensures smooth running of the project. We are fortunate to have an enthusiastic Kenyan consultant orthopaedic surgeon and a Kenyan middle-grade doctor who play vital roles in directing team development.
We live, eat and work together for the duration of the trip. Consequently, we gain an increased insight into each other’s specialities that leads to enhanced multi-disciplinary working. We operate a non-hierarchical team, with all views and opinions valued.
Anaesthesia provision in Kenya - what services are available?
Kenya does not have a national health service. There is no primary care, and few emergency departments. Healthcare can be purchased for 500 shillings per month (£3.80), but only applies to a nominated hospital. Populations distant from Nairobi are less well catered for.
Anaesthetic equipment is variable, but there is usually a good quality anaesthetic machine with a circle system. Halothane and isoflurane are typically available, with oxygen supplied from either a concentrator or a cylinder. A gas analyser and ETCO2 monitor are not guaranteed, but blood pressure, ECG and oximetry are available. Post-operative monitoring, and the presence of skilled recovery staff, are scarce in the peripheral hospitals. Bed sharing is common, with family members playing a significant role in patient care.
Postoperative pain management does not get the same level of attention as in the NHS. This needs addressing as a systems failure; there is an abundance of good will, but staff education alone will not ensure success. In addition, cultural differences exist: complaining of pain in Northern Kenya may be seen as a sign of weakness. Promotion of good analgesia to achieve rapid return to full function would clearly be beneficial.
History-taking is challenging; several languages are spoken in rural areas. There are no translation services so hospital staff, relatives and sometimes other patients act as interpreters. This can lead to inaccurate history-taking and explanation of surgical procedures, as interpreters may not appreciate the nuances of medical terminology. The impact on patient confidentiality is obvious.
Who delivers anaesthesia in Kenya?
Kenya has a population of 43 million, with three cadres of anaesthesia providers: Physician Anaesthesiologists, Registered Clinical Officer Anaesthetists (RCOA) and Kenyan Registered Nurse Anaesthetists (KRNA). With all three cadres combined, the ratio of anaesthesia providers to population stands at about 1.7 per 100,000, significantly below the recommended world standards of five physician anaesthesiologists per 100,000.
Clinical officer anaesthetists undertake a 3-year medical diploma after high school, followed by a 1-year internship. This is followed by two years as a general clinical officer, and then 18 months in anaesthesia. Approximately 100 clinical officer anaesthetists are trained per year. They are accredited by the National Association of Clinical Officer Anaesthetists which has 1600 members.
Nomenclature is important. Clinical officers and nurse anaesthetists are referred to as anaesthetists, whilst those with medical degrees and formal training in centres like Nairobi are referred to as anaesthesiologists, an example we may need to adopt in the UK in the future.
Task-shifting will be vital for developing anaesthesia in Kenya. Training anaesthesiologists at a rate fast enough to provide the population with access to safe surgery is impossible without significant investment. Currently clinical officer anaesthetists and nurse anaesthetists deliver the majority of anaesthesia. With the WHO recognition of essential surgery and anaesthesia as vital components to universal health coverage, there is a need for increased investment in strengthening both access to, and quality of, surgery and anaesthesia care [3].
Task-shifting is not unique to Kenya. Nurse anaesthetists and physicians assistants are becoming common in Europe. The concept of matching the skillset to the job carries substantial merit in terms of finance and the speed of workforce expansion.
Taking the project forward
Historically, FHA attempted to engage local anaesthesiologists and clinical officers, however they are often too busy (usually undertaking emergency caesarean sections concurrently in shared operating theatres). Subsequently, we have invited anaesthetists from other localities to join us for on-the-job teaching and learning.
Recently our focus has been teaching ultrasound-guided nerve blocks. Regional anaesthesia has more to offer in terms of delivering safe anaesthesia than it does in the UK. It avoids reuse of airway equipment and the use of volatile anaesthesia in the absence of end-tidal monitoring. An awake, comfortable patient is safer in recovery, given the lack of monitoring and staffing. Kenyan anaesthetists are highly skilled with spinal anaesthesia, but less experienced with limb blocks. Teaching ultrasound-guided blocks comes with the same problems as it does in the UK: knowledge of anatomy, hand-eye co-ordination, and safety principles are new to a number of those delivering anaesthetic services. Some hospitals have an ultrasound machine (often shared with other departments and not easily repairable). As ultrasound has so many advantages in this setting, our vision is to enthuse local teams about the benefits of ultrasound-guided regional anaesthesia.
Future Health Africa – trainee perspectives
Since its inception, Future Health Africa has offered anaesthetic trainees in the South West Peninsula Deanery a valuable experience working beyond the NHS. In November 2019, we joined the trauma teams travelling to Nyahururu and Marsabit hospitals.
Katharine Sprigge, Nyahururu
Nyahururu Hospital is four hours North-West from Nairobi. It serves an urban population of 36,450 and the surrounding rural inhabitants. Approximately one third of patients present with trauma.
Our patients arrive at the hospital in response to adverts and word-of-mouth. The surgeons and physiotherapists methodically review each patient’s suitability for surgery. Each case is carefully considered: does the damaged limb remain functional? Is osteomyelitis present? What are the chances of postoperative complications, and can they be managed after we leave? Observing the complex decision-making gives me a new insight into my colleagues’ roles and responsibilities. I assess the patients chosen for surgery with the help of a Kenyan orthopaedic surgeon who has joined us for the week. She kindly offers to translate so that I can consent patients for spinals and regional nerve blocks.
Seeing patients with chronic displaced limb fractures is upsetting when you are accustomed to a nationally-funded health service. I meet a 40 year-old man with two broken forearms, the fractures are months old. He could only afford one operation on his dominant arm, which is now infected. He is diabetic, but taking none of the medications that he would receive free under the NHS. He has been unable to work and support his family since his injury. We list him for surgery on both arms.
The following day surgery begins with an 80 year-old lady with a fractured distal femur. She has confusing X-rays, having sustained the same injury on her other leg the previous year which was left to heal conservatively. The WHO checklist illustrates its use as a safety net to prevent wrong site surgery. She receives a distal femoral nail under spinal anaesthesia, with a femoral nerve block at the end.
Later in the week a patient requires a general anaesthetic. Having never used halothane before, what can I remember about it from the FRCA examination? Not to let the ETCO2 get too high for fear of cardiac arrhythmias? There is no ETCO2 or gas monitoring available anyway, so I proceed up a very steep learning curve, frequently peering under the drapes to check the chest movement and feel for regular pulses.
Our anaesthetic team is joined by a Kenyan anaesthetic officer, Fenwick Muthangya. He gives us his insights into provision of anaesthesia in Kenya, and we are thankful for his help as a translator. The FHA anaesthetists teach him ultrasound guided femoral nerve block, practising needle technique on a goat’s leg before successfully placing one in a patient. We pass on the Association of Anaesthetists guidelines for managing local anaesthetic toxicity.
On the wards I offer pain management teaching to the junior doctors. Knowledge of nociceptive pathways and the WHO analgesic ladder is well established, but neuropathic pain and chronic pain models are new concepts. We discuss the rationale for regional anaesthesia to avoid opioid side effects, as well as the physiological and psychological benefits of good pain management.
The trauma team meets each evening for a ward round, which gives us a chance to see how our patients are managing following surgery (and how hard the physiotherapists are working to encourage function and mobility). Later, after dinner we discuss and plan our patients for the following day. Working in such close proximity means that our MDT has become highly functional very quickly. We go into the following day well prepared, with a more holistic understanding of our patients’ treatment.
My time spent in Kenya has undoubtedly reinforced my appreciation for the resources we have available in the UK. I hope to bring back with me a better regional anaesthesia skill set and a new understanding of the challenges of providing safe anaesthesia outside the NHS. I would highly recommend the FHA project for fellow trainees considering volunteer work abroad.
A regional anaesthesia perspective - Gareth Meredith, Marsabit
Peripheral nerve regional anaesthesia is little practised in Kenya. Having completed advanced training in regional anaesthesia, I felt well prepared to deliver loco-regional techniques to facilitate awake surgery. I was less prepared for the challenging conditions in which this would be provided.
The benefits of regional techniques seen in patients in the UK are only emphasised in Marsabit. Avoiding resource-heavy general anaesthesia, often in the absence of ETCO2 and gas monitoring, has significant patient and economic benefits. Beyond that, immediate post-operative pain control is well provided for, avoiding reliance on systemic analgesia in a system with few nurses and doctors delivering postoperative care with limited drugs. Patients are reluctant to request analgesia, which is likely to be because of cultural but also financial reasons. Recovery facilities are exceptionally limited, occurring in a corridor outside theatres without monitoring. To have an awake, haemodynamically stable, comfortable patient without the need for airway support is a significant benefit. Morning discussions were held with the team, exploring the expected duration and course of surgery and the expectations and needs of the physiotherapists for post-operative management.
Clearly there are significant challenges in bringing regional anaesthesia to the Kenyan rural population. However, this should not be seen as insurmountable. Formal training will provide the greatest challenge. We spent time teaching basic ultrasound scanning, probe handling and needle orientation as well as ultrasound-guided brachial plexus, forearm and femoral nerve blocks. The recent editorial by Turbitt et al. recognising regional anaesthesia ‘not just for the cognoscenti’ certainly carries weight in Kenya [4].
I would whole-heartedly recommend joining the FHA team to provide regional techniques for trauma patients. I returned to the UK with a renewed vigour, a greater understanding of the roles of our non-anaesthetic colleagues, an increased appreciation for the NHS, and a reinforced belief in what regional anaesthesia has to offer.
Gareth Meredith
ST7 Anaesthetics
William Jewell
Consultant Anaesthetist
Katharine Sprigge
ST7 Anaesthetics
Royal Cornwall Hospitals NHS Trust, Truro
References
- United Nations. Sustainable development goals, 2015. https://sustainabledevelopment.un.org/?menu=1300 (accessed 17/6/2020).
- Future Health Africa. FHA Trauma Team, 2020. https://www.futurehealthafrica.org/traumateam (accessed 17/6/2020).
- TUKO. Shortage of anaesthetists in Kenya big threat to safe surgeries, 2019. https://www.tuko.co.ke/314660-shortage-anaesthetists-kenya-big-threat-safe-surgeries.html (accessed 17/6/2020).
- Turbitt LR, Mariano ER, El-Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia 2020; 75: 293-7
