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Department of Anesthesiology, Perioperative and Pain Medicine
Here at Boston Children’s Hospital, our doctors and nurses are not only working to help the patients that come through our doors every day, but also for children all over the world. In the Department of Anesthesiology, Perioperative and Pain Medicine, we have physicians, as well as certified registered nurse anesthetists (CRNAs) who work in collaboration with organizations like Harvard Medical School, Partners Healthcare, Brigham and Women’s Hospital, and many more to participate in international medical initiatives.
Initiatives range from emergency response trips for diseases and disasters to educational visits that are meant to aid local healthcare workers in learning new methods and safe practices to carry out on their own. Areas where physicians and CRNAs from our department have gone to work thus far include Haiti, Africa, South America, and more.
Boston Children's Hospital's certified nurse anesthetist John Welch, CRNA along with Partners in Health and the Haitian Health Care Ministry have made successful efforts to establish viable healthcare infrastructure and resource access to those in need at Haiti's largest hospital, the University Hospital of Mirebalais.
The 300-bed, 6-OR hospital provides primary care services to about 185,000 people in Mirebalais and two nearby communities. 700 patients are seen daily at Mirebalais's ambulatory clinics. Patients from central Haiti and areas in and around Port-au-Prince can receive secondary and tertiary care. The hospital's first medical residents have received training in pediatrics, general surgery, and internal medicine.
A letter written by staff member, John Welch, CRNA, to the Department about his experiences treating Ebola patients in Liberia:
As many of you know, I have taken a leave of absence in order to work as the Chief Clinical Officer for Partners In Health Ebola response. I am writing to you from Monrovia, Liberia having recently returned from an Ebola Treatment Unit (ETU) in Bong County where International Medical Corps has been operating for the last month. I spent a week shadowing the staff and working in the ETU in order to safely operationalize the Partners In Health units. I humbly offer my reflections. show_more_start
The initial emotions arriving at the unit are many and come in a flurry. All of the news, hysteria, and-in our case-preparation become acutely real as I approach the gate and see the hygienist in PPE waiting to receive me. This will be the first of dozens of times I wash my hands in chlorine this hour alone. Chlorine is my friend. My shoes are sprayed and I walk twenty feet to another gate, where I repeat the process again. The sprayer thanks me and I move along towards the tent where the IMC staff is gathered.
I am quickly welcomed into the fold and taken on a tour of the facility. The ETU is as I envisioned, though I am continually awed that we are operating in a place that only 2 months ago was a dense forest. Ebola will leave its mark in more ways than one. The most confronting part of the tour comes as we approach the burial ground, a few minutes walk down the hill behind the ETU and into a wooded area.
Twenty-eight grave markers note the names of 28 lost souls and the dates of their "sunrise" and "sunset." There is about one death per day at this ETU. Chills move up my spine then back down again and the lump in my throat grows. Adjacent to the graves are another dozen holes, pre-dug and perfect. There is no greater resolution to what lies ahead than digging graves a dozen at a time. This is the work of men determined to do right by the dead in a country that has banded together to fight the most dire public health emergency of our time.
Liberian national staff at the ETU outnumbers expatriates by a dozen to one. Each person I encounter is kind, welcoming, and gracious beyond expectation. I spend some time speaking to James, a sprayer. He is a physical education teacher who has not been able to teach for months now. He said it is his duty to work here, to save his family and to save his country. He has not seen his wife and two children for over a month now, but said he will fight until the war is through. In Liberia, war is not that far away, but now the fight is against a common enemy. The national solidarity moves me. This work is the right work.
It is really difficult to describe the inside of the ETU. High-level care is so dangerous and quite difficult in full PPE in the afternoon heat (90º+ with 85% humidity) so care can be a bit sporadic. Conceptually, the ETU is a simple idea: isolate suspected cases from probable cases from confirmed cases. In practice, however, this is very difficult. Each set of PPE is around $80, and there are 250 changes per day for a 50-bed unit. It takes about 15 minutes to safely don the PPE, and 20 minutes to doff, washing your hands no fewer than a dozen times in the process. The unit requires an average of 150 liters of water per patient per day for hygiene and infection control alone. Staff and patient flow through the unit is one way, from suspected cases to confirmed of course, and everything which enters the unit will be burned.
Care is supportive and mostly empiric: antibiotics, antimalarial (prevalence ranges from 7-20%), antipyretics, antiemetic, anti-diarrheal, antiepileptic, analgesics, oral rehydration solution or IV fluids, multivitamins, and nutrition supplements. Patients fall anywhere along the spectrum of illness from awake, ambulatory, and conversing to unconscious. In the final stages, there is not much one can do but keep the patient comfortable and do his best to avoid self-exposure to the massive volume loss, which in this phase and just after death carries the highest viral load.
One of my first tasks on entering the unit after training is to move two children aged 6 and 14, from the suspect ward to the confirmed ward-their Ebola PCR results have just been phoned from the US Navy mobile lab a few miles away. Their parents are both dead for a week now. Their middle brother is already in the confirmed ward in a dreadful state, though he has been more awake today and taking PO hydration. Maybe he is coming around. Their grandmother, with whom they arrived 12 hours ago, who has cared for the entire family including her deceased daughter and son-in-law, remains curiously asymptomatic and her third PCR is negative. We make a particular note of what now seems strongly like some type of innate immunity, but we are quick not to jump to conclusions. Clearly, and not surprisingly, there are things we do not understand about the virus.
Separating the children from their grandmother, the only living adult family member they have left, is like a punch to the gut. The little girls cries, but is too weak to fight. She tells me again and again she is scared, and I cannot say I blame her. The rain now beats on the tin roof of the ward so loud it is impossible to communicate without yelling. The four of us in the unit, dressed as astronauts, move methodically and systematically. I bribe the little girl with some cookies, which she chases with a healthy swig of oral rehydration solution. We tuck them in, change the linens of their middle brother who is now incontinent, but asking for more to drink, and leave them alone. My soul feels completely battered.
In the morning, their brother is dead. If leaving them alone the night before was soul crushing, this is indescribable.
Following the week with IMC, I return to Monrovia where I am working closely with the Liberian Ebola Incident Management System-Ministry of Health, WHO, CDC, USAID, MSF, EU, DOD, UN, and all other partners-to understand best where PIH fits into the game. Over the last week, PIH has been heavily engaged by the MOH and Liberian President to manage the entire Southeastern region of Liberia, as it is the most rural and the most underserved. PIH believes strongly that an epidemic like this is only a symptom of a broken healthcare infrastructure; thus, an emergency Ebola response cannot be divorced from health systems strengthening at the community, primary, and district levels. As such, we have agreed to construct and operate 3 50-bed ETUs in the counties along the Ivory Coast boarder, each affiliated with 1-2 smaller "mini-ETUs" of 10 beds each positioned in rural zones where patients currently have no access to Ebola care whatsoever.
In the coming months, these mini-ETUs will be tied to community health careworkers and primary clinics so patients can be referred bi-directionally depending on their Ebola status. Recommencing essential health services has been a struggle and the lack thereof has already claimed more lives than we know-imagine, nowhere to turn for insulin, prenatal care or a C-section, traumatic injury, and on and on?
Currently, the caseload in the Southeast region seems low, but CDC field teams seem confident that this is due to underreporting and poor case finding structures. What's more, the dry season will bring a much-feared ease of movement of people across the borders and around the country, carrying Ebola with them. Our first ETU will be operational mid-November, though our response in this area must be much more agile than here in Monrovia where the sheer volume of cases overwhelmed the system.
In the rural areas, we will need to deploy to the cases and quickly operationalize the mini-ETUs where the hotspots are. In so many ways, this epidemic and response is unprecedented. We will rely heavily on UN aircraft to move our staff and supplies around the Southeast in order to have any impact at all. Meanwhile, PIH, with our partner in Liberia, Last Mile Health, is the only NGO consortium ready and willing to provide a full package of support in this region. High-level rural healthcare is our niche.
The situation is desperate, but there is also a lot of hope that fills the ETU and the country. We stand at one of those moments in history where we must ask ourselves, "what is the right thing to do?" In healthcare, we must always remember: if you know how to help someone, you should. I feel your support and encouragement from afar, and I am endlessly appreciative of it. I leave you with a thought by Nelson Mandela, a human rights warrior: "Courage is not the absence of fear, but the triumph over it."
In gratitude, with hope and solidarity always,
John C. Welch, CRNA, MSN
"The population base in Africa has the steepest growth curve of any region of the world. As this population grows, the number of children needing surgery every day will grow exponentially and based upon current estimates, thousands of African children will die due to unsafe anesthesia in the vast majority of African countries. This program will directly address this tragic reality by training East African anesthesiologists in the specialty of pediatric anesthesia within a program rooted in a country’s national system." - SPA News, Volume 27; Issue 2 show_more_start
Unlike anesthesia providers in the United States, anesthetists in low-resource settings lack the opportunity to attend medical school or participate in more rigorous and concentrated training environments through residency and fellowship programs. Faye Evans, MD along with Mark Newton, MD, associate professor of Clinical Anesthesiology at Vanderbilt University have made global outreach efforts to create a fellowship program for certified anesthetists in Nairobi, Kenya, which has a total of five anesthesiologists for a population of 45 million. One in 144 patients die in East Africa from perioperative mismanagement and complications; the fellowship combats this morbidity and mortality issue by providing certified physicians such as Susane Nabulindo, MBChB from the University of Nairobi, hands-on training and the opportunity to observe anesthesia practices in the U.S. Through a two-week observership at Vanderbilt University and BCH, fellows such as Nabulindo, who is the inaugural class's first SPA fellow, are given the resources and skills to implement pediatric anesthesia best practices.
Through the collaborative efforts between the University of Nairobi School of Medicine, Department of Anesthesiology, the World Federation Societies of Anesthesiologists (WFSA), the Society for Pediatric Anesthesia (SPA), the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the University of Nairobi Pediatric Anesthesiology Fellowship went live in September.
In order to benefit patients and anesthesia students in Kenya, approximately half of Vanderbilt's fourth-year anesthesia residents will participate in the Kijabe rotation, a month-long clinical rotation on the edge of the Great Rift Valley.
It is the hopes of Evans for this collaborative East African fellowship to serve as model for other programs and to continue the live interaction between fellows in Nairobi, Vanderbilt University, and Boston Children's Hospital with routine case studies via tele-conference expected to launch in November 2014. These topic-specific case studies will require participants to work as a group in creating a management style for any given prompt in order to allow all fellows to learn from each other's practice variation. With the vision of achieving a self-sustaining program, the fellowship's key partners have strategically sought to expand pediatric anesthesia educators into many other East and Central African countries. show_more_end
Boston Children's Hospital's Perioperative Anesthesia attending Faye Evans, MD has participated in a number of global practice improvement initiatives and collaborative efforts to aid anesthesia providers in low-resource settings.
One of these collaborations, Safer Anesthesia from Education (SAFE) Pediatric Anesthesia, provides continuing medical education opportunities for physician and non-physician anesthesia providers and serves as a model for knowledge translation for safer anesthesia practices worldwide. show_more_start
Based on the success of the SAFE Obstetrics Anesthesia Course, Evans has worked with an international team of pediatric anesthesia colleagues to develop a refresher course on pediatric anesthesia to improve the knowledge and skills of physician and non-physician anesthetists in management of pediatric patients in low income countries (LICs). The course material is clinically relevant and has been designed to address the core and potential extended roles of all anesthesia providers.
The three-day course focuses on the delivery of safe anesthesia for neonates, infants and children in the low-resource setting. This short course is delivered in workshop format to maximize learning by the participants and to avoid the lengthy periods of time away from the workplace. The course addresses core concepts in pediatric anesthesia using a variety of educational tools. Active learning principles are used and didactic lectures are kept to a minimum. Small group interactive sessions use a variety of teaching modalities such as case scenarios, facilitated discussions, simulation, and skills training.
Pediatric anesthetists from the UK and USA with experience of working in LICs have developed the course content. In addition, input has been sought from surgeons and anesthesia providers from LICs to ensure clinical relevance. Topics include common conditions of childhood, common congenital abnormalities such as cleft lip and palate, trauma, and basic critical care and resuscitation. Also included are sessions on fluid management, drug calculations for the pediatric patient, as well as anesthesia and resuscitation for the neonate.
Evaluation of learning is a core component of the SAFE Paediatric Anaesthesia Course. There are pre- and post-course tests of knowledge and skills and all participants are asked to complete a post-course evaluation form in which they rate individual sessions. Participant evaluation as well as their feedback is critical to future course development and modifications.
The inaugural SAFE Pediatric Anaesthesia course was held in Masaka Uganda in July 2014, in collaboration with the Uganda Society of Anaesthesia, funded by the Association of Anaesthetists of Great Britain and Ireland (AAGBI), World Federation Societies of Anaesthesiologists (WFSA) and Mercy Ships. Two three-day sessions were run back-to-back, with a total of 104 participants attending. The feedback was uniformly positive and the knowledge and skills scores improved consistently after each course. The most common written feedback from participants was a request for more financial support to attend similar courses, as well as increased frequency in this type of training opportunity.
Based on the experiences and feedback from the inaugural course, the course has been updated and three courses are scheduled so far for 2015 in Uganda, Madagascar, and western Kenya. The course materials will soon be available for anyone interested in running the course. It is copyrighted under a creative commons licensing but the goal is for the course to evolve and course materials to be adapted to the learners to keep the teaching clinically relevant. show_more_end
HRH has partnered with Rwandan health-professions schools and clinical training sites to upgrade medical and nursing professions by developing and implementing health care mentorship and education. The program seeks to improve health care at all cross-sections and develop a model of foreign medical assistance to create a sustainable and high quality health care system in Rwanda. The affiliated U.S. medial schools will act with the Ministry of Health in Rwanda in order to support the educational and clinical development of future faculty and current specialists while improving the quality of care of patients.
HRH Program: Rwanda Aims and Strategies
This global health initiative is based on applied principles that will focus on encouraging country ownership, building sustainability by strengthening health systems, promoting research and innovation, leveraging partnership, and improving metrics, monitoring, and evaluation. HRH is also based on key national policies and goals; Economic Development and Poverty Reduction Strategy, Vision 2020, Rwanda Aid Policy 2006, and Health Sector Strategic Plan 2009-2012.
According to Rwanda‘s minister of health Dr. Agnes Binagwaho, ―…through this program we plan to strategically, systematically, and comprehensively address the most challenging obstacles to high quality healthcare in Rwanda including: the critical shortage of skilled health workers; poor quality of health worker education; inadequate equipment in health facilities; and inadequate management of health facilities. The Rwanda HRH Program is a strong next step in ensuring a healthy Rwanda. Through continued collaboration and implementation of this program, I am confident that we will revolutionize Rwanda‘s health sector.
HRH Program: US medical schools’ areas of practice.:
We are grateful to have been ranked #1 on U.S. News & World Report's list of the best children's hospitals in the nation for the third year in a row, an honor we could not have achieved without the patients and families who inspire us to do our very best for them. Thanks to you, Boston Children's is a place where we can write the greatest children's stories ever told.”