Anestesi- och Intensivvårdsprojektet

Rapport: IMP-2020-004 Anestesi- och Intensivvårdsprojektet personliga reflektioner efter resa till Gondar februari 2020 Resedatum: 1-7 Feb 2020 Författare: Jonna Idh, OP/IVA, Västerviks sjukhus Verksamhet: Internationella Medicinska programmet www.regionostergotland.se

1 Inledning Denna resa var en del i projekt Anaesthesia and Intensive Care Partnership mellan IMP och Gondar University Hospital. I denna rapport framkommer personliga reflektioner att använda internt inom IMP. För mer formell rapport hänvisas till en engelska versionen som bifogas Anaesthesi and Intensive Care Partnership Training in Mechanical Ventilation invasive and non-invasive, Jan-Feb 2020. Målet med denna resa har varit att: 1. Förbereda en site visit från anestesi/iva-teamet i Gondar till Sverige under 2020. 2. Förbereda för svenska ST-läkare i anestesi att under 2020 auskultera i Gondar. 3. Genomföra workshops i ventilatorbehandling. 4. Inventera möjligheter för gemensamt ST/AT-projekt. Med på denna resa var även min man, Rickard Kindgren, psykiater i Västervik, och våra två barn, Kalle 5 år och Bengt 3 år. Det gav en ny dimension till vistelsen och mottogs mycket positivt av alla kollegor i Gondar. 2 Genomförande 2.1 Projektgruppen Från Sverige: Dr Richard Jansson, OP/IVA, Västervik. Dr Jonna Idh, OP/IVA, Västervik. 2.2 Genomförda aktiviteter Dr Richard Jansson flög ner en vecka tidigare och hade på så sätt hunnit förbereda ett program för min vistelse. Som tidigare har det varit svårt att detaljplanera hemifrån trots idoga försök till detta. Vårt kontaktnät är nu befäst och vi lyckas ändå på kort tid att arbeta fram ett program för vår vistelse vilket inte hade varit möjligt för ett år sedan. Att resa med viss överlappning som Richard och jag gjorde denna gång var ur planeringssynpunkt bra då det ger utrymme att planera på plats. Sammanfattningsvis genomfördes: Föreläsning Invasiv ventilatorbehandling Richard Jansson Medicinkliniken ca 60 deltagare Föreläsning Non-Invasiv ventilatorbehandling Richard Jansson Medicinkliniken ca 60 deltagare Föreläsning Non-Invasiv ventilatorbehandling Richard Jansson Kirurgkliniken ca 60 deltagare Workshop Invasiv ventilatorbehandling och luftvägshantering Jonna Idh och Dr Yonathan Abebe, anestesiolog Dep of Surgery 18 ST-läkare Workshop Invasiv ventilatorbehandling och luftvägshantering Jonna Idh, Richard Jansson, Dr Yonathan Abebe, anestesiolog Dep of Internal Medicine ST-läkare 12 + 10 deltagare Utöver detta tillbringade Richard tid om mentor bedside både på kirurgiska och medicinska intensivvårdsavdelningarna och konsulterades angående svårare fall på operation. Undertecknad hade möte med ledningen för kirurgkliniken (Dr Miklol och Dr Mensur), medicinkliniken (Dr Tesfaye som är ny chef där), anestesikliniken (Mr Amare) och ansvarig på medicinska IVA (Dr Nebiyu). Glädjande nog hann vi träffa Dr Hussein Endris, anestesiolog, som just avslutat sin ST i Addis och nu flyttar åter till sitt hemuniversitet för att bli den första stationär anestesiologen på många år. Han kommer att www.regionostergotland.se 2 (4)

jobba tillsammans med Dr Yonathan i några veckor innan han tar över själv. Dr Hussein deltog i vår första ventilator workshop 2018, då sponsrad av The Ethiopian Association of Anaesthesiologists. Tre personer utseddes att delta vid den planerade visiten till Sverige i höst. Dr Nebiyu från medicin-iva, Dr Hussein från kirurg-iva och Mr Amare från anestesin. Dr Mensur var för övrigt mycket glad för inbjudan till IMP-dagen i vår. Då vi vid besöket hade fått en förfråga från en AT-läkare i Östergötland att genomföra ett forskningsprojekt i samarbete med KMC/IMP undersöktes dessa möjligheter med Dr Nebiyu och detta mottogs positivt och ter sig genomförbart. Vidare har kontakt upprätthållits med Dr Mahelet, Dep of Thorasic Anaesthesia, Black Lion och Dr Gosa, head of Dep of Anaesthesia i Bahir Dar. Min man Rickard Kindgren har varit med i Gondar en gång tidigare, 2012. Han besökte då Dep of Psychiatry som då varken hade psykiater eller möjlighet att vårda patienter inneliggande. Rickard besökte nu kliniken igen och mottogs med stor entusiasm. Framtida samarbetsmöjligheter diskuterades och kontaktuppgifter utbyttes. Om IMP är intresserade av mer information hänvisas till kindgren72@hotmail.com. 2.3 Vad ska projektet ge Region Östergötland? Efter nu två års arbete med att etablera ett samarbete inom anestesi och intensivvård tycker vi oss ha uppnått en sådan stabilitet och förtroende att det är läge att erbjuda ST-läkare att delta i verksamheten i Gondar. Närvara av Dr Nebiyu och Dr Hussein kommer påtagligt att öka kvaliteten på en sådan vistelse. 2.4 Vad ska projektet ge mottagarlandet? Utöver de faktiska föreläsningarna och workshops som hitintills hållits ter sig utbytet ha ett stort värde i att stötta anestesin som specialitet och de nya anestesiologer som nu kommer till Gondar. De anestesiologer som rekryterats månadsvis från Black Lion, Addis, har uttryckt stor tacksamhet till att ha en erfaren kollega (läs Mats Johansson, Johan Berkius och Richard Jansson) att bolla med. Anestesörerna har hitintills axlat den tunga uppgiften, att utan anestesiologer, sköta avancerad anestesi och intensivvårdskrävande patienter. I den task shift som nu stundar hoppas vi kunna buffra och stötta för att alla inblandade ska finna sina roller och arbetsuppgifter. Vi väcker också ett intresse för anestesi och intensivvård som inte funnits i Gondar och tror att vi på så vis lockar fler kollegor att välja denna bana. Efter årets site visit till Sverige hoppas vi kunna expandera utbytet till ffa anestesisjuksköterskor vilket vi tror är av stort värde för att höja kvaliteten på vården i Gondar. 3 Utfall Utvärderingarna från de workshops som hölls och muntliga kommentarer efter Richards föreläsningar var genomgående positiva. I wish we could have had this lecture as a resident during my roation at the ICU. It would have made my stay there so much easier. Dr Tsebaot, Senior Consultant in Cardiology. För undertecknad var denna resa ett kvitto på att vårt arbete med att etablera utbytet har gett resultat och att ett ömsesidigt förtroende har skapats. 4 Slutsats Ett stort tack till IMP som sett bortom ekonomiska begränsningar och regiongränser och sponsrat denna resa i form av resa och logi. Vi ser nu fram emot Mr Amare, Dr Nebiyu och Dr Husseins vistelse i Sverige. www.regionostergotland.se 3 (4)

5 Bilagor Bilaga 1 - Anaesthesi and Intensive Care Partnership Training in Ventilatory Treatment invasive and non-invasive, Jan-Feb 2020. www.regionostergotland.se 4 (4)

Report from the Anaesthesia and Intensive Care Partnership Gondar University Hospital Jan/Feb 2020 Intensive Care and Mechanical Ventilation Submitted by Dr Jonna Idh This workshop and visit was a collaboration between: the Department of Anaesthesia, the Department of Surgery and the Department of Internal Medicine, at Gondar University Hospital, Ethiopia and the Department of Anaesthesia and Intensive Care, Västervik Hospital, Sweden Financial support for visitors from Sweden was provided by the International Medical Program (IMP), Centre for Teaching and Research in Disaster Medicine and Traumatology, Östergötland County, Sweden. Facemasks for non-invasive ventilatory treatment were kindly provided by Fisher&Paykel.

Background Within the Anaesthesia and Intensive Care Partnership, a visit to Gondar University Hospital was undertaken by Dr Richard Jansson and Dr Jonna Idh, both from the Dep of Anaesthesia and Intensive Care at Västervik Hospital/IMP, Linköping. This was the sixth visit from Sweden to Gondar within the project, since 2018 when the health profession link took a start. Travel expenses and hotel costs were kindly covered by IMP, Region Östergötland. Aim The aim of the visit was to: 1. prepare for a site visit from Gondar to Sweden during the autumn 2020. 2. prepare for Swedish residents in anaesthesia to visit Gondar for four weeks rotation in November 2020. 3. if possible, support colleagues at the medical and surgical ICU as well as the anaesthesia team in their clinical everyday work. 4. continue the introduction and use of non-invasive ventilatory support both at the medical and surgical ICU. 5. train medical and surgical residents in invasive mechanical ventilation and in basic airway management. Faculty and preparations The visit duration was from the 28th of January till the 7th of February 2020. For planning in advance, mail correspondence was held between Dr Richard and Dr Jonna in Sweden and Dr Workagegnehu Hailu, Dr Tesfaye Yesuf, Mr Amare Hailekiros, Dr Miklol Mengistu and Dr Mensur Osman Yasin. Practical support in Gondar was kindly given by Mr Nigussie Simeneh and Mr Habtamu from the Dep of Anaesthesia and Dr Melese from the Dep of Surgery. Dr Yonathan Abebe, anaesthesiologist from Black Lion, who worked at the surgical ICU during our stay, took great part in the teaching. The venues were provided by the Dep of Internal Medicine and the Dep of Surgery. For the Dep of Surgery, demonstration of airway management was done within surgical skills teaching lab and the demonstration of the ventilator was done bedside at the SICU. For the Dep of Medicine, we were not able to work on the actual machine due to technical issues that could not be solved. The Department of Anaesthesia provided three mannequins as well as airway equipment. Participants and format Lectures on non-invasive and invasive mechanical ventilation was held for the Dep of Surgery and Dep of Internal Medicine by Dr Richard, Dr Jonna and Dr Yonathan. Lectures 1. Invasive mechanical ventilatory treatment Richard Jansson Dep of Internal Medicine approximately 60 participants 2. Non-invasive mechanical ventilatory treatment Richard Jansson Dep of Internal Medicine approximately 60 participants 2

3. Non-invasive mechanical ventilatory treatment Richard Jansson Dep of Surgery approximately 60 participants Workshops 1. Invasive mechanical ventilatory treatment and airway management Jonna Idh and Dr Yonathan Abebe Dep of Surgery 18 surgical residents participated 2. Invasive mechanical ventilatory treatment and airway management Jonna Idh, Richard Jansson, Dr Yonathan Abebe Dep of Internal Medicine 12 + 10 residents participated Workshop content and format The workshop for second year surgical residents was held at one occasion and lasted for 3 hours. The training included a lecture held by Dr Yonathan and Dr Jonna covering the history of ventilatory treatment, modes and settings of ventilators and, good to know when handling a critical ill patient in need of ventilatory treatment in the ICU. This was followed by an interactive skill stations where participants were able to go through the actual settings on a ventilator in the SICU (Philips Respironics V200), and two station simulating how to initiate ventilatory treatment in a critically ill patient in the ICU. This included practical skills of airway management on a mannequin and equipment needed in such a situation. Focus was securing a free airway and bag-mask ventilation while waiting for assistance from the anaesthetist for the actual intubation. Practical skill stations were demonstrated by Mr Nigussie, Dr Yonathan and Dr Jonna. According to the evaluation of the previous workshop we took more time for trouble shooting and discussions in small groups. For the residents in internal medicine the lecture was held by Dr Richard Jansson for the entire department and the workshop with practical stations was then held for residents alone. Two groups, 10+12 residents, á 2,5-3 hours started with discussions on trouble shooting and common alarms and continued with hands on training. Figure 1. Dr Yonathan (left) and Dr Richard (right) teaching at the workshop. 3

Figure 2. Surgical residents at the workshop (left) and Nigussie teaching at the airway station (right). Non-invasive ventilatory treatment (NIV) At two previous occasions introductory lectures on non-invasive ventilation have been held. Dr Nebiyu has so far tried to use NIV on a few patients at the MICU and there are now six masks donated by Fisher&Paykel available at the hospital. Dr Richard presented the technic and indications for NIV in a lecture for both the Dep of Internal Medicine and the Dep of Surgery. Hopefully this will enable the initiation of noninvasive ventilation as an alternative to invasive ventilation for selected patients at the intensive care units. Mentoring at the intensive care units Apart from lecturing Dr Richard shared his time between rounds in the medical and surgical ICU as well as helped out in preoperative evaluation of patients undergoing major surgery. Both the medical- and surgical ICU have made great improvements due to committed work by Dr Nebiyu, guest anaesthesiologists from Black Lion Hospital, devoted anaesthetists and nursing staff. Workshop evaluation Both surgical and medical residents showed great interest in the topic and were very engaged during the practical sessions. All participants evaluated the workshop by anonymously giving their suggestions on what to improve and what they found positive with the training. In summery the evaluations were positive but the lack of a functioning ventilator for the residents in internal medicine as well as no functioning laryngoscope for the surgical residents was commented as a drawback. (For a detailed list of comments please see Appendix A.) Summary This was the third occasion with workshops focusing on mechanical ventilatory treatment in the ICU. The format is now established and easy to organize. The topic is best presented in collaboration with staff from both the anaesthesia and intensive care side and it was a great experience to deliver the training together (Dr Yonathan, Mr Nigussie, Dr Richard and Dr Jonna). Although no formal evaluation was done, the senior staffs seemed to appreciate the hands-on lecture in the basics of mechanical ventilatory modes and in the update on non-invasive ventilation, now available in Gondar. 4

Future plans During the last day of our stay Dr Hussein Endris, who just finished his residency program in anaesthesia and intensive care at Black Lion Hospital, joined Gondar University Hospital. We look very much forward to collaborate with Dr Hussein and hope to support him in his new position. Discussions were held with the Dep of Surgery, Dr Miklol och Dr Mensur, Dep of Internal Medicine, Dr Tesfaye, Dr Workagegnehu and Dr Nebiyu, and Dep of Anaesthesia, Mr Amare, Mr Nigussie and Dr Hussein, on the coming site visit to Sweden and the plan for Swedish residents in anaesthesia and intensive care to come to Gondar during the autumn. For the visit to Sweden the preliminary plan is for Dr Nebiyu, Dr Hussein and Mr Amare to join us in Sweden for two weeks during late August/early September. Exact date needs to be settled. The process with visa application etc will then be initiated. For potential research areas we have not yet identified a specific project. Loose plans for a Swedish intern to do a research month in Gondar was discussed but soon after this the person was not more eligible as planned. We will continue to look for potential areas of common interest both in the field of anaesthesia and intensive care. During 2020 we look forward to welcoming our Gondar guests to Sweden and also meet in Gondar during the end of 2020 for a follow-up on thoracic anaesthesia and intensive care. Figure 2. Dr Hussein Endris, new anaesthesiologist in Gondar, together with Dr Yonathan Abebe, anaesthesiologists from Black Lion Hospital, Addis. Corresponding author; Jonna Idh, jonnaidh@yahoo.se. 5

APPENDIX A - Feedback Comment given by workshop participants upon a request to evaluate the workshop by writing one positive comment and one suggestion of improvement. If the same comment was given by more than one participant this is indicated with a figure in brackets. Positive feedback Yonathan, you are so friendly, I hope you stay here! Thank you for taking your time to prepare this. (3) I got basic skills in ICU care as well. The training was very good, please continue in the future. (3) Very interesting and helpful training. (12) It was amazing, thank you. (2) It gave a good understanding of modes in the ventilator. (1) Very nice training and useful time for me. Thank you for your collaboration with our department. This was a good scientific explanation and teaching technique. Good that the training was both theoretical and practical, it will help us deal with situations that we will face in the future. (2) Excellent, both the discussion and demonstration. Made us more comfortable in handling M.V and caring for patients in M.V. Keep up the good job. (3) Good to start with a lecture. It was good since I have been confused over the alarms in the M.V. I personally learnt a lot. (to intubate, to proceed with the machine, to follow the patient) The presentation was clear. It gave me a good start and I will get more out of studying after this. (3) A very good approach. Friendly appearance comfortable to learn. (2) Suggestions for the future Please give us handouts or papers for our continuous training. (3) Please extend the training to longer time. (6) Good with practical training. (4) Provide us material to read in advance. (3) Make it more than one day. (3) The presentation could be more interactive. We had a session in the morning, and we were a bit tired. The mannequin was not so good, and the laryngoscope stopped working. Would be better if we practiced on the real ventilator. (7) Include case-based discussions and how to set modes dependent on the diagnosis. (2) 6