
Mongolian Society of Anaesthetists/Australian Society of Anaesthetists Annual Australian-Mongolian Medical Project 2012, trip report In the week beginning June 18th 2012, a large group of Australian doctors, nurses and midwives spent one week providing didactic, interactive, simulation based and clinical teaching to our colleagues in Mongolia.
Through the workshops, it appeared that the Mongolians are becoming more proactive and demonstrative. The candidates, however do need a fair bit of prompting when it comes to role playing.
The group of volunteers consisted of 5 teams of people. Our "anaesthetic team" led by Dr David Pescod and Dr Amanda Baric taught at our annual MSA/ASA seminar, the theme of which was Anaesthetic Emergencies. The team members included Dr Ian Hogarth, Dr Hella Deifuss, Dr Elmo Mariampillai, Dr Roni Krieser, Dr Sam Kennedy, Dr Phillipa Hore, Dr Richard Clarke, Dr Sion Davies, Dr Debra Devonshire and Dr Roger Goucke. The seminar ran over two days (Monday 18th and Tuesday 19th of June).
Our Mongolian hosts were Dr Ganbold Lundeg, Dr Lkhagvajav Unurzaya (current MSA president) and Dr Batgombo. They arranged for the teaching to take place at the Health Sciences University in Ulaanbaatar and translated all the presentations into Mongolian to allow for dual projection of slides (English and Mongolian). The number of participants was about 90-100, which proved a challenge when we were divided into three groups for our workshops, particularly as one of the rooms was just big enough for twelve. A large group of anaesthetists were from Hospital number one, the main teaching hospital in UB, where elective surgery had been cancelled to allow their anaesthetists to attend our seminar. Most of the current cohort of trainees from the new anaesthesia program was present and about 20 doctors had traveled from remote parts of Mongolia to be there.
Monday's teaching began with a showing of "Just a Routine Operation", the story of Elaine Bromiley, who died from cerebral hypoxia after a can't intubate, can't oxygenate situation during general anaesthesia. The film was expertly subtitled by Dr Batgombo and was used to put the seminar into context. Much discussion was generated around the film during the two days. A short presentation on an approach to common problems, including how to avoid them and how to apply a systematic approach to problem solving under anaesthesia, was followed by workshops on cardiovascular problems including arrhythmias, ischaemic heart disease and disturbances of blood pressure under anaesthesia.
The afternoon session involved the showing of a video of an airway problem (high airway pressures and low saturation) followed by an interactive discussion led by Dr Ian Hogarth, who opened up dialogue with the audience to demonstrate a structured approach to a common intra-operative problem. Dr Roni Krieser then gave an excellent presentation on monitoring in anaesthesia. He was able to engage the audience by using prizes to reward those who contributed to the discussions and introduced capnography to an audience who had at best infrequently or at worst never seen it in use.
The afternoon workshops focused on airway emergencies and Dr Richard Clarke ran one on aspiration of gastric contents, Dr Deifuss led the skills station on surgical airway and Dr David Pescod led a workshop on airway obstruction, which created much conversation about how to avoid laryngeal spasm.
The second day of the seminar ran in a similar way; with a video of a crisis (anaphylaxis) followed by debrief by Dr Hogarth and Dr Deifuss. Dr Deifuss then delivered a lecture on the principles of crisis management. The lights went out towards the end of the crisis management lecture, so we all went to plan B - workshops in the break-out rooms, where there was ample natural light and white boards and markers. Although the initial plan for these workshops was to use PowerPoint as a visual aid, they ran exceptionally well, and the participants felt at ease, contributing to sometimes quite animated discussion! The topics covered were anaphylaxis, massive transfusion and postoperative neurologic deficit.
The afternoon session started with another video, consisting of a "patient" with airway obstruction in the recovery room. The workshops in the afternoon focused on recovery room problems including postoperative respiratory complications, delayed emergence, pain and postoperative nausea and vomiting.
Feedback from the participants and Mongolian hosts was positive overall and the breadth of material covered was wide. Each delegate received a hard copy of the seminar manual that was written and compiled by our team prior to arrival. It is a comprehensive manual that will become a resource for the participants, given the general lack of access to current texts and journals. They also received a USB stick with all the PowerPoint presentations and a p.d.f. version of the manual for future reference.
Dr Phillipa Hore wrote and distributed a survey for the participants to gain an understanding of what sized hospital they were from, what monitoring was available to them and what medications were in use to treat pain. The initial results suggest that there is a general paucity of monitoring equipment in the Mongolian hospitals. Oximetry is becoming more widely available, but the understanding of its use to guide treatment is incomplete. Capnography is generally not available. Morphine is available, but is not used commonly. Fentanyl is used much more commonly during procedures and there is a strong reliance on non-steroidal medication (albeit in alarmingly large doses). The other medications available for pain include paracetamol, local anaesthetics, ketamine, pentazocine and "Analgin".
Dr Roger Goucke, Ms Patricia Clarke and Dr Debra Devonshire formed the core of our "pain team". They spent time visiting the hospitals to gain a better understanding of current pain management and to teach about the treatment of acute pain. They spent time visiting Hospital Number One, Hospital Number three (which is the centre for cardiac and neurosurgery), the trauma hospital, the burns hospital and the cancer hospital.
On Wednesday 20th of June, members of the anaesthetic and pain team ran the first Essential Pain Management Course in Ulaanbaatar. A small group of Mongolian anaesthetists attended (8) to receive training in English and most returned on Thursday to attend the train the trainer course before they all ran the first ever Mongolian language EPM on Friday 22nd of June with 30 local participants. The local EPM was supervised by the Australian team who were very impressed with the quality of teaching delivered by our new Mongolian instructors.
Our general surgery team, (Mr Binh Nguyen and Dr Manash Patel), spent 4 days in the countryside teaching in the Khentii Aimag at Ondorkhaan hospital and performing clinical work. Ondorkhaan has a population of 15,000 however the catchment area includes 100, 000 living in smaller towns and nomadic farmers.
They worked alongside the local surgeon and anaesthetist. The hospital staff were keen to learn some general anaesthetic and airway management techniques. Mr Muhkbat, the only surgeon in Ondorrkhann was on call 24 hours 7 days a week, though other doctors are multi-skilled and the anaesthetist was able to do an appendicectomy.Dr Patel was able to demonstrate the use of laryngeal mask airways. There was no capnography available, but oximetry was in use. The Mongolian anaesthetists were very skillful at spinal anaesthesia but were very grateful for the opportunity to practice general anaesthesia. Mr Nguyen was able to perform over 14 procedures including open cholecystectomy, hernia repair and circumcision. Laparoscopic facilities were planned for Ondorkhaan in the future but currently was not available.
Mr Binh Nguyen observed that though scrubbing and gowning was done appropriately, there was no time out process and no obvious counting of instruments. The theatre lacked light handles and lights were adjusted by scout nurses. The set up lacked kidney dishes for transfer of scalpels, which were simply wrapped with gauze and handed to the surgeon. Needles were not guarded.
Overall, it was “an eye-opener” for Mr Binh, learning how surgery can be achieved in remote locations, and how doctors adapt to what they have. He would prefer to have spent a longer time.
The midwifery team spent 5 days teaching newborn resuscitation in First Maternity Hospital, which was the current location of the (very busy) Third Maternity Hospital that was closed for renovation. Interestingly, Third Maternity had been closed due to a series of deaths due to maternal sepsis. It was thought that this was due to the decrepit state of the building. Rhonda Keenan and Eleanor Teare were very busy teaching in large and small groups, as well as in the wards, where one-to-one instruction was given to medical and nursing staff, and students. The neonatologists were very grateful, as up until now, they have been the only ones qualified to perform newborn resuscitation and they were very understaffed for the number of deliveries that took place in the hospital.
Our Gynaecology surgery team was led by Dr Kym Jansen (obstetrician and gynaecologist) and Dr Phil Popham (anaesthetist). They were involved in presenting material at the international gynaecology seminar and then doing clinical work at First Maternity Hospital, where they operated on very complex cases, some of which were televised live to the conference. The other team members included Dr Emma Readman, Dr Stephen Lee, Dr Maggie Wong, Dr Kim Fuller and Dr David Dolan. Some of the team were able to visit the Maternal and Child Health Research Center, where they assessed the possibility of providing laparoscopic gynaecology surgery under general anaesthesia.
The obstetric team returned to Mongolia this year after an absence last year. Dr Rebecca Szabo, Dr Lauren de Luca and Dr Alexandra Miglic were our obstetricians. They visited both major maternity hospitals and were able to run some practical workshops on the use of vacuum for delivery and post partum haemorrhage. They visited the wards and did some in theatre clinical teaching. Their observations included the improvement of hand washing between patients (with the installation of alcoholic handwash dispensers throughout clinical areas), and they demonstrated some safe sharps handling that was taken up by the local obstetrician. Given the widespread problem of maternal sepsis and hospital-acquired blood borne infection (particularly hepatitis B and C) this was a major step forward. There are plans to utilize the obstetricians more effectively next year and run an international obstetric meeting in Ulaanbaatar (the first).
The areas of need in Mongolia include:
- Improving the availability and teaching of the use of intra and postoperative monitoring, including management of hypoxia and perturbations in physiologic parameters
- Improving airway management techniques
- Improving the safety and maintaining anaesthetic machines, other equipment and hospital supply of gases and suction.
-Improving the use of analgesic agents (particularly limiting the use of very high doses of non-steroidal anti-inflammatory medications)
-Improving availability of monitoring of patients receiving opioids for analgesia and education in recognizing and treating respiratory depression (the fear of which is a major barrier to the effective use of opioid analgesics). Increasing access to naloxone.
- Increasing the use of intrapartum monitoring in labour ward, where there is little if any monitoring of the fetus. Teaching the correct interpretation of CTG monitoring
- Improving the use of good surgical and perioperative techniques to avoid postoperative infection and hospital acquired infection
The following equipment and material was donated to our hosts and volunteers to use for teaching:
Two Mama Natalie simulation dolls to teach PPH management and Vacuum extraction and one newborn resuscitation manikin for teaching newborn resucitation donated by Interplast Australia.
Two Nonin oximeters one for the Khentii Aimag hospital and one to First Maternity hospital (thanks to Abbott and Device Technologies for funding)
One Airway Resuscitation Kit that went to the Khentii Aimag hospital (with thanks to Abbott and Solmed)
Finger pulse oximeters (for Khentii Aimag, MCHRC and First Maternity Hospitals) donated by Abbott
One VGA projector for the Mongolian Society of Anaesthetists to use for teaching (donated by Abbott)
USB sticks loaded with teaching material for both the Emergencies in Anaesthesia and Essential Pain Management (donated by Abbott)
Two boxes of spinal needles (for MCHRC and First Maternity Hospitals) donated by The Northern Hospital
Disposable self-inflating bags and masks, laryngeal masks and endotracheal tubes
Disposable laryngoscopes for the paediatric, maternity and Khentii Aimag hospitals (from Multigate Medical Devices)
Many thanks go to all of our hosts, volunteers and generous donors who have made this project so successful. We anticipate an equally successful project in 2013, when we anticipate the extension of our project into emergency care (first aid and basic emergency care prior to transfer), continuation of EPM, newborn resuscitation, surgical teaching, laparoscopy for gynaecology and obstetric care.
Through the workshops, it appeared that the Mongolians are becoming more proactive and demonstrative. The candidates, however do need a fair bit of prompting when it comes to role playing.
The group of volunteers consisted of 5 teams of people. Our "anaesthetic team" led by Dr David Pescod and Dr Amanda Baric taught at our annual MSA/ASA seminar, the theme of which was Anaesthetic Emergencies. The team members included Dr Ian Hogarth, Dr Hella Deifuss, Dr Elmo Mariampillai, Dr Roni Krieser, Dr Sam Kennedy, Dr Phillipa Hore, Dr Richard Clarke, Dr Sion Davies, Dr Debra Devonshire and Dr Roger Goucke. The seminar ran over two days (Monday 18th and Tuesday 19th of June).
Our Mongolian hosts were Dr Ganbold Lundeg, Dr Lkhagvajav Unurzaya (current MSA president) and Dr Batgombo. They arranged for the teaching to take place at the Health Sciences University in Ulaanbaatar and translated all the presentations into Mongolian to allow for dual projection of slides (English and Mongolian). The number of participants was about 90-100, which proved a challenge when we were divided into three groups for our workshops, particularly as one of the rooms was just big enough for twelve. A large group of anaesthetists were from Hospital number one, the main teaching hospital in UB, where elective surgery had been cancelled to allow their anaesthetists to attend our seminar. Most of the current cohort of trainees from the new anaesthesia program was present and about 20 doctors had traveled from remote parts of Mongolia to be there.
Monday's teaching began with a showing of "Just a Routine Operation", the story of Elaine Bromiley, who died from cerebral hypoxia after a can't intubate, can't oxygenate situation during general anaesthesia. The film was expertly subtitled by Dr Batgombo and was used to put the seminar into context. Much discussion was generated around the film during the two days. A short presentation on an approach to common problems, including how to avoid them and how to apply a systematic approach to problem solving under anaesthesia, was followed by workshops on cardiovascular problems including arrhythmias, ischaemic heart disease and disturbances of blood pressure under anaesthesia.
The afternoon session involved the showing of a video of an airway problem (high airway pressures and low saturation) followed by an interactive discussion led by Dr Ian Hogarth, who opened up dialogue with the audience to demonstrate a structured approach to a common intra-operative problem. Dr Roni Krieser then gave an excellent presentation on monitoring in anaesthesia. He was able to engage the audience by using prizes to reward those who contributed to the discussions and introduced capnography to an audience who had at best infrequently or at worst never seen it in use.
The afternoon workshops focused on airway emergencies and Dr Richard Clarke ran one on aspiration of gastric contents, Dr Deifuss led the skills station on surgical airway and Dr David Pescod led a workshop on airway obstruction, which created much conversation about how to avoid laryngeal spasm.
The second day of the seminar ran in a similar way; with a video of a crisis (anaphylaxis) followed by debrief by Dr Hogarth and Dr Deifuss. Dr Deifuss then delivered a lecture on the principles of crisis management. The lights went out towards the end of the crisis management lecture, so we all went to plan B - workshops in the break-out rooms, where there was ample natural light and white boards and markers. Although the initial plan for these workshops was to use PowerPoint as a visual aid, they ran exceptionally well, and the participants felt at ease, contributing to sometimes quite animated discussion! The topics covered were anaphylaxis, massive transfusion and postoperative neurologic deficit.
The afternoon session started with another video, consisting of a "patient" with airway obstruction in the recovery room. The workshops in the afternoon focused on recovery room problems including postoperative respiratory complications, delayed emergence, pain and postoperative nausea and vomiting.
Feedback from the participants and Mongolian hosts was positive overall and the breadth of material covered was wide. Each delegate received a hard copy of the seminar manual that was written and compiled by our team prior to arrival. It is a comprehensive manual that will become a resource for the participants, given the general lack of access to current texts and journals. They also received a USB stick with all the PowerPoint presentations and a p.d.f. version of the manual for future reference.
Dr Phillipa Hore wrote and distributed a survey for the participants to gain an understanding of what sized hospital they were from, what monitoring was available to them and what medications were in use to treat pain. The initial results suggest that there is a general paucity of monitoring equipment in the Mongolian hospitals. Oximetry is becoming more widely available, but the understanding of its use to guide treatment is incomplete. Capnography is generally not available. Morphine is available, but is not used commonly. Fentanyl is used much more commonly during procedures and there is a strong reliance on non-steroidal medication (albeit in alarmingly large doses). The other medications available for pain include paracetamol, local anaesthetics, ketamine, pentazocine and "Analgin".
Dr Roger Goucke, Ms Patricia Clarke and Dr Debra Devonshire formed the core of our "pain team". They spent time visiting the hospitals to gain a better understanding of current pain management and to teach about the treatment of acute pain. They spent time visiting Hospital Number One, Hospital Number three (which is the centre for cardiac and neurosurgery), the trauma hospital, the burns hospital and the cancer hospital.
On Wednesday 20th of June, members of the anaesthetic and pain team ran the first Essential Pain Management Course in Ulaanbaatar. A small group of Mongolian anaesthetists attended (8) to receive training in English and most returned on Thursday to attend the train the trainer course before they all ran the first ever Mongolian language EPM on Friday 22nd of June with 30 local participants. The local EPM was supervised by the Australian team who were very impressed with the quality of teaching delivered by our new Mongolian instructors.
Our general surgery team, (Mr Binh Nguyen and Dr Manash Patel), spent 4 days in the countryside teaching in the Khentii Aimag at Ondorkhaan hospital and performing clinical work. Ondorkhaan has a population of 15,000 however the catchment area includes 100, 000 living in smaller towns and nomadic farmers.
They worked alongside the local surgeon and anaesthetist. The hospital staff were keen to learn some general anaesthetic and airway management techniques. Mr Muhkbat, the only surgeon in Ondorrkhann was on call 24 hours 7 days a week, though other doctors are multi-skilled and the anaesthetist was able to do an appendicectomy.Dr Patel was able to demonstrate the use of laryngeal mask airways. There was no capnography available, but oximetry was in use. The Mongolian anaesthetists were very skillful at spinal anaesthesia but were very grateful for the opportunity to practice general anaesthesia. Mr Nguyen was able to perform over 14 procedures including open cholecystectomy, hernia repair and circumcision. Laparoscopic facilities were planned for Ondorkhaan in the future but currently was not available.
Mr Binh Nguyen observed that though scrubbing and gowning was done appropriately, there was no time out process and no obvious counting of instruments. The theatre lacked light handles and lights were adjusted by scout nurses. The set up lacked kidney dishes for transfer of scalpels, which were simply wrapped with gauze and handed to the surgeon. Needles were not guarded.
Overall, it was “an eye-opener” for Mr Binh, learning how surgery can be achieved in remote locations, and how doctors adapt to what they have. He would prefer to have spent a longer time.
The midwifery team spent 5 days teaching newborn resuscitation in First Maternity Hospital, which was the current location of the (very busy) Third Maternity Hospital that was closed for renovation. Interestingly, Third Maternity had been closed due to a series of deaths due to maternal sepsis. It was thought that this was due to the decrepit state of the building. Rhonda Keenan and Eleanor Teare were very busy teaching in large and small groups, as well as in the wards, where one-to-one instruction was given to medical and nursing staff, and students. The neonatologists were very grateful, as up until now, they have been the only ones qualified to perform newborn resuscitation and they were very understaffed for the number of deliveries that took place in the hospital.
Our Gynaecology surgery team was led by Dr Kym Jansen (obstetrician and gynaecologist) and Dr Phil Popham (anaesthetist). They were involved in presenting material at the international gynaecology seminar and then doing clinical work at First Maternity Hospital, where they operated on very complex cases, some of which were televised live to the conference. The other team members included Dr Emma Readman, Dr Stephen Lee, Dr Maggie Wong, Dr Kim Fuller and Dr David Dolan. Some of the team were able to visit the Maternal and Child Health Research Center, where they assessed the possibility of providing laparoscopic gynaecology surgery under general anaesthesia.
The obstetric team returned to Mongolia this year after an absence last year. Dr Rebecca Szabo, Dr Lauren de Luca and Dr Alexandra Miglic were our obstetricians. They visited both major maternity hospitals and were able to run some practical workshops on the use of vacuum for delivery and post partum haemorrhage. They visited the wards and did some in theatre clinical teaching. Their observations included the improvement of hand washing between patients (with the installation of alcoholic handwash dispensers throughout clinical areas), and they demonstrated some safe sharps handling that was taken up by the local obstetrician. Given the widespread problem of maternal sepsis and hospital-acquired blood borne infection (particularly hepatitis B and C) this was a major step forward. There are plans to utilize the obstetricians more effectively next year and run an international obstetric meeting in Ulaanbaatar (the first).
The areas of need in Mongolia include:
- Improving the availability and teaching of the use of intra and postoperative monitoring, including management of hypoxia and perturbations in physiologic parameters
- Improving airway management techniques
- Improving the safety and maintaining anaesthetic machines, other equipment and hospital supply of gases and suction.
-Improving the use of analgesic agents (particularly limiting the use of very high doses of non-steroidal anti-inflammatory medications)
-Improving availability of monitoring of patients receiving opioids for analgesia and education in recognizing and treating respiratory depression (the fear of which is a major barrier to the effective use of opioid analgesics). Increasing access to naloxone.
- Increasing the use of intrapartum monitoring in labour ward, where there is little if any monitoring of the fetus. Teaching the correct interpretation of CTG monitoring
- Improving the use of good surgical and perioperative techniques to avoid postoperative infection and hospital acquired infection
The following equipment and material was donated to our hosts and volunteers to use for teaching:
Two Mama Natalie simulation dolls to teach PPH management and Vacuum extraction and one newborn resuscitation manikin for teaching newborn resucitation donated by Interplast Australia.
Two Nonin oximeters one for the Khentii Aimag hospital and one to First Maternity hospital (thanks to Abbott and Device Technologies for funding)
One Airway Resuscitation Kit that went to the Khentii Aimag hospital (with thanks to Abbott and Solmed)
Finger pulse oximeters (for Khentii Aimag, MCHRC and First Maternity Hospitals) donated by Abbott
One VGA projector for the Mongolian Society of Anaesthetists to use for teaching (donated by Abbott)
USB sticks loaded with teaching material for both the Emergencies in Anaesthesia and Essential Pain Management (donated by Abbott)
Two boxes of spinal needles (for MCHRC and First Maternity Hospitals) donated by The Northern Hospital
Disposable self-inflating bags and masks, laryngeal masks and endotracheal tubes
Disposable laryngoscopes for the paediatric, maternity and Khentii Aimag hospitals (from Multigate Medical Devices)
Many thanks go to all of our hosts, volunteers and generous donors who have made this project so successful. We anticipate an equally successful project in 2013, when we anticipate the extension of our project into emergency care (first aid and basic emergency care prior to transfer), continuation of EPM, newborn resuscitation, surgical teaching, laparoscopy for gynaecology and obstetric care.