ASRA Pain Medicine Update

As a former Health Volunteers Oversees – Society for Education in Anesthesia traveling fellow, I was delighted to have the opportunity to chat with Dr. Niyant Jain about his experience in Kumasi, Ghana. Our conversation brought back many memories of my time teaching anesthesia in Blantyre, Malawi, in 2015.  As a final-year anesthesia resident, I was delighted to test my clinical skills in a challenging environment and even more thrilled to be able to share some of my knowledge with the anesthesia trainees. I found the entire experience immensely rewarding, and I constantly reflect on how my time in Malawi has influenced my current practice. 

My time in Malawi allowed me to practice anesthesia in a resource-limited setting in a controlled fashion, and, in my opinion, it prepared me to face some of the supply chain and personnel limitations brought on by the COVID pandemic.  Also, I often draw on my global health experiences when teaching residents and medical students to encourage them to think outside the box and not be overly reliant on some of the more sophisticated medical technologies we often take for granted in the United States. 

Dr. Jain is a regional anesthesia fellow at the University of Pittsburgh Medical Center. I hope you enjoy reading his reflections on his time in Ghana teaching regional anesthesia and pain medicine as part of ASRA Pain Medicine’s Global Health Fellowship.

Nenna Nwazota, MD
Newsletter Liaison

Reflections on a Global Health Fellowship in Ghana

Niyant Jain, MD
Fellow, Regional Anesthesiology and Acute Pain Medicine
University of Pittsburgh Medical Center, Pittsburgh, PA

Over the past few decades, major strides have been made to improve global health, particularly in the treatment and prevention of communicable disease. Nevertheless, the World Health Organization suggests that within the next few decades, the global burden of disease from malaria, tuberculosis, and HIV will be surpassed by diagnoses requiring surgical intervention. The Lancet Commission on Global Surgery adds that “embedding surgery within the global health agenda, catalyzing political change, and defining scalable solutions for provision of quality surgical and anesthesia care for all” must be prioritized over the coming years.¹

Formal residency and fellowship training in anesthesiology is challenging. It is the final phase of education before becoming a consultant in anesthesiology. During the rigorous transformation from medical student to physician, trainees become self-directed learners and detail-oriented, professional, and academically robust, all while learning how to become clinically sound. Thousands of hours are spent in the hospital, and it becomes easy to lose focus and difficult to balance one’s extracurricular interests, aspirations, and passions. Although many anesthesia trainees have an interest in global health and humanitarian outreach, it can be daunting trying to gain firsthand experience working in low- and middle-income countries.

Rotations like the ASRA Pain Medicine Global Health Fellowship provide opportunities for anesthesia fellows to pursue these interests. As the 2022 ASRA Pain Medicine Global Health fellow, I spent two weeks at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. I participated in training and educating KATH anesthesia faculty, residents, and medical students, and I experienced firsthand the unique challenges to delivery of safe regional anesthesia and effective pain medicine in this setting. I worked alongside Hospital for Special Surgery faculty including anesthesiologists specializing in regional anesthesia and chronic pain management and an orthopedic surgeon.

Photo 1: A group photo outside of the Accident and Emergency Department at KATH with members of the KATH orthopedic and anesthesia team 

The care provided by anesthesiologists at KATH is exceptional given their resource limitations, and I observed several differences in the practice of anesthesia there compared to the United States. Over 10,000 anesthetics are performed at KATH each year, and almost half are performed under spinal anesthesia. This made sense when I noted the scarcity of capnography and complete lack of arterial line transducers in the operating theatres. If a surgical case can be performed under spinal anesthesia, then general anesthesia will be avoided. Also, it is rare to administer sedation after a neuraxial block.  There is no patient expectation to not “hear or remember” anything after a regional or neuraxial anesthetic, which is a common desire among patients in the United States.

Although in 2015, fewer than 150 of the roughly 10,000 anesthetics were performed under regional anesthesia, the utilization of regional anesthesia is growing at KATH. Over the years, a reproducible training model for resource-limited settings called Global Regional Anesthesia Curricular Engagement (GRACE) has been implemented.² With GRACE, regional anesthesia as the primary anesthetic has become more common and standardized. In addition to teaching regional anesthesia as part of GRACE, I helped lay preliminary groundwork for the development of scalable models of training for chronic pain management. Chronic pain management is still in its infancy in Ghana, and the Ghana College of Surgeons and Physician recently established a combined, two-year regional anesthesia and chronic pain management fellowship.

The importance of capacity building and creation of sustainable care models was reinforced during my time there. Building relationships with hospital administration, pursuing interprofessional development with other specialties, forging partnerships with global health organizations, continuously assessing needs and adjusting accordingly, and learning from the current system are paramount to strengthen care.

Photo 2 (from left to right): Drs. Ofungwu (KATH regional and interventional pain fellow), Grose (orthopedic surgery, Hospital for Special Surgery), Jain (ASRA Pain Medicine fellow), and Singh (pain management, Hospital for Special Surgery) enjoying a quick break from the operating theatres. Of note, a halothane vaporizer is on the table. 

There are countless takeaways from my time at KATH. I learned so much from the clinical and hands-on skills honed by healthcare providers without the “crutch” of technology and ample resources. I have made an enduring network of people who are passionate about global health. ASRA Pain Medicine’s support significantly defrayed costs and eliminated the financial stress of my rotation. Without this opportunity, I am not sure I would have had the chance to get involved in global health during my training. This fellowship allows trainees without global health opportunities within their training program to participate in the delivery of anesthesia in developing countries and contribute to the development of education and clinical care programs in resource-limited settings.

I encourage all trainees to become involved in ASRA Pain Medicine and, if interested, its Global Health and Regional Anesthesia Special Interest Group. It may be difficult for a trainee to travel during residency; rest assured, global humanitarian outreach is achievable both at home and abroad and there is a need for more anesthesiologists to become involved. I am thankful for this opportunity and appreciate the support from both ASRA Pain Medicine and the leadership within my fellowship program to make it possible.

References

1. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386(9993):569-624. https://doi.org/10.1016/S0140-6736(15)60160-X.

2. Brouillette MA, Aidoo AJ, Hondras MA, et al. Regional anesthesia training model for resource-limited settings: a prospective single-center observational study with pre–post evaluations.” RegAnesthPain Med 2020; 45(7):528–35. https://doi.org/10.1136/rapm-2020-101550.