My name is Dr. Benard Kenemo, anaesthesiologist and Head of Department at Bugando medical centre. My name is Dr. Rebecca Samwell, anesthesiologist from Bugando Medical Centre. Hi. My name’s Matt Bouwker. I’m a post CCT fellow in anaesthesia visiting and working at Bugando Hospital in Mwanza, Tanzania. Bugando Medical Centre is a tertiary referral research and teaching hospital which is located in the north and the western part of Tanzania. It has a bed capacity for 950 patients with a wide range for medical specialties. It has over 1,300 medical staff. The directors of surgery manages both inpatient, outpatients, with the various departments– a general surgery, ENT, cardiothoracic, obstetrics and gynaecology, orthopaedics, urology, paediatric surgery, neuro surgery, maxillofacial.
And our department offers anaesthesia throughout those departments. Besides that, it also provides anaesthesia services out of a property theatre for sedation, for procedures in endoscopy, in oncology , and also sedation in A&E. We have two anesthesiologists from Tanzania, and two working under contract who are coming from UK and one from Cuba. We have a total of 26 nurse anesthetists who have one year training of training in anaesthesia. We have drugs like adrenaline, ephedrine, atropine, ketamine, propofol, thiopentone, muscle relaxants. We have suxamethonium, pancuronium, atracurium, meperidine and morphine, as well as paracetamol. Our department also has a wide variety of machines which are started as machines for military and General Electric. Here is similar to any anaesthetic setting.
It’s usually prepared on a case by case basis including a variety of sizes of facemasks or oropharyngeal airways, nasapharyngeal airways. Laryngeal mask airways are available but are quite limited. Gum elastic bougies, again, are available, but in a limited supply. Through donations we’ve also obtained a video laryngoscope, a GlideScope, which is kept on the ICU. Investigations that are available include fine nasal endoscopy. However, this is sometimes of limited availability but can be obtained through communication with the ENT surgeons. CT Of the neck and airway is also available, but can sometimes depend on the financial situation of the patient, including insurance coverage. Difficult airways in Tanzania can in some ways be very similar to difficult airways in the UK or elsewhere.
The case mix can include thyroidectomies with large goitres, ENT surgeries such as tonsillectomies, foreign body aspiration, as well as diagnostic broncoscopies and laryngoscopies. So at BMC as well we also receive and encounter these patients who is difficult airway so frequently. They’re mostly, or a majority of patients we see with difficult airway are those patients with hydrocephalus. And those patients who come from maxillofacial, ENT patients who come with fairly huge neck masses. We encounter those patients who have facial trauma. We encounter those cases with airway malignancies like laryngeal tumours. We encounter patients with spine, both acute and chronic. They come with contractures on the neck, so it is also difficult to intubate those patients.
But also we have our oncology unit now growing here. So maybe sooner or later, we’ll be receiving those patients with radiotherapy who will come with difficult airways because of– they had been. Protocols for difficult airways have been developed for the ICU and are currently in development for the theatre setting. These are based primarily on the difficult airway society guidelines with some modifications reflecting some of the equipment limitations. We also offer training and mentorship through the hospitals by doing an average of one outreach service per week. But also we do the nurse training– one year training. In teaching the anaesthetic residents and nurse anaesthetists, we emphasise the importance of preoperative assessment and airway examination.
This is similar to airway assessment in the UK, including mallampati assessment, thyromental distance, mouth opening, as well as neck range of movement. We have started to introduce, through teaching in theatres and lectures, the assessment of the Calder Score to assess jaw protrusion. Teaching methods for the anaesthetic residents range from PBL type tutorials, theatre based teaching, as well as simulation teaching. We’ve recently obtained– as well as basic care resus Annie models– two iPads which can be used for interactive monitoring to increase the fidelity of simulations. And we can therefore simulate difficult airways. And it’s all– the important thing in order to avoid all those complications, the good thing that we should recognise is earlier.
And that’s what we do at our own station. We tried to recognise that earlier, and we prepare all the necessary equipment and they’re all available we have. Because due to the limited resources, we have limited resources at our institution to manage this difficult airway. But we prepare what we have, and then also we prepare the team. The anesthesiologists, the nurses, the ENT team, together, so in case we face difficulties, they can be there to do tracheostomy or other management.
Patients are anaesthetised in theatre. This can be problematic as there is very little in terms of facilities for optimization of patients. Patients are induced– laid flat on the theatre table with very limited pillows available to optimise their position. However, this can be an advantage, as any severe airway obstruction or strider can be elucidated by the patient being unable to tolerate this. One of the limitations in Bugando is the lack of availability of a flexible fibre optic scope. This limits the strategies available for an anticipated difficult airway. Techniques therefore consist of either a gas induction or a combination with IV induction and short acting muscle relaxants, or progressing directly to awake tracheostomy.
This is done as a purely local anaesthetic technique with very little sedation provided. Local anaesthetic is injected directly into the trachea via the ENT surgeons.
So, in summary, this is what we see and often we encounter at Bugando Medical Centre Anaesthesia Department, our daily practise. It’s much better as compared to Anaesthesia services offered in peripheral hospitals. Most of the challenges that the peripheral hospitals face– lack of expertise, trained Anaesthesia providers, and lack of protocols for difficult airway, as well as lack of equipment to manage difficulty airway, like bougies and laryngeal mask airways. Due to lack of knowledge, they just do sedation with atropine, ketamine, and diazepam. And if fairly– that’s the literal they can do, and majority do not even do intubations. And the Ministry of Health encourages to refer most of these difficult airways patients to referral centres like ours, Bugando Medical Centre.
But often we get late referrals, and most of the time we have to do a thorough preoperative assessment in order to discover these difficulty airways. In addition to referral system, we as Bugando Medical Centre– we offer mentorship to small hospitals in the region, so for them to be able to manage these difficult airways, as most of these occur as emergencies. So this is actually what we have been trying to offer as Bugando Medical Service, to help improve and minimise the complications that can arise from failure to manage difficult airways. Thank you.