Zambezia (1987), XIV (li).ANAESTHETICS: FRUSTRATIONS, HOPESAND REWARDSH. M. CHINYANGADepartment of Anaesthetics, University of ZimbabweI WILL START my lecture tonight by giving you a summary of its conclusions. Thisis to avoid the possibility that some members of this audience may be overcomeby its sterility and thus fall asleep before I finish. The message I wish to get acrosswould therefore be lost, or received in a distorted fashion, depending on the levelof cortical depression those individuals will have reached.I am going to recommend the following: Firstly, that a post-graduate trainingprogramme in anaesthetics should be established here in Zimbabwe withoutdelay. Secondly, that the course and examinations should be local; both shoulddraw from experience gained in Africa and abroad. Thirdly, that every effortshould be made to inform and encourage both medical students and graduates ofthe Medical School to join the local training programme since this is the onlylogical way that improvement in anaesthetic coverage can be achieved in areasonable time. Fourthly, that we should be prepared to spend money on thisproject since the strength of the discipline of surgery depends on stronganaesthetic services.The speciality of anaesthetics goes back to antiquity, the time when a 'deepsleep' was 'made to fall upon him'. The 'him' was an innocent and well-meaningyoung man named Adam. During the 'deep sleep' Adam's twelfth rib wasresected for cloning Eve. Following this major operation and its outcome, therewas never a dull moment in the Garden of Eden.The other major recorded milestones in the development of anaesthesia are:Firstly, on 30 March 1842, in Boston Massachusetts, Crawford Long adminis-tered ether to James Venable for the removal of a lump in his neck. Then, on 18October 1846, at Massachusetts General Hospital, Dentist William T. Mortonremoved a lump from the jaw of a man who was under the effects of ether. Inrecognition of this contribution to anaesthetics, the inscription on Morton's tombreads:Inventor and revealor of anaesthetic inhalation.By whom Pain in Surgery was Averted and annulled.* An inaugural lecture delivered as Professor of Anaesthetics before the University of Zimbabweon 9 October 1986.9394ANAESTHETICS: FRUSTRATIONS, HOPES AND REWARDSBefore who in all times, surgery was agony.Since whom science has control of pain.Acceptance and status came to the speciality in 1883. Chloroform wasadministered to Queen Victoria of England for the delivery of Prince Leopold.John Snow was the anaesthetist.Ether, being safer and easier to use than chloroform, became the agent ofchoice in the USA while chloroform was used more in the UK and its colonies.This resulted in the situation in which the administration of 50 per cent of theanaesthetics in the USA is carried out by non-physician anaesthetists, while onlyphysicians administer all anaesthetics in the UK and Canada. In this country wehave both physician and noe-physician anaesthetists. The decision for this wasbased on more complex arguments than the comparative ease of administeringthe two anaesthetics. Chloroform because of its toxicity is now used only inanimals.The principal tasks of the anaesthetist are to provide relief from pain to thepatient and optimal operative conditions for the surgeon. Both should be done inthe safest possible manner. I am aware that my surgical colleagues will deny that'optimal operative conditions' are ever achieved! Be that as it may, theseconditions can be achieved by either general or regional anaesthetic techniques ora combination of the two. It should be the aim of every anaesthetist to be acompetent physician and a clinical pharmacologist, with a broad knowledge ofsurgery, and he/she should be able to utilize and interpret correctly a variety ofmonitoring devices.The anaesthetist combines a knowledge of the patients' diseases, the drugstaken, the demands of the operation, and the patients' concern, in order to arriveat the proper choice of anaesthetic agents and techniques.The monitoring devices he or she uses in the operating theatre have beenmodified and extended for use in the care of the critically ill patients in intensivecare units. Here he remains a leading member of a highly specialized team ofmedical experts practising emergency medicine.The responsibilities and scope of anaesthetics continue to expand as moreadvances are made in the understanding of disease and of its management. Theseare: surgery Š including neurosurgery, cardiothoracic, obstetrics, paediatrics,transplant, ambulatory, cranio-facial and plastic, and hypothermia and hypoten-sive techniques Š pain clinics, cardiopulmonary resuscitation, and intensive-caremedicine.Some months before I came to Zimbabwe I wrote to the then Chairman of theDepartment of Anaesthetics asking him how many qualified anaesthetists therewere in Harare and the country as a whole. Following enquiries from the medicalregistration authorities the answers were that in Harare there were between 20H.M. CHINYANGA95and 24, and in Zimbabwe, 28 to 30. There were eight full-time university andgovernment anaesthetists.Until January 1986 the only existing local training programme in anaes-thetics mounted in the environment of the University was the one-year diplomacourse for nurse anaesthetists which was started in 1978 when the problem ofrecruitment became evident. The total number of graduates from this diplomacourse is twenty-four. Thirteen are still practising anaesthetics while eleven aredoing something else or have left the country. The reasons for the high drop-outrate are: there is no significant increase in remuneration in recognition of thegraduate's special skills; there is no promotion scale; and the public image of thesespecialists is confused. In the United States of America fifty per cent of the twentymillion anaesthetics given annually are administered by non-physician anaes-thetists. There is a close nurse-physician relationship. In this country the nurseanaesthetist programme continues to be a subject of debate and review, yet thecontribution made by the graduates is unquestionable, in spite of their poormorale.Until the beginning of this year the Department of Anaesthetics had had nolocal post-graduate training programme in anaesthetics. The Department hasassisted those who showed interest in anaesthetics by mounting a course ofseminars in anaesthetics. The course prepared the candidates to sit for the BritishFellowship Part I examinations in anaesthetics, after which they carried on theirtraining abroad. During all that time the local services lost their ever-growingskills. Also, for reasons difficult to understand, Black Zimbabwean physicians didnot feature prominently, if at all, in this project. Worse still is the fact that none ofthe graduates of the preparatory course has yet applied to the Ministry of Healthoffering his services upon successful completion of their training. This trend mustchange.The responsibilities of the Division of Anaesthetics are incredible. At HarareHospital there are over 20,000 deliveries a year, close to 300 Caesarean sections amonth, and over 10,000 local blocks, 2,000 emergencies and 250ICU admissionsper year. All this is supervised by only eight specialists!Armed with this knowledge it is easier to understand the suggestions whichhave been put forward in the last year. This follows a visit by a two-memberBritish team of anaesthetists invited to Harare in an attempt to help find solutionsto the anaesthetist manpower crisis. This visit was sponsored by the BritishCouncil.My British colleagues made the following observations. The scope andvolume of surgery at the two teaching hospitals would make it attractive as anexcellent teaching and research centre for anaesthetists at various levels oftraining. The problem of staffing the Department is mainly due to the absence of alocal complete post-graduate training programme and examination. (The junior96ANAESTHETICS: FRUSTRATIONS, HOPES AND REWARDSstaff stay for six months to one year only.) The lack of experienced middle-levelstaff puts a heavy clinical and teaching load on the consultants. The medicalstudents have insufficient exposure to the speciality of anaesthesia to stimulateand hold their interest enough to make them take up anaesthesia as their ownspeciality. Finally, they observed that a policy needs to be formulated onanaesthetic equipment and drug supply.The following proposals were put forward for consideration: that anequipment committee be set up to formulate a policy on the ordering ofequipment and the development of a reliable 'on site' maintenance service; thatqualified staff be recruited to assist in the development of the anaesthetic trainingprogramme in Zimbabwe; and that suitable training positions should be identifiedin the UK for suitable junior staff to attain higher qualifications and experiencebefore returning to Zimbabwe. It was further proposed that the teaching ofanaesthesia be expanded to medical students in the earlier years of their training,and that a six-month or one-year exchange programme be developed withsuitable hospitals in the UK. The long-term goal should be to establish at theUniversity of Zimbabwe a higher qualification in anaesthesia which will haveinternational standing.It is clear that a post-graduate training programme should be started inZimbabwe as soon as possible, as this is the only way of ensuring the developmentof a consistent supply of intermediate-level expertise and experience in theDivision of Anaesthesia for teaching and clinical purposes. The development ofthe local post-graduate training and examinations will follow similar lines to thatof the local ongoing M.Med. training in Surgery and in Obstetrics andGynaecology. Experience will be drawn from similar projects in Lagos andIbadan in Nigeria, in Nairobi, Kenya and in Khartoum, Sudan. The steps to befollowed in setting up such a programme will not be new, but the British staffinvolved should be carefully selected so as to ensure their suitability to such a roleand their adaptability to the Southern African environment. The main aim andprimary objective of the project is to make Zimbabwe, particularly thegovernment services and outposts (growth points), become self-sufficient inwell-trained anaesthetists. The result of such a project should become self-evidentin a reasonable space of time.The establishment of a training programme locally has become more urgentas training centres abroad are only producing a trickle of experts at a time. Also,serious cutbacks have taken place, or are about to, in overseas training posts in theUK and North America. Graduates trained abroad tend to have difficulty settlingback in their own countries and, therefore, tend to be lost to institutions abroad. Itis better for the trainees to do their basic training in Zimbabwe. After that theyshould be sent to carefully selected centres abroad for special experience inimportant aspects of the speciality.H.M. CHINYANGA97It is hoped that the climate is right for links to be developed between theDepartment of Anaesthetics of the University of Zimbabwe Medical School andselected universities and training hospitals in the UK. The main aim of the linkswill be the establishment, at the University of Zimbabwe, of a higher qualificationin anaesthetics as soon as possible. The qualification will be in line with similarestablished specialist qualifications which have international recognition. TheDiploma in Anaesthetics (Zimbabwe) started this year should be seen not as anend in itself but the beginning of such a course.It is hoped that the majority of the graduates from that programme will becitizens of Zimbabwe and that their presence will raise the quality and safety ofthe delivery of anaesthetics in Government Hospitals and services in general inZimbabwe. They will provide better supervision and training to the existingnon-physician anaesthetic staff who are, and for a long time to come will be,responsible for the delivery of a large percentage of anaesthetics in this country.The programme of events for the future reads as follows: firstly, the evaluationand upgrading of teaching facilities in the Department of Anaesthetics and in theteaching hospitals; secondly, the formalization of the necessary documents torecognize the University Medical School Teaching Hospitals for post-graduatetraining in anaesthetics. Thirdly, the decision on the date the programme willformally start, with the education syllabus in place and a timetable forexamination certification; and, finally, a review process to ensure that the originalspirit of the project is maintained during the formative years and thereafter.The opportunities for research in anaesthetics are unlimited. As yet, themechanism by which anaesthetics act is still unknown 130 years after theirdiscovery, ignoring the case of young Adam mentioned earlier. Curare was alaboratory curiosity for nearly ninety years until anaesthetists put it to use inanaesthesia. Every patient to whom an anaesthetic is administered presents theopportunity for recording clinical observations and accumulating data, providingthat the ethics of research are observed.Research has moved further from the traditional areas of cardio-respiratorysystems to include biochemical, metabolic, pharmacokinetic, cellular andimmunological effects. Anaesthesia bridges the gap between basic science andclinical practice. It is the discipline most suited to reinforce information learnt inbiochemistry, physiology and pharmacology in the context of patient's diseaseand care.In the intensive care unit an ideal setting is available to teach ventilatorycontrol, adequacy of respiratory gas exchange, circulatory monitoring, care of thecomatose, assesment of levels of consciousness and fluid balance. A high level ofmanual dexterity and calm rational action in the face of crisis should be thehallmarks of successful members of this speciality. All university departments ofanaesthetics should seek highly-qualified anaesthetists interested in teaching, in98ANAESTHETICS: FRUSTRATIONS, HOPES AND REWARDSresearch, as well as in clinical practice geared towards imparting knowledge andskill to the trainee.Surgeons and anaesthetists constitute a team of physicians dedicated to thewelfare of the surgical patient whose interest is best served if each member of theteam recognizes his or her responsibilities yet remains aware of problems faced bycolleagues. Recruitment into anaesthesia has been a chronic problem because thespeciality lacks glamour to the student unfamiliar with its scope. It is achallenging, interesting speciality compatible with a pleasant family life. I am suremy wife is saying, 'Really?'