Safer anaesthesia and pain-free treatment for Malawians thanks to Jonty

Q: Can you tell us how long you’ve been in practice and where you currently work?

A: Since qualifying two years ago I have been working as an anaesthetist in a hospital in Ipswich which is in the east of the UK. During that period however I have spent 6 months in Malawi.

Q: What inspired you to join Operation Smile and volunteer for three months in Malawi?

A: I’d heard of Operation Smile through a fellow anaesthetist, Clive Duke, who works at a hospital close by. He spoke very positively of the organisation and told me that they had been looking for someone who could help out in Malawi. This sounded like an exciting opportunity so I took it a step further and contacted Operation Smile to discuss what the possibilities were for a placement in Malawi and how we could work together.

Q: What did you do during your 3-month placement in Malawi?

A: As well as being involved in the cleft lip and palate programme, I worked at The Queen Elizabeth Central Hospital in Blantyre in the anaesthetic department, on weekdays. Each morning at handover there were usually 40 to 50 staff – most of whom were trainees or relatively junior staff. We discussed all the cases for the day, what was complex, what was going to need additional support (usually from myself) and any plans we had. The staff would go into their teams, and I’d discuss any perceived complications. We then had some impromptu or formal training on subjects such as ultrasound machines or basic airway skills.

Friday was the official teaching day, when we had a group of anaesthetic registrar trainees who were due to have exams in September. Their exams are based on those I was required to do in the UK. These were my main duties along with covering intensive care, but it was really on-the-job training and support in a variety of different ways on a daily basis, seizing learning opportunities as they arose.

Q: What do you think is the greatest need in Malawi from an anaesthesia point of view?

A: With regard to anaesthesia, the need is for sustained support from highly-trained, qualified and experienced practitioners. In the UK, from the early stages of medical school you are, for the most part supported by consultant grade doctors. They guided us in best practice medicine, suggesting alternative methods if/when appropriate. In Malawi this level of support does not appear to be available.

Q: What was your biggest achievement during that 3-month placement?

A: The greatest achievement for me, and certainly the greatest achievement of anything I’ve ever done, was the work I did on the burns unit. It was mentioned when I arrived about improving analgesia for the patients in the burns unit, which were nearly all children, mostly toddlers between the ages of one and three. I firstly began looking into different options for pain relief and it became quite clear that ketamine, which is a drug that is very good in certain situations, and is usually readily available and, given orally, is very safe. It was therefore the obvious drug of choice.

I spent many hours going between working in theater and visiting the burns unit. I began giving oral ketamine to the children on the unit before their dressings were changed. Dressing changes in burns patients are well known as being probably one of the most painful things imaginable to a human and they were essentially not getting pain relief for that process. They were being given paracetamol and some oral morphine, but they had become tolerant to it so rapidly that it had become almost completely useless. When it was burns dressing change time, the ward was just full of screaming toddlers, which I found very distressing.”

I worked very closely with the nurses and matron on the unit and over those three months I was there, we developed a protocol to which they had a lot of input and were really happy with. We discussed a potential range of varying situations and who they should be targeting. We trialed it with a varied range of people and in a supported way. This protocol has continued, and the nurses have carried on using this procedure. I continue to be in contact with them on pretty much a weekly basis. It had apparently been quite rare to get any anaesthetic support in the burns unit in the past so it was very important to try and encourage it to be nurse-led. They are a very dynamic, hardworking, and competent group of nurses who wanted to help. Whilst there I got to know the parents of some of the children really quite well and they absolutely loved this new procedure and so it was a really good and hopefully, sustainable change.

Dr Jonty Dean

Q: Can you tell us about the surgical programme you attended in Malawi, in Mzuzu? 

A: I was very impressed with the logistics of the programme and how we got all those people into one place.  There’s a very thorough pre-assessment process which meant we were able to pick up on all kinds of other conditions that weren’t already known about. The whole thing flowed very nicely – there were some problems as there always will be but we managed to solve those and still get all the operations done. Seeing all the patients coming back again post-operatively was good! A very positive experience!”

Q: What’s your favourite memory from your experience in Malawi? Is there a particular patient story that stands out for you?

Whilst I was in Malawi a cyclone hit the area close to the hospital, one of the biggest natural disasters they’ve had in the south of the country for many years. We had many people admitted as a result of trauma and because I was there, thanks to Operation Smile, I was able to support that work, essentially, because very few staff were able to get to the hospital because of the devastation in the surrounding area. As a result, I was the main person coordinating all the theaters and intensive care work for a two-week period. There was a young woman in her early twenties, who had multiple injuries and trauma, including broken limbs. The situation was memorable because myself and a colleague put her off to sleep and then noticed that we were suctioning mud out of her lungs. She had obviously very nearly drowned due to the mudslides when she had managed to get a lung full of mud which I’ve never come across before and probably never ever will again. Anyhow we completed the operation and she was taken to the ward where she remained for many weeks. She is still in hospital and I’ve heard she’s doing very well. She is certainly one of my most memorable patients who received the best of care from us.

Q: How has volunteering for Operation Smile impacted you personally, but also professionally?

A: Being supported in Malawi to be do this work was personally and professionally rewarding. One of the really good things about Operation Smile is the flexibility you are given. I’ve been given complete freedom to do what I think is useful. Having worked several times in Africa, I have an idea not only of what’s going to be needed, but also to take time to watch and see where the gaps in provision are. The opportunity to work on the burns unit has been very rewarding and it will be good to be able to go back and see the progress made.  It was good to be part of such a proactive and dynamic team.

Q: How will you spend your next three months in Malawi?  Do you already have an idea about what you will be doing and what you hope to achieve?

A: I will go back to The Queen Elizabeth Central Hospital in September. I’m taking an ultrasound scanner with me and will teach the team there how to use it to find veins. With burns, when they cover a lot of the body surface, you might only have one or two limbs where you can look for veins and after they’ve been used a couple of times, it’s very difficult to identify them. With an ultrasound machine, it opens up so many additional options. I have already done some teaching with the staff but they haven’t at present, got a machine of their own. They are a dynamic group of nurses and if I take them out a machine, teach them how to use it and leave it with them, I’m very confident that they will continue to use it, and it will, I am sure, prevent deaths in the future.

When I return, the trainee doctors have got exams coming up in the near future which means I will be involved in training, teaching, doing classroom sessions and exam practice.