Gambia-L,
I though I should share this report with those who might be interested. I
wonder if the recomendations have been followed?

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Vol 1 No 1 (1997) Article 5: Page 1 of 1

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The Anaesthetic Situation in the Gambia
(Development, Constraints & Recommendations)
Dr. Alex Ojabo,
Royal Victoria Hospital, Banjul, Gambia.


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The need for improving anaesthetic services in The Gambia was realised by
the Health Authorities as many as two decades ago. Then, most anaesthetics
took the form of local or spinal anaesthesia. General anaesthesia - ether
by face mask - was administered by theatre technicians to patients who were
obviously fit. Specialised anaesthetic care was not available for the
critically ill. The morbidity and mortality associated with anaesthesia was
very high.


The first full time anaesthetist to work in The Gambia arrived in 1978,
supported by The Danish International Development Agency. He established
the Department of Anaesthesia at the Royal Victoria Hospital (RVH) in the
capital, Banjul. Formal training of nurse anaesthetists was commenced with
a view to improving the standard of anaesthesia throughout the country. Ten
years later, at least five fully trained nurse anaesthetists had returned
from Nigeria, where they had been trained at the West African Health
Community-supported school of Anaesthesiology in Enugu.
The last eight years have witnessed a tremendous growth in anaesthetic
services in The Gambia. The National Health Development Project (NHDP),
supported by the World Bank, initiated local training of nurse
anaesthetists at The Royal Victoria Hospital in 1988. The Trainer/Co-
ordinator, Dr. Olaitan A. Soyannwo, a consultant anaesthetist, with the
assistance of senior nurse anaesthetists has since trained two sets of
nurse anaesthetists. Each set of eight trainee nurse anaesthetists had
lectures, tutorials and practical training sessions and was actively
involved in the management of patients for 18 months. At the end of the
training, they were well equipped to:-


Take care of anaesthetic equipment and drugs,

Perform pre-operative assessment of patients,

Assist in the care and resuscitation of emergency patients,

Administer safe general and spinal anaesthesia either single handedly or
under the supervision of a physician anaesthetist, medical officer or
surgeon and

Care for patients in the immediate post operative period.

As the anaesthetic machine available at the Royal Victoria Hospital and at
Health Centres was the EMO vaporiser, the main anaesthetic techniques
taught were:

Intravenous ketamine and thiopentone for minor surgical procedures

Endotracheal intubation with suxamethonium following intravenous induction,
maintenance with pancuronium and intermittent positive pressure ventilation
with ether (2-6%) and oxygen enriched air with reversal of relaxation with
neostigmine

Spinal anaesthesia for lower abdominal and lower limb surgery

Further training to upgrade knowledge and gain familiarity with more
sophisticated anaesthetic equipment and in Intensive Care was arranged for
them at the University of Ghana Teaching Hospital, Korle Bu, Accra.
Currently, the Gambian National Anaesthetic Service has five physician
anaesthetists and sixteen nurse anaesthetists spread across the country.
The main referral hospital (RVH) in Banjul, has four physician
anaesthetists and nine nurse anaesthetists. The RVH has six operating
theatres and workload has rapidly increased in the last three years.
Through joint co-operation between Non-Governmental Organisations and the
Ministry of Health, the RVH has acquired new anaesthetic machines and other
equipment. For instance, Dr. Pia Pfluger, a consultant anaesthetist from
the German Centre for International Migration and Development Programme has
acquired a standard Boyle's anaesthetic machine, a cardiac monitor, a pulse
oximeter, a ventilator and an oxygen concentration monitor. A second
Boyle's machine with Ohmeda 5 vaporisers for halothane and isoflurane and
an inbuilt ventilator with computerised monitoring system (Ohmeda 5250 RGM)
has recently been procured by the Health Authorities.

The Intensive Care Unit has also seen an improvement in its facilities
acquiring a cardiac monitor, volumetric infusion pump, and a 12 lead ECG
machine. Intensive Care nurses have been trained for the Unit. As a result
of these improvements, a wide range of major and complex surgical
procedures are now performed under good anaesthetic conditions with
decreased anaesthetic related morbidity and mortality. Laparoscopic
surgical operations are the latest of these.

Constraints

There is no indigenous Gambian physician anaesthetist. All five physician
anaesthetists presently in the public service are expatriates. This is
because anaesthesia is generally unattractive to young medical graduates in
the West African sub-region, as the financial remuneration is poor compared
to the other clinical specialities. There is also a shortage of nurse
anaesthetists due to expanding health facilities without a proportionate
increase in training programmes. Some trained nurse anaesthetists have
already left for more attractive and better paid jobs elsewhere.
Furthermore, nurse anaesthetists in The Gambia are faced with professional
frustration which often leads to resignation, for example, nurse
anaesthetic training is not recognised as a post-basic nursing
qualification.This makes career prospects poor. They are also subject to
arbitrary transfers to centres without theatre facilities where their
skills are wasted.

Routine servicing of anaesthetic equipment is inadequate due to the
unavailability of trained anaesthetic technicians. The recovery room is
currently not used because it is not properly equipped and staffed.
Inadequate laboratory and blood transfusion services sometimes make early
surgical intervention difficult for emergency cases.

Recommendations

To provide continuity, a Gambian physician anaesthetist should be trained
and encouraged to remain in the Public Service. Incentives such as
inducement allowances, responsibility allowance for those holding
administrative positions, furnished accommodation and planned postings
should be introduced to reduce frustration and low morale in the Public
Service.

Support services like laboratory and blood transfusion services should be
improved. Regular servicing of anaesthetic equipment and training of
anaesthetic technicians should be incorporated into the National
Anaesthetic Service.

The acquisition of more Boyle's anaesthetic machines will assist in the
provision of a better overall general anaesthetic service especially in the
Ophthalmic theatre where general anaesthesia is currently provided by
intravenous ketamine even for emergencies.

Finally, annual workshops on specific aspects of anaesthetic practice
should be organised for all anaesthetists in The Gambia. Overseas training
programmes/refresher courses should be encouraged to enable anaesthetists
to upgrade and reinforce the knowledge and skills they have acquired.

Acknowledgement

I am grateful to Dr. Pia Pfluger who made previous reports on Gambian
Anaesthetic practice available to me.

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