Thursday, April 3, 2008

CME in Afghanistan

This morning we went to visit the Kandahar Regional Military Hospital (KRMH). We had been invited to attend a weekly continuing medical education (CME) session for the doctors, nurses and technicians at the hospital, which serves members of the Afghan National Army (ANA). The hospital, although within the security perimeter of the Kandahar Airfield (KAF), is a 10 minute drive outside the main boundary of the camp.
I will not soon forget my ride there in a Bison armoured troop carrier. The security threat is deemed low and I am permitted by my wary military chaperones to ride with my head poking up through a hatch at the back of the Bison. Poking his head out of the hatch beside me is Capt. Marc Descoteaux an extremely likable emergency physician from the St. Jean, Quebec garrison who makes no attempt to hide his obvious excitement and pride at being a military physician on one of his first excursions beyond the main camp at KAF.

“I enrolled in the military specifically so I could deploy here to Afghanistan” he says grinning from behind his reflective ballistic eyewear.

This moment seems uniquely Canadian as we commiserate about the similar medical experiences and ethical end-of-life challenges we have had working in intensive care units back home. As a unilingual Anglophone I am a little envious of his perfect English accented in a musical Quebecois. We both have 8-year-old sons and it makes me happy to think that my son who is in French Immersion will one day be as comfortable in both official languages as Capt. Descoteaux. As we roll along through the outskirts of camp I ask him for his evaluation of public support within Quebec for Canada’s mission here.

For him the answer is very personal: “First I am a Canadian. Second I am a Quebecer. When I completed all my military training and received my commission many people came to me after the ceremony to say how much they support me and what Canada is doing here.”

His ardour for the mission here is so obvious that I sense he feels a little confined even here in KAF. “I really want to see what’s going on out there...” he trails off, looking out over the apocalyptic scene speeding past us.

Scattered all around lay the bombed out remnants of former neighbourhoods and commercial areas. One wrecked apartment block known as “the Russian village” is in fact still a home to a number of families despite the fact that it has no running water or reliable supply of electricity. That such conditions exist almost within site of KAFs diesel powered electrical generators leaves me feeling both angry and embarrassed.

Approaching the ANA camp’s perimeter we see a bone yard of old rusting Soviet tanks and rocket launchers, an unsettling reminder of only the latest unsuccessful attempt to forcibly pacify this virtually ungovernable frontier. The Bison disgorges us out on to the parking lot of the impressive, newly built hospital — a testament to the capacity the US Military is building with the fledgling ANA. The support is staggering. The US is spending 100 million dollars a year to construct a network of more than 120 hospitals and health care centres across Afghanistan to serve 80 000 Afghan army personnel and their dependants. A few weeks ago, this hospital received and triaged nearly half of the 100 casualties from a Taliban suicide attack in Kandahar city. Such capability would have been unthinkable a year or 2 ago.

The CME sessions were instigated in part by Canadian Col. Colin McKay, one of the previous Commanding Officers of the KAF hospital. The idea was to foster an educational partnership between our hospital and the KRMH with whom we often share patients. The leader of this outing is an American army major who has volunteered one morning a week to these CME sessions.

“We’ve finally convinced some of our Afghan medical friends to stop giving antibiotics for pain,” he tells me conspiratorially as we walk towards a comfortable conference room that is filling with eager, exclusively male Afghan health care workers.

During the visit, I learn more about the current state of medical and nursing education in Afghanistan from Col. Ed Fieg an emergency physician from Ohio who has been assigned to be a clinical mentor to the fledgling KRMH. Col. Fieg seems straight out a scene from M.A.S.H. with a gum-chewing, straight-talking swagger that conceals a fierce intelligence and genuine concern for the people of this country.

In 2001, the country had just over 4000 doctors and just over 4700 nurses. For its 32 million people Afghanistan has 8 medical schools each with different entrance requirements offering a 7 year curriculum with variable objectives and requirements for graduation. The medical training system has a dire shortage of qualified professors. Moreover, actual exposure to real patients in a clinical setting doesn’t take place until the final year. Consequently, most physicians here are essentially “textbook” doctors. Following graduation, doctors serve a 1 or 2 year rotating internship the quality of which depends entirely upon the dedication and competence of their mentors. The system is also marred by the fact that where a doctor’s reputation is concerned, age and political connections are of greater importance than actual clinical skill. In fact, says Col Fieg, younger physicians will defer judgment to elders even when the younger physician has more knowledge and training.

The state of nursing education is no better. Decades of war have left Afghanistan with a critical shortage of trained nurses. Training programs are unstandardized, varying in length from 2 months to 3 years. As with their medical counterparts, there is limited exposure to patients in nursing school. Nurses are poorly respected by the medical community and are regularly assigned to non-nursing roles such as patient registration clerks, librarians, logistics providers or cleaning staff. There are a lack of policies and procedures governing work hours, standards of care and scope of practice. Medication administration and other bedside activities are not considered to be essential duties of a ward nurse. Patient assessment skills are rudimentary and there is essentially no nursing documentation. Col. Fieg has witnessed only limited evidence of patient education, discharge planning or collaborative case management. Overnight staffing at the hospital is dangerously sparse.

Perhaps worst of all, the nursing profession is heavily male dominated in a culture with very conservative restrictions governing male-female interactions. Male nurses, perhaps considering such tasks unbecoming, are not keen to attend to the hygienic needs of their patients, almost all of whom are also men.

During a break, I chat with an American nurse anesthetist seconded to this hospital. Trying to impart her considerable knowledge to colleagues who are sometimes many years her senior, she feels a sense of exasperation. “They have read a lot and have some good factual knowledge but haven’t had enough clinical experience to correctly apply what they know from textbooks. Next week, I’m giving a talk on how to interpret vital signs because the other day we had a patient in shock who was tachycardic. I had to convince them to give fluids for the tachycardia rather than digoxin which they wanted to use to slow the pulse.”

The foregoing comments notwithstanding, attendance at the rounds is excellent, much better in fact than medical rounds at my own hospital back in Canada. To one side of the room sit the Americans and Canadians in their military dress with pistols holstered at their sides while along the opposite wall and around the conference table are 14 Afghans, most dressed in shalwar kameez and sandals. The topic today is chest trauma and, specifically, recognition of tension pneumothorax, needle decompression, chest tube insertion and management. There is excellent audience participation from both the NATO and Afghan staff. Laughter and learning occur in equal proportion and 3 hours later we pile back in to the Bison and head back to KAF.

Along the route home we see a few children walking along the roadside. I love how they smile and wave spontaneously. These children have so much to teach us about resilience and hope.

During the last few weeks, largely because of the commitment of Col. Fieg and Dr. Jack Oliver the Canadian civilian orthopedic surgeon, we have started to see signs of a more lasting collaboration between our hospital at KAF and the KRMH whose surgeons are now operating together with greater regularity. Today I spent time discussing our management at the bedside of a badly burned patient with 3 doctors from the KRMH who had come to visit for the morning. This is something new from last year when I was first here. Hopefully, this connection between NATO’s doctors and the ANA’s doctors will continue and eventually grow to include physicians from the local civilian hospital in Kandahar City.

No comments: