By: 9 October 2019
Getting to grips with ultrasound-guided pain control in Zambia

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Consultant and trainee anaesthetists from Surrey travelled to Lusaka with a point-of-care ultrasound (POCUS) system, to train Zambian colleagues in ultrasound-guided regional anaesthesia. Dr Madankumar Narayanan describes the educational objectives of the visit and the enthusiastic response from doctors in Zambia, as the team demonstrated the benefits of ultrasound-guided interventions in classroom workshops and on real patients.


Responding to a need in Zambia

Anaesthetic trainees in the UK often undertake an ‘out-of-programme’ fellowship to developing countries to expand their clinical and professional experiences. One such trainee visited the University Teaching Hospital in Lusaka for his fellowship and saw the challenges and limitations of managing patients’ pain without the use of ultrasound-guided nerve blocks. On his return, he decided to rally the support of his UK colleagues and arrange a training visit, to show Zambian anaesthetists how using ultrasound for vascular access and administering nerve blocks could transform care for their patients; he knew POCUS would significantly improve the pain management that was currently being offered. Three consultants and one trainee were able to commit to this project and linked up with two British trainees already in Zambia on fellowships at the time.


Well-equipped to introduce ultrasound

The University Teaching Hospital in Lusaka is the largest, most advanced hospital in Zambia and was a logical starting place for the training initiative. A seven day visit was planned – two days of classroom teaching, four days practical training in theatre and a day of consolidation – and the team from the UK was equipped with a portable and robust FUJIFILM SonoSite point-of-care ultrasound machine, donated for the training exercise and for the hospital in Lusaka to use in the future.


Anaesthetists at the University Teaching Hospital in Lusaka were unfamiliar with POCUS and did not have access to any machines. While their knowledge of anatomy was good, the process for choosing vascular access sites was based purely on clinical landmarks and they had used very little ultrasound in their diagnostic evaluations or management of pain – most of the theatre anaesthetists had never even seen nerve blocks performed. There is also very poor availability of pain-relief medication in Zambia; post-operative patients were having to tolerate significant levels of pain which often increased their length of stay in hospital. This presented huge scope to train the theatre anaesthetists to perform ultrasound-guided nerve blocks, and introduce a culture of making a real difference in the quality of care they were able to provide to their patients.


Delivering training

The UK team carried out a preliminary workshop for 20 anaesthetists from across Zambia; comprehensive reading material was provided beforehand to outline the context of ultrasound-guided regional anaesthesia and cover the theoretical basics. Although the workshop was in a classroom setting, its content was very practical, concentrating on demonstrations of how to use the machine, how to hold the needles, how to scan and most importantly, how to guide vascular access and identify individual nerves. Four theatre anaesthetists from the workshop were then selected, all of whom worked at the University Hospital, and provided with hands-on training on real patients in their theatres. This initially focused on simple, low-risk nerve blocks – femoral, fascia iliac, axillary and popliteal – to help them improve their confidence, and then moved on to some more advanced blocks. They were also instructed in submitting a maintenance and learning log to encourage them to develop their skills further after the team had left.


Response of Zambian doctors

The beauty of the SonoSite ultrasound machines, particularly in this kind of scenario, is that they are extremely intuitive and ‘non-threatening’ to those who have never used POCUS before. They can withstand plenty of use and occasional unintended knocks or drops, and are incredibly user-friendly, which encourages continued learning and use of the machine in the first instance. The presets are also very helpful and crucially, within a few minutes, the Zambian anaesthetists could correlate what they could see under ultrasound with what they already knew about anatomy, and quickly realise the benefits of clearly visualising important structures. Their excellent understanding of anatomy stood them in good stead for quickly progressing to use ultrasound to guide their identification of nerves and veins; the knowledge gained from the initial workshop was immediately consolidated and drawn upon in the following day’s theatre-based training session. After just two days of training, the local anaesthetists were very excited about developing the use of POCUS for the management of pain, particularly for patients following limb trauma surgery. They could immediately see huge potential for its use across Zambia and plans are already in place for the four anaesthetists trained in theatre to teach others within the hospital.


Continued collaboration in the future

Above all, the Lusaka project has been extremely successful in increasing awareness of POCUS for pain management across Zambia. Everyone involved is keen to continue the collaboration and the aim is to repeat the ultrasound training annually. The Zambian anaesthetists are enthusiastic to learn even more and develop their skills further; hopefully the word will spread to other hospitals in the country, they will start to see the benefits and be able to make the case for procuring more equipment and a proper infrastructure around POCUS. The UK team is eager to continue supporting hospitals in Lusaka and across the country, and to ultimately improve the lives of Zambians living with pain.