Using Lagos model to bridge gaps in pain management

What necessitates the establishment of the School of Anaesthetic Studies?
When I joined the Lagos State service in 2006, we had just 12 qualified anaesthetists in almost 24 hospitals at that time. That was grossly inadequate.

And most of the hands we had (especially the nurses) were elderly nurses. So, there was an urgent need to boost anaesthetic manpower for the state. So, this school was established primarily for that purpose. And that is for the internal training of anaesthetic manpower for the Lagos State Health Service Commission.

But because of the dearth of even the instructors and lecturers, we have to make do with what we have in the system. And we have few internally trained and senior anaesthetic matrons and some few consultant anaesthetists.

So, we gathered ourselves, and said we will train internally the manpower that Lagos State will need.

Each of the hospital as at that time needed minimum of six staff to operate, and if you multiply 6 by 24, you are talking about over 100 anaesthetists.

But we had just 12. Approval was given for us to start this training. But I insisted that we have to follow a definitive syllabus so that when we apply for accreditation it will not be difficult.

So, we used the syllabus of the West Africa College of Surgeons and Nursing and Midwifery Council of Nigeria (NMCN) to train anaesthetists.

We had nine doctors and 24 nurses as the first set of students in 2008. So, by the end of 2008, we were able to add nine doctors to the system, 14 doctors in 2010,16 in 2011, 14 in 2012, 13 in 2013 and 17 in 2014 and as at present, we have 12 in training.

On the whole, the school has passed out 83 doctors and 65 nurses. If you add the two numbers, you will find out that in total, we have been able to train 150 anaesthetic manpower for the entire state. But it is still not enough.

The school is essentially to train manpower internally for Lagos State. I must pay kudos to the Lagos State Commissioner of Health, Dr Jide Idris, under whom we got the approval to operate, and the former permanent secretary, Dr Olatunji, who was a source of encouragement to get this school started.

Subsequently, in order to standardise our programme, we applied to the West African College of Surgeons accreditation, and in 2009, the school was given partial accreditation to train doctors for the diploma programme. By the time we re-applied, we got full accreditation to train even up to fellowship level.

As at now, we have over 30 residents who are in the fellowship-training programme of the school. We are yet to get the accreditation of the NMCN, because of some human capital deficiency. And we are working very hard on that.

That is the story of the school and how Lagos State has been able to meet the anaesthetic manpower, which hitherto would have been very difficult, because anaesthetists are very, very rare to come by.

But the school has imparted positively in the reduction of the overall morbidity and mortality rate in surgical cases in Lagos State. I make bold to say that you can work into any of the general hospitals in Lagos State and be rest assured that you will have quality surgical service, because of the presence of these anaesthetists who are the denominators of effective surgical practice in the state.

We now have confidence of Lagosians in all our hospitals.The number of people patronising hospitals for delivery cases have improved, and we will continue to be the ‘baby factories’.

All our general hospitals are well equipped and manned effectively for at least in primary and secondary surgical cases, with the teaching hospitals providing the tertiary surgical care.

The school is also affiliated to the Lagos State University Teaching Hospital (LASUTH) because some specialised trainings we need for these doctors have to been done there. These are in neuro-anaesthesia (brain) cardio-thorasic anaesthesia (heart) as well as intensive care, and the complementary role of the department of anaesthetic of LASUTH has been very useful in getting the accreditation we have and in the success of our students.

And when we talk about success, it is reflective in the fact that all along we send students for external examinations; they have been doing very well.

And in few years’ time, we will produce the first three consultants in-house without loosing them to the system. The usual practice is that when you send students out, they are not normally available for your service. But these doctors are working in and at the same time, they are advancing professionally.

It is a success story for Lagos State in the sense that it is a pilot study for other states in the federation who have deficit of anaesthetic manpower.

Our result has been presented in international conferences, and it is well acclaimed that it is one of the best ways to really improve anaesthetic manpower in developing countries.

What is the level of deficiency in anaesthetic in Nigeria?
By the last census we did, there are just about 900 anaesthetists in Nigeria on paper. But some of these people are already drifting to greener pasture abroad. But Nigeria has about 170 million people. This is not acceptable. If not because of this school, Lagos state, which has about 18 million people, had just 12 anaesthetists by the time we started.

The only way, therefore, is for accelerated development programme of anaesthetic manpower. At the same time, there must be incentives for those people who come into this rare specialty.

And if you know that anaesthesia is a denominator to all other specialties, then it is important for each government to specifically give it priority in the recruitment of doctors and nurses. That means government tell the new recruits ‘look we are recruiting you solely for this specialty.

Take it or leave it.’ By that, we will be able to improve on the anaesthetics manpower. But if we continue to rely on doctors showing interest in anaesthesia, it will take a very long time before me can meet up. Also, it is important that we make sure that they are trained effectively.

By the way many people do not know what anaesthesia is. It is important as a trainer in anaesthesia to let the public know that anaesthesia deals with reversible, controllable and predictable methods of pain relief with or without loss of sleep.

We are also involved with intensive care management. Our principal aim is to relieve pain for operative surgery. But because we deal with this kind of bad situations, good ones, small ones and old ones, that makes us to be jack of all trade, especially when it comes to saving lives. We also deal with resuscitation medicine and we do teach that too.

It is not all the time you have to go to sleep for surgery. There are region techniques and local anesthesia that can be applied to ease the pain of surgery. When it comes to cancer pain, anaesthesia is involved, and when it comes to critical care, anaesthesia is involved. You can see that it is something that government needs to really give some degree of concerted effort to boost the manpower, just as what Lagos State is doing.

Why is there dearth of anaesthesia in Nigeria?
It is not only peculiar to Nigeria. There is dearth of anaesthetic all over the world.

Because it is not too lucrative like obstetric and gynaecology (O and G) surgery (people don’t see you), not many doctors want to come into anaesthesia, because the patient really does not know you.

Whereas in the surgical specialties (surgery, O and G), we may have about 800 to 1000 residents sitting for exams in the postgraduate medical colleges, in anaesthesia, we will be struggling to have about 50. And these surgeons, when they qualified, will require anaesthesia. That inverse proportion is there all over the world. That is why there is dearth of anaesthetic manpower.

But we know in anaesthesia that the most complicated surgery may not necessarily need complicated anaesthesia, and a very simple surgery may need complicated anaesthesia. We do allow some of our other colleagues like nurses to take some cases, which are safe and which we believe they can readily manage.

Just as midwives are to the gynaecologists and the ophthalmic nurse is to the ophthalmologist, we do allow our nurses to take the load off us. That is why we have been able to cope. Otherwise, we won’t have been able to cope.

Just as radiographers are to radiologists, we do have our components too, and which are complementary to the service.

But Nigeria as time needs one of this kind of school in the six geopolitical zones of the country if we have to catch up with anaesthetic manpower demand.

Can you throw more light on how to prioritise recruitment of anaesthetists in Nigeria?
In the first instance, there must be the willingness of the government to train anaesthetic manpower.

It must be the priority of the government. And when government give it a priority, it will be make clear in its recruitment of doctors and nurses.

Another way is that if someone come in for training in anaesthesia and come out successfully, he should be given some recognition by promoting him to the next level. It is all right that once doctors passed the fellowship examination of the postgraduate colleges (it does not matter whether they are in level 10 or 12 before) they are pushed to level 14 as consultants.

But it is not the same with the anaesthetic nurses and technicians. There ought to be some level of degree of encouragement by giving them some priority promotions.

The government can also give, though debatable, some allowances. But because of some agitation that may follow it from some trade unions, everybody will then want the same allowances. That may be dicey.