A talk by Lars Irestedt at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All of the conference content can be found here: https://scanfoam.org/ssai2017/ Developed in collaboration between scanFOAM, SSAI and SFAI.

1. Collaboration with a resource-
limited region in Africa:
Milestones and challenges Dar Es
Salaam versus Stockholm

2. The anaesthesiologist’s perspective
Lars Irestedt M.D. Ph.D.
Assoc. Professor
Karolinska Institutet
Vice Chairman, Life Support Foundation

3. • 234 million operations per year globally
• 5 billion people lack access to basic surgery
(Lancet 2015)
• 10% of deaths (4,7 million) due to surgically treatable
conditions (Lozano 2013)
• Only 3·5% of operations are in low-income countries
where 35% of the world’s people live
Global Surgery

4. Global Critical Care
Critical Care is often absent or poor quality
60% had ER, 40% had triage, 30% had ICU
80% no staff trained in triage or critical care
Mortality on ICU 50% (90% if hypotensive)
Acute treatments rarely given (3%)

5. Global Obstetrics
• More than half of women lack access to
Emergency Obstetric Care (80% in LIC)
(Holmer 2015)
• Good quality care could prevent
–113 000 maternal deaths

6. The Global Need
• Every girl in Tanzania has a 1 in 20 risk of dying
during childbirth
• 2 jumbo jets full of mothers crash every day
• 1 million babies die each year on the same day they are born
(and over 2 million are stillbirths)
Muhimbili National Hospital: • Perinatal death:
• Maternal Mortality:
9.6%
1.54%
2
Pembe, A. B., et al. (2014). "Maternal mortality at Muhimbili National Hospital in Dar-es-Salaam, Tanzania in the year 2011." BMC Pregnancy
Childbirth 14: 320.
2
• 5.8 million deaths from trauma yearly1
1 World report on road traffic injury prevention, WHO, 2004

7. Why did we start?
• 2005-2006 Dr Tim Baker worked as a
volunteer doctor in Tanzania.
• 2008 a request for help from Muhimbili
National Hospital to Karolinska University
Hospital

8. Global distribution of surgeons, anesthesiologists and obstetricians; per 100 000 population
Karolinska University Hospital: 187 (2400 in Sweden)
Muhimbili National Hospital: 5 (20 in Tanzania)

9. ”We encourage UK health workers
and employers to take advantage
of opportunities to engage in
global health.
Your involvement is important.”
Encouraging involvement in global health

10. 1. Recruitment and retention of all staff
2. Clinical skills
3. Managerial skills
4. Communication & teamwork
5. Patient Experience and dignity
6. Service/policy development & implementation
7. Academic skills
– added value of employment
– case load and rare cases
– innovation & ability to cope with limited resources
– multi-cultural and multi-disciplinary
– understanding of cultures and settings
– new perspectives
– opportunities to engage in education and research
Encouraging involvement in global health
at Karolinska Hospital?

11. Life Support Foundation
Established 2013
“an international, independent, medical
organisation aiming to prevent deaths due to
acute, life-threatening conditions in low-income
countries through improving the access to and
quality of basic life-saving interventions”

12. Life Support Foundation - Board
• Dr Tim Baker, Anaesthesiologist
• Dr Lars Irestedt, Anaesthesiologist,
Associate Professor
• Dr. Henrik Jörnvall, Anaesthesiologist
• Dr. Berith Tingåker, Obstetrician
• Dr. Claes Frostell, Anaesthesiologist and
Professor

13. Training
courses
Checklists
Staff
exchange
Supportive actions
of Link
MKAIC & LSF
Development
of protocols
Regional
activities
SATA
support
Research
Training of
trainers,
ABC
Support
anaesthesia
residency
Equipment
provision

14. Achievements
2008-2015
Establishing an Anaesthesia and Intensive Care partnership and aiming for national impact in Tanzania
Ulisubisya, Jörnvall, Irestedt, Baker. Globalization and Health (2016) 12:7
Läkartidningen
2016

15. Achievements 2008-2015
Establishing an Anaesthesia and Intensive Care partnership and aiming for national impact in Tanzania
Ulisubisya, Jörnvall, Irestedt, Baker. Globalization and Health (2016) 12:7

16. ”The least selected speciality was
Anaesthesiology”

18. Challenges
• Fund raising
• Organisation
• Professional recognition (MoU)
• Recruitment and education of volunteers
• Time
• Exchange management
• Cultural and ethical differencies
• Contemporary anaesthesia providers/ anaesthesiologists
• Attitude
• Huge burden of sepsis, obstetric emergencies, trauma, critical illness
• Lack of expertise
• Lack of emergency care, triage, critical care
• Need for focus on the basics – ABC, routines, systems, guidelines,
• Lack of good data & research
• Lack of equipment & maintenance

19. Malawi
• Poorest country in the world
(GDP $255 per capita)
• Politically stable democracy, no wars since
independence.
• Poverty, lack of natural resources & industry, land-
locked, corruption, difficulties with electricity &
water supply.
• 17 million population
• Maternal Mortality ratio more than 100 times that
in Sweden

20. 75 years
Similar journeys are possible in
resource-limited countries?!
Life Support Foundation will aid the journey.
The Development of Anaesthesia and Intensive care has fundamentally reduced
global and maternal morbidity & mortality worldwide.
Anaesthesia is the largest in-hospital speciality in Sweden.
Anaesthesia is as respected as any other speciality in Sweden.
Anaesthesia offers great career possibilities in Sweden.
Recipe for success, Future

23. what’s the problem?

24. 2013 Tanzania : 410 /
100 000
2014 Sverige : 5 / 100
000

25. We have the answer
• MKAIC’s approach
– Sustainable, long term, building capacity
– Improving knowledge, routines, practices
– Working together with local doctors, nurses and policy makers
– Use of Sweden’s knowledge & resources
• 2400 Anaesthesiologists in Sweden (20 in Tanzania)
– Emergency Care
– Critical Care
– Anaesthesia

28. Confidential Enquiries
Recurrent themes:
– Failure to recognise problems
– Failure to take action
– Failure to refer
– Inappropriate delegation to junior
staff
– Poor or non-existent teamworking
CEMACH,CESDI & NCEPOD

29. What do we do?
• Courses
• Exchanges
• Research
• Equipment
• 12 training courses and bedside teaching
• 500 doctors and nurses
• 20 staff exchanges from Tanzania
• Guidelines and checklists
• Karolinska Exchange Alumni
• 4 publications in peer reviewed journal
• PhD Thesis of Tim Baker
• 4 more ongoing projects
• 8 resident/masters/medical student projects
• 125 pulse oximeters donated to hospitals in Tanzania

30. What do we do?
• Courses
• Exchanges
• Research
• Equipment
• 12 training courses and bedside teaching
• 500 doctors and nurses
• 20 staff exchanges from Tanzania
• Guidelines and checklists
• Karolinska Exchange Alumni
• 4 publications in peer reviewed journal
• PhD Thesis of Tim Baker
• 4 more ongoing projects
• 8 resident/masters/medical student projects
• 125 pulse oximeters donated to hospitals in Tanzania
Sustainable, long term building capacity
Improving knowledge, routines & practices
Working together with local doctors, nurses & policy makers
Use of Sweden’s knowledge & resources
Emergency Care
Critical Care
Anesthesia

31. Anna
Life Support’s doctors arrive.
They re-start her heart
They manage to get the tube into her lungs and give her oxygen…
Anna

32. Cases like Anna & Simon are
happening everyday
• 2 jumbo jets full of mothers crash every day
• 1 million babies die each year on the same day they are
born (and over 2 million are stillbirths)
• Every girl in Tanzania has a lifetime risk of 1 in 20 of
dying in childbirth
• Most could be avoided

33. Life Support for Mothers & Babies in
Dar es Salaam
• Improving care in 9 hospitals
in Dar
• Training
• Motivation
• Equipment
• Guidelines & Checklists
• Research

34. Achievements since 2009
• 7 training courses in Dar es Salaam
300 doctors and nurses trained in Anaesthesia & Intensive Care
• 10 staff exchanges Tanzania  Sweden
• 3 research projects completed, 4 more ongoing
• 3 resident doctor projects completed
• 51 pulse oximeters donated to hospitals in Tanzania
• Development and Introduction of protocols and checklists
• Advocacy for Anaesthesia & Intensive Care at the Ministry of Health

35. • 10% of deaths (4,7 million)
due to surgically treatable conditions (Lozano 2013)
• Provision of essential surgical procedures
would save 1.5 million deaths a year
Global Surgery

37. Recipe for success, Past
• 1940. Torsten Gordh, Sweden’s first
Anaesthesiologist
• Reduced death in abdominal surgery by 40%
Europe

40. Anaesthesia related direct maternal deaths.
UK experience
0
5
10
15
20
25
30
35
40
70-72 73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96 97-99
Deaths
Triennium
• Triage
• Emergency care: ABC
• Regional Anaesthesia
• Senior Interest
• Routines and guidelines
• Improved Training
• Teamwork
• Communication
• Checklists
• Audit, M & M, systematic improvements

41. UK: preventable reasons for maternal
deaths
Recurrent themes:
– Failure to recognise problems
– Failure to take action
– Failure to refer
– Inappropriate delegation to junior staff
– Poor or non-existent teamworking

44. And the world is starting to wake up
to these ideas
• “To get a drop in maternal mortality requires a medical
health-care system that is responsive to the 24-hour
technical needs of a woman in labour” (Lancet 2012)
• “Strengthening the delivery of essential surgical services
must be a priority if we are to reduce mortality and
morbidity” (WHO Safe Surgery 2011)