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Know Your Specialist

Dr Julio C Gonzalez Gutierrez speaks on pre and post Operation anesthesia care

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Dr Julio C Gonzalez Gutierrez, Consultant Anesthesiologist and Medical Director of Trustanaesthesia Services (Pty) Ltd. affiliated with Bokamoso Private Hospital talks to SunHealth about the continuous medical care anesthesiologists provide before, during and after an operation to permit the surgeons to perform surgeries.

Despite being an integral part of modern surgery, most people know very little about the process that sends them to sleep before their operation. Explain to us what anesthesia is? What happens to the patient? Is it literally like going to dreamland or it’s a total blackout?
Good question: Anesthesia is combination of unconsciousness, muscle relaxation and pain free status. A person can be under general anesthesia for many hours, as long as the anesthesia is conducted by a properly qualified and well-experienced Anesthesiologist. For the patient it is like a total blackout yes.

What type of education did you have to pursue to become an anesthesiologist? And why did you decide to become one?
Anesthesiologist are Medical Doctors (6 years) first and then after concluding the post-graduate or community service they officially begin training in Anesthesiology specialty (4 year) of which concludes with board examinations and certification or equivalent. The duration of study is 10 years. It is after all this time that the real experience begins. In my case particularly, I decided to become a Doctor because I love and wanted to be that Doctor that keeps patient alive and safe during surgical procedure and that Doctor is the anesthesiologist.

What services does your practice offer?
We at “Trustanaesthesia Services” are involved in the preoperative period of the patient meaning (before/during and after the procedure). We play a pivotal role in the critically ill patient at the intensive care unit in particular, and provide chronic pain management service to selected patients. An anesthesiologist also plays a role in a hospital or clinic emergency room and in the MRI/Tomography room as well for selected patients as well.

What do your daily duties entail as an anesthesiologist?
Well our duties start the day or few days before surgery by consulting/examining and reviewing the patient. We look at conditions, Laboratory results, Radiological films and optimizing treatment if necessary, all this geared to tailor make the anesthetic plan for the particular patient and surgery that can yield the best results. No patient should be anesthetized without first being seen by the anesthesiologist to be able to evaluate the risk and possible complications during and after the procedure. A person’s life depends on that during the operation. Anesthesia is one of the safest specialties in medicine but usually direct anesthesia complications are lethal.

A typical day for you would be… ?
As explained before, we do clinical work during the procedure and also office work preparing or planning for the surgeries the following day. We also drink lots of coffee.
One little-known fact about anesthesiology is…
We are safety advocates in the OR suite.

I have read that patients who snore and those who are obese tend to be the most problematic when they are put under. Why is that?That is very true. Obesity brings a huge risk for the patients due to their massive size; everything becomes much more difficult to attain. To secure airways is extremely challenging because standard instruments are designed for normal size people and their cardio-respiratory reserves are limited. Obese patients are challenging from the pharmacology point of view due to their large surface area and concomitant diseases associated to obesity and last but not least in the recovery period, obese patients are at higher risk of respiratory complications compared to normal size patients. The anesthesia for these types of patients is always modified and very challenging.

There are cases where some patients wake up too early or worse never wake up at all. What would have happened?Well to answer this question we need to look at the history of anesthesia many years ago. Yes in those years lack of adequate instruments, lack of monitoring, un-purified drugs and poor training made anesthesia sometimes dangerous but today we can monitor everything during the course of anesthesia and detect anomalies early enough before the complication is evident. Training is more standardized and practices thrive for clean safety records. Nonetheless in emergency situation that cannot wait the risk of poor outcome is much higher.

Also the type of patients sometimes make surgery very risky; for example: a 90-year old patient that had MI last month and is known to suffer from renal failure now presented with stroke and acute appendicitis that needs to be operated – the risk is very high for complication from surgery and anesthesia during the peri-operative period. Now if a patient wakes up and awareness is detected during the anesthesia, probably the anesthetic gases would have run out and the patient became slightly conscious (situation that is easy to correct) without a bad outcome for the patient. Dying on the table is rare these days unless the surgery is done on high risk patients under emergency circumstances.

What do you say to people who fear being put under? Is that fear justified? Not at all, not in today’s modern Anesthesia. I would recommend seeing a consultant anesthesiologist before the surgery and rest assured she or he will put the patient’s mind at ease before the surgery and anasesthesia. I particularly don’t like to anesthetize frightened patients except where critical.

What are the tools of the trade that you use the most? Anesthetic machine, Laryngoscope, syringes and medications especially designed for the anesthesiologist to use but the most used tool of the trade is your ability to think and take corrective decisions under pressure. In this case your tools are your brain and training.

Does it bother you that despite the critical role anestheologists play in the operating room, they hardly ever get any recognition?That is very true especially in the modern medicine, but it doesn’t bother us because we know who have the patient’s life literally in their hands. We also know our involvement is brief but intense; we don’t expect you to remember us.

Why do you think there are so few anestheologists in the country?
Well, not only in the country but also in the whole world there are a few qualified anesthesiologist. I think it is possible that all the things mentioned earlier and the stress and pressure of the specialty have a role to play in the numbers. Here in Botswana anesthesiologist services are poorly recognized and hence poorly remunerated unlike in developed countries. In industrialized countries anesthesiologists are some of the highest paid specialists.

What do you find the most rewarding about the work you do?
Knowing that your prompt and effective interventions help safe patients. It is also in the way we make extremely complicated surgeriespossible.

And the challenges?
Time management and trying to convince your colleagues that your thinking in outcomes is not in the technicalities of the procedures.

On a basic level, what skills does your job demand?
Vast knowledge of how the body works (Physiology); vast knowledge of the disease of the patient (Pathophysiology); and vast knowledge of how medications work at cellular level. Anesthesia is a procedure-oriented specialty like the surgery; that is why they are intricately related – and last but not the least, it needs a cool and calm head under stress or pressure.

How is the job market/demand in the anesthesiologist field? How do you think it will develop over the next five years?
The market is ever growing and so are the demands for anesthesiologists in Botswana and the world over. New surgeries and techniques with better and safer instrumentation are being developed but at the end anesthesia has to be given by a human being, not by a machine.

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Know Your Specialist

Forgiveness is a virtue

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It’s hard to get through life without experiencing some resentment. Executive Director – Phronesis International College (PIC) and Counselling and Psychotherapist, Peacebuilding and Life Skills Education Specialist Dr Thelma Kgakgamatso Tlhaselo-Majela discusses forgiveness and why letting go is good for you.

What forgiveness?
Forgiveness is a process that positions one on a healing path by choice in an attempt to resolve the psychological stress and trauma one could be experiencing. These pains and emotional injuries may stagnate one into feelings of anger, bitterness and resentment and in worse cases depression, anxiety and post-traumatic stress disorders. If left for long, protracted unresolved psychological distress and or trauma could deepen one more into multiple losses.

It may generate hatred and desire to cause harm on the other and this can throw one into revenge and or vengeance. Forgiveness then starts from the cognitive ability to choose letting go of the emotional and cognitive baggage thus granting the self or inner being power to constructively open portals of intrapersonal empowerment. Moreover, a well-integrated process of forgiveness could shift one into an empathetic and compassionate psychological space filled with virtue and psycho-sociological attributes of restoration that accentuate positive benefits of healing.

In your experience,what are the common issues that need forgiveness?
Life by nature is riddled with so many issues and challenges characterised by diversity and complexity hence appropriate understanding is very important. People are social beings that co-exist through healthy connectedness and this may happen at the physical, personal, socio-cultural, psychological, financial, spiritual; political level to mention a few.
We all need a deepened awareness on how the intra-personal (within self), inter-personal (with others), inter-group (within groups) and international (nation to nation) relational connections play out in life. These healthy relationships deserve to be developed, nurtured and protected lest they become dysfunctional and corrosive.

The common issues for forgiveness are varied and highly individualised. One person may look at what another is struggling with and may consciously or unconsciously belittle it because for them it appears an easy or small matter but people are unique and this deserves respect. The relational betrayals, emotional injuries, corrosive conflicts and intractable may result in residual emotions that can cause people to drift into anger and bitterness. In such accounts, people may find themselves responding through avoidance or seeking revenge which has the potential to cycle one back into deeper pain.

The complexity of forgiveness may originate from the nature and quality of the relationship one had, the nature of the wrong committed with the cognitive interpretations one ascribes to the event. This includes significant others such as spouses (couples), children, family relatives, colleagues, bosses and subordinates in the work place.

Sometimes, it may be people we do not know that have hurt us such as a murderer, rapist or an abuser and may not even acknowledge that they have done anything wrong to us. It may also be about the symbolic losses where the people and or situations to forgive do not physically exist such as a dead person or a geographic disconnection. In such cases, the existential reality of the phenomenon remains true, real and alive in the psyche of the emotionally injured person and requires a healing process.

Is it possible to forgive when one is still angry and can you forgive someone who does not think they have done anything wrong?
Forgiveness is a process that one does by choice for oneself and not for the perpetrator because one understands that the pain and suffering one is experiencing has a direct injurious effect on one’s life. Similarly, revenge and vengeance which for long has been one of the rudimentary human responses can only promote increased pain as it stagnates one into more hurt and pain.

It often cycles one back into psychological trauma hence one needs to perceive value addition in engaging in forgiveness because it can be logically and rationally incomprehensible when one is caught up in this quagmire. A bitter-angry person may grapple with cognitive dissonance which is an internal struggle to understand why they have to release someone who according to them deserves a punishment or better still refuses to acknowledge that they have done anything wrong.

But irrespective of the reason, holding on to anger, bitterness and resentfulness within the inner self can only grant one false gratification that they are holding the perpetrator to ransom. Needless to say, we have no control on how the other person thinks and feels and we may actually be subjecting ourselves to increased injury and punishment from the very issue we are contending with.

Seeking professional help will assist one to work through the psychological defence mechanisms such as denial, repression, rationalisation, reaction formation, regression to mention a few that may promote dysfunctional tendencies in un/forgiveness processes. Notwithstanding, people need to be assisted with respect for human dignity within them and never be forced and or coerced into forgiveness when they are not ready to do so. Given that anger will consume the person already holding the pain and hurt whether it is perceived or real, working on forgiveness can be a desirable option to open the healing process.

Can you discuss the rewards or benefits of forgiveness?
As can be seen, it often pays to work through forgiveness hence the concept of working it out because people respond to pain and trauma differently. The rewards and benefits shared in this context are not by any means exhaustive because there are several psycho-social models for assisting people to process forgiveness issues and this requires well trained service providers.

*People who are angry and bitter are often not desirable in social contexts because they may consciously or unconsciously spill this negative energy on other people and this tends to repel instead of attract social connections. At intra-personal level, we are likely not to find our inner life peaceful and enjoyable if we are ever stuck psychosocially on anger and bitterness because it may promote self-hate, poor self-concept and negative self-esteem. So it pays to be gentle to love yourself enough to desire good emotions about and towards other people for that will rub corrosively on your personal well-being. The benefits of forgiveness include enabling one to circumvent these psychological pains and trauma that can affect quality of life with self and others which may compound stress levels.

In extreme cases people may sink into depression and anxiety which could ripple into other areas of life such as sexual dysfunction, eating disorders, substance use and abuse, relational conflicts and psychosomatic illness. Forgiveness builds a healthy mindset and that attracts a healthy personality which consequently leads to healthy social and physical well-being. Forgiveness fills the inner space with good attributes and this is shared with others. We then by addressing forgiveness issues reduce on maladaptive tendencies and lift on psychosocial protection thus leading to safeguarding the intra-personal, familial, corporate and societal communities from effects such as divorce and relational stressors.

At corporate and industrial level, a socio-psychological space that is riddled with un/forgiveness is a breeding ground for visible and invisible costs. For instance, a huge cost can emanate from a collective environment that is unproductive because of collective stress and restlessness. A workplace where people are transparent and honest and regard others with respect to deserve forgiveness often tends to promote healing communities where others feel safe and do not fear hence they can work to the optimum level of their potential.

We also benefit as a nation when we are characterised by forgiveness because we have a strategic desire to promote a knowledge-based community as the foundation for transformational change. Botswana considers people as a reservoir for knowledge and wisdom to lead as change agents and if we are a community that is unable to work through issues of forgiveness, we may create or nurture a psycho-sociological space that disempowers collective construct for healing communities.

A Motswana who is able to forgive is likely to live with people from other backgrounds and has a healthy and broader capacity of dealing with diversity and differences with virtue and competencies for the 21st century to advance the nation at local, regional and international level.

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Know Your Specialist

Rabiya Mahomed-McGeoff: Talking Marriage and Family Therapy

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Increased mental health awareness is leading to demand for therapists to serve couples and families. Licensed Marriage and Family Therapist, Lead Clinician, Rabiya Mahomed-McGeoff talks to SunHealth about being one of the most important confidants a person or family can have.

What is a Marriage and family Therapist?
A Marriage and Family Therapist is a mental health professional trained in psychotherapy and family system, and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couple and family system. A Marriage and Family Therapist treats a wide range of serious clinical problems including adult schizophrenia, depression, marital problems, anxiety, individual psychological problems and child parent problems.

How did you become a couple and family therapist?
When I did my undergraduate studies in Psychology, one of my professors was a Marriage and Family Therapist.
He introduced systems theories and they made sense to me. So I decided to pursue marriage and family therapy.I did my Bachelors in Psychology with a minor in Women Studies at University of Massachusetts. I did my Masters in Marriage and Family Therapy at Alliant International University in the US. After completing my Masters, I did clinical experience for two years, completing 3000 hours of direct client contact (which is a requirement in the State of California before one can seat for the licensing exams.)
I sat for the two exams and passed. I got licensed as Marriage and Family Therapist in California, USA.

What do you most enjoy about your work?
Giving clients hope, a voice, walking them through transitions and seasons in their lives and seeing them gain insight on their issues.

What is the most challenging thing about marriage and family counseling work?
The most challenging thing is when I work with teenagers where parents don’t want to get involved.
They just drop their children and expect me to fix their children. In most situations you find that parents are the ones with problems and are the ones who need therapy not the children.

What is the biggest myth about therapy?
That you only go to therapy when you have problems. That is not the case; therapy empowers and helps to facilitate personal growth in one’s life. For couples, therapy helps with tune in and awareness of issues before there is a problem.
It strengthens the family and the marriage bond. And also the assumption that therapy is free. I still get amazed by my educated friends who get shocked that therapy is a paid profession.

In general, what do specialists in this practice offer?
We offer couples therapy, individual therapy, child therapy, and group therapy on different issues; grieve therapy, premarital counseling, divorce mediation and recovery.
We consult for organisations on different issues including restructuring, retrenchment and workplace communication.

How do you stay detached from your counselling work? Is it even possible?
I have been practicing for more that 10 years now, throughout the years I have created some rituals that help me to transition from work to family life.
I have learned to set clear boundaries. At the end of my work day I put my phone on a silent mode for 30 minutes. I write down things that I have accomplished on that day and one thing that I am thankful for. I do basic breathing exercises. When I close my office door that’s the end of work – when I get in the car I listen to music until I get home.

What experiences are most useful for people becoming counsellors?
You need to be passionate, enjoy working with people and be willing to learn from your clients.

What seems to be the biggest obstacle for clients in therapy?
Not taking responsibility for the choices one has made over the years.

Mental health problems seem to be skyrocketing in our society lately? What are the reasons for this and what can be done about it?
I don’t think mental health issues are skyrocketing. Mental health issues have always been there. It is only that in our culture when we don’t understand something we find a way to label it. Mental health was often labeled as “botsenwa, mopakwane or boloi.”
There was a stigma for a person suffering mental health problem and their family. Often times they were ridiculed and treated as outcasts and shame to their families. Now people are beginning to be open about mental illness and it seems like it is skyrocketing because of the increased awareness.
We need to educate people more about mental health so that they can be aware and be sensitised on mental health issues.
That is a step to destigmatising mental health and learning the importance of early intervention, which can make a difference in one’s life.

If there is one thing you wished your clients or patients knew about treatment or mental illness, what would it be?
Mental health is a real illness. It’s not a character defect and it is okay to live with mental illness.
I have heard that after a couple has a child, which is notably one of the happiest times in anyone’s life that the satisfaction and overall happiness in the marriage can dramatically decrease. Is this true, and why is this? What can couples do to sustain their marital happiness after children?
Having a child is a transitional time in a couple’s life. The reason why it feels like a couple’s happiness has decreased is that the couple did not prepare for the transitional period and therefore they don’t know how to behave, or support each other with the introduction of this new person in their lives.
It is important for the couple to prepare for this period. This is another time in a couple’s life where couple’s therapy is necessary to help process and explore different ways of preparing for the anticipated additional member of the family.
The challenging thing in this transitional stage is that one partner takes a back seat while the other one is the driver of all things baby.
It is a normal transitional challenge and with preparation and awareness it can be handled better to ensure that the fire keeps burning.

What do you do to personally cope with stress in your life?
I pray, read, exercise, spend time with the people I love, balance family life and work life.

If you had your schooling and career choice to do all over again, would you choose the same professional path? If not, what would you do differently and why?
I will do it all over again. I feel honoured and humbled when people come to my office and choose to trust me with their inner fears. It often gives me joy to see them walking away with a smile.
As a therapist I make a difference in people’s lives.

What is the best advice you can offer to readers on leading a meaningful life?
Be true to who you are as a person.

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