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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

Caroline Gartland speaks on Children and Mental Health

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Tell us about yourself and your background
I’m originally from the UK but have been in Botswana for eight years so this is now home! I have a Combined Honours degree in Psychology an MSc in Mental Health and have had a pretty varied career.
I started off working with offenders doing rehabilitation programmes; went on to support the victims of domestic violence then ended up working in Child and Adolescent Mental Health Services for the National Health Service.
I’ve done a lot of work, mainly voluntary, in different fields since being in Botswana but my passion is now Early Childhood Mental Health.

What does your work entail?
Early childhood mental health is mainly working with parents, caregivers and teachers to help them understand how children develop and the best ways to support their mental health and brain development as they grow. It’s about providing training and opportunities for families to bond with their children and introducing new ways of playing and interacting.

What sparked your interest in early childhood mental health?
Quite simply, having my own children! My daughter was born five years ago and I was fascinated watching her develop and grow. It occurred to me that the younger you begin to consider mental health and provide tools for resilience against life’s adversities, the better outcomes you are likely to have.
I began reading everything I could get my hands on, and completed a diploma in Infant Mental Health. I’ve worked down the lifespan but I feel I’m now where I belong, working with babies and young children.

What mental health issues have you observed in children in Botswana?
Mental Health is still stigmatised around the world and Botswana is no exception. Most people immediately think of mental illness, but mental health is about so much more; we all have mental health and some days we are fine and able to deal with life’s challenges and some days we need more support and tools under our belt to help us cope.

Young children can experience mental health problems. Anxiety is a common one, but we are more likely to focus on the behaviour we see rather than how the child is feeling. An anxious child who refuses to go to school may be labelled as ‘difficult’ or ‘naughty’ but what they are expressing is a painful emotion that they need help dealing with.

Describe one thing you find fulfilling and challenging about working in this industry.
Working with children and families is a pleasure and a privilege. To make life a little bit easier for someone is all that matters, you don’t have to be out there saving the world to make a difference.
My major challenge is time. I would love to do more, I’d love to do an MSc in play therapy and a couple of other therapeutic techniques I’ve come across in Europe but that gets put on hold as I focus on my own family and business.

Can you share an anecdote about how mental health consultation works?
I think that education, understanding and connection are the three keys to giving a child the best start in life. Led by that, SensoBaby provides classes in the community for parents and caregivers to connect with their infants.

We offer workshops on parenting and play to foster understanding of child development and wellbeing and we are available to troubleshoot specific problems an individual or agency has with the young children in their care or the systems they have in place. When it comes to individual parents, mostly what they need is to feel heard, supported and guided in their parenting choices.
You can read all the baby books in the world but they won’t give you the answers you need for your child, through responsive parenting and connection, you’ll find you have the solutions you need.

What advice do you have for child-care providers or early childhood teachers who are at their wits’ end over a child’s challenging behaviour but don’t have access to a consultant?
Empathy is an important and undervalued skill – the ability to consider another’s viewpoint. What is that child feeling? Their behaviour might be challenging and hard to deal with but often the root cause is an unmet need. There’s a famous quote from an American Clinical Psychologist, “The children who need love the most, will ask for it in the most unloving ways.”

Does a mother’s mental health affect her foetus? How important would you say is paying attention to women’s well being during pregnancy as with their physical well being?
100% yes. It is so important to support a woman’s wellbeing during pregnancy. As an example, if the mother experiences significant stress and rising levels of cortisol (the stress hormone) during pregnancy, the foetus will be affected and in some cases will be more sensitive to stress in childhood or later in life.

Pregnant women and new families (Dads as well!) deserve nurturing care themselves and shouldn’t be afraid to ask for support. SensoBaby run FREE monthly coffee mornings to support pregnant and new mothers because we understand the importance of maternal wellbeing.

Do smart phones and television make our children mentally ill as is often purported?
I don’t think technology is always the villain it’s made out to be. The key is in the relationship with that technology. Moderate use of TV’s and smart phones are fine, as long as they aren’t a substitute for outdoor play, imaginative play and meaningful interactions. If a child is crying or upset and we hand them a device to keep them quiet then we have missed an important opportunity for connection, helping them process what is going on and supporting them to calm down and settle themselves.

Now, I know you are involved in an exciting programme that helps caregivers and children to bond and get the children off to the best start in life through play. Can you say a little bit about that work and just how you are seeing it play out?
SensoBaby is our baby; a project born from passion and a desire to support families in Botswana. We offer play-based classes for children and their caregivers that are underpinned by the principles of child wellness as well as early foundations for learning.

When you provide developmentally appropriate opportunities to play, you learn so much about your child. That understanding and observation builds strong connections, which will form the basis of that child’s future relationships and self esteem. Play is so much more than ‘a fun activity.’

We offer a number of trainings and workshops for parents, nannies and community stakeholders and hope to increase our offerings this year. Our community partnerships and voluntary programmes have been successful so far and we hope to see more impact in 2018.

We currently serve the Gaborone community but would like to expand throughout Botswana as opportunities arise. The response to SensoBaby has been fantastic so far and we can’t wait to see how far we can go with the concept!

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Know Your Specialist

Terence Mohammed explains intricacies of clinical trials

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What does a lab manager do?
As BHP laboratory manager, I am responsible for providing an oversight in the technical operations of the laboratory, including the clinical trials processing and testing labs. As part of the laboratory management, I also provide leadership in planning, implementing and completion of research activities and to ensure that laboratory operations and data generated is in accordance with Good Clinical Laboratory Practice. The lab manager is also expected to provide an oversight on the laboratory quality management system and laboratory expenditure.

Describe your career trajectory. How did you get to where you are now?
I joined BHP in 2007 as a laboratory research assistant. I worked for two years in various BHP clinical trials for diagnosing and monitoring of HIV/AIDS in clinical trials participants. In 2009, I got transitioned to the BHP research laboratory to work as a research fellow where I got assigned to work on various basic science projects. In 2014, I worked as a research laboratory coordinator where I was mainly involved in day to day routine management of the research laboratory activities including; conduct of research projects, preparation of education activities and mentoring of new research fellows, students and interns. In 2015, I got promoted to the position of deputy laboratory manager where I assisted the lab manager in overseeing the technical operations of the lab. In 2017, I got promoted to the position of lab manager.

What’s a typical day/week at the Botswana Harvard Partnership (BHP) for you?
I participate in a lot of weekly meetings; laboratory management and departmental meetings. I am also expected to attend meetings for the various clinical trials which we provide laboratory services to. These include local site meetings and international conference calls with study principal investigators and sponsors. I also review and authorise laboratory orders ensuring continuous operation of laboratory work and within allocated budgets. In addition, I also allocate time to walk around the different laboratory departments on a regular basis in order to interact with staff and learn more about their challenges. This facilitates discussions on how to improve our laboratory operations and working environment.

What are the main health and safety issues for lab technologists?
Exposure to blood, bodily fluids and tissues, which may contain infectious agents and also exposure to ultra-cold materials such as liquid nitrogen and dry ice. However, all necessary laboratory safety trainings are mandatory and staff has access to personal protective equipment including lab coats and gloves which are a requirement for certain tasks.

What aspects of your role do you enjoy the most?
I enjoy the daily interaction with researchers in the field of HIV/AIDS, both locally and internationally. It makes me proud to be part of a team that is working towards ending the HIV/AIDS pandemic in our region as it has decimated the population for over two decades now. With our work, I hope Batswana become increasingly cognisant of the task ahead of us and unify to bring an end to the pandemic.

What would you say the biggest challenge in your field is? Discuss one thing in particular?
Supply of laboratory reagents and consumables can be challenging as sometimes we experience supply stock-out and delays in delivery.

On a basic level, what skills does your job demand?
A lab manager should be able to organise and run effective meetings. It is important to set up an effective meeting agenda and be able to assign key action items to staff
-To be able to communicate effectively and create a positive atmosphere in the working environment. It is also important for the lab manager to be able to motivate staff and also be approachable to staff whenever required.
-A lab manager is expected to have leadership skills in order to provide direction to team members and ensure that the institution goals are effectively met.
-To be able to manage budgets and always be alert to ensure that the laboratory current spend does not exceed target spend.

You have done some research on HIV-1c gp120 in recently and chronically infected individuals in Botswana. For starters what is HIV-1c gp120? A brief background on the research and what the findings were?
Gp 120 stands for glycoprotein 120. This is a protein found on the outer surface of HIV and it used by the virus to enter human cells thereby causing infection. Previous research has shown that gp120 characteristics and properties could be susceptible to change overtime during the progression of the disease. Therefore, we used two groups of study participants at various stages of disease progression (i.e. recently and chronically infected) to see if there are changes in structure and properties of gp120 during the course of the disease. This research highlighted the need to further investigate gp120 in order to get information that maybe useful in the development and designing of an effective vaccine

What advice would you give someone interested in becoming a research fellow?
I would advise them to read a lot in their field of interest and also be aggressive enough to seek opportunities of attachment to a relevant institution. Furthermore, they should seek to interact with experts in the field in order to keep themselves in the loop should a research fellowship become available.

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