Myanmar

Shwedagon Pagoda

One of the reasons I was always interested in doing medicine as I was growing up was because I had this idealistic concept that I wanted to be involved in some kind of altruistic endeavour. I never believed I would save the world but I was always brought up with an acute awareness of how lucky I was and wanted to be able to contribute in some way back to society.

As a medical student, I remember thinking how incredibly courageous some of my friends were when they went and did interesting electives in developing countries. One of my friends went to Nepal, and some of the surgical situations she had to assist in were things we would have never seen at home and this filled me with terror. In my head, I was just a medical student and really had no idea about anything. I was the kind of intern who freaked out on day 1 about how much oral potassium I could safely prescribe. I convinced myself that there was no way I would be good enough as I just didn’t feel like I had knowledge or the skills to be useful. 

I kept expecting this sense of inadequacy to magically dissipate at different times throughout my career.  First, when I actually graduated from medical school, then after completing my internship, then after completing my residency. When this feeling was still there after starting my anaesthesia training I reconciled myself to the fact that maybe it would only be after I finished all my training and became a consultant before I would attain this elusive sense of adequacy. 

I am sure you know how this story ends. When I did finally finish my anaesthetic training, 6 years and 2 sets of exams later, I still felt inadequate. I didn’t feel like I had the self-assurance that many of my colleagues possessed and even though I was confident in my own abilities, working in an environment where there was equipment I was not familiar with, diseases I knew little about and a distinct shortage of medication and resources that I was so used to, petrified me. When I ran out of legitimate excuses like pregnancy, breast feeding and new born mothering, I knew I had to bite the bullet and do something otherwise I would never do it.

When the opportunity came up to go to Myanmar with a plastic surgery team in association with Interplast in 2014, I knew I had to take it. I left with a team of 3 nurses, 3 plastic surgeons and another anaesthetist for what was truly an eye-opening experience. The team has been visiting since 2001 and the program has evolved over the years to address the shortage of trained local plastic surgeons. Interplast’s main role in association with the University of Medicine 1, has been to establish and deliver the country’s first local postgraduate training program in reconstructive plastic surgery. 3 times a year these mentoring / training visits occur to support local trainees with the intention to make ourselves redundant in the near future.

In writing this particular blog entry, I have had to take myself back to my very first trip to relive the emotions of seeing some of these things for the first time. It is really difficult to capture all my thoughts and feelings about these trips, but I hope to give you a  little glimpse into what it has been like.

 Although I had been somewhat prepared with regards to what resources were available, the reality of the disparities between the health system in Australia and in Myanmar were quite confronting. Myanmar has a population of over 53 million people. It has approximately 250 anaesthetists for the entire country as compared to Australia that has over 4000 anaesthetists for a population of 24 million. Access to adequate healthcare is particularly difficult for those from rural communities, and basic health education in some isolated areas is still scarce.

Yangon General Hospital is a strikingly beautiful colonial style building built in the early 1900s. It has a whopping 2000 beds and caters for a range of surgical/medical specialities. Located opposite this beautiful but run-down hospital, (across a one way street of about 5 lanes), is a small white dilapidated 3 storey building which is the home of the department of Plastics, Maxillofacial & Oral Surgery.On the outside of this hospital, there is a hive of activity with people setting up stores selling food, betel nuts, (ironically something that causes oral cancers!) and general goods that might be necessary for hospital patients including dressings, catheters, blankets and cushions. There are often stray dogs loitering around the hospital grounds and often long lines of patients waiting to be seen in various clinics.

Yangon General Hospital

Nurses are scarce, particularly at night time and families are responsible for most of the nursing care of patients. This includes jobs such as personal hygiene, emptying catheter bags, buying prescribed medicine, and even recording fluid balance. There is usually one dedicated family member selected to do this. I remember a particularly diligent wife who used a 10ml syringe to carefully measure out urine she emptied from a 2 litre catheter bag, and despite us telling her that an approximation was adequate, she still documented every millilitre of urine on the chart. 

Power outages mid surgery are common and I soon became accustomed to taking out my iphone light in the middle of an operation.  Having a back-up plan with regards to my anaesthetic if the backup generator failed or if the battery on my anaesthetic machine ran out became vital. 

What I was not prepared for was how much I would gain from the experience both professionally and personally. Professionally, I have definitely learnt to be a lot more flexible. I am much more aware and conscious of using resources carefully. Here in Australia much of our equipment is one time use only with much packaging and we are almost flippant the way we use disposables. This not only has cost issues but environmental ones. I have learnt to be much more careful about the way I use even simple things like syringes.

Available medication in the hospital environment is dependent on what happens to be cheaper at that particular time. As a more junior anaesthetist, sometimes I feel the way we are trained can make us a little rigid in our approach to clinical scenarios and I’ve definitely learnt to become a bit more adaptable in different environments. I’ve had to use whatever is available and just try to make it work. It is also not uncommon for a single vial of medication to be divided into a few aliquots to avoid wastage. Post-operatively patients are expected to pay for many of their medications and consumables so it is important to take these factors into account when prescribing medications for the ward. Patients even have to pay for their own anaesthetic gas, something I have never ever had to even think about!

In writing this entry, I’ve realised that over my past four trips to Myanmar, I have become less surprised by what I see and certainly less frightened. More importantly, we are slowly seeing amazing changes in the hospital where we work. The surgical trainees are far less reliant on our surgeons for guidance. They are operating independently doing bigger and more complicated cases. Personally, I have developed close relationships with a few of the local anaesthetists and surgeons which has been wonderful. On some level, I feel guilty because what I get from each of these trips far outweighs what I am able to give back. Each time we return, there are new developments and improvements yet the familiarity is somewhat comforting. It will be sad in a sense when we do achieve our now truly tangible goal of becoming dispensible.