A matter of life, death and vodkaPosted 21st October 2014 by Clare O'Neil in Articles | 0 Comment
It was not a particularly enticing prospect. Eleven years ago, Melbourne doctor David Pescod was asked to represent Australia at an anaesthesia conference in cold and windy Mongolia. “It was winter,” Pescod says, “and no one spoke any English. It wasn’t a very attractive offer.”
But Dr Pescod finds it hard to turn down an adventure. (He had already worked in Papua New Guinea and Borneo and has since been involved in projects from Micronesia to Burma.) Two weeks of eating mutton, drinking vodka and listening to lectures in Mongolian followed – all in minus-20 degree temperatures – along with an emerging understanding of some of the issues facing a country in which half the population lives on a few dollars a day, and infant mortality rates are six times higher than in Australia.
At the end of the visit Pescod was approached by Dr Ganbold Lundeg, a genial Mongolian anaesthetist (and the only other conference attendee who spoke English), who asked if he would come back again the following year to give a lecture.
Expectations on both sides were low. But Pescod, who works at the Northern Hospital in Epping, returned, and kept returning, later joined by colleague Dr Amanda Baric, who now runs the program. Ten years on, and just over a dozen Melbourne doctors (joined by Rhonda Keenan, a Melbourne midwife of more than 40 years’ experience, and Dr Sam Kennedy, who practises in Echuca) are visiting Ulan Bator, Mongolia’s capital. Here they teach emergency medicine, gynaecology and anaesthesia to hundreds of students, provide advice to doctors and perform the occasional surgery.
The doctors conduct the lectures in a Mongolian training hospital that resembles a Soviet orphanage (the country is sandwiched between Russia and China), built with bare concrete walls almost a metre thick. The electricity goes out 20 minutes into the first lecture. After 30 seconds the lights flicker back on. No one skips a beat. Lectures are broken up with demonstrations of medical techniques, and most of the teaching is hands-on in small workshop sessions.
Teaching is just part of the support provided by the Australian doctors. Pescod has literally written the book on Mongolian anaesthetic practices. The standard texts were not appropriate for Mongolian students – they assumed access to drugs and materials used routinely in Western hospitals but unavailable there – and at $300 each they were too expensive even for some of Mongolia’s medical libraries.
Before Pescod’s arrival, students were using 1940s Russian textbooks (“God knows what was in them,” he mutters) and hand-copying passages in the library. With AusAID funding, Pescod’s textbook has been translated into Mongolian and distributed to all anaesthesia students for free. Pescod and Baric created Mongolia’s anaesthesia education program with help from doctors at the Northern Hospital. Now it is taught by local doctors.
The system was in dire need of overhaul. Most training was previously provided by senior doctors, some of whom had little interest in their young apprentices. Nipping out for tea and vodka while new trainees performed operations alone was common, says Dr Lundeg. The reputation of the specialty was low and the system turned out too few graduates. To boost numbers the government reduced the specialist training period to three months (training in Australia is six years), after which doctors were sent to remote areas to practice without supervision.
Pescod and Baric reached an arrangement with the Mongolian government: in return for them writing the Mongolian program, it agreed to extend training to 18 months. The program’s international imprimatur has given anaesthesia some much-needed cache.
There were 10 students in the first intake. In this third year, there are 30.
Hospital data is recorded erratically in Mongolia but anecdotally it is accepted that five years ago deaths due to anaesthetic complications occurred more than once a week. Now these deaths are infrequent. Many students and doctors arrived for the most recent course without basic life-support skills. By the end of the two-day seminar, most – though not all – are confidently and carefully practising CPR.
Five years ago Mongolian hospitals had no recovery rooms. After operations, patients were sent straight back to the wards, where they were checked on every four hours. Blocked airways, brain damage and death were among the dangers.
After some surgeries, doctors were not reversing the paralysing drugs that make up part of many anaesthetics, leaving patients unable to move for hours until drugs wore off. Other drugs were being used incorrectly, with doctors believing they were providing pain relief because the drugs stopped patients moaning, when, in fact, the patients were just being giving sedatives. All these practices, at least in city hospitals, have been changed.
The program is inexpensive and unbureaucratic. Baric organises the events as a volunteer. Doctors pay their airfares and accommodation. “These are not overbearing professors,” Pescod says, “they’re just nice people.”
Recently, Pescod was awarded a Medal of Service to Mongolian Life, recognising the important improvements he and the team have made to how medicine is practised in the young nation. But he emphasises that the most important components of the program are the dozen young Mongolian doctors with whom the Australians work most closely and who are responsible for integrating and implementing the changes.
“In many developing countries,” Pescod says, “you provide education and you come back a year later and nothing has changed … you need to have someone in the base country who is willing to accept responsibility and drive it forward. The Mongolians are probably the best example in the world of that.”
No one disagrees that the country’s medical system has a long way to go. Rhonda Keenan, the Melbourne midwife, was horrified to find 60 neonatal babies, some with serious medical problems, being cared for by two overworked doctors. But the Australians are hopeful.
“Things always change slowly,” says Baric. “But they change faster here than in most places.”
Originally published October 15, 2011 in The Age