The Nomenclature Of Anaethesia Providers In Ghana

I have been following the debate on the nomenclature of the Anesthetists in Ghana. I wish to add my voice to the debate.

Anaesthesia in Ghana is practiced by Trained Doctors and Trained Nurses. This means that After training as a medical doctor, the doctor decides to specialize in Anaesthesia. Equally, after training as a nurse, the nurse decides to specialize in Anaesthesia. One studied Anaesthesia with a background in Medicine and the other with a background in Nursing. Both in this field, are not practicing Physicians or practicing Nurses but Anaesthetists.

I will deal with this topic under the following outline?

1. Who are Anaesthetists?
2. What is the curriculum for training Anaesthetists?

3. Are there any difference in their training?
4. Is there anything like a doctor or Nurse anaesthetist in practice

5. Why do Anaesthetist with medicine background want to supervise Anaesthetists with Nursing background?

6. Comparisons with Ghana, UK and USA
7. Why are Ghanaian doctor Anaesthetists apprehensive of the name CRA?

8. Conclusion
Who are Anaesthetists or anaesthesiologists?
Anesthesia or anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes. It may include analgesia, paralysis, amnesia, or unconsciousness. A patient under the effects of anesthetic drugs is referred to as being anesthetized.

Anesthesiology is the practice of medicine dedicated to the relief of pain and periprocedural care of patients before, during and after invasive procedures.

Anesthesiologists help ensure the safety of patients undergoing surgery. The anesthesiologist provides care for the patient to prevent the pain and distress they would otherwise experience. This may involve general anesthesia (“putting the patient to sleep”), sedation (intravenous medications to make the patient calm and/or unaware) or regional anesthesia (injections of local anesthetic near nerves to “numb up” the part of the body being operated on (i.e. nerve blocks or spinal/epidural injections.

These procedures are carried out by both Doctors and Nurses who have been trained for three or more years in a college of Anaesthesia.

In Ghana the Nurses who specialized in Anaesthesia were regulated under the Nurses and Midwifery Council. It was difficult for the Council to regulate and supervise them because Anaesthesia was a medical and not a Nursing practice. It was therefore considered reasonable for the medical and dental council of Ghana to take charge and regulate and supervise the Anaesthetists with Nursing background.

The council decided to change the name from Nurse Anaesthetists to Physician Assistant - Anaesthetists to differentiate them from the Physician Anesthetists.

This is the crux of the present standoff between the CRA Practioners and the MDC. The Practioners want to be referred to as Certified Registered Anesthetists because they have been certified and registered to practice anesthesia. The same Anaesthesia that is practiced by the Physician Anesthetists.

CURRICULUM FOR ANAESTHESIA PRACTICE
a) Physician Anesthetists
Membership.
The candidate will spend a period of 3 years (36 months) in basic and applied sciences,

clinical anaesthesia including pain management and critical care. After completion of 12

months training, the candidate will sit for the Part I membership examination in Basic and

Applied Sciences.
A further 24 months training qualifies the candidate to sit for the Part II

examination provided he or she has passed or being exempted from the Part I examination.

The candidate must complete the 36 months membership as detailed below:

A Log book to cover 600 cases over 3 years
General Surgery(80cases) 3 months
Orthopaedics and Trauma(50cases) 2 months
Urology(50cases) 3 months
ENT Ophthalmology(50cases) 3 months
Plastic and Dental(50 cases) 2 months
Paediatric,Daycare + Psychiatry(60cases) 3months
Obstetrics and neonatal care(60 cases) 4 months
Medicine (70cases) 3 months
ICU/HDU(30cases) 2 months
Gynaecology(50 cases) 2 months
Neuroanaesthesia(20cases) 1 month
Cardiothoracic anaesthesia(20Cases) 1 month.
DETAILED CURRICULUM CONTENTS
Definition and Guidelines of the Clinical Rotations:

Basic (Core) Anaesthesia Training.
During this rotation the resident will be assigned to theatre lists in the fields of

General Surgery
Urology
Orthopaedics and Trauma
Obstetrics and Gynaecology
ENT
Paediatrics
Day care Anaesthesia and Resuscitation
The level of involvement will be at all phases i.e. pre, intra and postoperative care,

resuscitation and acute/chronic pain management wherever it may be required.

The first 12 months for any trainee will be in basic anaesthesia and resuscitation.

OBSTETRIC ANAESTHESIA
This rotation is specially designed to cover management of labour pain, operative obstetric

cases and resuscitation of the critically ill obstetric patient and neonate. Experience with

regional analgesia and anaesthesia is to be obtained during this rotation.

PAEDIATRIC ANAESTHESIA
Paediatric anaesthesia begins during the first year and continues in the subsequent 2 years

to cover congenital anomalies and major procedures in the neonatal and other paediatric

age groups.
An introduction to the following subspecialties will be done during the 3 year rotation:

CARDIOTHORACIC ANAESTHESIA
NEUROSURGICAL ANAESTHESIA
INTENSIVE CARE
PAIN MANAGEMENT
SKILLS AND PROCEDURES:
During residency training all trainees are expected to become proficient in the following

skills and procedures:
• Administration of general and local anaesthesia

o Administration of inhalational anaesthesia
o Administration of intravenous anaesthesia including total intravenous

anaesthesia(TIVA)
o Simple infiltration and nerve blocks
• Airway management
o Oropharygeal and naso-pharyngeal airways
o Laryngeal mask airways
o Endotracheal intubation
o Fibre optic intubation
• Ventilation modes and techniques
• Vascular Access
o Peripheral intravenous cannulation
o Central venous cannulation
o Arterial cannulation
o Insertion of pulmonary arterial floatation catheter (Swan-Ganz)

• Measurement of cardiac output
• Insertion of chest drains
• Regional Anaesthesia and analgesia
o Subarachnoid anaesthesia
o Epidural analgesia and anaesthesia and analgesia
o Intravenous regional anaesthesia (Biers’ block)

o Brachial Plexus Block
o Stellate ganglion block
o Major nerve blocks and field blocks
• Monitoring
o Basic e.g. clinical evaluation
o Standard e.g. NIBP, ECG, Pulse oximetry,PNS, Temperature, ETCO2

o Advanced e.g. ICP, SSEP, BIS
• CPR including cardio-version
• Interpretation of arterial blood gas analysis.

• Reading 12 lead ECG for arrhythmias and ischaemia

• Reading and interpreting Chest-X-ray, and other imaging techniques.

• Reading and interpreting basic laboratory data on FBC, electrolytes, renal and liver

functions.
• Management of acute pain, PCA, PECA, NCA, and chronic pain e.g. cancer pain.

BASIC AND APPLIED ANATOMY
• Upper airway- nose, pharynx, larynx, trachea

• Lower airway- bronchus, alveoli, diaphragm
• Cardiovascular system
• CNS and vertebral column and canal
• Autonomic nervous system
• Foetal circulation
• Major nerves of the upper and lower extremities

• Major nerve plexuses (brachial, lumber, and sacral)

• Surface anatomy for the major nerves, veins, arteries (upper and lower limbs)

PHYSICS AND CLINICAL MEASUREMENT
• S.I. units
• Work and Energy
• Electricity
• Ultrasonic waves(Electromagnetic spectrum)
• Gas laws
• Fluid and gas dynamics
• Vaporization and vapour pressure
• Medical gases production, storage and delivery

• Recording of biological potentials
• Pressure
• Temperature
• PH
• Measurements from the catheter to display
• Gas analysis
• Monitoring of neuromuscular function
• Cardiac output
• Respiratory function tests
• Humidity, Nebulizers and humidifiers
• The anaesthetic machine and its safety features

• Anaesthetic circuits
• Mechanical ventilators
• The basic anaesthetic equipment: Laryngoscopes, Masks, laryngeal mask

airway, spinal and epidural needles
• Medical gases and gas cylinders
BASIC APPLIED PHYSIOLOGY AND BIOCHEMISTRY
• Physiology of nerve and muscle
• Respiratory system and blood gases, oxygen transport and delivery

• Cardiovascular system (heart as a pump)
• Cardiac conduction (rhythm generation and conduction)

• CNS and Autonomic nervous system
• Renal system
• Acid base system
• Electrolyte and body fluids and homeostasis.

• Hepatic function
• Haematology, basic haematology functions
• Physiological changes during pregnancy
• Nutrition including TPN
• Immunology introduction
• GIT
• Fat, Protein and Carbohydrate metabolism
• Temperature
• Endocrinology
BASIC AND APPLIED PHARMACOLOGY
• Pharmacokinetics and pharmacodynamics
• Inhalation anaesthesia, mechanisms and agents

• Local anaesthetics, mechanism and agents
• Intravenous anaesthesia drugs
• Analgesics, narcotics and their antagonists
• Muscle relaxants
• Anticholinergic and anticholinesterases
• Antiemetic and antihistamines
• Inotropic and pressor drugs
• Antihypertensive drugs
• Antiarrhrrythmics
• Antimicrobials and cytotoxics
• Bronchodilators
• Clinical trials
• Pharmacogenetics
• CNS drugs
• Renal drugs
STATISTICS AND RESEARCH METHODOLOGY
• Basic statistics
• How to read medical journals
• How to critique medical journals
• How to write articles
• Library studies
MEDICAL CONDITIONS INCLUDING PATHOLOGY
• Pain pathways, acute, chronic and cancer pain

• Head injury and conditions with increased intracranial pressure

• Ischaemic heart disease
• Valvular heart disease
• Hypertension, essential and other causes
• Cardiac arrhythmias
• Malignant hyperpyrexia
• Hypothermia
• Anaemia, sickle cell and other haemoglobinopathies

• Diabetes mellitus
• Acute and chronic renal failure
• Patients with liver disease
• Endocrine diseases and morbid obesity syndromes

• The patient with respiratory disease (obstructive and restrictive)

• Congenital diseases in neonatal and paediatric patients

• Arthritis and other orthopaedic problems
• Shock syndromes (hypovolemic, cardiogenic, septic, and anaphylactic)

• The psychiatric and mentally challenged
• Genetic and congenital diseases relevant to anaesthesia.

• Pregnancy related diseases
• Infections and infestations
• Connective tissue and degenerative diseases
• Neuromuscular diseases
Resuscitation and critical care management of all the above cases and their

perioperative management.
CLINICAL ANAESTHESIA
• Preoperative assessment, patient preparation for surgery

• Principles of obstetric anaesthesia
• Principles of paediatric anaesthesia
• Principles of geriatric anaesthesia
• Principles of neuro-anaesthesia
• Principles of cardiac anaesthesia
• Principles of thoracic anaesthesia
• Dental and day care anaesthesia
• Principles of mechanical ventilation (IPPV)
• The use of blood components and massive blood transfusion

• Anaesthesia for bronchoscopy and airway laser surgery

• General anaesthesia techniques and principles

• Regional anaesthesia techniques and principles

• Airway management (the normal and the difficult airway)

• Post-operative care (Recovery Room) including to control

• Anaesthetic complications and mishaps and their prevention.

CRAs undergo the same programs full time for 3½ to 4yrs. Presently the BSc program is 4 yrs full-time.

3. Are there any difference in their training?
In Ghana the Physician Anesthetists are mostly trained in Korle-bu, Komfo Anokye, 37 Military hospital, and Tamale Teaching Hospital.

CRAs are Trained in Komfo Anokye Teaching Hospital, Ridge Hospital, 37 Military Hospital, Tamale Teaching hospital and Cape Coast hospital

Korle-bu Teaching hospital has refused training CRAs even though they employ and use them for administration of Anaesthesia.

Training of Anesthetists is intensive both theoretically and practically. CRAs dominate the administration of Anaesthesia in Ghana. Presently there are about 800 CRAs in Ghana Manning all the hospitals in Ghana. Physician Anaesthetists are about 50-60 in Ghana based in Korle-bu, Komfo Anokye, Ridge and Tamale and Cape Coast hospitals.

Teaching.
The Anaesthesia schools are controlled by Physician Anesthetists mostly diploma holders. Before 2013 CRAs were Certificate or diploma holders. BSc Anaesthesia was introduced with reluctance because the Physicians felt it will downgrade them.

They have refused to allow CRAs to officially teach even though CRAs teach the medical and CRA students theory and practice in the theatres.

The MDC controlled by Doctors have refused to introduce a Master's program because of fear that CRAs will take over the running of the schools. How can a country develop like this. We shall continue to be a developing country if leaders continue like this.

Practically CRAs are far better than Physician Anaesthetists, a fact that cannot be contested because CRAs practice more than them.

4. Is there anything like a doctor or Nurse anaesthetist in practice

It is only a nomenclature. We don't have Anaesthesia that is reserved for Doctors and Anaesthesia reserved for CRAs. Doctors have tried to carve a niche for themselves but have failed. The only difference is that one is paid as a doctor and the other as a CRA due to the Nursing background.

All Anaesthetists can specialize in any field so long as the opportunity exist.

5. Why do Anaesthetist with medicine background want to supervise Anaesthetists with Nursing background?

It is a paradox. When it comes to Anaesthesia, both have studied the same books and uses the same equipment, drugs and techniques.

Besides the knowledge that CRAs possess in Medicine, Surgery, Paediatrics, Pharmacology, Psychiatric, pathology among others, they are also professional Nurses. Combining these knowledge, it will be hard to underrate an Anaesthetists with these rich background. Any patient will feel more comfortable with the CRA than the Physician Anaesthetists.

6. Comparisons with Ghana, UK and USA
In the USA the number of physicians
Anesthesiologists are 50,121
As of 2018, CRNAs represent 50% of the anesthesia workforce in the United States, with 52,000 providers, according to the American Association of Nurse Anesthetists, and administer approximately 40 million anesthetics each year in a population of about 300 million,

The United kingdom has a physician Anaesthetists population of about 10000 and about 5000 Nurse Anaesthetists in a population of 65 million.

With this ratio of almost 1:1 in USA and 2:1 in UK they can afford to say that CRAs should be supervised by Physician Anaesthetists. Considering the fact that CRNAs perform about 40million Anaesthesia a year in the USA, they are certainly not under any supervision.

Physician Anaesthetists in Ghana are about 50. CRAs are about 800. Out of the 50 physician Anaesthetists, 20 are based in Korle-bu whilst about 30 are distributed still in Accra, Cape Coast and Tamale and a few other areas. Ghana has more than a thousand health facilities that perform surgical operations daily.

Greater Accra by 2015 had about 90 hospitals, Ashanti Region 60 hospitals, Brong Ahafo 30, C/R 30 etc.

How can doctor Anaesthetists based in Korle-bu, Ridge, police hospital and 37 Military hospital supervise CRAs in almost all these hospitals? Impossible. Most of these CRAs are more experienced than the doctor Anaesthetists.

Majority of CRAs trained and practiced Anaesthesia before most of the Anaesthesia consultants in Korle-bu. How are these consultants going to supervise people who are more experienced than them?

7. Why are Ghanaian doctor Anaesthetists apprehensive of the name CRA?

Certified Registered Anesthetists have been in practice in Ghana for decades. Before a Ghanaian doctor administered Anaesthesia in Ghana probably in 1963, CRAs were already giving Anaesthesia.

Agogo Presbyterian hospital is the olders GHAG hospital in Ghana established around 1932. CRAs have administered Anaesthesia till date. No Physician Anaesthetists has ever practiced in that hospital. They perform about 5000 surgeries a year ranging from general surgery, obstetrics and gynaecology, and ophthalmic surgeries. They have never been in need of a physician Anaesthetists because he/she brings nothing in addition.

The over 100 Chag hospitals in Ghana are manned by CRAs. More than 90% of Anaesthesia is administered by CRAs in Ghana. Thousands of our mothers and sisters would die every year without CRAs. Physician Anaesthetists are only found in comfort areas in the regional capitals where they work with CRAs. They are scared to work alone because of lack of experience. They hide behind the CRAs to project their images. Majority of CRAs work in singles in hospitals dotted around Ghana. How many physician Anaesthetists work alone in Korle-bu, Ridge, Cape Coast, 37 or Tamale? None. They are all scared

9. Conclusion
To conclude, Anaesthesia is Anaesthesia. There is nothing like Physician or Nurse Anaesthesia. There are no special books or equipment of Anaesthesia that belong to only Doctors or nurses. There are no special drugs in Anaesthesia that only doctor Anaesthetists can administer. The Anaesthesia curriculum is the same everywhere in the world. There is no particular kind of surgery that is reserved for only doctor Anaesthetists to administer Anaesthesia.

The only difference is that a doctor Anaesthetists earn a doctor's salary and allowances whilst the CRA earns a Nurse's allowances and salaries. They both have the same work description or prescription.

It is my hope that the authorities in Ghana will not yield to the selfish and parochial desires of about 50 physician Anaesthetists to jeopardize Anaesthesia practice in Ghana.

The title Certified Registered Anesthetists does not affect any doctor. CRA is not equivalent to Physician Anaesthetist.

They want to be referred to as Doctor/Physician Anaesthetists or Anaesthesiologists. It is not contested by anybody.

We also want to be called Certified Registered Anesthetists. Why are they having problem with this?

Doctors want to control everything in the hospitals. They want to control Radiology, Pharmacology, and Laboratory departments. If care is not taking, they will one day want to control Nursing in the hospitals.