Since 2001, anaesthetists, have volunteered their time to conduct medical education in Mongolia. We have conducted annual seminars, site visits, in theatre and in hospital teaching and helped to develop a new training program for the Mongolian Society of Anesthesiologists. In recent years, as other craft groups in Mongolia have witness the value of the anaesthesia education assistance, we have responded to specific request by expanding education to include emergency physicians, gynaecologists, obstetricians, midwives, paediatricians, midwives and surgeons Our aim is help build capacity in a country that had long been isolated from the rest of the world and had a medical system that was poorly funded and cumbersome.

Initial Emergency Care During our visit in 2012, we were asked by the Mongolian Society of Anesthesiologist to develop a basic emergency course with the aim of training a core group of doctors and other medical providers in emergency medicine, which currently does not exist as a separate medical specialty in Mongolia and is in need of development.

The development of Emergency Medicine is a high priority as documented in The National Emergency Medical Retrieval Network Programme of Mongolia 2010-2016 (Annex to the Mongolian Government’s Resolution #318 of 2010) .

Specifically within the document

4.2.1.to introduce ‘emergency care training in medical, disaster and critical cases’ to the undergraduate and postgraduate curriculum of the medical university and nursing colleges

4.2.2. to provide professional training for physicians and nurses managing medical emergencies and to train them abroad for specialization;

4.2.3. to organize the training of paramedics and other staff in specialized emergency care service

The vision of the MSA was to create a train the trainer course that would be adaptable from field Felshers, through to tertiary hospital doctors. We undertook the challenge and over 9 months, with the invaluable help of emergency physicians, remote general practitioners and anaesthetists crafted the Initial Emergency Care course (IEC). We based much of our material on "Emergency Department Guidelines", largely written by a hard working emergency physician, Dr James Hayes, from the Northern Hospital and based the format of the course on the highly successful Primary Trauma Course (PTC) and Essential Pain Management (EPM). IEC comprises a two-day workshop, a one-day instructor workshop and additional resources.

Initial Emergency Care has been developed to improve the initial care of patients presenting to emergency and primary care providers in resource-limited settings. It is intended that the health care worker will gain the skills to administer first aid, and to be able to perform an initial assessment and treatment of life-threatening or limb-threatening conditions prior to referral to definitive care at the same or a different medical facility

The Initial Emergency Care Reference Text (licensed under a Creative Commons Attribution-Non Commercial 3.0 License) presents concise, point form management plans. The material is produced for resource rich environments, and hence includes investigation, treatment and disposition options that will not be universally available.

The IEC instructor workshop is designed to provide participants with the knowledge and skills to become an IEC instructor

The instructors listed below developed a reference text, slide set and instructor manual. Our Mongolian colleagues translated the slide set and printed in “pocket book” form the IEC reference text.

In 2013 we ran a two-day course in Ulaanbaatar from June 20-21st titled "Initial Emergency Care" (IEC) followed by a one-day instructor course at the MSA training centre. We then traveled to two remote locations, Arkhangai Aimag and Khentii Aimag, to teach the course at a regional level on 24th and 25th of June. (See separate formal report). The doctors who instructed IEC were:

Dr Simon Smith, FACEM, Emergency Physician, Victoria, Australia
Dr Loren Sher, Emergency Physician, Victoria, Australia
Dr Simon Hendel, Provisional Fellow, Australian and New Zealand College of Anaesthetists (travelling on the ANZCA scholarship award)
Dr Andrew Lees, General Practitioner, Victoria, Australia
Dr Samuel Kennedy, General Practitioner, Victoria, Australia
Dr David Pescod, Anaesthetist, The Northern Hospital, Australia
Dr Amanda Baric, Anaesthetist, The Northern Hospital, Australia
Dr Hella Deifuss, Anaesthetist, The Northern and Austin Hospitals, Australia
Dr Leona Leong, Anaesthetist, The Northern Hospital, Australia
Mr Timothy Furlong, Surgeon, Royal Melbourne Hospital, Australia
Dr Sathi Seevanayagam, Anaesthetist, Singapore

The IEC course:
Day one included an introduction to Initial Emergency Care, a pre-test, trauma management and head injuries, pre-hospital emergency care and transport, communication, triage, cardiac and respiratory emergencies, skills stations on ECG interpretation, CXR interpretation, airway management and intercostal catheter insertion.

Day two included burns, wound care, fractures, paediatric and obstetric emergencies, abdominal pain, diabetes, the alcoholic patient and skills stations on the primary trauma survey, FAST and basic life support and a post test.

The Instructor course included sessions on: adult teaching, how to lecture effectively, running a discussion, teaching a skill and scenario teaching.

IEC Ulaanbaatar: was attended by in excess of 100 medical professionals. It was evident that though the content of IEC was appropriate to the city medical professionals, the format of the lectures will need refinement.

IEC Provinces: was attended by approximately a dozen soum and aimag doctors who, as expected, have a great deal less resources and substantially different priorities of treatment and learning to their city counterparts. The content of IEC was significantly less appropriate to the province doctors and small number of attendees would promote a change in education techniques, however the IEC was greatly appreciated by Soum health professionals and there is a very significant need for Soum and Intra soum education.

It is evident that a universal IEC for tertiary and provincial health care providers is less optimal than courses tailored for the two significantly disparate environments. The task now is to separate craft courses that provide optimal training. We believe that the Mongolian emphasis at the moment may be for a course that is aim at provincial health care workers

Since our return Ganbold has (email from Ganbold 21/8/13)   “met with the director of Center for Health Development (this is the government agency which implement the policy of MoH and government) while we talked about the CME for rural doctors (Soum and InterSoum). Your country have plenty of experiences and organizations in this field. The Director Dr. Bat-Erdene (CHD) was also interested in the training and working condition in Emergency as well as intensive care system in your country, this is a priority in building up the current policy and realization in routine practice as whole system.” The MOH hopes “to link and a find most appropriate way to broaden the structured training modules (like Initial Emergency Care; Primary Trauma Care; Essential Pain Management and otheres) in Mongolia which we developed through our project realization in last 10 years”

Mongolian Society of Anaesthetists/Australian Society of Anaesthetists Annual Australian-Mongolian Medical Project 2012, trip report In the week beginning June 18th 2012, a large group of Australian doctors, nurses and midwives spent one week providing didactic, interactive, simulation based and clinical teaching to our colleagues in Mongolia.

Through the workshops, it appeared that the Mongolians are becoming more proactive and demonstrative. The candidates, however do need a fair bit of prompting when it comes to role playing.

The group of volunteers consisted of 5 teams of people. Our "anaesthetic team" led by Dr David Pescod and Dr Amanda Baric taught at our annual MSA/ASA seminar, the theme of which was Anaesthetic Emergencies. The team members included Dr Ian Hogarth, Dr Hella Deifuss, Dr Elmo Mariampillai, Dr Roni Krieser, Dr Sam Kennedy, Dr Phillipa Hore, Dr Richard Clarke, Dr Sion Davies, Dr Debra Devonshire and Dr Roger Goucke. The seminar ran over two days (Monday 18th and Tuesday 19th of June).



Our Mongolian hosts were Dr Ganbold Lundeg, Dr Lkhagvajav Unurzaya (current MSA president) and Dr Batgombo. They arranged for the teaching to take place at the Health Sciences University in Ulaanbaatar and translated all the presentations into Mongolian to allow for dual projection of slides (English and Mongolian). The number of participants was about 90-100, which proved a challenge when we were divided into three groups for our workshops, particularly as one of the rooms was just big enough for twelve. A large group of anaesthetists were from Hospital number one, the main teaching hospital in UB, where elective surgery had been cancelled to allow their anaesthetists to attend our seminar. Most of the current cohort of trainees from the new anaesthesia program was present and about 20 doctors had traveled from remote parts of Mongolia to be there.

Monday's teaching began with a showing of "Just a Routine Operation", the story of Elaine Bromiley, who died from cerebral hypoxia after a can't intubate, can't oxygenate situation during general anaesthesia. The film was expertly subtitled by Dr Batgombo and was used to put the seminar into context. Much discussion was generated around the film during the two days. A short presentation on an approach to common problems, including how to avoid them and how to apply a systematic approach to problem solving under anaesthesia, was followed by workshops on cardiovascular problems including arrhythmias, ischaemic heart disease and disturbances of blood pressure under anaesthesia.



The afternoon session involved the showing of a video of an airway problem (high airway pressures and low saturation) followed by an interactive discussion led by Dr Ian Hogarth, who opened up dialogue with the audience to demonstrate a structured approach to a common intra-operative problem. Dr Roni Krieser then gave an excellent presentation on monitoring in anaesthesia. He was able to engage the audience by using prizes to reward those who contributed to the discussions and introduced capnography to an audience who had at best infrequently or at worst never seen it in use.

The afternoon workshops focused on airway emergencies and Dr Richard Clarke ran one on aspiration of gastric contents, Dr Deifuss led the skills station on surgical airway and Dr David Pescod led a workshop on airway obstruction, which created much conversation about how to avoid laryngeal spasm.

The second day of the seminar ran in a similar way; with a video of a crisis (anaphylaxis) followed by debrief by Dr Hogarth and Dr Deifuss. Dr Deifuss then delivered a lecture on the principles of crisis management. The lights went out towards the end of the crisis management lecture, so we all went to plan B - workshops in the break-out rooms, where there was ample natural light and white boards and markers. Although the initial plan for these workshops was to use PowerPoint as a visual aid, they ran exceptionally well, and the participants felt at ease, contributing to sometimes quite animated discussion! The topics covered were anaphylaxis, massive transfusion and postoperative neurologic deficit.



The afternoon session started with another video, consisting of a "patient" with airway obstruction in the recovery room. The workshops in the afternoon focused on recovery room problems including postoperative respiratory complications, delayed emergence, pain and postoperative nausea and vomiting.

Feedback from the participants and Mongolian hosts was positive overall and the breadth of material covered was wide. Each delegate received a hard copy of the seminar manual that was written and compiled by our team prior to arrival. It is a comprehensive manual that will become a resource for the participants, given the general lack of access to current texts and journals. They also received a USB stick with all the PowerPoint presentations and a p.d.f. version of the manual for future reference.

Dr Phillipa Hore wrote and distributed a survey for the participants to gain an understanding of what sized hospital they were from, what monitoring was available to them and what medications were in use to treat pain. The initial results suggest that there is a general paucity of monitoring equipment in the Mongolian hospitals. Oximetry is becoming more widely available, but the understanding of its use to guide treatment is incomplete. Capnography is generally not available. Morphine is available, but is not used commonly. Fentanyl is used much more commonly during procedures and there is a strong reliance on non-steroidal medication (albeit in alarmingly large doses). The other medications available for pain include paracetamol, local anaesthetics, ketamine, pentazocine and "Analgin".

Dr Roger Goucke, Ms Patricia Clarke and Dr Debra Devonshire formed the core of our "pain team". They spent time visiting the hospitals to gain a better understanding of current pain management and to teach about the treatment of acute pain. They spent time visiting Hospital Number One, Hospital Number three (which is the centre for cardiac and neurosurgery), the trauma hospital, the burns hospital and the cancer hospital.



On Wednesday 20th of June, members of the anaesthetic and pain team ran the first Essential Pain Management Course in Ulaanbaatar. A small group of Mongolian anaesthetists attended (8) to receive training in English and most returned on Thursday to attend the train the trainer course before they all ran the first ever Mongolian language EPM on Friday 22nd of June with 30 local participants. The local EPM was supervised by the Australian team who were very impressed with the quality of teaching delivered by our new Mongolian instructors.



Our general surgery team, (Mr Binh Nguyen and Dr Manash Patel), spent 4 days in the countryside teaching in the Khentii Aimag  at Ondorkhaan hospital and performing clinical work. Ondorkhaan has a population of 15,000 however the catchment area includes 100, 000 living in smaller towns and nomadic farmers.

They worked alongside the local surgeon and anaesthetist. The hospital staff were keen to learn some general anaesthetic and airway management techniques.  Mr Muhkbat, the only surgeon in Ondorrkhann was on call 24 hours 7 days a week, though other doctors are multi-skilled and the anaesthetist was able to do an appendicectomy.Dr Patel was able to demonstrate the use of laryngeal mask airways. There was no capnography available, but oximetry was in use. The Mongolian anaesthetists were very skillful at spinal anaesthesia but were very grateful for the opportunity to practice general anaesthesia. Mr Nguyen was able to perform over 14 procedures including open cholecystectomy, hernia repair and circumcision. Laparoscopic facilities were planned for Ondorkhaan in the future but currently was not available.

Mr Binh Nguyen observed that though scrubbing and gowning was done appropriately, there was no time out process and no obvious counting of instruments. The theatre lacked light handles and lights were adjusted by scout nurses. The set up lacked kidney dishes for transfer of scalpels, which were simply wrapped with gauze and handed to the surgeon. Needles were not guarded.

Overall, it was “an eye-opener” for Mr Binh, learning how surgery can be achieved in remote locations, and how doctors adapt to what they have. He would prefer to have spent a longer time.

The midwifery team spent 5 days teaching newborn resuscitation in First Maternity Hospital, which was the current location of the (very busy) Third Maternity Hospital that was closed for renovation. Interestingly, Third Maternity had been closed due to a series of deaths due to maternal sepsis. It was thought that this was due to the decrepit state of the building. Rhonda Keenan and Eleanor Teare were very busy teaching in large and small groups, as well as in the wards, where one-to-one instruction was given to medical and nursing staff, and students. The neonatologists were very grateful, as up until now, they have been the only ones qualified to perform newborn resuscitation and they were very understaffed for the number of deliveries that took place in the hospital.

Our Gynaecology surgery team was led by Dr Kym Jansen (obstetrician and gynaecologist) and Dr Phil Popham (anaesthetist). They were involved in presenting material at the international gynaecology seminar and then doing clinical work at First Maternity Hospital, where they operated on very complex cases, some of which were televised live to the conference. The other team members included Dr Emma Readman, Dr Stephen Lee, Dr Maggie Wong, Dr Kim Fuller and Dr David Dolan. Some of the team were able to visit the Maternal and Child Health Research Center, where they assessed the possibility of providing laparoscopic gynaecology surgery under general anaesthesia.

The obstetric team returned to Mongolia this year after an absence last year. Dr Rebecca Szabo, Dr Lauren de Luca and Dr Alexandra Miglic were our obstetricians. They visited both major maternity hospitals and were able to run some practical workshops on the use of vacuum for delivery and post partum haemorrhage. They visited the wards and did some in theatre clinical teaching. Their observations included the improvement of hand washing between patients (with the installation of alcoholic handwash dispensers throughout clinical areas), and they demonstrated some safe sharps handling that was taken up by the local obstetrician. Given the widespread problem of maternal sepsis and hospital-acquired blood borne infection (particularly hepatitis B and C) this was a major step forward. There are plans to utilize the obstetricians more effectively next year and run an international obstetric meeting in Ulaanbaatar (the first).

The areas of need in Mongolia include:

- Improving the availability and teaching of the use of intra and postoperative monitoring, including management of hypoxia and perturbations in physiologic parameters

- Improving airway management techniques

- Improving the safety and maintaining anaesthetic machines, other equipment and hospital supply of gases and suction.

-Improving the use of analgesic agents (particularly limiting the use of very high doses of non-steroidal anti-inflammatory medications)

-Improving availability of monitoring of patients receiving opioids for analgesia and education in recognizing and treating respiratory depression (the fear of which is a major barrier to the effective use of opioid analgesics). Increasing access to naloxone.

- Increasing the use of intrapartum monitoring in labour ward, where there is little if any monitoring of the fetus. Teaching the correct interpretation of CTG monitoring

- Improving the use of good surgical and perioperative techniques to avoid postoperative infection and hospital acquired infection

The following equipment and material was donated to our hosts and volunteers to use for teaching:

Two Mama Natalie simulation dolls to teach PPH management and Vacuum extraction and one newborn resuscitation manikin for teaching newborn resucitation donated by Interplast Australia.

Two Nonin oximeters one for the Khentii Aimag hospital and one to First Maternity hospital (thanks to Abbott and Device Technologies for funding)

One Airway Resuscitation Kit that went to the Khentii Aimag hospital (with thanks to Abbott and Solmed)

Finger pulse oximeters (for Khentii Aimag, MCHRC and First Maternity Hospitals) donated by Abbott

One VGA projector for the Mongolian Society of Anaesthetists to use for teaching (donated by Abbott)

USB sticks loaded with teaching material for both the Emergencies in Anaesthesia and Essential Pain Management (donated by Abbott)

Two boxes of spinal needles (for MCHRC and First Maternity Hospitals) donated by The Northern Hospital

Disposable self-inflating bags and masks, laryngeal masks and endotracheal tubes

Disposable laryngoscopes for the paediatric, maternity and Khentii Aimag hospitals (from Multigate Medical Devices)

Many thanks go to all of our hosts, volunteers and generous donors who have made this project so successful. We anticipate an equally successful project in 2013, when we anticipate the extension of our project into emergency care (first aid and basic emergency care prior to transfer), continuation of EPM, newborn resuscitation, surgical teaching, laparoscopy for gynaecology and obstetric care.

The Age
15 October, 2011 Sourced online

A matter of life, death and vodka

Clare O'Neil

Dr Davod Pescod has spent a decade training Mongolian doctors.

Photo: Jason South

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.

The Age
15 October, 2011 Sourced online

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.''