A Train the Trainer Model Chalks up New Successes in Africa

Training room, Dar Es Salaam.

Karima Khalid can feel the beads of sweat on her forehead, her pulse quicken, her shoulders tense. It’s just a simulation, she reminds herself,reorienting. The patient is becoming hard to ventilate, and a laryngospasm is detected.There’s no IV line by which to administer fluids. Seconds turn into minutes. PediSim is now in critical condition.

The training provides a solution. Drugs can be injected under the patient’s tongue to resolve the laryngospasm. As the exercise comes to a close, there’s the feeling of relief that it’s only a simulation, tempered by the understanding that this could happen in real life.

Naren Bhimsan and Karima Khalid, trainer and trainee, recounted this incident as they shared the exciting progress that’s being made in Africa, as simulation training technology is being taken to new countries and new doctors.

Switching to Simulation

Bhimsan came to simulation via an interesting route. Armed with a degree in biochemistry and physiology, he got a job at the Discipline of Anaesthesiology & Critical Care at the Nelson R Mandela School of Medicine in 1990. In those early days he became involved with cutting edge medical research projects like human placental perfusion. But about a decade into his career, one day, while conducting clinical research, he cut his finger and came face-to-face with the risks of getting HIV in his line of work. “I knew I didn’t want to have a lab accident and then have to be on a regimen of antiretrovirals for the rest of my life,” he recounted.

The incident made him start to think about other pathways he might pursue.

Around this time, in 2003, the department bought a secondhand simulator. “Those days no one knew what to do with them,” he said, chuckling and recalling a time when using simulators was relatively new. “Then I came across the HPS, the Rolls Royce of simulators,” he said. “When you give it gas, it goes to sleep, when it awakes, it passes urine. Now I could see how you train using a simulator.”

Birth of the SMART Center

In the early aughts there was no structured program in simulation at the Nelson R Mandela School of Medicine. But undergraduate students would complete a two week rotation in anesthesia and trauma. With his hallmark savvy, Bhimsan started to bring four to five students over to the SMART Center and began training them using simulation technologies.His methods were so successful that 2 years later, training at the Center became a standard part of the teaching curriculum. Today, Bhimsan runs a state of the art Center based inside the hospital, and oversees a multidisciplinary training program. Through the Center, they train about 200 undergraduate students a year, plus doctors from the 6-7 metropolitan hospitals around Durban.

 In 2013, came a transformational shift. The Center got accredited to run a course in MEPA (Managing Emergencies in Pediatric Anesthesia) which provided a significant boost to their work and reputation. “This was a major turning point for us,” said Bhimsan. “We were approached by a pharmaceutical company to train doctors in many Sub Saharan countries -Kenya, Zambia, Malawi etc.” From 2015 to the present day, the Center has trained around 150 of these doctors in anesthesia, ultrasound, airway management etc. The designation as a COE has also spurred development in other areas.

An exported “train the trainer” model

More recently, Bhimsan began to reflect on how to provide greater value to practitioners in other countries. “I realized we cannot bring everybody to Durban. And when we bring people here, we’re depriving patients of physicians for longer,” he said, describing the shift to a new model where the trainers, rather than the participants, travel to share their knowledge. 

Nowadays, in an “export” model, Bhimsan and a team of anesthesiologists, take the training to where it’s needed. So far they have successfully conducted trainings in two countries: in 2017, they took the MEPA training to Tanzania and in 2018, they went to Zambia. A future trip to Ghana is in the works.

One of the significant benefits of the new model is that it creates a set of local trainers who can train others. Khalid works at the Muhimbili Orthopaedic and Neurosurgical Institute(MOI) and Muhimbili University of Health and Allied Sciences (MUHAS). Initially a participant in the Durban training, Khalid later became a trainer herself when Bhimsan and his team took the training to Tanzania. Khalid shared that being part of the on the ground training in Tanzania helped her transition from participant to teacher. “I got to work behind the scenes and understand how the simulator works. I learned to prepare scenarios, to figure out when to intervene and when to provide information,” she shared. The experience has heightened her enthusiasm for simulation and helped her develop her own approach.

Value of Simulation in Resource Challenged Countries

Africa faces some very fundamental challenges in anesthesiology. There is a severe lack of both practitioners and equipment. Given these realities, I asked Bhimsan and Khalid about the role for simulation based training in Sub-Saharan African countries. Bhimsan was emphatic in his response. “There is a real hunger for the training,” he said. “By getting it,doctors are able to get to the next level.” Khalid shared why it’s been important in Tanzania.“Having a simulation lab to learn things helps to reduce the burden of training when you’re in the OR,” she said. “Doctors know the skills, and it’s easier for them to take over. And for events that are rare, it’s much safer.”

And Khalid would know. A week after the training, Khalid had a new patient: a baby, with a laryngospasm. There was no IV line to turn to. But Khalid was cool under pressure. She had seen this situation before. She injected the drugs under the baby’s tongue, relieving the obstruction. She saved the baby’s life.


by guest author Sharmila Shankarkumar