The Role of Anesthesiology in Global Health A Comprehensive Guide Ram Roth Elizabeth A.M. Frost Cli ord Gevirtz Editors Carrie L.H. Atcheson Associate Editor 123 The Role of Anesthesiology in Global Health Ram Roth • Elizabeth A.M. Frost Clifford Gevirtz Editors Carrie L.H. Atcheson Associate Editor The Role of Anesthesiology in Global Health A Comprehensive Guide Editors Ram Roth Elizabeth A.M. Frost Department of Anesthesiology Department of Anesthesiology Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai New York , NY , USA New York , NY , USA Clifford Gevirtz Department of Anesthesiology LSU Health Sciences Center New Orleans , LA , USA Associate Editor Carrie L.H. Atcheson Oregon Anesthesiology Group Department of Anesthesiology Adventist Medical Center Portland , OR , USA ISBN 978-3-319-09422-9 ISBN 978-3-319-09423-6 (eBook) DOI 10.1007/978-3-319-09423-6 Springer Cham Heidelberg New York Dordrecht London Library of Congress Control Number: 2014956567 © Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To Aren, who encouraged me to go on my fi rst surgical mission many years ago and inspires me every day. Only two of many reasons that I love you. R.R. To my many friends and colleagues around the world who continue to amaze and humble me by how much they achieve, often with much less than I have. E.A.M.F. To my beloved wife, Alison, and my sons, Theo and Graham, who are a constant source of inspiration; to Elizabeth Frost, a teacher, colleague, and friend who has always given me brilliant perspective and wisdom; and to my patients who teach me every day, meliora. C.G. To my husband, Eric, whose love of the written word and commitment to service make him my constant companion and inspiration. C.L.H.A. F o r e w o r d Ram Roth and his coeditors have created a unique book. Anesthesiology is focussed on the relief of acute and chronic pain and the preservation and enhancement of life in all aspects of medical care. Despite this, many people, both medical and lay, would not realize this wide spectrum of care and would consider those who practice in our specialty as physicians who merely remain in the operating theatre. Medical knowledge has developed in different civili- zations at different times. While many currently affl uent societies were rigidly blaming illnesses on personal sin and treating with complex herbal mixtures and prayer, other currently less affl uent areas had sophisticated therapeutics and surgery based on sound physiological knowledge. This persistent inequality in access to medical care has changed from country to country as civilizations come and go, but in today’s world, appalling inequality still exists. If the mortality purely from anesthesia in, say, London is around 1:200,000, that in parts of West Africa right now is 1:150. This is not acceptable and has to be changed. Humanity has always had individuals who want to make a difference. Initially, these might have been medical missionaries who combined teachings about their faith with simple improvements in healthcare. Soon this was associ- ated with travelling surgeons and nurses; with the advent of modern anesthesia, this, too, would be added into the travelling mix. In the early days, this provision of pain relief would be part of the surgical remit, but as anesthesia developed and became specialized, slowly, anesthetists started to travel and teach. Early medical missions went to areas and built hospitals, taught locally, and stayed for the rest of their lives. Often, however, their deaths resulted in a loss of service and a return to “the old ways.” As time passed, all countries started medical schools and local doctors emerged, but anesthesiology has always been regarded by many as a “low-quality” speciality. This is now changing, but not fast enough. Nowadays, there is a very confusing picture of humanitarian aid through- out the less affl uent world. Some NGOs have found it diffi cult to demonstrate that donated funds reach those most in need. Many “aid workers” go into an area and do tremendous surgical or medical interventions but then depart without any thought of leaving a legacy beyond those individual lives they have changed. There is almost a sense of medical tourism for some, with the collecting of photographs of terrible pathology and beautiful landscapes for what almost seems like the “entertainment” of people back home. vii viii Foreword It is now obvious what needs to be done to improve essential surgical and anesthesia care around the world. Governments can see what could be done and they need to allocate appropriate resources to make this happen. Those who travel to teach need to “teach the teachers” and leave a legacy on which further developments can be built. At this time, the WHO realizes that death from infectious diseases is falling, while death from essential surgery and anesthesia is rising. They, too, will seek to infl uence governments. The WFSA will seek to assist them in this work. This book describes many sound ways forward. It is a great start, but the fi nish will come when inequality in care is abolished. David J. Wilkinson, L.R.C.P., M.R.C.S., M.B., B.S. World Federation of Societies of Anaesthesiologists (WFSA) London , UK May 2014 Pref ace No man is an island entire of itself … any man ’ s death diminishes me , because I am involved in mankind. John Donne, Devotions upon Emergent Occasions, 1624 . Anesthesiologists provide acute and critical medical care to patients as well as the necessary infrastructure to enable surgeons to implement dramatic, life- changing interventions around the world. In and around any operating room anesthesiologists are the professionals who provide preoperative evaluation, consult with the surgical team, and create a plan tailored to each individual patient—including airway management, intraoperative life support, pain con- trol, and postoperative management. It is in this capacity as perioperative physi- cians that anesthesiologists improve the safety and effi cacy of surgical interventions for underserved patients in low- and middle- income countries. When we fi rst embarked on this project to identify the role of anesthesiol- ogy in global health, we knew that many organizations around the world were already involved in medical missions. We came to this task with different perspectives, from resident to senior practitioner, and diverse experiences, gained over the years from travels, consultations, and basic care in many countries. We suspected that anesthetic care providers would identify com- mon areas of concern and similar diffi culties. What we have learned from writing this book is so much more. Through reports from so many mission providers, we learned that many of the problems are the same … lack of basic supplies, education, infrastructure, and communication. A need to understand that more can indeed be done with less is a recurring theme. The diffi culties have all been identifi ed succinctly and on many occasions, but no common solutions have been determined. Moreover, in diverse corners of the world anesthesiologists have developed programs that they individually believe to be unique but in fact are mirrored to a greater or lesser extent by other practi- tioners. Thus, the need for a collaborative effort and true development of a global health strategy is underscored. Can this be done by one entity such as a government or medical school or international organization? Probably not! Rather, as some of our authors present, representatives and leaders from among the ranks of health care professionals should put aside different agen- das to develop a workable health program that is truly global. The resources are there: organizing and harnessing those resources is the next step in the process. If readers fi nd that there is duplication in some chapters, they are correct. We have deliberately left it that way to underscore the need for closer ix x Preface alliances and communication.