A Comprehensive Guide Ram Roth Elizabeth A.M. Frost Clifford Gevirtz

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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. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. 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.

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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 civilizations 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 associated 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 throughout 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 control, and postoperative management. It is in this capacity as perioperative physicians 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 anesthesiology 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 common 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 practitioners. 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 agendas 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. It is our hope that with this text we might, in some small way, help jump-start the process of globalization in anesthetic services. We are fortunate that we have been able to incorporate the experiences of many professionals from around the world in this text; we are grateful to them for sharing so much of their time, experience, and efforts. Our thanks go also to the staff at Springer, especially Jeff Taub and Shelley Reinhardt, for their continuing assistance.

New York, NY, USA Ram Roth New York, NY, USA Elizabeth A.M. Frost New York, NY, USA Clifford Gevirtz Portland, OR, USA Carrie L.H. Atcheson Acknowledgment

We would like to thank Ms. Shelley Reinhardt and Ms. Joanna Perey from Springer Science+Business Media, LLC for their support and help in bringing this project to fruition.

Ram, Elizabeth, Cliff , and Carrie

Contents

Part I Evolution and Development of Missions

1 Medical Missions: A Short History from There to Here ...... 3 Elizabeth A.M. Frost 2 The Evolution of Surgical Humanitarian Missions ...... 19 Ofer Merin 3 The Global Burden of Surgical Need ...... 31 K. A. Kelly McQueen 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income Countries: Providers, Training, Equipment, and Techniques ...... 41 Steven Dale Boggs and Nicholas W. Chee 5 Planning a Mission, Fundraising, and Building a Team ...... 59 Medge Owen and Helen Akinc 6 Developing Anesthesia Equipment for Low-Resource Environments ...... 85 Angela Enright 7 Materials Management and Pollution Prevention ...... 93 Jodi Sherman and Dorothy Gaal 8 What Do Patients and Communities Expect of a Medical Mission? ...... 105 V. Lekprasert , S. Pauswasdi , and B. M. Shrestha 9 Anesthesia in Resource-Poor Settings: The Médecins Sans Frontières Experience ...... 117 Miguel Trelles , Patricia Kahn , Jason Cone , and Carrie Teicher 10 Quality of Care: Maintaining Safety Through Minimum Standards ...... 127 Kathryn Chu and Monique James

xiii xiv Contents

11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture ...... 141 Jeffrey S. Freed

Part II Speciﬁ c Case-Related Implementation

12 Strategies for Patient Assessment and Scheduling ...... 159 Laurent Jouffroy 13 Perioperative Follow-Up and Quality Maintenance ...... 179 Curtis L. Baysinger , Ivan Velickovic , and K. A. Kelly McQueen 14 Women’s Rights to Pain Relief After Surgery and Labor Analgesia ...... 193 Fiona Turpie and Ronald B. George 15 Saving Sight in Developing Countries ...... 203 Ebby Elahi and Natalie F. Holt 16 Cardiothoracic Anesthesia and Intensive Care: What Is the Role of Missions? ...... 217 Peter M. J. Rosseel and Carrie L. H. Atcheson 17 Anesthesia Considerations for Facial Deformity Repair in Lesser Developed Countries ...... 243 Clifford Gevirtz 18 A Regional Anesthesia Service in a Resource-Limited International Setting: Rwanda ...... 257 Alberto E. Ardon and Theogene Twagirumugabe 19 Management of Pain in Less Developed Countries ...... 265 Clifford Gevirtz 20 Living the Mission in Serbia and Other Less Affluent Worlds ...... 273 Miodrag Milenovic 21 Anesthetic Management During the Lebanese Civil War ...... 281 Anis Baraka 22 Trauma, War, and Managing Vascular and Orthopedic Injuries ...... 295 John Benjamin and John Rotruck 23 Anesthesiologists’ Role in Disaster Management ...... 305 Debbie Chandler , Yenabi Keﬂ emariam , Charles James Fox , and Alan David Kaye

Part III Education at Home and Abroad

24 Surgical Mission Trips as a Component of Medical Education and Residency Training ...... 325 Peter J. Taub and Lester Silver Contents xv

25 Building a Global Health Education Program in an Urban School of Medicine ...... 331 Natasha Anushri Anandaraja , Ram Roth , and Philip J. Landrigan 26 Closing the Gap in Europe Through Education: A Reverse Mission ...... 345 Gabriel M. Gurman 27 The Role of the Visiting Anesthesiologist in In-Country Education ...... 359 Julia L. Weinkauf , Marcel E. Durieux , and Lena E. Dohlman 28 Letters from Around the World ...... 377 Ram Roth 29 The Future of Anesthesiology and Global Health in a Connected World ...... 403 Carrie L. H. Atcheson

Appendix ...... 417

Index ...... 419

Contributors

Helen Akinc, M.B.A NavyBrat LLC , Winston-Salem , NC , USA Natasha Anushri Anandaraja, M.B.Ch.B., M.P.H. Arnhold Global Health Institute, Mount Sinai Medical Center, New York, NY, USA Departments of Preventive Medicine & Medical Education , Icahn School of Medicine at Mount Sinai , New York , NY , USA Alberto E. Ardon, M.D., M.P.H. Department of Anesthesiology , University of Florida , Jacksonville , FL , USA Carrie L.H. Atcheson, M.D., M.P.H. Oregon Anesthesiology Group, Department of Anesthesiology, Adventist Medical Center, Portland, OR, USA Anis Baraka, M.D., F.R.C.A. (Hon.) Department of Anesthesiology , American University of Beirut Medical Center , Beirut , Lebanon Curtis L. Baysinger, M.D. Department of Anesthesiology , Vanderbilt University School of Medicine , Nashville , TN , USA John Benjamin, M.D. Department of Anesthesia, Walter Reed National Military Medical Center , Bethesda , MD , USA Steven Dale Boggs, M.D., M.B.A The James J Peters VA Medical Center , Bronx , NY , USA The Icahn School of Medicine at Mount Sinai , Manhattan , NY , USA Debbie Chandler, M.D. Department of Anesthesiology , LSU School of Medicine Shreveport , Shreveport , LA , USA Nicholas W. Chee, M.P.H. Hospital for Joint Diseases , NYU Langone Medical Center , New York , NY , USA Kathryn Chu, M.D., M.P.H. Eerste River Hospital , Eerste River , South Africa Jason Cone, B.A. MSF-USA , New York , NY , USA Lena E. Dohlman, M.D., M.P.H. Department of Anesthesia, Critical Care, and Pain Management , CHA/MGH , Boston , MA , USA Marcel E. Durieux, M.D., Ph.D. Department of Anesthesiology , University of Virginia , Charlottesville , VA , USA

xvii xviii Contributors

Ebby Elahi, M.D. The Icahn School of Medicine at Mount Sinai , New York , NY , USA Angela Enright, O.C., M.B., F.R.C.P.C. Department of Anesthesia , University of British Columbia, Royal Jubilee Hospital , Victoria , BC , Canada Charles James Fox, M.D. Department of Anesthesiology , LSU School of Medicine Shreveport , Shreveport , LA , USA Jeffrey S. Freed, M.D., M.P.H., F.A.C.S. Department of Surgery , Icahn School of Medicine at Mount Sinai , New York , NY , USA Elizabeth A.M. Frost, M.B., Ch.B. DRCOG Department of Anesthesiology , Icahn School of Medicine at Mount Sinai , New York , NY , USA Dorothy Gaal, M.D. Department of Anesthesiology, Yale University School of Medicine , New Haven , CT , USA Ronald B. George, M.D., F.R.C.P.C. Department of Women’s & Obstetric Anesthesia , IWK Health Centre , Halifax , NS , Canada Erin Gertz, M.D. Global Women’s Health Division, Department of Obstetrics, Gynecology and Reproductive Sciences , Icahn School of Medicine at Mount Sinai , New York , NY , USA Clifford Gevirtz, M.D., M.P.H. LSU Health Sciences Center , New Orleans , LA , USA Somnia, Inc. , New Rochelle , NY , USA Gabriel M. Gurman, M.D. Professor Emeritus, Anesthesiology and Critical Care, Ben Gurion University of the Negev , Beer Sheva , Israel Natalie F. Holt, M.D. Yale School of Medicine, 333 Cedar Street, TMP 3, P.O. Box 208051 , New Haven , CT , USA Grace Hsu, M.D. Department of Anesthesiology and Critical Care Medicine , The Children’s Hospital of Philadelphia , Philadelphia , PA , USA Monique James, M.D., M.P.H. Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital , New York , NY , USA Laurent Jouffroy, M.D. French Society of Anesthesia and Intensive Care, Anesthesiology and Critical Care, Ambulatory Surgery Unit, Clinique du Diaconat, Strasbourg, France Patricia Kahn, Ph.D. MSF-USA , New York , NY , USA Alan David Kaye, M.D., Ph.D. Department of Anesthesiology , LSU School of Medicine , New Orleans , LA , USA Yenabi Keﬂ emariam, M.D. Department of Anesthesiology , LSU School of Medicine Shreveport, Shreveport, LA , USA Contributors xix

Philip J. Landrigan, M.D., M.Sc., F.A.A.P. Department of Preventive Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA V. Lekprasert, M.D., M.S. Department of Anesthesiology , Ramathibodi Hospital, Mahidol University , Bangkok , Thailand Kate M. Liberman, M.D. Department Anesthesiology, Perioperative and Pain Medicine , Brigham and Women’s Hospital , Boston , MA , USA K. A. Kelly McQueen, M.D., M.P.H. Department of Anesthesiology , Vanderbilt University Medical Center , Nashville , TN , USA Ofer Merin, M.D., M.H.A. Shaare Zedek Medical Center , Jerusalem , Israel Miodrag Milenovic, M.D. Department of Anesthesiology and Intensive Care Medicine , Clinical Center of Serbia , Belgrade , Serbia Medge Owen, M.D. Wake Forest University , Winston-Salem , NC , USA Kybele, Inc. , Winston-Salem , NC , USA Somsri Pauswasdi, M.D. Department of Anesthesiology , Ramathibodi Hospital, Mahidol University , Bangkok , Thailand Maria Eugenia Interiano Portillo, M.D. Hospital Leonardo Martinez Valenzuela , San Pedro Sula , Honduras Peter M.J. Rosseel, M.D. Department of Cardiothoracic Anesthesia and Intensive Care , Amphia Hospital , Breda , The Netherlands Ram Roth, M.D. Icahn School of Medicine at Mount Sinai , New York , NY , USA John Rotruck, M.D. Department of Anesthesia , Walter Reed National Military Medical Center , Bethesda , MD , USA Jodi Sherman, M.D. Department of Anesthesiology, Yale School of Medicine , New Haven , CT , USA B. M. Shrestha, M.B.B.S., D.A., F.R.C.A.T. Department of Anaesthesia and lntensive Care, Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu , Nepal Lester Silver, M.D., M.S. Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA Peter J. Taub, M.D., F.A.C.S., F.A.A.P. Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA Carrie Teicher, M.D., M.P.H. Epicentre , Paris , France Miguel Trelles, M.D., M.P.H., Ph.D. MSF-Belgium , Brussels , Belgium xx Contributors

Fiona Turpie, M.D., F.R.C.P.C., D.T.M.H. Department of Anesthesiology, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax , NS , Canada Theogene Twagirumugabe, M.D. National University of Rwanda , Rwanda , Africa Ivan Velickovic, M.D. Department of Anesthesiology, State University of New York Downstate Medical Center , University Hospital of Brooklyn , Brooklyn , NY , USA Julia L. Weinkauf, M.D. Department of Anesthesiology , University of Virginia , Charlottesville , VA , USA P a r t I Evolution and Development of Missions Medical Missions: A Short History from There to Here 1

Elizabeth A.M. Frost

Gross ignorance, superstition and fanaticism, Rabbis of the Talmudic period were also physicians. caste, social habits and national prejudices are bar- As late as the Middle Ages it was still common for riers which the mere missionary fi nds diffi cult to overcome and which may compel him to remain the positions of physician and Rabbi to be held by for years in isolation and shunned, if not despised the same person. Talmudic scholars, including and thus the opportunity of doing good for which translators, could use the practice of medicine to he yearns is utterly denied him, whilst, to the mis- earn a living. Indeed it is thanks to Jewish physi- sionary physician, the hovel and the palace are alike opened to his approach, suspicions are cians that many Arab and Greek medical treatises allayed, prejudice is disarmed, caste distinction for were translated into Latin and Hebrew and vice the time at least is over come: even the harem versa [1 ]. where the brother may not intrude is not too sacred First mentioned by Isaiah, the coming of a for the “infi del.” John Lowe 1903. Messiah who would bring physical and spiritual Thus was the difference between the mission- healing was heralded by the prophet who wrote ary and the medical missionary defi ned. “the spirit of the Lord God is upon me because But the words for healing and salvation are the Lord has anointed me to preach good tidings closely linked. Healing, and hence health, denote to the needy. He has sent me to bind up the bro- a state of well-being and salvation indicates deliv- kenhearted, to proclaim freedom to the captives erance from suffering. The word “salve” means to by opening of the prison to them that are bound… soothe like a curative ointment and a means to to comfort all who mourn… to bestow on them achieve a better existence. Thus it is hardly sur- beauty for ashes, the oil of gladness instead of prising that these two concepts have been linked mourning and a garment of praise for the spirit of to religious organizations for centuries—a heal- despair” [2 ]. Some 600 years later during a ser- ing of the body and mind with deliverance to a mon in a synagogue in Nazareth, a prophet higher power. The main codifi cation of Jewish named Jesus Christ read the same passage aloud law, the Shulchan Arukh, compiled in the six- to the congregation and confi rmed that it was his teenth century, states that the Torah gives the mission [ 3 ]. physician permission to heal, adding that this is a This close association between medical mis- religious precept, included in the category of sav- sions and religious teaching from earliest times is ing life (Yoreh Deah, no. 336). Many well-known clear. While the intention may well have been to bring relief to suffering peoples, the relationship often resulted in zealous crusading and evangeli- E. A.M. Frost , M.B.,Ch.B. DRCOG (*) cal spreading of Christian beliefs, practices often Department of Anesthesiology , Icahn School of Medicine at Mount Sinai, New York , NY , USA regarded with grave suspicion by the people of e-mail: [email protected] “invaded” countries.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 3 DOI 10.1007/978-3-319-09423-6_1, © Springer International Publishing Switzerland 2015 4 E.A.M. Frost

(the Ecclesia Abhoret a Sanguine edict of 1163). Earliest Missions Henceforth, monks, the educated class, were pro- hibited from performing surgery. But up to that Again in the Bible, Luke recorded; “Now when point, following in the Greco- Roman tradition and the sun was setting, all they that had sick with the teachings of the Talmud, many operations such divers diseases brought them unto him: and he as wound care, lithotomy, amputations, reduction laid his hands on every one of them and healed of dislocations, and even Cesarean sections had them” [4 ]. Maimonides, (Fig. 1.1 ) (1135–1204) been carried out in monasteries. The barbers who the great Spanish (Cordoban) philosopher, Rabbi had shaved the monks’ heads and who had often and physician spent most of his life in Egypt assisted the monks took over the practice of sur- where he carried out a very busy clinical practice gery often with disastrous results [7 ]. Monks were in Cairo, disapproved of charms and incantations left to rely on herbal and other ancient methods of and spoke against believing things which were care. For example, leprosy was endemic in medi- not objectively attested. At variance with earlier eval Europe. While avoidance of contact with the traditions that healing was a religious obligation sick and their isolation had been advocated both in and thus should be done free, he earned his living the Bible and by Jewish law, in 1313, Philip the from the practice of medicine among Jews and Fair of France ordered that all lepers should be Gentiles [5 ]. He also strenuously attacked the burned [8 ]. Fortunately, before this edict could be growing commercialism of Rabbinic learning fully executed, some 17,000 monasteries of Saint and the increasing numbers of “quacks” who Lazarus (a brother of Martha and Mary who is said used superstition and magic arts on a gullible to have been raised from the dead by Christ, population. His teachings were further advanced Fig. 1.2 ) were set aside for these victims who were by the ﬁ fteenth century Jewish philosopher, Isaac then cared for, mostly in complete solitude by Arama, who preached that man must not rely on monks, who were themselves lepers. These facili- Providence alone or on miracles when it comes to ties were known as lazarettos and numbered over healing and sickness [6 ]. 19,000 in Europe alone. By the end of the sixteenth During the Middle Ages, Catholicism became century, the pestilence had died out in that part of dominant in the religious world. Much of the the world and lazarettos were abolished by Louis responsibility of the care of the sick fell to monastic XIV in 1656, the proceeds from their sale used to orders. Unlike in the Jewish tradition, monks, while build hospitals [8 ]. learned, were not usually physicians and had not studied anatomy or completed an apprenticeship with a medical teacher. In addition, the Roman Catholic Church declared that the shedding of blood was incompatible with holding holy ofﬁ ce

Fig. 1.1 Maimonides eighteenth-century portrait of Fig. 1.2 Christ Raising of Lazarus, Athens, twelfth to Maimonides, from the Thesaurus antiquitatum sacrarum by thirteenth Century (From Wikipedia accessed March Blaisio Ugolino (Wikipedia accessed March 11th 2014) 11th 2014) 1 Medical Missions: A Short History from There to Here 5

Fig. 1.3 The Salem witch trials were a series of hearings them women. The central ﬁ gure in this 1876 illustration of and prosecutions of people accused of witchcraft in colo- the courtroom is usually identiﬁ ed as Mary Walcott (from nial Massachusetts between February 1692 and May 1693. Wikipedia accessed March 11th 2014) These trials resulted in 20 people being executed, most of

Several other diseases were assigned to saints where they where cared for by monks who where and adopted by specifi c monastic orders. The proclaimed to have special knowledge of the order of St. Anthony was founded in the eleventh respective disorders. century to take care of sufferers of acute ergot poisoning which was named St. Anthony’s fi re [9 ]. Midwives had also used controlled amounts Eighteenth to Late Nineteenth of ergot to induce abortions for centuries. St. Centuries Anthony’s fi re was later determined to be due to tainted rye and the convulsions associated with In its earliest stages, the missionary movement consumption of the bread have been claimed to from the West mainly centered on enlightened be the accusations of bewitchment that spurred views of healing and incorporated them into the- the Salem witch trials between 1692 and 1693 ology and practice. In essence, Western medicine (Fig. 1.3 ). There was said to be an abundance of was brought to a world beyond the west, often for rye in the region [10 , 11 ]. The association of a the fi rst time and became established as the main saint to a disease was often determined by the source of health care for the region. Common manner in which the saint died. St. Appolonia remedies and purges might be dispensed, pro- had her teeth and jaw shattered and it was to her grams for community hygiene commenced, anes- that one prayed for relief of toothache. St. Vitus’ thesia introduced, planning for medical facilities dance (Sydenham chorea) was named after the started, and research established into fi nding patron saint of dance. St. Agattin who suffered a the cause for diseases. But while medical knowl- double mastectomy was the patron saint of nurs- edge and new means of treatment were advanced, ing women and St. Valentine oversaw the care of people on missions found out that they were epileptics. For cure of these and many other dis- exposed to and often in confl ict with other concepts orders, pilgrimages to the designated monasteries of the causes of illnesses. Radically different 6 E.A.M. Frost modes of treatment and contrary understanding and some nurses who joined them at the mission of what constitutes human wellness were diffi cult site how to dispense medicines, apply dressings, notions to embrace. In addition, the economics of and instill eye drops among other simple proce- missions changed. Ethical and theological issues dures (Audrey Ronning Topping, personal arose as to how or if treatment should be paid. communication). Medical missions changed many assumptions as Rev John Lowe the secretary of the Edinburgh to how hospitals should function and what role Medical Missionary Society in the nineteenth women should play. century wrote a handbook on the place and power Although monasteries were declining as a of medical missions, fi rst published around 1903. center for healing, major achievements were Therein he set out some of the requirements for a made by many medical missionaries dispatched successful mission. First of all, the missionary’s and funded often by religious organizations or professional education should be thorough and governments in the United Kingdom and other comprehensive. He emphasized the need for sur- parts of Europe. Perhaps one of the fi rst physi- gical training, pointing out that “natives almost cians sent from a Protestant Church and spon- everywhere have a kind of intuitive knowledge of sored by Germany and Denmark was Dr. Kaspar the medicinal virtue of indigenous plants and Gottleib Schlegemilch in 1790. Sadly he died of although they are as a rule, utterly ignorant of the dysentery in India only a month after his arrival diseases they presume to treat, yet much confi - and thus was able to achieve little [12 ]. He was dence is placed in the native doctors and their nos- followed by other Dutch and German doctors trums, and, somehow they do at times appear to who did not stay long or also died of tropical dis- effect wonderful cures; but they can do nothing eases [ 12 ]. But many more physicians and other whatever in surgery, even in the simplest cases” healthcare providers travelled to distant lands, [ 13]. Rev Lowe eschewed any private practice as some with little medical training. Missions usu- a means to improve the circumstances of medical ally lasted for years, the health of the provider men, nor should they be paid more than ordinary often the determining factor. During this time, missionaries, ideas that were generally not well clinics and facilities were established and supply received. Fluency with the native language was a lines set up. Only within the past few decades prerequisite and having overcome that obstacle, have missions been arranged for days or weeks to the medical missionary should open a dispensary areas where infrastructures already exist. in as central a locality as possible, “associating The need for medical training was slowly himself with an earnest, intelligent, judicious becoming realized, but not all missionaries were native evangelist.” Patients could then be followed so enlightened. The Rev Halvor Ronning, his wife, up in their homes by the associate. Lowe goes on Hannah, and sister Thea went to China from the to say; “Two or three intelligent native Christian United States (Later they became Canadian citi- youths should as soon as possible be selected and zens) in 1891 to found a Lutheran mission in the trained as assistants. They will soon be able to dis- interior of China in the city of Fancheng in Hubei pense medicines, serve as dressers and do all the Province. Once there they established a school and drudgery of dispensary work and thus much of the had great success extending medical care to the medical missionary’s time will be set free for indigent, including abandoned female newborns more important duties.” A hospital, on a small and breaking the boundaries of outmoded tradi- scale, perhaps for 2–3 patients only was to be tions by offering “modern” education to young opened as soon as possible. men and especially to women. Hannah would not Later on Lowe remarks on the practices of permit girls with bound and broken feet into the women “doctors” of the Madi or Moru tribe of school which went on to become the largest estab- Central Africa. These women treated all cases lishment in the area. Although they had no medical except wounds, accidents, and snake bites (left to training they quickly learned from the two doctors male doctors). Management was the same for (who also had no more than 2 years instruction) most diseases: a double magic wand about a foot 1 Medical Missions: A Short History from There to Here 7 long, one part fi lled with small stones and the John Scudder other empty was waved and rattled over the affected part accompanied with incantations. The Dr. John Scudder, the fi rst American medical lady “doctor” then placed her hand into the empty missionary, went to Ceylon in 1819 and later trav- tube and extracted the disease [14 ]. Several other elled to India. Apart from providing medical care, spells were also commonly used and predictions he established schools and a college. He had seven made as to whether the patient should live or be sons, many of them also physicians who served as killed. Séances often terminated in convulsions medical missionaries. His granddaughter, Dr. Ida for the healer who upon recovery collected her Sophia Scudder, became a third- generation fee, usually of a small domestic animal. American medical missionary in India of the It is not diffi cult to see that many areas of the Reformed Church in America [16 ] (Fig. 1.4 ). She world would welcome practitioners with some dedicated her life to the plight of Indian women better grounding in medical matters and improved and the fi ght against bubonic plague, cholera, and chances of success. A few of the early medical leprosy. In 1918, she started one of Asia’s fore- missionaries and the work they accomplished are most teaching hospitals, the Christian Medical mentioned: College and Hospital, Vellore, India.

John Thomas Peter Parker

In 1793, Dr. John Thomas who had already been In 1834, The American Board of Commissioners in Calcutta was in England seeking funds for a for Foreign Missions sponsored Dr. Peter Parker return mission to India. He met William Carey, to travel to China in 1834 where he had the dis- known as the “father of modern missions.” Carey tinction of being the fi rst full-time Protestant was one of the founders of the Baptist Missionary medical missionary [17 ] (Fig. 1.5 ). Trained as a Society and as a missionary in the Danish col- surgeon at Yale Medical School and ordained as a ony, Serampore, India, he translated the Bible Presbyterian minister also at Yale, he performed into Bengali, Sanskrit, and numerous other lan- many of the fi rst surgical procedures in China. guages and dialects. The two travelled to India In 1835, he opened the Ophthalmic Hospital in together where they established the fi rst Protestant Canton, which later became the Guangzhou Boji mission [15 ]. Hospital (the Canton Hospital). Although Parker

Fig. 1.4 Ida S. Scudder as a young Woman (accessed from Wikipedia March 12th 2014) and later with Mahatma Gandhi 8 E.A.M. Frost

auditing a chemistry class at Hamilton College and a few medical lectures in Pittsfi eld, Massachusetts. He did not receive a formal college degree. Despite the establishment of several medical schools by the early nineteenth century, most “doctors” assumed the title after apprenticeship to local physicians and may never have attended any medical lectures. In Utica Dr. Grant became involved with the Presbyterian Church and also set up practice as a general practitioner. In 1835, at the age of 27, and sponsored by the American Board of Commissioners for Foreign Missions he sailed with his wife, age 20 and also a missionary, to the Middle East. Within days of arrival he became ill with cholera, a disease from which he never fully recovered. Nevertheless, both he and his wife were able to build up a stellar reputation for the quality of medical care they provided and for the many schools they opened and supervised. Sadly his wife and twin children died of Fig. 1.5 Dr. Peter Parker, photograph by Mathew Brady (this is a fi le from the Wikimedia Commons. Accessed malaria within 5 years. He continued his work, March 12, 2014) both in providing medical care and in his many attempts to convert the Nestorians (Assyrians), a specialized in diseases of the eye, including fi erce isolated people who lived in the mountains cataracts, and also resected tumors it soon became of Hakkari across the border in Ottoman Kurdistan. apparent that many other maladies required care. He died of malaria and cholera in 1844 at the age Over 2,000 patients were admitted the fi rst year. of 37. His success as a physician not only saved his Parker also introduced Western anesthesia in the life on several occasions (he travelled with a lancet form of sulfuric ether and instructed Chinese stu- and bled himself frequently, treatment believed to dents before the establishment of medical schools. be benefi cial at that time), but opened the way for Later, Parker served as the main interpreter and missionary successors. negotiator of the Treaty of Wanghia with the Qing Empire. In 1845 he became a secretary and interpreter to the new embassy from the United States, Paul Brand while still keeping the hospital in operation. It was said that Parker “opened China to the gospel at the Only towards the end of the nineteenth century did point of a lancet.” some Protestant denominations start to provide some basic medical training for missionaries before they left their native countries. Not infre- Asahel Grant quently, these people were the only “doctors” available in the areas to which they were assigned. The fi rst American missionary to Persia and Turkey Dr. Paul Brand’s parents were missionaries in was Dr. Asahel Grant [18 ]. Born in Marshall, India and with little training and very limited sup- New York in 1807, he seemed to be destined to plies, for many years they were the only source of be a farmer, before slicing his foot with an axe. care for many remote villages. Brand, himself, After a stint teaching in a country school, he stud- was born in India in 1908 where he sustained fre- ied medicine with Dr. Seth Hastings in Clinton, quent bouts of dysentery and malaria [19 ]. Back in New York. His further medical training included the United Kingdom, he received 12 months of 1 Medical Missions: A Short History from There to Here 9

Fig. 1.6 Florence Nightingale and the medal she received from Queen Victoria (from Wikipedia; accessed March 13th 2014) medical training and then returned to India as a from cholera, typhoid, and typhus was ten times builder. During the second World War, he studied that of battle wounds. Enlisting the help of the medicine at the University College Hospital in British Government she was able to reverse these London and as a surgeon, went back to India statistics and, on her return to England, set stan- where he pioneered reconstructive work in lep- dards for hospital management and nursing care, rosy, especially tendon transplants. emphasizing the use of pie charts as a visual means to understand data [21 ]. She established the Nightingale Training School for nurses at St. Nurses and Medical Missions Thomas’ Hospital in 1860. Apart from or as an extension of her ideas of Undoubtedly the best known nurse in medical social reform, Nightingale was as early promoter missions is Florence Nightingale (Fig. 1.6 ). Born of medical tourism. During 1856, she sent several to a very wealthy family in Florence, Italy in letters back to her family and friends in the 1820, she resisted her family’s efforts to require United Kingdom describing spas in the Ottoman her to conform to their gentriﬁ ed ways. Rather Empire. She had interviewed and overseen the she persisted in her desire to study nursing. A cel- care of several patients in these facilities and was ebrated social reformer and statistician, and the impressed with the excellent health conditions, founder of modern nursing, she came to promi- physical plants, general well-being, and dietary nence when she was sent to serve as a nurse care. She noted especially that the treatment was during the Crimean War [20 ]. With 38 volunteer much less expensive than in Switzerland where nurses that she had trained and 15 nuns she went rich families tended to send their members, to Scutari, a large and densely populated district often for the care of tuberculosis. She opened the and municipality in Turkey, where the death rate Nightingale Training School at St. Thomas 10 E.A.M. Frost

Hospital on 9 July 1860. A few years later, she mentored Linda Richards, who was to be recognized as “America’s fi rst trained nurse,” and enabled her to return to the United States with adequate training and knowledge to establish her own, high-quality nursing schools. Linda Richards went on to become a great nursing pioneer not only in the United States but also in Japan. Several other nurses have also contributed in major fashion to medical missions. Elizabeth Bernard, who had been trained as a nurse and served in the US army from 1918 to 1920, went to China in 1933 to care for the sick and orphans. She stayed there in Hong Kong until her death in 1972 [12 ]. Alvin and Georgia Hobby had been missionaries in Northern Rhodesia. They returned to the United States in 1962 and after fi nishing nursing training, returned to Zambia where they stayed for almost 40 years and established a clinic at the Namwianga Christian School, which remains in operation [22 ]. Kate Marsden also a nurse was a British missionary, explorer, and writer. Born in London in Fig. 1.7 Kate Marsden showing the clothing she wore 1859, her interests in nursing developed early (she with a map of her journey (Wikipedia: 3/13/14) was a nurse by age 16). She fi rst went to Bulgaria with others to nurse Russian soldiers wounded in Russia’s war with Turkey in 1877. There she met from Moscow to Siberia to fi nd this magical cure. two lepers and became convinced that it should be Her journey took her some 11,000 miles her mission to study this disease and care for its (17,000 km) across Russia, by train, sledge, on victims [23 ]. But restrained by family ties she fi rst horseback, and by boat (Fig. 1.7 ). As she recorded went to New Zealand to nurse her consumptive in her memoirs, “Riding through Siberia”: [24 ]. sister until the latter died. She then became Lady During the summer the mosquitoes are frightful, Superintendent at Wellington Hospital, an institu- both in the night and in the day; and when you tion primarily for the Maoris where she claimed to arrive at a yourta [yurt], which serves as a post- have treated lepers although it was not a disease station, the dirt and vermin and smell are simply disgusting; bugs, lice, fl eas, etc., cover the walls, as indigenous to those people. Before she returned to well as the benches on which you have to sleep. England she established the fi rst New Zealand Even on the ground you will fi nd them, and, as branch of the St. Johns Ambulance Brigade. soon as a stranger comes in, it seems as if the She continued to work as a nurse but fi nally insects make a combined assault on him in large battalions; and, of course, sleep is a thing never left England to treat leprosy. After obtaining dreamed of. After a few days the body swells from the support of Queen Victoria and Princess their bites into a form that can neither be imagined Alexandra, she went to Russia hoping to obtain nor described. They attack your eyes and your funding from the Russian Royal family. On the face, so that you would hardly be recognised by your dearest friend. Really, I think the sufferings of way she met an English doctor in Constantinople this journey have added 20 years to my age. But I who told her of the curative properties for leprosy would willingly do it ten times over to aid my poor of an herb found in Siberia. Now with support lepers who are placed in the depths of’ these also of Empress Maria Fedorovna, she travelled unknown forests. You are always running the risk 1 Medical Missions: A Short History from There to Here 11

of being attacked by bears here, so that we always As a gifted musician he was able to raise suf- kept our revolvers ready at our side or under our fi cient funds to equip a small hospital and with heads; and two Yakuts as sentinels, with large fi res at each end of the little encampment, we were his wife and infant son he travelled to Lambaréné, obliged to travel in the night, because our horses had in Gabon in the spring of 1913. During the rest of no rest in the day time from the terrible horse- fl ies that year, he and his wife treated more than 2,000 that were quite dangerous there. They instantly patients for diseases such as yaws, malaria, sleep- attacked the wretched beasts, so that it was an awful sight to see our horses with the blood running down ing sickness, tumors, and hernias. They also dealt their sides, many of them becoming so exhausted with fetishism and cannibalism among the that they were not able to carry our luggage. Mbahouin. Their fi rst hospital was a shed, built as a chicken hut. By the autumn of 1913, they Along the way she was noted for helping relocated to a corrugated iron structure with two prisoners, especially women. At Yakutsk she rooms (examination room and an operating obtained the herb that she believed might be the room). They also built a dispensary and an area cure. Although the herb did not bring the success for sterilizing equipment as well as a dormitory she had hoped for, she continued to work amongst and waiting room, constructed like native huts the lepers in Siberia where she created a leper out of unhewn logs. treatment center. Schweitzer’s wife, Helene, (Fig. 1.9 ) had Yet another example of nursing involvement studied history, art, philosophy, nursing, and the- in missions was the enormous efforts of Mrs. ology. She acted as an anesthetist for her hus- Francis Piggott who proposed the Colonial band’s surgeries although it is unclear if she had Nursing Association in 1895 to supply the colo- any training in the specialty, probably using nies and dominions of the United Kingdom with open drop ether [ 28 ]. She was an avid skier but trained nurses. Between 1896 and 1966 when the had broken her back in a skiing accident. Later Association was terminated over 8,400 women she developed tuberculosis but despite her physi- supported the health of white colonists abroad. cal disabilities she continued to work with The mission was to use personal and public Schweitzer for many years. She returned to hygiene mainly to create physical and cultural New York in 1937 to raise money and tell the boundaries around white patients and thus put United States about their work with the hospital. colonists apart from the colonial setting [25 ]. Back in Lambaréné, by 1940, she spent WWII at the hospital, before leaving Africa in 1946. She returned only once in 1956 before her death in Albert Schweitzer 1957 [ 26 ]. Later, accusations were made in Europe of Physician, philosopher, organist, missionary, and unsanitary conditions at the hospital. On the day theologian, Albert Schweitzer (Fig. 1.8 ) was born of Schweitzer’s death, an African contended: in the province of Alsace-Lorraine, at that time part “How do they (Europeans) know? They have of the German Empire [26 ]. He received the 1952 never come here to see us. The grand Doctor, Nobel Peace Prize for his philosophy of “Reverence he came here and stayed for most of his life and for Life,” and is probably most famous for found- gave us all he had to give, and that was a great ing and sustaining the Albert Schweitzer Hospital deal” [26 ]. in Lambaréné, now in Gabon, west central Africa After Schweitzer died in 1965 at the age of (then French Equatorial Africa) [27 ]. At age 30, 90, administration of the hospital was handed he embarked on a 3 year course towards the degree over to his daughter, Mrs. Rhena Eckert. The of a Doctorate in Medicine, a subject in which he hospital is now supported by the Albert had little knowledge. He planned to spread the Schweitzer Fellowship, which was founded dur- Gospel by healing, rather than preaching. In June ing 1940 in the United States [29 ]. It remains 1912 he married Helene Bresslau. the primary source of health care for a large 12 E.A.M. Frost

KAMERUN AFRIKA

GABUN REP. KONGO DEMOK. Lambaréné REPUBLIK KONGO

300 KM

ANGOLA

ATLANTIK SAMBIA

Fig. 1.8 Albert Schweitzer (accessed from Wikipedia; 3/13/14). (a ) Dr. Albert Schweitzer and a map of Gabon, indicat- ing his clinic

surrounding region. Over 35,000 outpatient vis- cine, surgical, and obstetrical patients. The its and more than 6,000 hospitalizations occur National Institute of Health has recognized the annually. Two surgeons and their teams carry hospital’s research laboratory as a leading facil- out some 2,200 operations every year. There are ity engaged in studies of malaria, HIV/AIDS, 160 members on staff. The current facility and tuberculosis and children with severe includes two operating rooms, a dental clinic, malaria at the Schweitzer Hospital have the low- and inpatient wards for pediatric, adult medi- est mortality rates in Africa. 1 Medical Missions: A Short History from There to Here 13

Fig. 1.9 Mrs. Helene Schweitzer Breslau Fig. 1.10 Dr. David Livingstone (accessed Wikipedia 3/13/14)

David Livingstone

Born in a single-end (a one room fl at), in Blantyre near Glasgow in 1813 David Livingston(e) (his family name had no “e” but after his medical certifi cate was issued with the letter, he used it thereafter) became one of the greatest of the Victorian pioneers and medical missionaries (Figs. 1.10 and 1.11 ) [30 ]. Employed as a piecer (a person who joins the ends of broken threads) at the local mill by the age of 10, his further schooling was during the 2 h that followed after his 12 ½ day shift, 6 days a week. On Sundays, he was required to attend church in nearby Hamilton. At one of these services, his father found a pamphlet written by Karl Friedrich August Gützlaff. Gützlaff, was a German missionary to the Far East, and one of the fi rst Protestant missionaries in Bangkok (1828), China, and Korea (1832) [31 ]. What impressed the young Livingstone, now 20 years old, was a new idea presented by Gutlaff Fig. 1.11 Dr. Livingstone’s birthplace in Blantyre, Scotland that missionaries should be trained as physicians. For the next 2 years Livingstone studied medicine wanted to go to China but the opium wars pre- at the Anderson’s College in Glasgow and later vented that journey. He applied to the London continued his medical studies in London. He Missionary Society (LMS), at that time the major 14 E.A.M. Frost mission society in the United Kingdom for an from John Snow of Paternoster Row in 1853 appointment. The LMS was, also, the only society indicates his continuing intellectual interests. open to him as the other Anglican, Baptist, and He also learned to use chloroform, quinine, and Methodist societies were clearly denomination- even arsenic in small doses [30 ]. ally defi ned [30 ]. The LMS, founded in 1795, Before Livingstone, Africa’s interior was was rooted in the tradition of Evangelicalism, almost entirely unknown to the outside world. believing that denomination was secondary for Vague notions prevailed about its geography, converted Christians [ 32 – 34]. It continues today fauna, fl ora, and human life. Livingstone disas the Council for World Missions. pelled much of this ignorance and opened up In London, Livingstone met Dr. Robert Africa’s interior to further exploration. No one Moffat, who was in England to create interest in made as many geographical discoveries in Africa his South African mission. Livingstone learned as Livingstone, and his numerous scientifi c obser- of “a vast plain to the north where he had some- vations were quickly recognized [35 ]. times seen, in the morning sun, the smoke of a He received many honors including the Gold 1,000 villages, where no missionary had ever Medal of the Royal Geographical Society of been.” He decided that Africa was his destiny. which he became a fellow. The London Missionary On December 8, 1840, he sailed for that mainly Society honored him; he was received by Queen unknown continent, going out by way of Brazil Victoria; and the universities of Glasgow and and the Cape of Good Hope, learning on the way Oxford conferred upon him honorary doctorates how to use the quadrant for navigation and take [34 ]. In November 1857 his fi rst book, “Missionary nautical observations, useful skills for his later Travels and Researches in South Africa,” includ- journeys [29 ]. ing a sketch of 16 years residence in the interior of As an explorer he obsessed with discovering Africa, was published by John Murray, Albemarle the sources of the River Nile a goal that he never Street, London [36 ]. reached. Nevertheless, his travels covered one- third of the continent, from the Cape to near the Equator, and from the Atlantic to the Indian Ocean. Twentieth Century On November 15th 1855, he was probably the fi rst European to reach the falls on the Zambezi River, With the advent of the twentieth century it was known by the Africans as “the smoke that thun- clear that good medical care and especially anes- ders” or Mosi-oa-Tunya and which he named the thetic management was far from universally avail- Victoria Falls, in honor of the Queen. During his able. The Unitarian Service Committee (USC) explorations he drew the attention of the world to Medical Missions was established in 1940 as a the horrors of the African slave traffi c showing standing committee of the American Unitarian that the African was “wronged” rather than association, a nonsectarian voluntary agency with depraved, and slavery must be outlawed. He saw a mission to promote human welfare and justice a cure for injustice in Christianity and commerce [37 ]. Between 1945 and 1956 teams were orga- and inspired enterprises such as the African Lakes nized to teach the latest developments to many Company. After him came European settlements countries around the world. Distinguished anes- and the colonial rush to Africa with many of the thesiologists were sent to 13 different countries tensions that followed. including Drs. Beecher, Cullen, Dillon, Dripps, Recognizing the constant threat of tropical Kohn, Krayer, Morris, Robbins, Rovenstein, diseases, especially trypanosomiasis and malaria Saklad, Straus, Visscher, Volpitto, Wassermann, and the need to provide an array of medical care, and White [38 ]. In 1950, medical missions to Livingstone maintained a kind of mail order edu- Tokyo and Osaka-Kyoto helped establish the new cation, arranging for papers, books, and lectures specialty of anesthesiology in Japan. on advances in medicine to be sent to him at The origins of anesthesia in Japan can be frequent intervals. A long list of books he ordered traced back to 1804 when Sieshu Hanaoka gave 1 Medical Missions: A Short History from There to Here 15 anesthesia [39 ]. Also, in 1860, the Tokugawa The effects of these three missions have been Shogunate dispatched a group of Japanese, to enable an orderly transition to an American headed by Masaoki Niimi, the ambassador to style medical system, especially in anesthesiol- Washington to ratify a treaty of commerce and ogy and to shape the specialty in Japan. Many amity. After the ratifi cation, the group visited Japanese have travelled to the United States and Baltimore and Philadelphia to see other institu- returned to their country where they have become tions. Three Japanese medical doctors observed a leaders in their departments. From 2002 to 2007 lithotomy operation by Dr. Samuel Gross at the Japanese anesthesiologists presented over 300 Jefferson Medical College and ether administra- papers at the annual meetings of the American tion by Dr. William Morton, who had demon- Society of Anesthesiologists. strated his anesthetic technique in Boston on Founded by a Buddhist nun, Dharma Master October 16th 1846 [40 ]. Neither of these oppor- Cheng Yen in 1966, the Tzu Chi is a global ser- tunities appear to have benefi tted or furthered the vice network of over 5,500 licensed doctors and specialty of anesthesia in Japan. Such modern nurses who serve as volunteers [41 ]. Based on the advances did not take hold until two programs concept of “educating the rich to help the poor; from the USC were initiated in the 1950s, both inspiring the poor to realize their riches,” the supported by the US government [37 ]. foundation’s mission has expanded from its At the end of World War II there was no orga- beginnings in the remote area of Hualien in nized anesthesiology service in Japan until the Taiwan to all 5 continents with chapters and University of Tokyo founded an independent offi ces in 47 countries that provide aid to 70 department of anesthesia in 1952. Before that, countries and over one million people. Starting anesthesia was given by junior surgeons and with charity, and quickly understanding that there was not one physician trained in anesthesi- charity provide at best a temporary solution to a ology in all of Japan. There was little or no anes- problem while sickness leads to poverty, the thetic equipment and less than 10 % of cases organization extended to medical care, including were done with general anesthesia. Death from surgery, education, and the building of schools local anesthetic toxicity was not uncommon. and humanistic culture. The Tzu Chi Medical Libraries were bare because regulations prohib- Association with the vision of “Curing Sickness, ited Japanese currency as a medium for foreign Healing People, Healing Hearts” was later exchange limiting subscriptions to foreign medi- expanded to “Tzu Chi International Medical cal journals. Association” or TIMA. Rather than a religion, The fi rst mission to Tokyo comprised physi- Buddhism seeks to instill a way of life, marking cians from several specialties with Dr. Meyer its goals aside from many of the earlier mission- Saklad from Rhode Island representing anesthe- ary works. Some of the most important efforts siology. He presented many lectures and joint have been realized during disasters when mem- sessions with his colleagues. The mission then bers of the Tzu Chi Disaster Relief committee journeyed to Osaka and Kyoto and repeated the travel to the stricken areas to treat the sick and educational endeavors and also arranged for the wounded and provide support to devastated rela- donation of desperately needed books. A second tives (recently to the relatives of Malaysia Fl 370, mission was organized in 1951. This time Dr. lost March 8th 2014). Volpitto from the Medical College of Georgia spearheaded the anesthesia section. Four teams visited 12 medical schools, giving lectures, round A Reverse Mission table, and panel discussions and clinical demonstrations. A third mission, this one initiated by Lady Mary Wortley Montagu, born in England in Japanese physicians, was again invited from the 1689, was an English aristocrat and writer USC. Presentations now related mainly to research (Fig. 1.12 ) [ 42]. Early in 1716, her husband, projects. Edward Wortley Montagu, was appointed 16 E.A.M. Frost

contracting the disease had a 20–40 % mortality rate. But inoculation gained acceptance and in 1754, 8 years before her death, Lady Mary was recognized for bringing the practice to Britain [ 43].

Concluding Statement

Medical missions have spanned many centuries and changed dramatically in scope and practice. From bands of evangelists who travelled for years to establish churches and hospitals, often with no medical training, few supplies, and little support it is now common practice for highly trained spe- Fig. 1.12 Lady Mary Wortley Montague (from cialists to mount well fi nanced and organized Wikipedia; 3/13/14) enterprises for a few days or weeks with excellent support mechanisms and the aim to introduce and teach new methods of care needed and applicable Ambassador at Istanbul. Over some inadvertently to the country thus allowing local healthcare circulated satirical remarks concerning members teams to become self-suffi cient. of the Royal family, Lady Mary was disgraced at court and thus accompanied her husband to Turkey. He was recalled in 1717, but they References remained in Istanbul until 1718. During her stay in that city, she became acquainted with many of 1. Collins K. Go and learn. Aberdeen: Aberdeen the customs of the local women, specifi cally their University Press; 1988. p. 3–4. ISBN 0 08 036408-X. practice of inoculation against smallpox—vario- 2. The Holy Bible. King James Version Isaiah. 61:1–3. lation (from varus, Latin for pimple)—which she 3. Ibid. Luke. 4: 14–30. 4. Ibid. Luke 4: 40. termed engrafting, and she wrote home about it 5. Baron AW. A Social and Religious History of the [3 ]. She herself had suffered from smallpox and Jews, vol. 8. New York, NY: Columbia University her brother had died of the disease. Variolation Press; 1958. p. 233–4. ISBN ISBN-10: 0231088450 involved live smallpox virus in liquid form taken ISBN-13: 978-0231088459. 6. Jakobovits I. Jewish medical ethics. New York, NY: from a blister in a mild case [44 ]. She had her son Bloch Publishing Co; 1975. p. 4. ISBN ISBN-10: inoculated while in Turkey. When she returned to 0819700975; ISBN-13: 978-0819700971j. London, she promoted the procedure, but encoun- 7. Silen W, Frost EAM. Surgery before and after the dis- tered resistance from the medical establishment, covery of anesthesia. In: Eger EI, Saidman LJ, Westhorpe RN, editors. The wondrous story of anes- because it was an “Oriental” process. A smallpox thesia. New York, NY: Springer; 2014. p. 167–8. epidemic struck England in 1721 and Lady Mary ISBN 978-1-461-8440-7. also had her daughter inoculated. She then per- 8. Haggard HW. Devils, drugs and Doctors. New York, suaded a Royal to authorize the process on seven NY: Blue Ribbon; 1929. p. 194–5. 9. Ibid. p. 216–7. condemned prisoners (in exchange for their lives) 10. Caporael LR. Ergotism: the satan loose in Salem. as well as six orphans. They all lived. Science. 1976;192(4234):21. doi: 10.1126/science.769159 . But in another household, six servants became Bibcode: 1976 Sci…192…21C. PMID 769159. ill with smallpox after a child was inoculated. 11. Matossian M. Ergot and the Salem witchcraft affair. Am Sci. 1982;70(4):355. Bibcode: 1982 Am Sci.. 70.. Clergymen then announced that trying to prevent 355M. PMID 6756230. the illness was against God’s will. Indeed inocula- 12. Boyd HG. A brief history of medical missions gospel tion carried about a 3 % risk of dying while advocate. 1990;132(12):14–5. 1 Medical Missions: A Short History from There to Here 17

13. Lowe J. Medical missions their place and power. 5th 31. Lutz JG. Opening China: Karl F.A. Gützlaff and Sino- ed. Oliphant Anderson and Ferrier: Edinburgh; 1903. Western relations, 1827–1852. Grand Rapids, MI: p. 41–50. William B. Eerdmans Pub. Co.; 2008. ISBN 14. IBID. p. 165–8. 080283180X. 15. Dodd EM. The gift of the healer. New York, NY: 32. Wadsworth KW. Yorkshire United Independent Friendship; 1964. p. 14. College: two hundred years of training for Christian 16. Wilson DC. The story of Dr. Ida Scudder of Vellore . ministry by the congregational churches of Yorkshire. New York, NY: McGraw-Hill; 1959. p. 18. ASIN: London: Independent; 1954. B002AT0OT6. 33. Parker I. Dissenting academies in England: their rise 17. Gulick EV. Peter Parker and the opening of China. and progress, and their place among the educational Cambridge: Harvard University Press, Harvard systems of the country. Cambridge: Cambridge Studies in American-East Asian Relations; 1973. p. 3. University Press; 1914. p. 140. ISBN ISBN 0-674-66326-8. 978-0-521-74864-3. 18. Taylor G. Fever and thirst. An American doctor amid 34. Lovett R. The history of the London Missionary the tribes of Kurdistan, 1835–1844. Chicago: Society, 1795–1895. London: Henry Frowde; 1899. Academy Chicago Publishers; 2005. p. 1–13. ISBN 35. Swinton WE. Physicians as explorers. David 978-0-89733-572-0. Livingstone: 30 years of service in darkest Africa. 19. Anderson GH. Biography of Paul Wilson brand. CMA J. 1977;117:1435–40. Cambridge: Wm B Eerdmans Pub Grand Rapids and 36. Ross A. David Livingstone: mission and empire. Cambridge; 1999. p. 86. ISBN 978-0-8028-4680-8. London: Hambledon; 2001. p. 118. ISBN 1 85285 20. Gill CJ, Gill GC, Gill GC. Nightingale in scutari: 285 2. her legacy reexamined. Clin Infect Dis. 2005; 37. Ikeda S. The Unitarian service committee medical 40(12):1799–805. doi: 10.1086/430380. ISSN 1058- mission. Anesthesiology. 2007;106(1):178–85. 4838. PMID 15909269. PMID:17197860. 21. Nightingale F. Preface. In: Nightingale F, editor. 38. Ikeda S. American anesthesiologists’ contribution to Notes on nursing: What it is and what it is not. post world war ll global anesthesiology. J Clin Glasgow & London: Blackie & Son Ltd.; 1974. First Anesthesia. 2011;23(3):244–52. doi: 10.1016/j. published 1859. ISBN 0-216-89974-5. jclinane.2010.08.013 . PII: S0952-8180(11)00118-8. 22. Eichman P (2014) Medical missions among the 39. Ikeda S. American contributions to Japanese anesthe- churches of Christ. History of medical missions siology-a historical view. Masui. 2013;62(6):761–9. Chapter 2. 2nd ed. 2002. P. 3–6. http://bible.ovu.edu/ PPMID: 23815010. missions/medical/medbook2.htm . Accessed 5 Mar 40. Matsuki A. New study on the history of anesthesiology- 2014. three Japanese doctors who observed William TG 23. Bessonov Y (2014) An outstanding journey of a Morton’s ether anesthesia at the Gross Clinic in 1860. British nurse to the Yakut Lepers in Siberia. J Nurs. Masui. 2005;54(2):202–8. PMID 15747522. http://rnjournal.com/journal-of-nursing/ 41. http://www.tzuchimedicalfoundation.org/index. an-outstanding-journey-of-a-british-nurse-to-the- php?option=com_content&view=article&id=14&Ite yakut-lepers-in-siberia . Accessed 5 Mar 2014. mid=96 . 24. Mission of Mercy, Long Riders Guild. http://www. 42. Grundy I. Lady Mary Wortley Montague. Oxford: thelongridersguild.com/marsden.htm. Accessed 5 Mar Oxford UP; 1999. p. 103. 2014. 43. Lady Mary Wortley Montagu (1689–1762): Smallpox 25. Howell J, Rafferty AM, Wall R, et al. Nursing in the Vaccination in Turkey Lady Mary Wortley Montagu, tropics: nurses as agents of imperial hygiene. J Public Letters of the Right Honourable Lady Mary Wortley Health (Oxf). 2013;35(2):338–41. doi: 10.1093/ Montague: Written During her Travels in Europe, pubmed/fdt016 . Asia and Africa…, vol. 1 (Aix: Anthony Henricy, 26. Cousins N. Albert Schweitzer’s mission. New York, 1796), p. 167–69; letter 36, to Mrs. S. C. from NY: Norton; 1985. p. 11–4. 68–70, 302. ISBN Adrianople, n.d. Modern History Sourcebook: 0-393-02238-2. Fordham University. 27. Nobel Peace Prize 1952 Award Ceremony Speech. 44. Case CL, Chung KT. Montagu and Jenner: the cam- The Nobel Peace Prize 1952. Albert Schweitzer. paign against smallpox. SIM News. 1997;47(2): Nobelprize.org (1953-12-10). Retrieved on 6 Mar 2014. 58–60. 28. http://www.ﬁ ndagrave.com/cgi-bin/fg.cgi?page=gr& GRid=34278577 . Accessed 6 Mar 2014. 29. http://en.wikipedia.org/wiki/Albert_Schweitzer_ Hospital . Accessed 6 Mar 2014. Further Reading 30. Ross A. David Livingstone: mission and empire. London: Hambledon; 2001. p. 2–26. ISBN 1 85285 Cousins N. Albert Schweitzer healing and peace. New 285 2. York, NY: Norton; 1985. ISBN 0-393-02238-2. 18 E.A.M. Frost

La Berge AF. Mission and method the early 19th century Taylor G. Fever and thirst an American doctor among the public health movement. Cambride: Cambridge tribes of Kurdistan 1835–44. Chicago: Academy University Press; 1992. Chicago Publisher; 2005. Ross A. David Livingstone: mission and empire. London: Lowe J. Medical missions: their place and power (1903). Hambledon; 2001. ISBN 85285 285 2. 5th ed. Ithaca: Cornell University Library; 1903. Topping AR. china mission a personal history form the Digital Collection from Oliphant, Anderson and last imperial dynasty to the people’s republic. Baton Ferrier, Edinburgh and London. Rouge: Louisiana State University Press; 2014. The Evolution of Surgical Humanitarian Missions 2

Ofer Merin

the burden of surgical conditions and the unmet Abbreviations needs for surgical care [3 ]. Every year thousands of physicians and nurses FMTs Foreign medical teams travel to developing countries, with stays ranging NGOs Nongovernmental organizations from days to years. The increased ease of world travel and transport and the heightened interest in international matters have led to greater numbers Introduction of healthcare providers involved in these humanitarian efforts. Humanitarian assistance can be in International aid agencies have traditionally the form of a single individual, a group, part of a focused on infectious diseases in resource-limited nongovernmental organization (NGO), a govern- settings. Global health initiatives, however, are ment agency, or under the auspices of a United now increasingly addressing surgical conditions Nations (UN) Organization, such as the World as well. A growing awareness of the heavy bur- Health Organization (WHO). den of surgically treatable diseases and condi- This chapter will briefl y describe the history of tions has led to extensive involvement of both surgical missions, update the current situation and public and public resources in surgical interna- identify the main global players, and then focus on tional humanitarian missions, which perform and the main challenges and dilemmas faced by these teach surgery in order to improve healthcare missions. The benefi ts will be balanced against any worldwide [1 , 2 ]. These services can be in the potential harm resulting from their deployment. form of a preplanned mission to an underserved Some of those challenges will be described in region, or an acute response in the aftermath of a greater detail than others. Just as little guidance major disaster or humanitarian crisis. The latter is exists on how to measure the benefi ts of outreach provided by medical and surgical units, collec- trips, even less is known about what harm they tively referred to as “foreign medical teams” might cause or how to deal with that harm. This (FMTs). A “global burden of surgical disease chapter will conclude with a vision for the future. working group” was established in 2008, and it arrived at a strategy consensus of how to measure History

O. Merin , M.D., M.H.A. (*) Before World War II (WWII), two institutions Shaare Zedek Medical Center , P.O. Box 3235 , Jerusalem 9103102 , Israel dominated international health development: e-mail: [email protected] The Pasteur Institutions (functioning mainly in

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 19 DOI 10.1007/978-3-319-09423-6_2, © Springer International Publishing Switzerland 2015 20 O. Merin the Far and Middle East and Africa) and the on communicable and infectious diseases, since Rockefeller Institute (functioning mainly about 25 % of deaths in developing countries are throughout Latin America). Their efforts were secondary to those diseases compared to only largely directed to the control or eradication of 3–4 % in developed countries. It became evident major infectious scourges, such as malaria, over the last decade, however, that global epide- typhoid, plague, and other tropical and sanitation- miologic and demographic shifts have been based public health problems. Basch character- changing the burden of disease in all societies. ized international health after WWII as having Developing countries are now facing a dramatic evolved through four distinct stages [4 ]: increase in noncommunicable diseases, including 1. 1945–1950: Period of general international injuries and chronic illnesses [7 ]. This change is stability with intergovernmental cooperation gradually producing a parallel shift in the focus for reconstruction. of healthcare provision in terms of individual 2. 1950–1970: Development of various UN patients vs. cohorts/populations. Today, surgeons agencies largely around a medical model and anesthesiologists are becoming involved in focused on eradication of diseases. humanitarian efforts to a much greater extent 3. 1970–1980: UN agencies’ development of a than ever before. series of “agendas,” such as primary health Although there is an increasing awareness of care, community empowerment, and women’s the importance of unmet needs for surgical care issues. worldwide, it is still estimated that up to one-half 4. 1980–1990: The World Bank, the International of the world’s population lacks access to basic Monetary Fund (IMF), and various NGOs surgical needs [8 ]. The burden of surgical care is focusing more on underlying health and soci- potentially enormous. It was estimated that 2–3 etal system-level issues as obstacles to opti- billion people (approximately one-third to one- mum health. half of the world’s population) have no access to The publication of the Global Burden of basic surgical care [ 9 , 10 ]. Despite this clear Disease Report in 1996 [5 ] has increased the imbalance around the world, surgery is still “the awareness of the impact of chronic diseases and neglected stepchild of global health” as noted by injuries on the overall health burden, leading to Farmer and Kim [11 ]. There are probably many recognition by international development agen- reasons for this, one of which is that interna- cies that more attention must be directed toward tional health was dominated for decades by those them. Remarkably little attention was drawn to concerned with communicable diseases, from surgical missions throughout this entire period. smallpox to AIDS. Another reason is that surgery is much more complex and more expensive to deliver than vaccinations [11 ]. The Present The international projects that aimed to fi ll the gaps in surgical needs may be classifi ed into Global health policy in the developing world tra- three types: clinical, relief projects, and develop- ditionally emphasized primary prevention and mental projects. categorical vertical programs aimed at communicable disease, maternal health, perinatal and child Clinical : These are preplanned delegations that health, and nutritional defi ciencies. Such categor- deal mainly with chronic conditions and dis- ical health initiatives have achieved considerable eases, often targeted to a specifi c disease. success in developing countries [6 ]. They empha- Humanitarian missions to underserved areas size healthcare delivery at the primary care level, throughout the world aim to relieve specifi c sur- and provide preventative measures, health promo- gical conditions. Examples include plastic surgi- tion activities, and essential primary care services. cal procedures [ 12 , 13 ], pediatric cardiology Their premise is that “an ounce of prevention is surgery [ 13 , 14 ], ophthalmology (mainly cataract worth a pound of cure.” It makes sense to focus surgery) [15 , 16], pediatric neurosurgery [ 17 ], 2 The Evolution of Surgical Humanitarian Missions 21 and combined specialties, such as otorhinolaryn- be reasonably self-suffi cient local surgeons who are gologists and plastic surgeons who repair facial able to cope with most of the surgical problems in deformities [18 ], among others. district hospitals in the developing world.

Relief : These include surgical teams that respond to needs that result from natural disasters or wars Major Players in Humanitarian (see Chap. 11). They are “acute” missions, orga- Assistance nized within a short time frame, and frequently deal with many uncertainties. Their aim is to alle- The total number of humanitarian aid workers viate a time-limited crisis. These include foreign around the world was 210,800, as calculated in medical teams (FMTs) that respond in the after- 2008 by the Active Learning Network for math of sudden impact disasters, either to substi- Accountability and Performance in Humanitarian tute or complement the local medical system. Actions (ALNAP), a network of agencies work- They have three distinct purposes [19 ]: ing in the humanitarian system [21 ]. The last 1. Early emergency care. This period lasts up to decade has witnessed increasing involvement in 48 h following the onset of an event. the provision of humanitarian aid: it is estimated 2. Follow-up care for trauma cases, emergen- that the humanitarian fi eldworker population has cies, and routine health care (from day 3 to been increasing by approximately 6 % per year day 15). During this phase, the local health [ 21]. Those workers include medical students, services are progressively overwhelmed by residents, senior and retired surgeons who were the need for secondary or maintenance care involved in short-term missions and physicians/ for the trauma victims. The primary roles of nurses who devoted longer periods (months/ the FMTs are to temporary fi ll the gaps in years) in order to treat the needy and train local emergency medical assistance resulting either health providers. from a large number of casualties or the The involvement of medical students in this inability of the local health services to respond system has been increasing. For example, 22 % to the usual emergencies. of US medical students had completed an inter- 3. Act as a temporary facility to substitute for national educational experience in 2004 [22 ], and damaged local facilities during the rehabilita- 47 % of accredited MD-granting medical schools tion phase until a permanent solution (recon- had established initiatives, centers, institutions, structive phase) is available. This phase usually or offi ces of global health by 2008 [ 23 ]. All of the starts from the second month and can last up plastic surgery residents who participated in such to several years. missions reported that this experience had an important impact upon their life and career [13 ]. Developmental: These are organized for a long- Two-thirds of responders to an American College term framework and their aim is to create or aug- of Surgeons (ACS) survey asked to be placed on ment local capacity to address the burden of a mailing list of surgeons interested in volun- surgical disorders. There is an increasing under- teerism [24 ]. Similar responses were received to standing that short-term medical missions cannot a questionnaire of the American Association of substitute for a continuing investment in the local Thoracic Surgeons [25 ]. health infrastructure and staff training that will The major participants in humanitarian assis- allow low- and middle-class countries to develop tance typically fi t into one of the fi ve following their own long-term surgical capacity [ 20 ]. categories [26 ]: Training programs, when carefully considered 1. United Nations (UN) organizations and other and implemented, can be mutually benefi cial and international organizations. Included are provide a sustainable and lasting solution to the the UN High Commissioner for Refugees unmet health needs of the developing world. (UNHCR), the WHO, and the International The outcome of such a training program should Committee of the Red Cross (ICRC). 22 O. Merin

These organizations typically provide the provide medical care in acute crises, as well as oversight, coordination, and funding for raising international awareness of potential NGOs and program implementers. humanitarian disasters. Other large organiza- 2. Governmental organizations. Various indus- tions include the International Rescue trialized countries maintain funding agencies Committee, CARE International, Catholic dedicated to relief and development. Examples Relief Services, and World Vision. include the US agency for International 4. Private industry, consulting fi rms, and academic Development and the relief and disaster organizations. There has been a signifi cant branch, the United Kingdom’s Department for growth in the participation of for-profi t organi- International Development, The European zations and consulting fi rms in humanitarian Commission Humanitarian Aid Offi ce, the aid and post-disaster reconstruction. Similarly, Canadian, Danish, and Australian Agencies greater numbers of academicians in the vari- for International Development, and many ous fi elds of medicine, public health, human more. These governmental agencies set priori- rights, epidemiology, and social services have ties for funding and provide fi nancial support been providing assistance. Universities, such for implementing partners through grants and as Johns Hopkins, Harvard, Tufts, Columbia, contracts. and others, have academic programs in vari- 3. NGOs and private voluntary organizations. ous aspects of humanitarian aid. The American The World Bank defi nes NGOs as being pri- College of Surgeons (ACS) has also become vate, independent organizations that initiate involved in volunteer activities by establish- activities to relieve suffering, promote the ing the volunteer initiative, Operation Giving interests of the poor, provide basic social ser- Back (OGB) [29 ]. vices, and/or undertake community develop- 5. The military. Various military branches are ment [27 ]. These organizations are the primary involved in important humanitarian aid in the implementers of relief assistance. Today, there form of security, communications, and logistic are over 40,000 actively engaged NGOs [28 ]. operations, as well as the provision of medical They can be large or small, local or interna- assistance, food, shelter, and public health around tional, religious or secular, and have a wide the globe. The Offi ce for the Communication range of expertise. In some countries, like of Humanitarian Affairs developed a set of Haiti, NGOs account for over 70 % of the total guidelines for the use of military assets in healthcare delivery. The need for external non-confl ict relief operations known as the governments not to be seen as directly inter- “Oslo guidelines” [30 ]. vening in another sovereign territory is one cause for the NGO’s expansion. Government- funded NGOs generally work from a position Challenges of neutrality and impartiality and are therefore regarded as being free of political infl uence. A foreign team is parachuting into a foreign envi- Their ability to gain easier cross-border access ronment. Medical care in underserved and under- and attract less attention and scrutiny than resourced areas is provided in a diffi cult governmental agencies has motivated major environment for a foreign medical team. Primary funding from governmental donors and care is often not available in many of these areas, spurred their global growth. This increased and therefore many medical conditions are under- funding has promoted the growth of some diagnosed and undertreated. Surgeons on overseas well-known established international agen- missions will wrestle with challenges that are a far cies, such as the Medecins Sans Frontiers cry from their usual clinical practice, sometimes to (MSF: Doctors without Borders). The MSF the point of appearing surreal. received the 1999 Nobel Peace Prize in recog- Surgeons on humanitarian missions are inargu- nition of its members’ continuing efforts to ably engaged in a noble cause, but good intentions 2 The Evolution of Surgical Humanitarian Missions 23 alone cannot ensure success. The principle of patient, the hospital, and the local physicians non-malfeasance, often defi ned as the obligation should clearly prevail. According to Welling to “do no harm,” must be rigidly upheld under all et al., “One good rule is to offer the types of conditions. Many medical initiatives automati- procedures that are minimally invasive, cally focus on what and how to provide appropri- relieve immediate discomfort, and require ate medical/surgical care. Equally imperative, little follow-up care, especially for missions however, is what not to offer. One has to be aware that are short term” [32 ]. Complications may of the risk in conducting a mission that provides be inevitable, but when they affect an impov- temporary, short-term solutions but fails to take erished patient in a developing country who in the entire picture. was treated by a volunteer physician, the sit- It is impossible to establish clear-cut guidelines uation can be politically as well as emotion- before embarking upon humanitarian missions in ally charged [35 ]. foreign countries, but it is important to take Choosing the most appropriate anesthetic appropriate precautions when planning and exe- technique is another challenge. It should be cuting such missions. The line between an exem- tailored to the kind of care, monitoring, and plary voluntary humanitarian effort of altruistic skills that will be available postoperatively. It health providers that has an important positive is sometimes better to choose a different impact and a mission criticized and labeled as approach from what one might usually “neocolonialism,” “surgical safari,” “medical tour- employ (our preference is to use regional/ ism,” and “short-term overseas work in poor coun- local anesthesia, instead of general anesthesia, tries by clinical people from rich countries” [31 ] is if at all possible). sometimes not clear enough. Not infrequently, and 2 . Follow-up. Short-term missions provide despite the best of intentions, mistakes are made in clinical/surgical care for patients who may attempts to help others. Groups must be aware of never be seen again by the foreign team. and avoid, as much as possible, “the seven sins Continuum of care which is a basic and of humanitarian medicine” [32 ] and the potential essential part of surgical treatment is lacking. pitfalls [33 , 34 ]. The local community sometimes criticizes The following Ten Commandments are pro- this failure to provide follow-up care. One posed to describe some of the unique challenges example was the accusation of Operation in planning and executing surgical humanitarian Smile volunteers by local surgeons of “dump- missions. They are based on accounts in the lit- ing” their complications once their mission erature as well as on personal insights after was over. The organization refuted this charge responding to disaster areas around the globe: [35 ], but one should bear in mind that this can 1 . Careful selection of cases and of the most be a sensitive issue. When it is not possible to appropriate anesthesia. One important sur- provide long-term follow-up care, it is rec- gical challenge in these short-term missions ommended that chronic care medications and is to perform the right procedure. It is a com- elective surgery be avoided. mon temptation to perform complex surgery 3 . Cultural competence . This item refers to the when indicated. However, once the short- ability of healthcare providers to deliver term mission leaves, the local physicians will effective services to racially, ethnically, and have to deal with any complications from culturally diverse patient populations. A cul- surgeries which they themselves cannot per- turally competent physician is aware of dif- form, or do not have the knowledge or exper- ferent cultural beliefs or concepts of illness tise to properly treat. It is sometimes better to and health and has the skills to explore how do a simpler procedure within the abilities of and whether these beliefs are relevant to a a given local system. Better to leave with specifi c individual [ 36 ]. There are several hope than with desperation. When choosing models available that emphasize the important the proper procedure the best interest of the concepts of cross-cultural communication 24 O. Merin

process. One such example is the RESPECT religious differences may exist, and that model, developed by the Boston University relief workers are at risk of delivering cultur- Residency Training Program in Internal ally inappropriate services. Medicine, Diversity Curriculum Taskforce 5 . Cooperation with local authorities . Foreign [37 ]. The RESPECT model stands for: healthcare teams are supposed to support and Respect, Explanatory model, Sociocultural reinforce the national health system, not context, Power, Empathy, Concerns and replace it. Every attempt should be made to fears, Therapeutic alliance/trust. Personnel collaborate with the local system. By ignor- involved in such work should understand and ing local healthcare providers, many volun- respect the local culture and be aware of the teer programs undermine the local local customs. How we dress, how we act, infrastructure, create new barriers to care, what we drink, and other behaviors will and cause harm. Local practitioners who defi ne us to our hosts. Miscommunication must earn a living in the community cannot and misunderstanding may lead to potential compete with volunteers who donate their harm. Therefore, one should establish an services. While assisting the Philippine peo- effective method of communication and ple after the 2013 typhoon, it was the deci- become familiar with cultural norms before sion of our group to integrate our team with departure. Awareness of a given culture’s the local hospital, creating one coordinated beliefs and practices is important because it facility [40 ]. Collaboration with local sur- fosters an environment of trust and mutual geons is especially critical in surgical mis- respect, which may translate to better com- sions since the latter need to provide pliance and greater effectiveness of medical follow-up care and treat complications after treatment [38 ]. the guest surgeons’ departure. 4 . Informed consent . The principle of informed 6 . Triage and ethical dilemmas. Mass casualty consent is aimed at the legality of health triage needs to be implemented when avail- assistance and refl ects the concept of auton- able resources are insuffi cient to meet the omy and of decisional auto-determination of needs of all patients in a disaster situation. the patient. Operating even in a disaster sce- The basic principle is to do the maximum nario does not allow another individual to good for the most casualties with the least decide for a conscious and coherent patient. amount of resources. Disasters require phy- The same rules apply as they do within the sicians to shift to “utilitarian-based ethics” in United States. The World Medical which medical decisions are based on avail- Association (WMA) 1994 statement on able resources, much in the way that a triage medical ethics in the event of disasters states system prioritizes victims who are predicted there may not be enough time for informed to have the best chance of survival [32 ]. consent to be a realistic possibility in a disas- The WMA statement on medical ethics in ter response situation [39 ]. This may also disasters recognizes these unique situations apply when responding to disasters in one’s and noted “The physician must act according own country, but we believe that a different to the needs of patients and the resources approach should be taken when one arrives available. He/she should attempt to set an to a foreign country as a relief delegation. order of priorities for treatment that will save Our team, which has vast experience in the greatest number of lives and restrict mor- response to natural disasters, is very strict bidity to a minimum” [ 39 ]. Such situations about this issue. We never operate or perform will inevitably lead to serious ethical dilem- an invasive procedure on a patient without mas. Efforts will be needed in order to achieve his/her consent (or consent of a surrogate) a balance between individual and collective after a clear explanation by a local interpreter. rights. There is generally a confl ict between It should be borne in mind that cultural and autonomy of the individual and the desire to 2 The Evolution of Surgical Humanitarian Missions 25

protect and promote public health. This “dual International humanitarian volunteers have loyalty” also exists in many disaster situa- different levels of knowledge, medical educa- tions. It is necessary to develop a system that tion, and levels of competence. Medical per- identifi es patients by their medical/surgical sonnel in resource-poor locations are subject needs and the likelihood of benefi t, espe- to the same ethical principles of their own cially in the context of disaster response, but countries. Licensure is important since it may also during short-term initiatives. Because of serve as restraint against unethical conduct the complexity of triage in such conditions, [ 46]. Although medical negligence lawsuits the basic concept underlying the process are not currently a signifi cant problem for should be decided before departure. In addi- humanitarian medical/surgical groups [47 ], tion, the process must be fair, transparent, many of them are becoming more concerned and meet the principles of distributive justice that such lawsuits may soon have an impact [41 ]. Triage can confl ict with human rights upon their missions [48 ]. legislation, and even with humanitarian laws, 8 . Mutual expectations. A key to success is to but “accountability for reasonableness” can promise less than what can be delivered, and temper the disagreements on the setting of to deliver more than what was promised. priorities. Triage in a disaster setting, how- Accordingly, humanitarian aid providers ever, requires a basic change in thinking. Of should avoid creating false or unreasonable necessity, this adjustment includes dealing expectations on the part of the recipients. with ethical dilemmas for which there is lit- 9 . Standard of care . Volunteers should not pro- tle preparation [42 , 43 ]. Among the many vide medical services beyond their level of proposed approaches to triage, perhaps the expertise. Personnel must be aware of the pit- most common is the utilitarian notion of falls in practicing beyond their abilities. doing the most good for the most people. Alarmingly, medical students and residents Our personal recommendation after dealing often view medical missions to developing with ethical and triage issues while respond- countries as opportunities to gain unrestrained ing to the Haiti earthquake is that it is imper- exposure to techniques and procedures they ative to establish and strictly follow clear-cut are not qualifi ed to perform in their home guidelines [44 ]. countries [49 ]. One has to fi nd the right bal- The ethical “code of conduct” of the ance in this twofold goal: allow residents an International Red Cross (ICRC)/Red Crescent opportunity to both learn and serve. Visiting seeks to outline the principles of conduct of physicians sometimes feel compelled to treat foreign teams responding to a disaster [45 ]. patients outside their specialty, simply The main ethical principles in the provision because no specialist is available, even though of health services during an event and during lowering the standard of care for patients in the early response phase of disasters pertain developing communities is unprofessional, to non-malfeasance, benefi cence, justice, and unsafe, unethical, and oftentimes illegal [50 ]. the respect of autonomy. Healthcare providers working in humanitar- 7 . Licensure, credentialing, and malpractice ian missions should be able to recognize their issues . Unlike country/state licensure and limitations and act accordingly. Humanitarian hospital accreditation which is standardized, missions can have an important role in mod- there is no comparable international system, ern surgical training, but they should never and this is an area that causes much concern turn into a self-serving opportunity for the for surgeons. These issues cannot be dealt visitor at the expense of the recipient nation with before departure to disaster areas. Recent which could feel that it is being treated as an discussions have highlighted the diffi culties experimental guinea pig. and concerns with using untrained volunteers 10. Know and understand what is unique to the to deliver care in international settings. operating zone . Diseases can be encountered 26 O. Merin

with unfamiliar presentations and with unex- reference to registration on arrival. According pected patient profi les. All of these factors to this document, the foreign medical teams should have direct implication on clinical are expected to declare to which of three dis- decision-making. Members operating in tinct categories they belong according to their remote areas should be familiar with endemic capacity and capabilities. Once an FMT local pathology. We encountered patients in declares its capability to offer a specifi c type of Haiti, and later on in the Philippines, who care and any additional services, it is expected presented with abdominal pain which we ini- to comply with the technical standards related tially considered as being caused by an acute to those services. The next step will be registra- abdomen (with which we were familiar), but tion of that FMT [ 53]. This concept of an inter- which turned out to be typhoid fever (which national registration process could be a fi rst we had never seen before). In resource-poor step toward future accreditation of FMTs. countries, one may encounter higher rates of 2. Operational guidelines. The WHO/Pan- malnutrition and underweight in children, American Health Organization (PAHO) pub- and of low plasma protein concentration and lished essential guidelines for the FMTs as anemia in adults. Thus, patients treated by follows [19 ]: members of a surgical mission may be more – Be fully operational within 3–5 days. prone to wound infection, wound dehiscence, – Be self-suffi cient with minimal need for and other related complications, factors that support from the local communities. have to be taken into account when offering – Have basic knowledge of the health situa- surgical care. tion and language and respect for the culture. – Include health professionals in selected The Future specialties. – Ensure capacity for sustainability, including More and more individuals and teams are involved appropriate technology costs. in surgical humanitarian aid with understandably Of the 44 FMTs responding within the varied levels of quality. Questions concerning the fi rst month after the Haiti earthquake, only competence of some of the deployed medical 11 adhered to essential deployment require- teams have recently been raised. These fi ndings ments and none followed all the require- have promoted the international community to ments of WHO/PAHO [54 ]. Volunteer call for “greater accountability, stringent perfor- efforts need to be preplanned in order to mance oversight, reporting, and better coordina- respond within an adequate time frame. tion” [51 ]. In the coming years, we will be seeing Individuals interested in taking part should a trend toward better and closer control in some of belong to a designated team ready to be the following areas: deployed. One example is the Disaster 1. Classifi cation and accreditation of FMTs. The Medical Assistance Teams (DMATs), foreign medical teams working under the aus- which are groups of medical personnel set pices of the global health cluster and the WHO up to respond to disasters or unusual events. recently (2013) commissioned a document Composed of about 35 individuals or more, entitled: “Classifi cation and minimum stan- they are rapid responders and provide pri- dards for foreign medical teams in sudden mary care or augment local staff [55 ] . onset disasters” [52 ]. It introduces a simple 3. Sustainability. Suchdev et al. [33 ] suggested a classifi cation, minimum standards, and a reg- model for sustainable short-term international istration form for FMTs that arrive to provide medical trips. They identifi ed seven areas of surgical and trauma care in the aftermath of a focus: developing a clear mission, collaborat- sudden disaster. These guidelines can also ing with the local community, educating serve as tools to improve the coordination travelers and the local community, making between foreign medical teams, and be the the commitment to serve the needs of the local 2 The Evolution of Surgical Humanitarian Missions 27

community, engaging in teamwork, having well as a complete electronic medical record sustained capacity building, and developing a and a lightweight picture archiving and com- system for periodic evaluation. The benefi ts of munication system (PACS). Patient transfers these medical initiatives should extend beyond within the hospital are noted, and an online the presence of foreign medical assistance. command dashboard screen is generated. Sub-specialized surgical care may be best Patient care is delivered by means of an elec- addressed with visiting teams, but a much tronic medical record. Digital radiographs are more preferred expanded model of sustain- acquired and transmitted to stations through- able delivery of surgical care, which empha- out the hospital. The system helps to intro- sizes empowerment of local healthcare duce order into an otherwise chaotic situation practitioners through education, equipment and enables adequate utilization of scarce support, and quality benchmarks, has been medical resources by continually gathering described [56 ]. information, analyzing it, and presenting it to 4. Accountability. There is no single offi cial defi - the decision-making command level. The nition of accountability in the humanitarian establishment of electronic medical records context. Accountability per se is defi ned as promotes facilitated continuity of care. Based having three components: transparency, on our experience, we encourage disaster responsiveness, and compliance [19 ]. response teams and agencies to consider the Accountability is mainly at the organization use of information technology as part of their level, but there is also a component of individ- contingency plans. ual accountability. We should expect that mis- A 2011 Davos global health risk forum confer- sions would use evidence-based medicine as ence reviewed emergency surgical fi ndings to the benchmark, although it is diffi cult to come date and called for improved data collection [ 60]. up with a single set of outcome measures and There is a consensus of a strong need to establish levels that fi ts all the different environments in an international standardized reporting format. which these missions operate. Working with A proposed standard data collection form for sud- its partners, disaster survivors, and others, den onset humanitarian crisis and natural disasters Humanitarian Accountability Partnership was suggested [61 ]. Multiple FMTs were mobi- International (HAP International) produced lized following the recent large-scale disasters the HAP 2007 Standard in Humanitarian specifi cally, the 2010 Haiti earthquake. Thousands Accountability and Quality Management. This of surgical procedures were performed to allevi- certifi cation scheme aims to provide assurance ate pain, save lives, and allow rehabilitation and that certifi ed agencies manage the quality of recovery. Many of these FMTs provided high- their humanitarian actions in accordance with quality care, but they lacked basic medical record- the HAP standard [57 ]. keeping. In the absence of systematic information 5. Data collection. Humanitarian missions deliver management and data collection, it is unlikely that health care in especially diffi cult environ- the true impact, both positive and negative, of ments where patients may be more prone to FMTs in a crisis setting will ever be known. It is complications. This makes the evaluation of disappointing to note that the massive medical these different programs of utmost impor- response, presumably at immense cost, is inade- tance. Only a few groups have collected data, quately documented. Without basic outcome data, and even fewer have evaluated those data or there can be neither accountability nor a report of statistics [58 ]. Our group has developed a spe- lessons learned. cially tailored information technology solu- Some groups recently began to collect and tion which is implemented in the fi eld hospital report outcome measures. In 2005, Operation we deploy in disasters [59 ]. This solution Smile International (OSI) implemented an elec- includes a hospital administration system as tronic medical record system that helps monitor a 28 O. Merin number of critical indices that are essential for global-burden-of-surgical-disease-working-group- quality assurance reviews of surgical missions. need- and-impact-of-surgical-services-in-low- resource- countries-unaccounted-for/ . In one retrospective analysis of more than 8,000 2. Ozgediz D, Jamison D, Cherian M, McQueen K. The cases (mostly cleft palate procedures in children), burden of surgical conditions and access to surgical the complication rates were similar to those care in low- and middle-income countries. Bull World reported in the United States and United Kingdom Health Organ. 2008;86:646–7. 3. Bickler S, Ozgediz D, Gosselin R, Weiser T, Spiegel [62 ]. This fi nding is in accordance with other D, Hsia R, et al. Key concepts for estimating the bur- reports. In an analysis of data from three otology den of surgical conditions and the unmet need for sur- surgical missions conducted in Paraguay and gical care. World J Surg. 2010;34:374–80. Honduras from 2003 to 2006, the authors con- 4. Basch PF. Textbook of international health. 2nd ed. New York, NY: Oxford; 1999. cluded that the results fall within those expected 5. Murray CJ, Lopez AD. The global burden of disease: in developed nations [63 ]. The information in a comprehensive assessment of mortality and disabil- these reports are testimony to the importance of ity from diseases, injuries and risk factors in 1990 and precise record-keeping and self-monitoring projected to 2020, Global burden of disease and injury series, vol. I. Cambridge, MA: Harvard School of which would be invaluable to the efforts of orga- Public Health; 1996. nizing and regulating surgical humanitarian aid 6. Lee JW. Global health improvement and WHO: shap- the world over. ing the future. Lancet. 2003;362:2083–8. 7. Smith J, Haile-Mariam T. Priorities in global emergency medicine development. Emerg Med Clin North Am. 2005;23:11–29. Concluding Remarks 8. Gosselin RA, Gyamfi YA, Contini S. Challenges of meeting surgical needs in the developing world. Humanitarian aid is a young science. The medi- World J Surg. 2011;35:258–61. 9. Taira BR, Kelly McQueen KA, Burkle Jr FM. Burden cal/surgical care provided in disasters or remote of surgical disease: does the literature refl ect the scope areas is unique and different than that of routine of the international crisis? World J Surg. 2009;33: practice in the industrialized countries. 893–8. Adaptability to the different scenarios is essen- 10. Contini S. Surgery in developing countries: why and how to meet surgical needs worldwide. Acta Biomed. tial. As more and more medical personnel become 2007;78:4–5. involved, we may see these missions turning into 11. Farmer PE, Kim JY. Surgery and global health: a a separate medical specialty. Toward that end, view from beyond the OR. World J Surg. 2008;32: Farmer et al. [64 ] described a novel concept of 533–6. 12. Bermudez LE. Operation smile: plastic surgery with creating a global health equity residency at few resources. Lancet. 2000;356:S45. Harvard’s Brigham and Women’s Hospital. 13. Campbell A, Sherman R, Magee WP. 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K. A. Kelly McQueen

include vaccines, medicines, and surgery [ 1 ]. Abbreviations (Figures 3.1 and 3.2 ) Surgical disease is specifi cally defi ned for the BoSD Burden of surgical disease purposes of communicating with the global health GBD Global burden of disease community, and the burden of surgical disease is LMIC Low- and middle-income countries described as the disability and premature death NCD Noncommunicable disease that is prevented or potentially averted by surgical DALY Disability adjusted life years intervention [2 ]. Similarly surgical interventions, POMR Perioperative mortality rate or operations, are identifi ed and the provision of anesthesia is included as necessary for a majority of operations. The inclusion of safe anesthesia as D e fi ning Surgical Need a necessary element for meeting surgical need is essential [3 ]. The global health community defi nes need based Early estimates of the burden of surgical dis- on measureable population outcomes, primarily ease (BoSD) suggested that 11 % of the overall disability and premature death. The burden of GBD could be prevented or averted by surgical disease, or the contribution of a disease, group of intervention [4 ]. In the years since this pivotal diseases, or conditions to the overall disability chapter by Debas et al., the epidemiologic shift in and premature death in a population, is a complex GBD from communicable disease to noncommu- estimation reported in Disability Adjusted Life nicable disease (NCDs) has been recognized [5 ] Years (DALYs). One DALY is equal to 1 year of and this has led to new estimates that surgical healthy life lost due to death or disability from a intervention and safe anesthesia comprise up to disease process. The global burden of disease 38 % of GBD [ 6]. The BoSD is equal to the total (GBD) is a dynamic estimate of global health surgical need in a community, including the met and is infl uenced by acute and chronic disease need (i.e., that proportion of surgically treatable patterns as well as by the interventions that conditions that are seen and treated), the unmet impact or avert disease burden. These interventions need (i.e., that proportion of surgically treatable conditions that remain unseen and untreated), K. A. K. McQueen , M.D., M.P.H. (*) and the unmeetable need (i.e., that proportion of Department of Anesthesiology, Vanderbilt Institute potentially surgically treatable conditions that for Global Health, Vanderbilt University Medical are so severe that death and/or disability could Center , 1301 Medical Center Drive, #4648 TVC , Nashville , TN 37232 , USA not be averted even with adequate access to quality e-mail: [email protected] surgical care) [7 ].

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 31 DOI 10.1007/978-3-319-09423-6_3, © Springer International Publishing Switzerland 2015 32 K.A.K. McQueen

Fig. 3.1 Country Development based on World Bank GDP are also those with the greatest unmet surgical needs: Status. Countries with less economic development (Less in Greatest need in dark orange ≫ High need in orange orange and Least in dark orange ). Developed Countries

1. Canada: 27.8 2. USA: 32.8 3. Mexico: 38.8 4. Guatemala: 16.3 5. Belize: 28 6. Honduras: 13.0 7. Guyana: 13.3 8. Bolivia: 18.6 2.5 speciality physicians per 100,000 population 1 speciality physician per 100,000 population <1 speciality physician per 100,000 population

Fig. 3.2 Countries surveyed by infrastructure surveys [41 ] by physicians per 100,000 [38 ] and cesarean section rates

Global unmet surgical need is large and growing, with a majority of the need existing in The Elements of Unmet the poorest countries with the fewest healthcare Surgical Need resources for surgery and anesthesia. In 2010 it was estimated that two billion people worldwide Surgical intervention and safe anesthesia for had no access to emergency or essential surgery noncommunicable diseases (NCDs) including [8 ], with the greatest burden and fewest resources cardiovascular disease and trauma are grossly in Africa [9 ]. underserved in LMICs. Importantly, surgical and 3 The Global Burden of Surgical Need 33 anesthesia capacity are similarly underserved for Table 3.1 Anesthesia-related and perioperative mortality obstetric emergencies in LMICs [10 ]. Unmet sur- in high-income countries (HICs) gical need will only be addressed when surgical Prior to 1970 Since 1990 and anesthesia capacity are increased in tandem, Anesthesia-related mortality 357 34 and when appropriate technology, education and per million population training, and access to equipment, essential med- Perioperative mortality per 10,600 1,170 million population icines, and blood products are uniform [11 ]. Perioperative Mortality in HICs has improved dramati- Perioperative outcomes are dependent upon cally over the past 40 years, demonstrating that with ade- timely surgical intervention and safe anesthesiol- quate professional training, appropriately directed ogy. Currently, successful surgical outcomes are healthcare resources, and application of evidence-based critically limited by absent or unsafe anesthesia interventions, undergoing anesthesia can be very safe Adapted from Bainbridge D, Martin J, Arango M, practices in the countries in greatest need [ 12 ]. In the Cheng D, Evidence-based Peri-operative Clinical following section, each of these related areas of Outcomes Research Group. Perioperative and anaes- unmet surgical need is explored in more detail. thetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 2012;380:1075–81 Safe Anesthesia Care

The global anesthesia crisis [13 ] limits access to emergency and essential surgical intervention, a healthcare system must build capacity in all and contributes to poor patient outcomes. The areas: physical infrastructure, surgeons, anesthe- survey data among practitioners in LMICs shows siologists, nurses, and technicians. that a lack of education, limited training, and Anesthesia in resource-rich countries is very dwindling interest in the specialty have contrib- safe [ 14 , 19 ]. Adequate numbers of physicians, uted to a lack of or absence of trained anesthesia supervision of nonphysician personnel, the con- providers [13 ]. Unpredictable access to essential tinuous use of required safety monitoring, as well medications and limited safety equipment has as an ample supply of medications, equipment, resulted in unsafe conditions for the provision of and blood products contribute to the safety and anesthesia and surgical intervention [13 ]. successful outcomes in developed countries. The contribution of anesthesia to unmet surgi- Outcomes related to anesthesia and surgery have cal need is difﬁ cult to quantify and measure [ 3 ]. steadily improved in these countries since the Evidence from developed countries conﬁ rms that 1970s (Table 3.1 ). acceptable surgical outcomes—including mortal- Too little is known about anesthesia resources ity rates—depend on safe anesthesia practice, and practices in LMICs but the mortality rates and safe anesthesia practice can only occur when reported in a few countries tell the shocking truth trained anesthesia providers, safety equipment, [ 15 – 18 , 20 ]. Deaths attributable to anesthesia in essential medicines for anesthesia, and systems most LMICs result from limited training and for pain control and resuscitation are available education, including continuing education, as [ 14]. With this in mind, surgical burden, inclusive well as limited or absent resources, especially of both met and unmet surgical need, is predi- safety monitoring. Published reports reveal mor- cated on lack of anesthesia care. In LMICs the tality attributed to anesthesia as high as 1 in 133 scarcity of anesthesia resources may limit the anesthetics [15 ], with other reports of avoidable provision of surgical intervention, but unfortu- anesthesia-related death rates as high as 1 in 144 nately, more often the intervention proceeds [ 16] and 1 in 504 anesthetics [17 ]. Of even greater without appropriate anesthesia care. The result- concern is that many of the preventable anesthe- ing high anesthesia-related mortality rates are sia deaths occurred in otherwise young, healthy doubly tragic in the context of patient suffering patients, many of whom were women undergoing [ 15 – 18 ]. Therefore, in order to impact the BoSD, cesarean delivery [20 ]. 34 K.A.K. McQueen

Essential Medicines medicine guidelines is infl uenced by resources as well as weighted prioritization within the health- The WHO Model List of Essential Medicines [21 ] care system and Ministry of Health. Despite this guides procurement of medications for govern- planning and strategizing, in many LMICs the ments internationally and includes a wide variety availability of medicines is inconsistent, especially of pharmaceuticals for treatment or therapeutic in the fi rst referral hospitals in LMICs. For exam- uses—including anesthesia and pain management. ple, oxygen, considered requisite to safe anesthe- The fi rst Model List of Essential Medications was sia, was only added to the WHO Essential Medicine published in 1977, and since 2007, the list has been list in 2013, and is available consistently in only updated every two years. The anesthetic and anal- 45.2 % of district hospitals and is unavailable in gesic medications from the 18th edition released in 35.0 % of these primary referral hospitals [23 ]. 2013 are listed in Table 3.2 . The WHO’s process of In addition, rescue medicines for hypotension selection utilizes a relatively small number of and dysrhythmias are not consistently available. experts and who meet over a short period of time; Finally, the paucity of narcotic pain medicines for in 2011, 20 experts met for 5 working days. Their treating acute and chronic pain in many of the goals are to “satisfy the health care needs of the poorest countries is of great concern. Regulatory majority of the population” while ensuring cost- issues, misinformation, and too few heath care effectiveness and promoting quality [22 ]. The list practitioners providing access to these important lacks many medications routinely used in HIC, medications contribute to this disparity1 [24 ]. many of the medicines not included are hotly debated annually, and the medicines within each category are included because they fulfi ll Blood Banking and Blood Products a specifi c function, are least expensive, or most consistently available. The ability to cross-match and transfuse blood to Consistent with many guidelines provided by patients with symptomatic anemia or hemorrhage the WHO, country-level adherence to the essential was a great medical advance that has positively impacted surgical and anesthetic outcomes glob- Table 3.2 The World Health Organization’s list of essential ally over the past 40 years [ 25 ]. The ability to medicines for anesthesia and pain management collect, match, and test blood for infectious dis- Medication class Specifi c medication listed ease is considered a prerequisite for surgical, Inhaled gas Oxygen, halothane, isofl urane, obstetric, and trauma programs [26 ] but even as Muscle relaxant nitrous oxide surgical care advances in LMICs, solutions for Sedative/hypnotic Suxamethonium, atracurium Narcotic Ketamine, propofol or the provision of a safe and predictable blood sup- Local anesthetic thiopental, midazolam, diazepam ply are not obvious. The limitations of blood Anti-infl ammatory Morphine, codeine banking in LMICs primarily relate to basic issues Antiemetic Lidocaine, bupivacaine of electricity and refrigeration, as well as the Chronic pain relief Ibuprofen Reversal agent Paracetamol unavailability of pathology services [ 27 ]. Rescue medicines Ondansetron Inexpensive and rapid blood typing and infec- Amitriptyline tious disease screening are available [28 ], but the Neostigmine widespread use of this technology is often under- Naloxone Epinephrine, atropine, ephedrine utilized due to the greater issues of predictable, constant electricity necessary for refrigeration. The anesthetic and analgesic medications included in the 2013 WHO Model List of Essential Medicines were Uninterrupted electricity is only available in selected for their unique pharmacologic contribution to 59 % of primary referral hospitals in Africa and balanced and safe anesthesia, cost-effectiveness, and wide availability. Interestingly oxygen was included for the fi rst time in 2011 1 See the chapter entitled “The Global Burden of Acute Adapted from WHO Model List of Essential Medicines and Chronic Pain” in this text for a more in-depth discus- 2013. www.who.int/topics/essential_medicines/en sion of this topic. 3 The Global Burden of Surgical Need 35

Asia [23 ]. Utilizing “walking” or “living” blood Table 3.3 Anesthesiology workforce banking—the practice of either formally or infor- Number of Population mally tracking blood types among community Country anesthesiologists (in millions) members with organized collection of whole Afghanistan 9 32 blood and transfusion on demand—remains a Bhutan 8 0.7 viable practice in low-resource settings [ 26 , 29 ]. Rwanda 0 8 However, even this practical solution is limited Uganda 13 27 by the spread of misinformation, especially United Kingdom 12,000 64 within the countries ravaged by the HIV pan- The number of trained physician anesthesiologists in ﬁ ve countries representing the extremes of the disparity in demic, about the relationship of the donating and anesthesiology workforce for 2001–2010. (Adapted receiving blood products [30 , 31 ]. from ref. 40 )

Surgical Capacity Many of the emergency and essential surgical interventions that address unmet surgical need in The challenges of developing suffi cient surgical LMICs are cost-effective [40 – 43] as is the provi- capacity—the personnel, infrastructure, and sion of safe anesthesia [44 – 47 ]. Ample documen- systems—to meet surgical need in LMICs are tation in the literature, as cited above, has brought many. Most advanced medical care including sur- attention to the issue, but such emphasis has not gical procedures, diagnostic testing, and spe- yet led to improved access or patient safety. cialty care is centralized in LMICs [9 ]. At the fi rst referral hospital where many patients in LMICs access health care there is limited infrastructure Surgical Outcomes and few human resources. These primary care hospitals, often referred to as “district hospitals,” Too little is known about the longitudinal patient indicate regional hospitals, but transportation is outcomes of surgical and anesthesia interven- limited, and even regional hospitals in the poorest tions in LMICs or about outcomes related to the countries have limited capacity to provide emer- absence of emergency surgery or late access to gency and essential surgery [10 , 11 ]. surgery. Improving data collection and reporting In the past decade many reports from LMICs is a critical component of addressing surgical have documented the extent of limited infrastruc- need. ture, lack of anesthesia and surgical providers, An absence of surgical and anesthesia outcome and unpredictable availability of essential medi- data limits the investment of resources into surgi- cations, monitors, and safety equipment; studies cal infrastructure and safe anesthesia in LMICs. have also documented how these conditions Little is known about the incidence of mortality impact access to surgery and anesthesia creating directly attributed to lack of surgical access espe- the unmet need for surgical intervention for a cially in LMICs where death certifi cates are often spectrum of disease [32 – 36 ]. not issued and most patients die at home where The surgical and anesthesiology workforce is data collection is sparse [48 ]. In a majority of one area of well-documented disparity. It is esti- operating theaters in LMICs the only documenta- mated that a ratio of 7 surgeons per 100,000 peo- tion of a serious operative complication or death ple is needed to meet the surgical needs of a is the paper logbook of the operating theater [ 49]. population. In the United States, there are 5.8 Little outside of the logbook is known about the surgeons per 100,000 population (with more in perioperative mortality rate (POMR) of the hospi- urban and less in rural areas), but in many LMICs tal, region, or country. Follow-up of patients after there is less than one surgeon per 100,000 people surgery is limited to the time they are hospital- [ 37 , 38 ]. The anesthesiology workforce is even ized, and once discharged to home few patients more disparate (see Table 3.3 ) [39 ]. are followed [50 ]. 36 K.A.K. McQueen

Additional information about surgical and Table 3.4 Cost-effective emergency and essential surgical anesthesia outcomes would provide information interventions recommended for all LMICs about patient safety in LMICs and may also allow Emergency and essential surgery benchmarking from a baseline quality indicator at fi rst referral hospitals such as the POMR if routinely collected and Emergency Cesarean Section/D&C reported [49 ]. The POMR is nonspecifi c, and Appendectomy/Ex Lap Anesthesia/Emergency Airway similar to the Maternal Mortality Rate (MMR) is ORIF/I&D easy to collect and the trend over time allows for Essential Hernia analysis of interventions and system changes. If Cataract the POMR is stratifi ed for ASA status, age, and Cleft Lip/Club Foot gender the rate will become increasing valuable [50 ]. Measuring a baseline and following mortality rates even while access to surgery and safe access to operative deliveries for indications such anesthesia is limited is important. Tracking a as obstructed labor and eclampsia; in many low- health indicator such as POMR brings awareness income countries the rates are less than 5 %, and to the issue of unmet surgical need and anesthesia even 1 % [52 ]. This low rate corresponds with safety, and allows the impact of interventions to high maternal mortality rates, and likely also cor- be prospectively evaluated. responds with the inability to provide emergency surgery in general. Interventions could focus on only one service line, such as obstetric surgery. Meeting Surgical Need in LMICs Building infrastructure for one group of surgical services will increase the overall ability to Progressing from the description of the BoSD provide surgical intervention and anesthesia and unmet surgical needs in LMICs to the imple- due to the overlap in equipment, medicines, and mentation of appropriate surgical services is the personnel. next step in the continuum of responding to the Essential or elective surgery is underserved as projections of the 2010 GBD [5 ], and planning well in LMICs. The growing evidence for the for the Post-2015 Development Goals [ 29 , 30 ]. cost-effectiveness of essential surgery encour- The Millennium Development Goals, which ages global health and national governments to emphasized MMR, HIV, and other pressing increase infrastructure and therefore access to health concerns of 2000, signifi cantly impacted basic essential surgery, including surgery for her- and improved the related health indicators due to nia, congenital malformations, cancer, and cata- the increased attention and funding received sec- racts [53 ]. Debates regarding the inclusion of ondary to the UN focus on ten goals. The success surgical interventions on the “essential list” have of improving access to surgical intervention in been ongoing for more than a decade; however LMICs will only be realized when investments inclusion of these effective and appropriate oper- are made for the totality of surgical care—from ations is inclusive to the basic right to health [54 ]. early diagnosis through treatment and from infra- The prioritization of surgical interventions has structure to patient safety and outcome monitor- been considered for LMICs based on costing [ 49 , 51 ]. effectiveness, prevalence, burden, and the suc- Emergency surgery is embraced as a neces- cess of the intervention (see Table 3.4 ) [14 , 55 ]. sary component of a healthcare system, and, yet The initial ability to provide safe surgery and many LMICs lack the ability to provide emer- anesthesia for any basic operation is likely to gency surgery including cesarean sections and increase access to an increasing number of surgi- trauma surgery outside of the largest regional cal services over time (see Table 3.5 ) [5 , 56 ]. hospitals [5 ]. The World Health Organization rec- Increasing access to safe anesthesia and ommends cesarean delivery rates to be 5–10 % of surgical intervention in any hospital, country, or the live birth rates, which corresponds to adequate region must begin by engaging, working with, 3 The Global Burden of Surgical Need 37

Table 3.5 Disability and death potentially averted with these unmet needs is growing. Hope is on the surgical interventions and safe anesthesia horizon for the effective treatment of the growing Potentially averted with burden of surgical disease in LMICs. Surgical disease type intervention (28 % of GBD) (%) Trauma 38 Malignancy 19 References Congenital anomalies 9 Pregnancy and 10 perinatal 1. Murray CJ, Lopez AD. Global mortality, disability and the contribution of risk factors: global burden of Cataracts 5 disease study. Lancet. 1997;349:1436–42. During the course of many surgical diseases, there is an 2. Bickler S, Ozdegiz D, Gosselin R, et al. Key concepts opportunity for surgical intervention that would result in for estimating burden of surgical conditions and an increase in DALYs for the population. Listed are those unmet need for surgical care. World J Surg. 2010; surgical diseases for which improved surgical capacity 34(3):374–80. would result in averted disease burden and improved qual- 3. McQueen KA. Anesthesia and the global burden of ity of life surgical disease. Int Anesthesiol Clin. 2010;48(2): Adapted from Surgical Intervention Impact on Global 91–107. PMID: 20386230. Burden of Disease (GBD). Murray CJ. The Global Burden 4. Debas HT, Gosselin R, McCord C, Thind A. Surgery. of Disease Study. Lancet 2012;380:2053–260 In: Disease Control Priorities in Developing Countries, vol. 1. 2nd ed. New York, NY: Oxford University Press; 2006. p. 245–60. 5. Murray CJ. The global burden of disease study. and building upon the existing structure of surgical Lancet. 2012;380:2053–260. care. Trained anesthesia providers are the rate- 6. Debas H, Mock C, Kruk M. “Essential Surgery” Disease control priorities in developing countries, 3rd limiting step for access to surgery, and are also a ed . Advance online publication: http://www.dcp-3. contributor to poor outcomes, including death org/chapter/essentialsurgery . Accessed 14 May 2014. [16 – 18]. LMICs with small numbers of local 7. Ozdegiz D, Hsia R, Weiser T, et al. Population metric physician anesthesiologists will benefi t from for surgery: effective coverage of surgical services in low-income and middle-income countries. World J functional groups of technicians providing anes- Surg. 2009;33(1):1–5. thesia. Improving the ability of technicians to 8. Funk L, Weiser T, Berry W, et al. Global operating the- provide safe anesthesia while simultaneously ater distribution and pulse oximetry supply: an esti- increasing the delivery of anesthesia through mation from reported data. Lancet. 2010;376(9746): 1055–61. nurse and physician providers is practical and 9. Ozdegiz D, Jamison D, Cherian M, McQueen K. The benefi cial to the population. Physician leadership burden of surgical conditions and access to surgical for training, education, certifi cation, and over- care in low and middle income countries. Bull World sight cannot be discounted, but in LMICs the Health Org. 2008;86(8):646–7. 10. Hogan M, Foreman K, Naghavi M, et al. Maternal practicalities of meeting surgical needs will mortality for 181 countries, 1980–2008: a systematic require a diverse workforce including nurses and analysis of progress toward millennium development technicians [57 , 58 ]. goal 5. Lancet. 2010;375(9726):1609–23. 11. Lebrun DG, Chackungal S, Chao TE, Knowlton LM, Linden AF, Notrica MR, Solis CV, McQueen KA. Prioritizing essential surgery and safe anesthesia Conclusions for the post-2015 development agenda: operative capacities of 78 district hospitals in 7 low- and Surgical disease signifi cantly contributes to middle- income countries. Surgery. 2014;155(3): 365–73. premature disability and death. Low- and middle- 12. Notrica MR, Evans FM, Knowlton LM, Kelly income countries suffer with the largest BoSD McQueen KA. Rwandan surgical and anesthesia and are dramatically underserved with respect to infrastructure: a survey of district hospitals. World J diagnostic services, surgical intervention, and Surg. 2011;35:1770–80. 13. Dubowitz G, Detlefs S, McQueen K. Global anesthe- safe anesthesia. Documentation of the cost- sia workforce crisis: a preliminary survey revealing effectiveness of emergency and essential surgery shortages contributing to undesirable outcomes and and safe anesthesia is in place, and awareness of unsafe practices. World J Surg. 2010;34(3):438–44. 38 K.A.K. McQueen

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Steven Dale Boggs and Nicholas W. Chee

A person is a person because he recognizes others 6. To combat HIV/AIDS, malaria, and other as persons. diseases. Desmond Tutu, 7 September 1986. 7. To ensure environmental sustainability. 8. To develop a global partnership for The stark inequities in economic benefi ts that development. are spread among the members of the world’s These eight factors are inextricably linked, community highlight how the place of one’s birth with at least three of these goals specifi cally deal- in large part determines one’s fate. To address ing with health care. More specifi cally, Thomas this imbalance, the Millennium Summit of the LaVeist of the Bloomberg School of Public health United Nations in 2000 [1 ] set out three broad [2 ] has identifi ed six key factors that cause categories for improving the welfare of the healthcare disparities: socioeconomic conditions, world’s peoples: human capital, infrastructure, social and physical environments, access to qual- and human rights (social, economic, and politi- ity care, cultural competency, health literacy, and cal) with the intent of increasing living standards. empowered healthcare consumers. These factors More specifi cally, eight Millennium Development are inextricably linked. To provide excellent Goals were established: healthcare, each factor must be optimized. 1. To eradicate extreme poverty and hunger. As is seen in the USA at present, funding 2. To achieve universal primary education. alone is not suffi cient for the delivery of effi cient 3. To promote gender equality and empowering and high-quality healthcare. However, in low- women. and middle-income countries (LMIC), the prob- 4. To reduce child mortality rates. lems are both lack of funding and also knowing 5. To improve maternal health. where to start to address the multitude of medical problems. This chapter will outline several issues that impede the provision of surgical and anesthetic care in LMICs. Included is a discus- S. D. Boggs , M.D., M.B.A. (*) sion of the global disparities in access to surgical The James J Peters VA Medical Center , and anesthetic care, the differential risk of anes- Bronx , NY , USA thesia in high-income countries (HIC) and The Icahn School of Medicine at Mount Sinai , LMICs, the distribution of anesthesia providers Manhattan , NY , USA e-mail: [email protected] worldwide, and how certain anesthetic techniques and methods have been adapted for situations N. W. Chee , M.P.H. Hospital for Joint Diseases , NYU Langone Medical with limited access to providers and adequate Center , New York , NY , USA infrastructure.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 41 DOI 10.1007/978-3-319-09423-6_4, © Springer International Publishing Switzerland 2015 42 S.D. Boggs and N.W. Chee

surgical conditions account for up to 15 % of Essential Surgical and Anesthesia total disability adjusted life years (DALYs) lost Services worldwide (see Appendix). Urbanization and industrialization have seen an increase in the In its most recent report [3 ], the UN Millennium number and severity of traffi c accidents, in part Development Goals Report (2013), striking suc- because road quality has not improved at a cesses have been noted. The proportion of people commensurate rate. By 2030, road traffi c acci- living in extreme poverty has been halved at the dents are expected to be the seventh leading cause global level. Over two billion people gained access of mortality and the fourth cause of DALYs in to improved sources of drinking water despite sig- Low- Income Countries. The most severely nifi cant population growth. Remarkable gains affected age group are those between 5 and 14 have also been made in the fi ght against smallpox, years and those in the age range between 5 and 59 malaria, and tuberculosis. The hunger reduction account for almost 75 % of those killed—that is, target is within reach and the proportion of under- a population in the most productive years. Injuries nourished people in developing regions decreased in general kill more than fi ve million people from 23.2 % in 1990–1992 to 14.9 % in 2010– globally and account for one out of every ten 2012. New HIV infections are declining. From deaths [6 ]. 1990 to 2011, 1.9 billion people gained access to a The WHO began to examine global disparities latrine; globally the maternal mortality ratio in the delivery of surgical and anesthetic care by declined by 47 % over the last two decades, from hosting the fi rst WHO Global Initiative for 400 maternal deaths per 100,000 live births to 210 Emergency and Essential Surgical Care (GIEESC) between 1990 and 2010; and worldwide the mor- Biennial Meeting in 2005 Geneva, Switzerland tality rate for children under fi ve dropped by [ 7]. Subsequently, there have been four more of 41 %—from 87 deaths per 1,000 live births in these conferences, the most recent in October 1990 to 51 in 2011. 2013. The GIEESC meetings have focused on six While these successes are admirable, they also areas (below), which in many ways refl ect the underscore the problem of global inequitable problems Médecins Sans Frontières have been access to safe surgery and anesthesia. Historically, addressing for years [8 ] (Table 4.1 ). world health has focused on the treatment and These defi nitions do require some care, how- prevention of communicable disease. Surgery ever. Certain conditions that should be classifi ed and anesthesia have been viewed in the past as as surgical—for example long bone traction— high technology solutions that do not yield suffi - may not be so classifi ed because no anesthetic or cient return on investment and therefore as being operating suite is involved. Conversely, other interventions that would be addressed when pri- conditions that do not require a surgical incision mary care systems were in place. Yet, data from but are also on the spectrum of surgical care— the World Health Organization (WHO) now sug- fl uid resuscitation and emergency airway man- gest that by the year 2026 the global burden of agement—may also be misclassifi ed [9 ]. disease from malaria, tuberculosis, and HIV will While surgery does require signifi cant input in be eclipsed by surgical disease [4 ]. terms of skilled labor (e.g., surgeons, anesthe- There is a need to prioritize surgical care glob- tists, and nurses) and is technologically intensive ally, especially in LMICs. Six years ago, Paul (surgical and anesthetic equipment, dedicated Farmer, a physician well known for his historic operating room space), the presented evidence focus on bringing general medical care to and suggests that the return in quality life years for combating HIV in disadvantaged communities, selected patients can exceed the expenditure. For observed that surgery is the neglected stepchild example, emergency obstetric care at a rural hospi- of global health [5 ]. Surgical disease is among tal in Bangladesh was calculated to be US$10.93 the top 15 causes of disability, and inadequate per DALY averted [10 –12 ]. 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 43 ing Elective care of simple Elective conditions: surgical – Hernia – Clubfoot – Cataract – Hydrocele – Otitis media 100,000 children born annually with club feet Congenital disease 50 % of congenital abnormalities can be treated with surgery EESC promotes and cost-effective disability-preventative measures icts Natural disasters Armed confl Disasters and emergencies Timely access reduces Timely death rate and disability with EESC works partners to provide guidance for disaster preparedness and response stulae per per stulae stulae complications: – Obstruction of labor – Hemorrhage Women’s Women’s health Obstetric fi 287,000 deaths per year due to complications pregnancy-related 800 deaths per day 2,000,000 obstetric fi year 1/3 of all pregnancy- related 1/3 of all pregnancy- complications can be treated with surgery EESS works for EESS works early detection HIV Handling of obstetric Chagas Cholera Leishmaniasis Malaria Measles Meningitis Tuberculosis Trypanosomiasis High-HIV transmission risk in Africa to EESC works safety of improve clinical procedures cation system that Debas uses for categorizing surgical management of abdominal and extra-abdominal emergent and life-threaten emergent management of abdominal and extra-abdominal surgical cation system that Debas uses for categorizing rst-referral facility facility rst-referral Provision of competent care to Provision injury victims deaths Reduce preventable Decrease personal dysfunction on families Decrease burden to injuries 1,200,000 deaths per year due to road accidents 50,000,000 injured due to road accidents Injuries Infectious disease Cancer Pregnancy-related complications fi to strengthen EESC works care essential surgical ] 5,000,000 deaths per year due ] Optimal management starts at 7 94 – ] 92 8 ] Medical and surgical issues facing LMICs LMICs issues facing Medical and surgical 91 Group Table Table 4.1 WHO data [ Debas (author) four Sig. types of [ surgery No exact counterpart conditions the classifi WHO GIEESS [ Médecins Sans Frontières [ 44 S.D. Boggs and N.W. Chee

government. At the other extreme Eritrea, Disparity in Access to Surgical Care Ethiopia, Central African Republic, Madagascar, the Democratic Republic of the Congo and Niger Before analyzing discrepancies in surgical care all spend less than $20 USD per capita annually between HIC and LMICs, the framework utilized on health care (Table 4.3), which is extremely to make these comparisons must be understood. low, even when calculated in terms of purchasing The WHO classiﬁ es member countries depend- power parity (PPP). ing on both Gross National Income and Region, Data from the World Bank [16 ]. PPP is used in based on World Bank criteria [13 ]. international comparisons based on currencies to WHO Member States are grouped into six estimate what market basket of goods a currency regions (2012) including the African Region, could purchase. They are used in economics to the Region of the Americas, the Eastern eliminate distortions that can occur when com- Mediterranean Region, the European Region, parisons are made on the basis of market the South-East Asia Region, and the Western exchange rates. Paciﬁ c Region. WHO Member States are grouped into four gross annual income groups (GNI) per capita (low, lower middle, upper mid- Table 4.2 World Bank categories of countries by income dle, and high) based on the World Bank list of group economies for the year 2011 (released July Gross income groups Criteria (per capita) 2012) (Table 4.2 ). Low income (LI) Less than $1,035 In the USA, annual per capita healthcare Lower middle income (LMI) $1,036–$4,085 spending (2011) is on the order of $8,608 [ 14 , Upper middle income (MI) $4,086–$12, 615 15 ]. Of this, roughly US$4,400 is spent by the High income (HI) Greater than $12,616

Table 4.3 Purchasing Rank Country Region $PPP THE % GDP power parity, total 3 Qatar a 80,470 1,707 1.9 healthcare expenditure, and a healthcare expenditure as a 8 Singapore 60,110 2,787 4.6 percentage of GDP, 2012 USA a 52,610 8,608 17.9 data (World Bank) 140 Mongolia East Asia and Paciﬁ c 5,020 251 5.3 168 Nigeria Sub-Saharan African 2,450 139 5.3 170 Yemen, Republic Middle East and N. African 2,310 152 5.5 186 Zambia Sub-Saharan African 1,590 99 6.1 187 Afghanistan South Asia 1,560 50 9.6 187 Tanzania Sub-Saharan African 1,560 107 7.3 191 Nepal South Asia 1,470 68 5.4 194 Rwanda Sub-Saharan African 1,320 135 10.8 196 Haiti Latin American and Caribbean 1,220 94 7.9 199 Uganda Sub-Saharan African 1,120 128 9.5 200 Ethiopia Sub-Saharan African 1,110 52 4.7 207 Togo Sub-Saharan African 900 80 8.0 208 Niger Sub-Saharan African 760 39 5.3 209 Malawi Sub-Saharan African 730 77 8.4 210 Liberia Sub-Saharan African 580 112 19.5 211 Burundi Sub-Saharan African 550 52 8.7 211 Eritrea Sub-Saharan African 550 17 2.6 213 Congo, D.R. Sub-Saharan African 390 32 8.5 a Not classiﬁ ed by region—data not available + nurses and midwives 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 45

Table 4.4 Physicians, nurses, and hospitals beds Physicians Nurses+ Hospital beds Rank Country Region per 1,000 per 1,000 per 1,000 3 Qatar a 2.80 7 1.2 8 Singapore a 1.90 6 2.7 13 USA a 2.40 10 3.0 140 Mongolia East Asia and Paciﬁ c 2.80 4 6.8 168 Nigeria Sub-Saharan African 0.40 2 – 170 Yemen, Republic Middle East and N. African 0.20 1 0.7 186 Zambia Sub-Saharan African 0.10 1 2.0 187 Afghanistan South Asia 0.20 0 0.4 187 Tanzania Sub-Saharan African 0.00 0 0.7 191 Nepal South Asia – – 5.0 194 Rwanda Sub-Saharan African 0.10 1 1.6 196 Haiti Latin American and Caribbean – – 1.3 199 Uganda Sub-Saharan African 0.10 1 0.5 200 Ethiopia Sub-Saharan African 0.00 0 0.4 207 Togo Sub-Saharan African 0.10 0 0.7 208 Niger Sub-Saharan African 0.00 0 – 209 Malawi Sub-Saharan African 0.00 0 1.3 210 Liberia Sub-Saharan African 0.00 0 10.8 211 Burundi Sub-Saharan African – – 1.9 211 Eritrea Sub-Saharan African – – 0.7 213 Congo, D.R. Sub-Saharan African – – 0.8 a Not classiﬁ ed by region—data not available + nurses and midwives

As the above tables show, there are dramatic ment for competing professions (engineering) funding disparities from country to country. and the employment opportunities in countries However, even if funding were to be increased in which spend more money per capita on health- sub-Saharan Africa—the most concentrated, care, many individuals in LMICs either choose impoverished region—there would be major alternative professions or if they do enter medi- issues of healthcare delivery because there is no cine, they are induced to migrate elsewhere for established infrastructure coupled with a large better wages and living conditions. defi cit of healthcare providers here and in other A study of healthcare workers in Ghana LMICs. In Table 4.4 , we also see the signifi cant revealed a marked preference for migration to variation in the distribution of physicians, nurses, ODEC countries [95 ]. For healthcare workers, and available hospital beds when countries are this was of particular concern because their train- ranked by PPP. Regional variation again is striking is generally publically funded. One model ing, with sub-Saharan Africa having the greatest found that for the United Kingdom, the country shortages in all categories. had a net overall gain by the importing of foreign As seen in Table 4.4 , LMICs have fewer phy- physicians, the exact opposite was seen in the sicians, nurses and midwives, and hospital beds exporting country. Although only 1.91 % of the per capita compared to more affl uent countries. total population migrated, this was refl ective of Exacerbating this discrepancy however is the 8.07 % of the total expenditure on education of fact that compared to population growth rates, the current population. most-sub-Saharan African nations have an actual Access to surgery, operating suites, and negative annual growth rate in the number of phy- trained anesthesia personnel is even more starkly sicians produced [17 ]. Because of the hardships imbalanced between HI countries and those of sub- of practice in these locations, better reimburse- Saharan and other LI countries. Weiser et al. [18 ] 46 S.D. Boggs and N.W. Chee found that the global volume of major surgery was Table 4.5 Current comparative mortality rates in the UK between 187 and 281 million cases, which is and selected LMICs equivalent to one operation for every 25 people Study Mortality rate Reference(s) living in 2004. These researchers further found UK confi dential enquiry 1:185,000 [26 , 86 ] that countries spending less than USD $100 (2004) for perioperative death per person only had 295 major surgeries per University teaching 1:1,925 [87 ] Hospital, Zambia 100,000 people. In contrast, countries spending Central Hospital, Malawi 1:504 [88 ] more than USD $1,000 (2004) per person had District Hospital, 1:482 [9 ] surgical incidences of 11,110 per 100,000 people. Zimbabwe Weiser et al. also showed that MI and HI Teaching Hospital, Nigeria 1:387 [89 ] countries accounted for 30.2 % of the world’s Teaching Hospital, Togo 1:133 [90 ] population but received 73.6 % of the surgical operations, whereas poor expenditure countries (less than or equal to USD $100 per person) advances in anesthesia over the past six decades, accounted for 34.8 % of the global population with risk from dying from anesthesia being on and received only 3.5 % of all surgical proce- the order of 1:200,000 anesthetics, LMICs have dures. This striking difference is not primarily not seen any improvement. Anesthetic-related due to nonessential surgical care. For example, in mortality in these environments is worse than the USA in 2010 there were 51.4 million proce- experienced in the developed world since the dures performed on inpatients. Some of these inauguration of the age of anesthesia in the nine- procedures were endoscopies and cardiac cathe- teenth century [23 ]. terizations, but for the most part the procedures Differences in frequency of surgical procedures are those typically associated as “surgical” [19 ]. could perhaps be explained by availability of sur- The number of aesthetic surgical procedures per- gical resources. Funk et al. [24 ] noted that there formed in the USA in 2012 was 289,000 [20 ]. are more than 14 operating theaters per 100,000 Consequently, it can be seen that even with cos- people in high-income countries and 1–25 per metic and other procedures, the bulk of surgical 100,000 in middle to low-income countries. interventions in the USA and other HI countries Moreover, almost 20 % of operating rooms world- is not solely the result of nonessential interven- wide were not equipped with pulse oximeters and tion. Rather, what these data emphasize is that the this was not the case in high-income countries. extremely low volume of surgery performed in Pulse oximeters are not the only equipment- related LMICs underscores a lack of access to surgical resources missing in LMICs. As seen below, sim- services in these locations. With this large, unad- ple things such as functional operating table are dressed surgical disease burden worldwide, mea- frequently not available. And, basic infrastructure surement of surgical outcomes and public health requirement—such as electricity and water—can- evaluations in surgical disease are warranted. not be guaranteed (Table 4.6 ). In HI countries, mortality from anesthesia was found to be on the order of 6.4 deaths per 10,000 anesthetics by Beecher and Todd in 1954. By W o r k f o r c e 1980, the mortality rate from anesthesia had decreased to 2 deaths per 10,000 anesthetics and Differences in the availability of human resources current data indicates that anesthetic mortality is are also striking. In the USA (2011), there were on the order of 1 death per 100,000–200,000 approximately 35,000 anesthesiologists, an equal [ 21 ]. Major morbidity occurs in 3–16 % of cases. number of certifi ed registered nurse anesthetists In contrast, in developing countries, the death (CRNA), and 1,300 anesthesia assistants (AA) rate remains 5–10 %, which is 500–1,000 deaths actively practicing in the USA [25 ]. This yielded a per 10,000 administered anesthetics [ 22 ] trained anesthesia provider for every 4,295 individ- (Table 4.5). These data suggest that while affl u- uals in the USA. In the UK, the ratio is on the order ent portions of the world have benefi ted from of 1 anesthetist for every 5,333 persons (2007) [26 ]. 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 47

Table 4.6 Unavailability of requirements for administration 1. Most LMICs surveyed had ratios of 1 or less of anesthesia physician or nonphysician anesthesia provider % Unavailable Anesthesia specifi c per 100,000 populations. 74 Pulse Oximeter 2. Inadequate nursing and surgical staff and 59 No spinal solutions available at all times limited hospital beds are also critical issues. 23 Tilting operating room table 3. These discrepancies translate into low average 22 Oxygen source life expectancy, high infant mortality, and 21 Appropriately sized endotracheal tubes high under-fi ve mortality rates. Facility Specifi c 4. Again, as noted above, anesthesia-related 80 Electricity not always available mortality is extremely high. 44 Running water not always available Lack of funds and training are not the only 30 Fluids not always available problems, however. Even if appropriate funding were available, other problems for the provision In contrast to high-income countries, in a of healthcare services–especially anesthesia 2006 study in Uganda [27 ], questionnaires were service–remain. There is poor infrastructure, distributed to attendees at a national anesthesia inadequate equipment or equipment that is fre- refresher course sponsored by the Ugandan quently in disrepair, long and harsh working Society of Anaesthesia, the Association of conditions, bureaucratic roadblocks [ 29] and Anaesthetists of Great Britain and Ireland lack of professional recognition. There are also (AAGBI), and the World Federation of Societies incentives for trained personnel to migrate to of Anesthesiologists (WFSA). Of the 91 attend- urban settings or transnationally [ 30 ]. ees, only one was a physician anesthetist in the Within LMICs, most surgical and anesthesia group (all called anesthetists in this study). The providers cluster in urban environments, espe- vast majority of providers had attended a course cially treating patients with the fi nancial resources in the administration of anesthesia of 1–2 years to pay for care [ 31 ]. For example, if one looks at duration. Fewer than half had their own text- the statistics for the entire country of Haiti before books of anesthesia. In the UK, for 60 million the 2010 earthquake, low-end estimates of mater- people, there are roughly 12,000 anesthetists nal mortality are 523 per 100,000 live births. while in Uganda with a population of 27 million, Community-based surveys have placed this num- there are 13 medical anesthesiologists and 330 ber for the country as a whole at 1,400 per 100,000 nonphysician anesthesia providers. These fi g- live births [32 ]. This is in stark contrast to the ures are also seen in Afghanistan, with nine phy- much lower C-section rates and maternal mortality sician anesthetists for a population of 32 million rates seen in Haitian cities, which approach those and Bhutan with eight for a population of seen in the US. The maternal mortality ratio in 700,000 [ 28 ]. other LMIC countries is 240 per 100,000 births In this study, only 23 % of the Ugandan anes- versus 16 per 100,000 in HI countries with large thesia providers had the minimum requirements disparities within countries, between people with in their facilities for the safe administration of high and low income, and between people living general anesthesia, only 13 % of anesthetists in rural and urban areas [33 ]. were able to provide safe anesthesia to children, and only 6 % of anesthetists in this study could provide safe anesthesia for a C-section with Delivery of Anesthesia Care either a general or spinal anesthetic. Dubowitz et al. provides some explanation In general, three types of clinical personnel of a relationship between economic rank and administer anesthesia globally: anesthesiologists, anesthesia availability [ 94 ]. Using a descriptive anesthesia assistants, and nurse anesthetists or questionnaire mailed to the LMICs from the surgical nurses. Anesthesiologists are medical WHO, ministries of health, the following signifi - professionals who have received medical degrees cant fi ndings emerged: and appropriate training. Anesthesia assistants 48 S.D. Boggs and N.W. Chee are trained professionals that specifi cally assist ratio is much lower. No primary level hospitals had anesthesiologists. Nurse anesthetists are nurses a full-time surgeon or anesthesiologist. In primary who receive specialized training related to anes- facilities, 23 % had anesthesia administered by thesia, which may include drug administration. non-physician providers and 11 % had anesthesia In certain countries, surgical nurses are trained to administered by general physicians administering administer and/or monitor anesthesia. Thus, the anesthesia. There were no anesthesiologists specialty of nurse anesthetist does not exist. Each reported in the 44 sites sampled in the study. country has various restrictions that govern the Lack of trained personnel to administer anes- practice of each type of clinical personnel. thesia seems not to be explained by a lack of The level of training of personnel allocated to demand for surgeries. In surveyed hospitals in administering anesthesia seems to be directly Rwanda, over 45,000 surgical cases occur each related to a country’s total expenditures on year [34 ]. However, this lack of trained personnel healthcare. On one hand, nations, like the USA is not restricted to LMICs. A RAND study examin- and the UK, that spend considerably more on ing data from 2007 showed shortages of both anes- healthcare tend to rely on anesthesiologists to thesiologists and nurse anesthetists in the USA administer anesthesia-related care. On the other [38 ]. In most simulations, researchers projected hand, nations, like Rwanda and those in Sub- that it is likely there will be a shortage of anesthesi- Saharan Africa, which spend less on healthcare, ologists and a surplus of nurse anesthetists by 2020. tend to rely on nurse anesthetists, surgical nurses, Like in the USA, Europe has been experiencing and/or less-trained clinical personnel. shortages of anesthesiologists, which has induced Comparatively, in 2011, approximately 35,000 demand for nurse anesthetists [38 ]. anesthesiologists practice in the USA; while In terms of care delivery, a number of different Rwanda in the same year had a total of nine phy- kinds of models can be found internationally. sicians who practice anesthesia [ 34 ]. Similarly, Popularly in the USA, a “team” approach is used, when the survey was conducted in 2007, research- where an anesthesiologist supervises nurse anes- ers found that a total of 121 anesthesiologists thetists and/or anesthesia assistants; and they col- served the French-speaking part of Sub-Saharan laboratively implement an anesthesia care plan. Africa compared to 665 nurse anesthetists and Switzerland also uses a collaborative approach midwives. Researchers also found that in this given its lengthy historical use of nurse- region more than 80 % of anesthesia was pro- administered anesthesia [38 ]. This is not to say, vided by nurse anesthetists or midwives. In the however, that nurses and physicians do not have UK, there are approximately 12,000 physician confl icting views in these countries. For instance, anesthetists for 64 million people [ 26]. In con- anesthesiologists and nurse anesthetists in the trast, Uganda has 330 non-physician anesthetists USA continue to debate scope of practice [39 ]. In to help fi ll needs for anesthesiology, a number other countries, like the UK and Germany, where that still remains insuffi cient [27 ]. nurse anesthesia is a relatively new discipline, In the African region, the supply of physician anesthesia care remains more restricted to anes- is estimated at 2.5 per 10 000 population and in thesiologists [40 ]. In contrast, primarily due to the Southeast Asia region, it is 5.5 per 10,000 lack of supply of anesthesiologists, many LMICs population. These fi gures are much lower com- have used nurses and midwives to administer pared to those in the Americas where there are anesthesia-related care as stated previously. 20.4 physicians per 10,000 population [35 ]. In Mongolia [36 ], roughly half of the population lives in rural areas, diffi cult to access. In these Current Training for Healthcare regions, availability of surgical or anesthetic care is Professionals in Anesthesia limited. While Mongolia’s absolute supply of physicians (2.8 per 1,000) appears adequate, their dis- Both how anesthesia care is delivered and how tribution is homogenous. In Ulaanbaatar there are human resources are available when comparing 17.3 physicians per 1,000, while in rural areas the high-income countries to LMICs centers on how 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 49

Table 4.7 Educational training of physicians and nurses for careers in anesthesia Country Anesthesiologist education characteristics Nurse anesthetist education characteristics United States • Undergraduate college degree • Bachelor of Nursing or equivalent degree [39 , 41 , 42 ] • Four years of medical school (3–4 years) (3–4 years) • Four years of residency program • One year in acute care setting • Pass Medical Licensing Exam • Pass Nursing Licensing Exam • Most pass the American Board of • Two to three years of anesthesia graduate Anesthesiology Exam program • Pass national certifi cation exam United Kingdom • Five to six years undergraduate medical training • Complete foundational nursing education [43 , 44 ] • Two years foundational training in hospitals courses • Seven to eight year anesthesia training program • Secure employment as a nurse in a UK • Optional additional training in anesthesia Hospital • Become a Band fi ve nurse • Complete 6–12 month university education courses in anesthesia France [45 , 46 ] • Two years undergraduate studies and pass exam • Three years of nursing education at end of fi rst year • Two years of practical experience • Four years of master’s program study including • Two years of nurse anesthesia program clinical training and passing several exams (clinical practice and coursework) • Three to fi ve years of residency training for specialty and thesis defense Australia • Five to six years undergraduate degree or four • Bachelor of Nursing [45 , 47 , 48 ] years graduate degree • One year postgraduate study in anesthesia • Two years internship • Five years anesthesia training medical and nurse professionals are trained and led by clinical staff at the hospital then commences. educated. In high-income countries, like the Global agencies, such as the International Federation USA and the UK, educational standards for of Nurse Anesthetists, attempt to reduce these anesthesiologists and nurse anesthetists are inconsistencies and promote educational standards fairly established. Standards for both professions for nurse anesthesia [46 ]. are determined by a combination of government LMICs, however, face the summation of many entities and professional societies. Table 4.7 different problems including fragmentation in summarizes educational characteristics for both medical and nursing education. For instance, Bird professions for the USA, the UK, France, and and Newton summarize the problems facing Australia. increasing the anesthesia workforce in Africa [49 ]: From these countries, one can see signifi cant The lack of adequate numbers of training pro- similarities when comparing physician education grams; the insuffi cient numbers of graduates of requirements. Students across these countries medical schools in LICs [Low Income Countries] need approximately 11–15 years to complete who choose anesthesia; the shortage of proper training materials, including anesthesia books and physician education, are subjected to rigorous training modalities; the lack of academic educa- examinations, and must complete practical tional partnerships between resource-rich and training. resource poor countries; the lack of adequate basic While these countries all require some kind of medical infrastructure that would promote an anesthesia educational center; and the lack of alterna- postgraduate study, signifi cant variation exists in tive anesthesia care provider training models education for nurse anesthetists. France and the would each individually, but certainly collectively, USA seem to have the lengthiest requirements: contribute to the overall lack of anesthesia care 7 years, which is substantially shorter than anes- necessary for the millions of patients in LICs. thesiologist education durations. In contrast, the UK Moreover, Greysen et al. report that research has historically trained nurses through hiring stu- available on how specialists are trained compared to dents at a hospital. Practical training and education generalists in Sub-Saharan Africa is fragmented, 50 S.D. Boggs and N.W. Chee which in turn creates diffi culties for making For the administration of anesthesia, WHO improvements to the physician and healthcare recommends paramedical staff without formal workforce [50 ]. anesthesia training at Level I facilities, one or two trained anesthetists in Level 2 facilities, and clinical offi cers and specialists in anesthesia for Advancing Training in Anesthesia Level 3 facilities. These recommendations seem in LMICs to be consistent with past programs in LMICs. For example, one of the common tactics imple- A number of efforts on the international stage mented to help reduce anesthesia-related compli- have been implemented to help LMICs train more cations and deaths is to provide training to nurses anesthesiologists and nurse anesthetists. For and other non-physician personnel at hospitals. example, the WHO and World Bank actively Médecins Sans Frontières has trained nurse anes- works with LMICs to reform national health pol- thetists for over 10 years in Haiti [56 ]. In this pro- icy involving medical and nursing education, gram, in the 10-year period from 1998 to 2008, 24 such as efforts in Myanmar [51 ] and Nepal [52 ]. students completed the program, 19 continued to Other global agencies, such as the World work as anesthetists at the time of publication Federation of Medical Education (WFME), have (2010) and 5 emigrated. When these anesthetists also attempted to create some standardization in administered emergency care following Haiti’s medical education internationally [ 53 ]. For disastrous hurricane, the mortality rate was 0.3 % instance, the WFME has created medical educa- in 330 cases (one death). Additionally, signifi cant tion standards as well as guidelines for creating amounts of their cases involved administering medical education accreditation bodies. As an anesthesia independent of physician assistance. example for adoption, the European Society of Other tactics involved the training of physi- Anesthesiology offers the European Diploma in cians. In Nepal, in 1985 a 1-year diploma in Anesthesia and Intensive Care, which is an anesthesia (DA) training program for physicians examination to qualify as a specialist anesthesi- was created by the ministry of health (MOH) ologist [54 ]. Passing this exam grants European- with the support of the Canadian educated anesthesiologists more freedom to Anesthesiologists’ Society International Fund practice throughout Europe. Accreditation pro- [ 57]. Forty-three (43) individuals graduated this cedures for medical and nursing schools along course. Subsequently, in 1996, a 3-year anesthe- with standardization of education requirements sia residency program was established. could bolster the quality of overall education Following the establishment of the residency provided in many LMICs. As of 2011, only 7 of program, the ministry of health discontinued the 35 African countries with medical schools have recognition of the DA program. Nineteen (19) of accreditation procedures [54 ]. those graduates worked for the MOH at the time The WHO has compiled a “Guide to of publication (2006), 11 are in private hospitals Infrastructure and Supplies at Various Levels of and 13 have left Nepal. However, in the period of Healthcare Facilities—Emergency and time when the program was functioning, anes- Essential Surgical Care (EESC)” for anesthesia thesiologist (DA) were available at the ten hospitals which discusses the anesthetic requirements for outside the Kathmandu valley. Level 1 (Small Hospitals), Level 2 District A similar situation existed in Rwanda. In 1996, (Provincial Hospitals), and Level 3 (Referral an anesthesia-training program was initiated at Hospitals). This document gives recommenda- the Kigali Health Institute for high school gradu- tions for procedures to be undertaken in each ates who had studied health-related topics. If type of facility, the training of the personnel staff- admitted, these individuals had a 3-year training ing these facilities, medications to be utilized, program in anesthesia. From 1996 to publication and specifi c anesthetic equipment and disposable (2007) there were 96 graduates of this program. equipment [55 ]. In 2003, though, the National University of 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 51

Rwanda collaborated with the Canadian US$50,000 annually. This study found that there Anesthesiologists’ Society and the American were not more than 5,000 full-time equivalent Society of Anesthesiologists Overseas Teaching IHV working in the region in 2005, of which not Program to develop their own residency program. more than 1,500 of these were physicians (com- Tactically, however, some errors were made. plicating this study). The surveyed country Residents had to complete all of their training in experts did state that IHVs were defendable as a country. This was not popular. In addition, trying temporary measure. Similar concerns were to develop de novo an academic culture was not voiced by Acherman as it related to the training easy. As in all LMICs, availability of equipment of healthcare workers for HICs in LMIC loca- and support was, and remains challenging. tions [96 ]. Unsurprisingly, many individuals, groups, and Another problem is the issue of medical practitioners in HICs recognize the urgency of migration, or physicians who train in a country this situation. For decades, groups such as and relocate to another country [ 49]. The nega- ReSurge (formerly Interplast), Operation Smile, tive effects of medical migration are particularly ORBIS, Health Volunteers Overseas, and count- severe for LMICs. In fact, one in eight physicians less others have been working in LMICs to pro- trained in Sub-Saharan Africa is lost to medical vide otherwise unavailable surgical treatment and migration [63 ]. Also, physician emigration is necessary education and training for local clinical attributed to 6 of 47 Sub-Saharan African coun- staff. The US Department of State and the tries that lose over 60 % of their physician work- American Medical Association’s International force [62 , 63 ]. Health Database can provide a registry of health- Several criticisms highlight important areas oriented volunteer organizations [58 ]. for future surgical and anesthesia training pro- In spite of these successes in directly educating grams to consider in reducing the surgical burden clinical staff in LMICs, there have been some of disease in LMICs: observations that detract from programs’ sustain- • Education and training of the local workforce is able progress. For example, there has been grow- imperative if any long-lasting change is to occur. ing concern about the costs versus benefi ts of • Local authorities and other signifi cant parties medical volunteerism [59 ]. Maki et al. evaluated must feel that they are part of a lasting 543 medical mission trips that conducted 6,000 relationship. annual short-term programs [ 95 ]. The average • Metrics must be utilized to assess impact, out- expenditure was $50,000 per mission, giving a comes, and cost-benefi t. minimal estimate of $250 million per year for just • Volunteer staff should have an understanding those programs. Signifi cantly, there was a lack of of the community’s culture. standardization to evaluate patient safety, quality • Trained workforce are given incentives to stay control, and mission impact, so determining opti- in aided communities. mal performance was impossible. These authors Along these lines, the Bloomberg School of developed a tool to evaluate short-term surgical Public Health has developed an ethics curriculum (and medical) mission on six criteria: Cost, for short-term global health trainees [64 ]. As Effi ciency, Impact, Preparedness, Education, and observed with the WHO checklist, standardiza- Sustainability. tion promulgates norms for medical and surgical Moreover, further evidence from sub-Saharan care worldwide, in this case including such issues Africa questions current models of health volun- as appropriate informed consent, ensuring sus- teerism. Laleman et al. [60 ] reviewed the com- tainability, and not exceeding the provider’s level ments of in-country experts (medical offi cers of training. from sub-Saharan African countries). They had Groups, such as CapaCare (Capacity Building more negative than positive views of International and Training of Medical Staff), furnish examples Health Volunteers (IHV). The cost per expatriate of what can be accomplished in rural areas. With volunteer was calculated to be US$36,000– annual surgical production in the government 52 S.D. Boggs and N.W. Chee

(1,700 cases) and an unknown number in the hospital discharge. It could be argued that these private/military and nongovernmental organiza- factors are even more important in LMICs. It can tion (NGO) sector in 2008, CapaCare committed appear that people in LMIC accept pain as an itself as an organization to train 30 non-physician unavoidable part of life [ 64]. Patients often or young physicians to handle the most common appear stoic and medical and nursing staffs life-threatening obstetrical and surgical emergen- may either not have treatments to offer or may cies in Sierra Leone. Volunteer surgeons, nurses, and believe that pain is a part of the natural history of anesthesiologists do two (2) to six (6) week rota- the disease. tions, giving both didactic and practical training. Tobias et al. [ 67 ] pointed out that premedication The WHO Integrated Management for Emergency is frequently not administered, either intention- Essential Surgical Care program is an essential ally not given or forgotten. However, particularly component of the training. Collaboration with in diffi cult cultural situations, premedication may other NGO facilities is encouraged. Furthermore, be highly desirable. CapaCare has a timeline to evaluate costs in 2014 Local anesthesia, while not always the ideal and quality in 2015. This program includes all technique, may be the only option in certain cir- essential elements of a sustainable program that cumstances until anesthesia providers become will be cost-effective. more readily available. In extreme situations, even a C-section can be performed under local anesthesia [68 ]. Hemorrhoidectomies [69 ] and Innovations in Anesthetic urethrotomies [70 ] have also been performed suc- Techniques cessfully under local anesthesia, perhaps as much a testament to the surgical skill of the providers as In addition to improving training and access to to the fortitude of the patients. anesthesia providers and availability of anesthetic Ketamine [71 ] has been an invaluable agent in equipment, anesthetic techniques must be adapted LMICs. It offers multiple routes of administration to particular situations in LMICs. Ideally, patients (intravenous, intramuscular, oral, rectal, subcuta- in these locations will ultimately be afforded the neous, epidural, and transnasal routes) and its same anesthetic choices that patients in HICs ability to function as a preoperative sedative, receive. However, that is to ignore the current intraoperative anesthetic, and a postoperative situation. Surgeons and those who have adminis- analgesic is unique. Moreover, it preserves car- tered anesthesia in LMICs historically have relied diorespiratory function, a critical asset in regions quite heavily on both local anesthesia and seda- without reliable infrastructure for cardiopulmo- tion for pain relief. Vo et al. [28 ] found that nary resuscitation. regional anesthesia was offered by 56 % of facili- Spinal anesthesia is not used as frequently as ties surveyed, spinal anesthesia was offered by it could be, primarily due to limitations in avail- 65.5 %, ketamine by 71.5 %, and general inhala- ability of medications and equipment, especially tional anesthesia was offered by 58.5 %. spinal needles [36 ]. In addition, heretofore, train- The concept of pain—both chronic and also ing in regional has not been emphasized. acute surgical—has signifi cant cultural overtones and suffers from social constructs. In an editorial entitled, “Pain Management in Low and Middle Improvements in Basic Income Countries—Just Put Up With It?,” Infrastructure and Equipment Goucke and Morris [ 65] note that nociception from the periphery to the brain is the same in all The provision of safe surgery and anesthesia in humans, irrespective of where they live. There LMICs is limited by the fact that a signifi cant are innumerable benefi ts that accrue with treat- proportion of operating suites do not have reliable ment of surgical and chronic pain, including early sources of fresh water, electricity, or technicians mobilization, ability to self-care, and quicker to maintain equipment. Most modern surgical 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 53 equipment assumes the existence of such water for drinking, sanitation, and surgical infrastructure to run operating rooms. However, procedures. The total budget for the project was advances to overcome gaps in LMICs’ infrastruc- $61,266. Before the project, the hospital was tures are being made. buying at least three truckloads of water per week at $90 per truckload. Since the implementation, no disruptions in healthcare delivery because of Electricity and Water lack of water have occurred.

In the instance of electricity, there are a number of innovations that use alternative energy. One Oxygen such example is We Care Solar’s [72 ] “solar suit- case” which provides reliable DC electricity for The hospital choice between relying on tank oxy- any kind of environment where access to power gen or oxygen concentrators is also illustrative of is critical but unavailable. It is self-contained and how dependent decisions are upon external factors comes with everything needed to provide instan- such as road quality. To deliver oxygen to a patient taneous power right out of the box. Current pric- from an oxygen cylinder, the hospital must have a ing is $1,495 and for $1,595, a fetal Doppler is vehicle to get the cylinder, fuel for the vehicle, included. roads that can support the vehicle, a factory Other innovations include devices that use little (reasonably close by) that produces the oxygen to electrical energy. For instance, students at the fi ll the cylinder, and, of course, the money to University of Utah [ 73 ] have also developed a sur- acquire the tanked source. Largely because of a gical light that uses LED lights, a simple metal lack of public infrastructure, as much as 75 % of the frame, and a battery backup. At present, this device developing world has no oxygen supply, relying can produce 70 % of the light recommended by on oxygen concentrators. international standards for illumination in operat- However, in all resource-poor countries, inter- ing suites and the inventors believe that 100 % of ruption of supply occurs. In a WHO analysis [76 ], recommended levels is achievable. Another exam- it was suggested that if power is reliable, oxygen ple is the solar-powered autoclave. Resources dedi- concentrators are preferable while if the power cated to sterilization of surgical equipment are supply cannot be made reliable and if road trans- often scarce or in repair in LMICs. Solar-powered port is reliable, tank supplies are advantageous. autoclaves, which can be cost- effective, can help fi ll this need until a more developed and reliable electrical infrastructure is created. Medical Equipment In the case of water, sometimes distilled or deionized forms must be available. In small The WHO has estimated that 50–80 % of medical quantities, specialized water is not an obstacle. equipment in LMICs is out of service [ 77 ] while However, continuous sources are not typically another study suggests that the fi gure is closer to available. The lack of water [ 74] is often associ- 40 % [ 97]. In comparison in HICs less than 1 % ated with a lack of public infrastructure such as of medical equipment is out of service [78 ]. In a good roads, because in many cases, all water to comprehensive document, the Tropical Health remote locations is distributed via household ser- and Education Trust (THET) [79 ] reviews the vice, vehicle, truck, or bottled water. In addition, complex decisions associated with the donation to demonstrate how relatively inexpensive water of medical equipment to LMICs. can be provided for a hospital, a Canadian-Forces • Deciding whether to donate. led project to build three water tanks was com- • Planning the donation. pleted at HEAL Africa’s tertiary hospital in • Supplying the equipment. Goma, DRC [75 ] in August 2010. The tanks • Verifying the equipment’s quality and safety. ensure the hospital has a reliable source of clean • Storing packing and shipping. 54 S.D. Boggs and N.W. Chee

• Receiving the equipment. of the Surgical Safety Checklist worldwide, death • Putting the equipment into service. rates could be lowered by 50 % [24 ]. • Providing ongoing maintenance. It does the recipient country no good to receive equipment that it cannot maintain, either due to Anesthesia Machines budgetary, personnel, or procurement reasons. In addition, there is the added challenge that equip- As noted previously, signiﬁ cant amounts of ment may come from various sources, resulting equipment that have been donated to LMICs are in unusual mixes of types. Additionally, lack of hard to service, more complicated, and fragile training may make it impossible for anesthesia than required, with parts that are difﬁ cult and care providers to know how to use the equipment. costly to obtain. With the variety of material Health Partners International has created a, “How donated, even highly trained biomedical engi- to Manage,” series on all of the management neers in HI countries would be challenged to issues involved in Healthcare Technology [80 ]. maintain all the machines. These guides cover the topics: Gradian Health Systems has confronted this Guide 1: How to Organize a System of Healthcare problem and developed the Universal Technology Management. Anesthesia Machine. Dr. Paul Fenton had the Guide 2: How to Plan and Budget for Healthcare initial concept and currently the machine has Technology. the following advantages for use in challenging Guide 3: How to Procure and Commission your environments [82 ]: Healthcare Technology. • Integrated oxygen concentrator delivers 10 l/

Guide 4: How to Operate your Healthcare min of 95 % O 2 . Technology Effectively and Safely. • Compatible with cylinder, pipeline, and por- Guide 5: How to Organize the Maintenance of table oxygen as backup sources. your Healthcare Technology. • Accepts all standard pediatric and adult Guide 6: How to Manage the Finances of your breathing systems connections. Healthcare Technology Management Team. • Seamless transition to draw-over mode using

This group recognizes that human resources room air during power outages and O 2 and management are essential in strengthening shortages. health systems, and also that the planning for and • Accurate, low resistance draw-over vaporizers managing of assets are critical. Included also are work without compressed gas. health equipment, utilities, buildings, and other • Calibrated delivery of isoﬂ urane or halothane.

ﬁ xed assets. • Built-in oxygen monitor displays O 2 concentration of inspired gas and warns of hypoxic mixtures. Pulse Oximeters • Nitrous oxide can be used optionally and automatically shuts off if hypoxic mixture is Over 77,000 operating rooms worldwide operate detected. without pulse oximeters, technology that is man- • Hand-operated bellows allows ventilation datory in HI countries. The number of operating without electric power or compressed gas. theatres working without pulse oximetry ranges Diamedica also produces a similar machine from 41 % in Latin America [81 ] to 49 % in south that is functional in extremely challenging envi- Asia, to 70 % in Sub-Saharan Africa. Lifebox, a ronments [83 ]. This company produces a variety registered charity founded in 2004 by WFSA, of portable anesthesia machines that can function HSPH, and AAGBI, conducted studies that indi- with or without electricity. These examples illus- cated that by closing the gap in pulse oximeter trate the rethinking that is occurring in the devel- availability and use and by also increasing the use opment of medical equipment for LMICs. 4 Anesthesia Disparities Between High-Income Countries and Low- and Middle-Income… 55

While many of these innovations are signifi cant where the entire population lives to an advanced individual achievements, the cost- effectiveness age, free of disease and disability. of these technologies has not been fully evalu- DALYs for a disease or health condition are ated. In the end, much more infrastructural devel- calculated as the sum of the Years of Life Lost opment will be required before healthcare centers (YLL) due to premature mortality in the popula- in LMICs can fully use the available medical and tion and the Years Lost due to Disability (YLD) surgical devices found in HICs. for people living with the health condition or its consequences: Calculation: Concluding Statement DALY=+ YLL YLD The current status of anesthetic care in LMICs The YLL basically correspond to the number of is truly representative of the conundrum of deaths multiplied by the standard life expectancy whether the glass is half empty or half full. As at the age at which death occurs. The basic for- noted, there has been substantial progress in mula for YLL (without yet including other social meeting many of the UN Millennium preferences discussed below) is the following for Development Goals. Now that the issues of the a given cause, age, and sex: Global Burden of Surgical Disease are rising in YLL =ŃL the public consciousness and are starting to be addressed, there is cause for hope that resources where: required for improving anesthetic care world- N = number of deaths. wide can occur. L = standard life expectancy at age of death in This will require increases in funding, equip- years. ment specifi cally developed for LMIC situations, Because YLL measure the incident stream of anesthetic techniques appropriate to the practice lost years of life due to deaths, an incidence per- settings, and increased training of personnel for spective has also been taken for the calculation of the administration of these anesthetics. It may YLD in the original Global Burden of Disease prove to be cost-prohibitive and even unneces- Study for year 1990 and in subsequent WHO sary to transplant HIC models of anesthetic updates for years 2000–2004. administration into LMIC situations. Hybrid To estimate YLD for a particular cause in a practice models may need to be developed to particular time period, the number of incident ensure that all patients are afforded anesthetic cases in that period is multiplied by the average care in a timely manner, without cannibalizing duration of the disease and a weight factor that needed personnel from the nursing or medical refl ects the severity of the disease on a scale from professions. In addition, strategies need to be cre- 0 (perfect health) to 1 (dead). The basic formula ated to induce practitioners to remain in their for YLD is the following (again, without apply- communities. ing social preferences):

YLD =ÍDWL ´ Appendix: How to Calculate a DALY where: I = number of incident cases. Defi nition: One DALY (disability adjusted life DW = disability weight. years) can be thought of as one lost year of L = average duration of the case until remission or “healthy” life. The sum of these DALYs across death (years). the population, or the burden of disease, can be Prevalence YLD. thought of as a measurement of the gap between The recent GBD 2010 study published by current health status and an ideal health situation IHME in December 2012 used an updated life 56 S.D. Boggs and N.W. Chee expectancy standard for the calculation of YLL 13. World Bank. How we classify countries. http://data. and based the YLD calculation on prevalence worldbank.org/about/country-classifications . Accessed 20 Mar 2014. rather than incidence: 14. CMS.GOV. 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Medge Owen and Helen Akinc

Introduction Planning a Mission

Global health work can be many different things; Selecting and Assessing a Site exciting, frustrating, time-consuming, inspiring, life changing, however, one thing is certain, it is Selecting and assessing a site is an important initial never boring. There are many important consid- consideration that highly inﬂ uences the success erations when one goes about planning and exe- of a program. Individuals or organizations must cuting a medical or surgical mission. Building carefully ponder the political stability of the pro- the right relationships and executing a successful posed country, priorities within the country, the program can positively impact many lives, so get- state of the medical infrastructure, the presence ting it right is important. A poorly planned or of a local champion, language barriers, readiness executed program can negatively impact both par- for change among local practitioners, and overlap ticipants as well as country hosts. The goal of this with work already under way by other organiza- chapter is to lay the foundation for developing and tions or individuals [1 – 3 ]. executing a successful global health program Site selection begins with a dialogue with a host through planning a mission, fundraising, and country contact, usually a physician. Global health building a team. and medical meetings such as the World Congress of Anesthesiology (WCA) are excellent venues through which to meet and network with medical providers from other countries. The WCA is held every 4 years, and a schedule can be found on the website for the World Federation of Societies of Anaesthesiologists ( www.anaesthesiologists.org ). Many interesting panels and poster presentations highlight disparities and challenges that exist in providing anesthesia and surgical care across the M. Owen , M.D. (*) world. When trying to understand the various needs Wake Forest University , Winston-Salem , NC , USA that exist, it is important to start from the local Kybele, Inc. , Winston-Salem , NC, USA host’s perspective. e-mail: [email protected] Once communication begins, if goals between H. Akinc , M.B.A. the visiting and host organization are compatible NavyBrat LLC , Winston-Salem , NC , USA and mutually beneﬁ cial, an invitation may be

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 59 DOI 10.1007/978-3-319-09423-6_5, © Springer International Publishing Switzerland 2015 60 M. Owen and H. Akinc extended for a site visit to the host country. administrative duties or upcoming retirement. It is Ideally, this should occur at least 9–12 months very important, however, for senior colleagues to before arriving with a team. A site visit can conceptually buy into the program, as they can involve a few individuals, identifi ed as potential become stumbling blocks if they are excluded. program organizers, who travel to the prospective One example of a local champion success country in order to build relationships with medi- story is that of Croatian anesthesiologist Dr. cal personnel and conduct a needs assessment Dragica Kopic. One of the authors (MO) was [1 ]. It is helpful for the visiting physicians to speaking at a medical conference in Croatia and closely align with the host physician to better met Dr. Kopic. She was bright, energetic, and understand his or her goals for partnership. It is interested in learning about obstetric anesthesia also important to observe the conditions and but had little experience. Dr. Owen visited her medical practices that exist within several hospi- local hospital and made numerous observations. tals to develop a broader understanding of the Over the next few months, they continued to medical landscape. Figure 5.1 provides an exam- communicate via email. They conducted a survey ple of an assessment form developed and used by of obstetric anesthesia practices in Croatia and Kybele, Inc., a 501(c)(3) organization that profound a limited use of regional anesthesia tech- motes childbirth safety worldwide through edu- niques. Dr. Owen invited her to present her fi nd- cational partnerships ( www.kybeleworldwide.org ). ings at the Society for Obstetric Anesthesia and While largely focused on obstetrics, obstetric Perinatology’s annual meeting [ 7] and sponsored anesthesia and newborn care, this assessment can her visit. Dr. Kopic also spent several weeks be tailored to other surgical disciplines. Excellent observing obstetric anesthesia patient care prac- considerations for pediatric-focused surgical pro- tices at Wake Forest and Duke Universities. Once grams have been summarized by Fisher et al. [4 ] inspired, her accomplishments were nothing and Schneider et al. [5 ]. Another screening tool short of remarkable. Within the year of her visit, has been developed by The WHO Global she introduced into her university hospital the use Initiative on Emergency and Essential Surgery of regional anesthesia techniques for labor and Care (GIEESC), known as the Tool for Situational cesarean section. Prior to this, most patients Analysis for Emergency and Essential Surgical either had no labor pain relief or general anesthe- Care [6 ]. sia for cesarean section. She initiated monthly During the site visit, one should assess and childbirth education classes for prospective par- weigh the competence, infl uence, and leadership ents (Fig. 5.2 ). She raised funds to renovate and potential of the country host, otherwise deemed establish two special labor and delivery rooms— “the local champion.” This individual will be piv- deemed “apartments” in Croatian—to allow a otal to the overall success of the program and will family member to attend the birth, which was assist with many elements of planning. A local previously not permitted. She organized a fi ve- champion paves the way for understanding local member obstetric anesthesia team among her col- requirements, medical licensure, bureaucracy, leagues and appeared on local television to legal issues, culture, and lays the groundwork for discuss the merits of epidural analgesia for child- the program to be successful and well received. He birth. Other hospitals in her region heard about or she must be hardworking and collaborative, her and started asking for help. To address the with a positive demeanor, and capable of infl uenc- growing interest, Drs. Medge Owen and Margaret ing change within their countries. A “local cham- Sedensky, University of Washington, recruited a pion” is usually someone not too junior or senior. 14-member internationally based team of obstet- Young, junior colleagues lack clout within their ric anesthesiologists, a midwife, and an obstetric healthcare systems and often can’t infl uence internist to travel to Croatia in September 2005 change due to hierarchal barriers. Senior col- to work within nine university hospitals through- leagues may not have the drive or interest to out the country promoting the use of regional undertake a time-consuming collaboration due to anesthesia for obstetric care (Fig. 5.3 ) [8 ]. 5 Planning a Mission, Fundraising, and Building a Team 61

Fig. 5.1 Site assessment form example. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc 62 M. Owen and H. Akinc

Fig. 5.1 (continued) 5 Planning a Mission, Fundraising, and Building a Team 63

Fig. 5.1 (continued) 64 M. Owen and H. Akinc

Fig. 5.1 (continued)

Fig. 5.2 Photo courtesy of Kybele, Inc. Dr. Dragica Kopic leads a family centered educational forum on options for labor pain relief in Split, Croatia

Focusing on countries with established anes- eager to perform new techniques. The sites thesiology training programs is cost-efﬁ cient and selected should have an adequate healthcare achieves broad impact because, upon graduation infrastructure of supplies, even if there are limita- and job placement, young doctors can dissemi- tions. Having to continuously bring equipment, nate and promote new skills across a country [8 ]. medication, and supplies creates a culture of Physicians in training are also quick learners and dependency, which cannot be sustained. It is far 5 Planning a Mission, Fundraising, and Building a Team 65

Fig. 5.3 Photo courtesy of Kybele, Inc. Australian anesthesiologist, Dr. Amanda Baric (kneeling front left), with colleagues at Sisak University Hospital, Croatia more useful to provide education to better use the supplies already possessed and to develop internal supply chains through advocacy. This approach may limit projects in some of the poorest countries but unless a country has an established healthcare infrastructure it is unlikely that improvements can be sustained. To illustrate, Kybele conducted a program in the Republic of Georgia from 2006 to 2009 to encourage the use of regional anesthesia techniques for labor analgesia and cesarean section [ 9]. At the outset of the program, 10 % lidocaine was the only available local anesthetic and regional anesthesia was Fig. 5.4 Photo courtesy of Kybele, Inc. Grateful patient seldom used. Kybele sought permission from with labor analgesia in the Republic of Georgia with Kybele and local medical team Ministry of Health offi cials initially to bring bupivacaine, ephedrine, and other supplies into the country for teaching demonstrations. Local to bring in supplies, the vast improvements may physicians saw the immediate benefi t of regional have never materialized. anesthesia techniques (Fig. 5.4) and joint advocacy persuaded the Health Ministry to include these medications on the national formulary. As a Pre-trip Planning result, regional anesthesia techniques signifi cantly increased, supply chains improved, and costs for Once a site has been vetted and the decision to go epidural kits and spinal needles decreased across has been made, pre-trip planning takes center the country [9 ]. Had Kybele operatives continued stage. A project should be designed with input 66 M. Owen and H. Akinc from the host physician to fi t the specifi c needs of research is done, how much vetting of partici- the country [1 , 10 ]. Often, the host physician net- pants, and how well prepared the team leader works with other colleagues to determine interest thinks the group is, there will always be surprises. within one or among multiple potential hospital Flexibility, calmness under pressure, and sites. Goals of the trip, the number of partici- resourcefulness are important qualities of all par- pants, and required medical skill sets need to be ticipants. While on the trip, participants may planned in advance [11 ]. The local host can need to be reminded that they are representatives arrange housing, local transportation, and obtain of the coordinating organization or institution, permission for visitation and licensure for visi- and as such, need to exercise professionalism and tors. Figure 5.5 delineates the general responsi- cultural sensitivity. Particularly on a medical bilities for a local host, team leader, and mission trip, the work can be intense and emo- participants in advance of the trip. tionally draining. It is important for trip leaders Trips are often coordinated by one or two to assess the individual members participating team leaders. These are individuals who have and provide assistance when needed, to help demonstrated leadership, fl exibility, good judg- someone understand a diffi cult situation. A comment, intercultural competency, and strong inter- mon practice is to have a session in the evening personal skills along with the requisite traits of where people can recount the events of the day superb clinical skills, strong work ethic, and hon- and air any particular situations, concerns, or suc- esty. The team leader or leaders build the team, cesses. This session also helps to more fully make sure team members are prepared, and han- understand a participant, which is very useful for dle problems as they arise during the trip. An ori- identifying future team leaders and assessing the entation packet should be sent to the trip fi t of a particular individual for a specifi c role in participants approximately 3–4 months prior to possible future trips. Planning a sight-seeing out- departure. This should contain requirements ing at some point during the trip is fun, culturally regarding visas, immunizations, medications, enriching, and promotes team building (Fig. 5.9 ). and suggestions for travel, what to pack and While not to detract from the medical work at much more. See Fig. 5.6 for the suggested con- hand, this can give participants a needed break tents of a pre-trip orientation packet. and a time to relax and refl ect [1 ]. When entering a new hospital environment, participants are generally eager to jump right in Trip Execution and get started. Team members should be instructed to avoid this temptation, unless work- Once in-country, an introductory team meeting ing with Operation Smile or other such organiza- should be planned to outline the goals of the trip, tions where this type of schedule is expected. roles of participants, and for team members to Regardless of the sponsoring organization, it is become acquainted. Orientation should be pro- important to take the time to observe and to build vided to the team that focuses on the host country relationships with the local staff. In some cul- culture, particularly as it relates to the practice of tures proper introductions to administration and medicine, the role of doctors, nurses, and patients. hospital leadership are a prerequisite. Learn the Please see Fig. 5.7 for an example of an in- names of colleagues and try to understand the country orientation session that has been given local way of doing things. Western attitudes of by Kybele. superiority or “our way is the best way” should The actual trip itself will often present with be avoided. It is important to realize that an unexpected glitches and surprises, both good and approach from an institution abroad is not always bad. It is appropriate to follow the “Traveler’s 10 the right one for the local environment and there Commandments” (Fig. 5.8 ) and keep things can be negative ramifi cations. Think through lighthearted. No matter how much pre-trip situations carefully and make sure any technique 5 Planning a Mission, Fundraising, and Building a Team 67

Fig. 5.5 Roles and responsibilities. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. 68 M. Owen and H. Akinc

Fig. 5.5 (continued)

being introduced won’t introduce unnecessary Media Opportunities expense or potential harm [1 , 10]. Try to fi nd creative solutions to local problems through part- One needs to be prepared should the program nership. Neither side has all the answers and become a focus of media attention. This came mutual understanding can yield the best, innova- somewhat unexpectedly during Kybele’s fi rst tive results [12 , 13]. When building capacity, team excursion to Turkey. Eight obstetric anes- doing it the right way will undoubtedly take thesiologists visited ten teaching hospitals across longer, but the outcomes are more likely to be the country and within 1 week; the program sustained. landed on the front page of a major national As such, teaching must be appropriately tai- newspaper with a circulation in the millions. This lored to the setting [10 ]. Bring along a variety of led the fi rst televised birth, a cesarean section handouts and power point presentations because with regional anesthesia, live on prime time visitors may be asked to make presentations national television (excerpts can be viewed at without much advance notice (Fig. 5.10 ). Having www.kybeleworldwide.org ). This demonstrates a laptop is useful but be careful interchanging that improving medical care and healthcare stan- data across external memory devices as virus dards are important to the community at large, protection is often suboptimal. Bringing a text- not just to those behind hospital walls. In fact, book or two is also an appreciated gesture that nearly every program Kybele has conducted has can help for last minute lecture preparation and received print and television coverage (Fig. 5.12 ), then be donated to the hospital. If doing clinical so it is important to hone your message and be demonstrations, it is wise to bring familiar items prepared [14 ]. such as epidural or spinal kits because one Working with the media can help you spread doesn’t want to fumble around with unfamiliar an important message but there are a few things supplies and local staff are interested in seeing to remember when dealing with reporters. They what is commonly used back home (Fig. 5.11 ) are not medical experts and they have tight dead- [ 9]. Be sure that appropriate permission is granted lines. With this in mind, present the most relevant by authorities to bring medication and supplies information in simple terms and explain why it into the country, or contents may be seized at matters. Stick with two to three points and think the border [ 1 , 9]. Furthermore, it is nice to bring about the best ways to present these points. Keep small gifts for those who make the stay special, things easy to understand, interesting, and use as well as departmental leaders. It doesn’t need vivid examples that will stick in people’s minds. to be expensive and can represent someone’s Practice out loud to make the message short and hometown. succinct. In conversation and storytelling, it is 5 Planning a Mission, Fundraising, and Building a Team 69

Fig. 5.6 Pre-trip orientation. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. 70 M. Owen and H. Akinc

Fig. 5.6 (continued)

Fig. 5.7 In-country orientation. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. 5 Planning a Mission, Fundraising, and Building a Team 71

Fig. 5.8 Traveler’s ten commandments

Fig. 5.9 Photo courtesy of Kybele, Inc. Kybele team visits a local gere in Mongolia

easy to let a story build to the climax, giving the central message. Show passion and excitement, most important information last. Reporters, how- speak slowly and clearly, especially in dealing ever, want the impact ﬁ rst. It is important not to with language barriers. Finally, thank the inter- ramble as things can get off track. If that happens, viewer for their interest in spreading a message one must steer the interview back around to the that matters. Provide your contact information and 72 M. Owen and H. Akinc

Fig. 5.10 Photo courtesy of Kybele, Inc. Dr. Holly Muir, Duke University Medical Center, engages in a small group tutorial in Ghana

Fig. 5.11 Photo courtesy of Kybele, Inc. Dr. Virgil Fig. 5.12 Photo courtesy of Kybele, Inc. Dr. Simon Manica, TUFTS University, conducts a bedside teaching Miller, British anesthesiologist, being interviewed by the demonstration in the Republic of Georgia press in Armenia offer feedback and follow-up, if time allows. Ask takes one misplaced or well-intentioned but inac- where and when the interview will be released curate comment from a participant in a trip report and try to get a copy of the news piece. to threaten years of carefully developed relationships. It is common for participants to experience forms of culture shock when returning home. The Post-trip Follow-Up and Evaluation experience abroad will have likely been emotionally stirring and meaningful, one that colleagues, Following the trip, it is important for team mem- friends, or family may have limited ability to bers to communicate observations, impressions, understand. Written reports and presentations and reﬂ ect back on the trip as a whole. Be careful within home institutions are encouraged to help with reports, however, to make sure that feedback process what one has encountered. Assessments is properly channeled to the trip leader for review of the team members, both peer review and those and synthesis. Anything that is shared with the of the trip leader, are informative and important local host must be properly screened. It only (Fig. 5.13 ). The trip leader should gather all 5 Planning a Mission, Fundraising, and Building a Team 73

Fig. 5.13 Team member assessment. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. 74 M. Owen and H. Akinc

Fig. 5.14 Team leader report. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. information and generate a formal trip report that work in a different setting (Fig. 5.16 ). This cre- provides an overview of the entire program. ates a balanced sense of partnership and helps Figure 5.14 is a template for the team leader keep the communication lines open and strong. report, which can be as short or as long as desired, For lasting change to emerge, the motivation to as long as the questions are addressed. Host sites change and to maintain that change must con- also need the opportunity to formally evaluate the stantly be strengthened. The belief in self- quality of the program. An example of a host directed change is highly cultural, and in some country assessment can be found in Fig. 5.15 . cases, the sponsoring organization is working It is important to have ongoing, frequent com- against strongly held cultural beliefs that self- munication with the host country physicians directed change is impossible. Seeing a system or while the program is in place. Assuming that at technique work fi rst hand solidifi es the concept. some level, the goal of the program is to bring about change, to sustain that change requires attention, reinforcement, and maintaining the Ethical and Legal Considerations motivation to change. There are many ways to do this. At Kybele, team leaders and country hosts It is important to manage the medical volunteers communicate frequently via email and Skype in such a way that the patient always comes fi rst telecommunication. Kybele has found that and that his/her personal information is protected. including articles about host country leaders and Determining who should be taught, and which others in electronic newsletters and news fl ashes skill sets and techniques should be taught, is a generates pride and a sense of accomplishment consideration, especially when working with within the host country. It is important to try to individuals having less formal education and invite those identifi ed as being strong host coun- training than those performing the techniques try leaders to visit the participant’s hospitals to back home (Fig. 5.17 ) [10 , 15 , 16 ]. Safety is the learn how the techniques they are being taught fi rst and foremost priority. Informed consent 5 Planning a Mission, Fundraising, and Building a Team 75

Fig. 5.15 Host country report. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. 76 M. Owen and H. Akinc

Fig. 5.15 (continued)

authors, getting liability insurance and malpractice insurance for all of the medical volunteers is usually not necessary or practical. Generally, with proper screening of participants, serious adverse events will be minimized. It is however advisable to obtain medical credentials of all participants, health and emergency contact information, and letters of recommendation. The local hosts should be made aware of any plans for resident physicians to be part of the visiting team (Fig. 5.18 ). They should only participate if it is mutually agreed to be benefi cial and they must be accompanied by supervising credentialed physicians as Fig. 5.16 Photo courtesy of Kybele, Inc. Midwives from per standards in developed countries [1 ]. Ghana observe obstetric care at Forsyth Medical Center, To protect a nonprofi t or other similar spon- Winston-Salem, NC during an invited visit soring organizations, insurance can be obtained to protect their offi cers and boards of directors. Some policies even provide ransom payments in from the patient is essential prior to any procedure the event a participant is kidnapped while work- and should be conducted in the patient’s language ing within the host country. In addition, many and with respect to cultural and ethical beliefs organizations require that volunteers sign a [1 ]. Photographs at a bare minimum require per- waiver, releasing the organization from any liabil- mission of those being photographed and a rec- ity that arises from the volunteers’ participation ognition that standards of decorum vary greatly on a trip. If the individual refuses to sign the docu- from culture to culture. As a general rule, partici- ment, the person is denied a spot on the team. It is pants should be advised to simply observe, listen, wise for sponsoring organizations to require that and build rapport during the initial phases of participants purchase supplemental emergency work. Photography is not the fi rst priority and medical evacuation insurance. A simple internet medical tourism should be avoided. search will reveal that there are many companies It is diffi cult to identify every single legal that provide this for a nominal fee. With so many issue that could possibly arise while doing work ethical and cultural considerations, it is impossi- overseas. Many cultures are not as litigious as the ble to delineate policies that will govern every United States, but there can still be issues or conceivable situation, but with care and common medical complications. In the experience of the sense, risk can be minimized. 5 Planning a Mission, Fundraising, and Building a Team 77

Fig. 5.17 Photo courtesy of Kybele, Inc. Dr. Michael Rieker, CRNA, instructs nurse anesthesia students at Ridge Regional Hospital, Accra, Ghana

Fig. 5.18 Photo courtesy of Kybele, Inc. Dr. Brittany Clyne, obstetric anesthesia fellow, lectures at Uludag University, Bursa, Turkey

Research during a trip. Normally data will be the property of the nonproﬁ t or sponsoring organization. This Experimental procedures should not be performed may need to be explicitly stated in preparatory on surgical missions [1 ]. Any research involving trip documents. Both the sponsoring organization human subjects or record review needs institu- and hosts should be aware of and approve any- tional review board approval from both sponsor- thing presented or published in a public domain. ing institutions as well as host sites (Fig. 5.19 ). It is preferable to involve the host country princi- There is, by nature of this work, a grey area pals in collaborative research, presentations, and when it comes to who owns the data gathered publications to improve their intellectual capital 78 M. Owen and H. Akinc

meals, local housing, and local transportation. Over the years, Kybele has found that the average cost per person to make a 2-week medical mission trip is $2,000–$2,500. Costs can be covered in a variety of ways. Kybele uses a cost sharing approach whereby volunteers pay for their passport, visa, immunizations, and airfare with the remaining expenses divided between the organization and the local hosts. Having some fi nancial ownership from the local hosts, even if it is small, creates buy-in, because some degree of cost generates a sense of value. There are a myriad of reasons for this; it facilitates acceptance of change, helps alleviate roadblocks, and invests the Fig. 5.19 Photo courtesy of Kybele, Inc. Dr. Medge host in the whole process more completely. It also Owen discusses research collaboration with Dr. Emmanuel Srofenyoh and Erica Ahiapokpor at Ridge Regional gives the organization leverage when asking for Hospital in Accra, Ghana donations in the home country, as it is truthful to say that the local people are invested and materi- ally contributing to the success of the mission. An individual, or group of individuals, may want to start a nonprofi t organization in order to bring about some type of change, support an ideal, or hope to help people, but quickly learn that raising money becomes the central task, at least for a while. In the beginning when one is starting up the nonprofi t there will be expenses, such as getting registered and becoming incorporated. It takes signifi cant time and expertise to complete the required forms and paperwork, which may vary from state to state. That is why it is important to get knowledgeable help and seek expert input from a lawyer and accountant who have experi- Fig. 5.20 Photo courtesy of Kybele, Inc. Kybele team member Dr. Ivan Velickovic and Serbian host Dr. Boraslava ence in nonprofi t work, to facilitate start-up, Pujic present a poster of their work in Serbia at the annual even though the process can still take months. meeting for the Society for Obstetric Anesthesiology and Talk with people who are involved in other non- Perinatology profi ts. Collaboration is a good thing. See Fig. 5.21 for a quick run-down of frequently made and visibility (Fig. 5.20 ). A useful discussion of mistakes to avoid. research considerations in global health has been Once a nonprofi t is established, it is important published by Stephen and Daibes [13 ]. to be judicious and a good steward of the funds received. The organization must be forthright regarding scope, quality, and quantity of the work Fundraising they perform with honest evaluations available regarding how money is spent [1 ]. Many non- There are a number of costs to consider when profi ts struggle and eventually fail due to lack of planning a global health program including pass- funds, so it is not something to be taken lightly. ports, visas, immunizations, prescription medica- Grants, corporate donations, individual donors, tions, air fare, emergency evacuation insurance, fund-raising special events, etc. are all ways to 5 Planning a Mission, Fundraising, and Building a Team 79

Fig. 5.21 Fundraising mistakes to avoid. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc. build a cushion. In the authors’ experience, to Developing a cushion of funds to enable the keep the fi xed costs as low as possible, it is best organization to provide services requires visibility, to utilize volunteers as well as contract employees publicity, and asking for help. Having a sparkling, (who are essentially self-employed and work by up-to-date website is essential. It must be updated the hour). Such a staff—some of whom are paid— on a continuous basis and there should be an easy can handle fi nancial management, grant writing, way for the casual surfer to donate money if he/she event organization, correspondence, trip planning, is moved by the information provided on the site. and communications (newsletter, social media, Brochures are important, particularly when visit- etc.). The paid employees’ hours may increase ing potential donors. Speaking engagements, pre- when needed, but the organization is not paying senting at professional conferences, interviews for time that is not being used. A reliable stream on local television or for newspaper articles of monthly donors in the $10–$100 range will are all ways to get the word out (Fig. 5.22 ). help cover the fi xed costs. To maintain fi duciary The more people know about the organization, responsibility and minimize risk, every nonprofi t the more likely it is to lead to donations which should have an accountant and a lawyer. ultimately improve success. 80 M. Owen and H. Akinc

Fig. 5.22 Photo courtesy of Kybele, Inc. Kybele fundraising event at the Toronto International Film Festival Building in Toronto, Canada during the annual meeting for the Society for Obstetric Anesthesiology and Perinatology

adaptable [11 ]. It is not uncommon for very Building a Team talented individuals to become unraveled or rigid when out of their comfort zone [17 ]. Depending For many participants on medical mission trips, upon the specifi c medical mission, a variety of the motivation to participate is multifaceted. The medical skill sets will be needed (Fig. 5.23 ). Each core human desire to help, to share expertise and has a different role and each has to be able to gifts one has received, and to heal someone in work together. It goes without saying that team need are at the center of many different types of members must be team players. Working in a dif- medical volunteerism. Participating on a medical ferent culture requires that team members have mission trip is also a way to enhance one’s experi- trust, patience, and good communication skills ence, as familiarization with global medicine is because in a medical setting, lives are at stake. important in today’s healthcare landscape and it Poor communication, ego, or power struggles can enhance one’s resume. There are often signifi - should never be the root of adverse medical care. cant research opportunities which are important Cultures differ widely in how they express grati- in building an academic career. Others love travel tude, criticism, respect, and power in ways that and crave adventure. Still others have deep rooted may not be easily understood by someone from religious convictions at the core. These are some another culture. Developing cultural competence of the motivations that typically lead individuals results in an ability to understand, communicate to participate, although there are undoubtedly with, and effectively interact with people across other reasons. cultures [18 ]. While not everyone on the team How does one go about building a successful will have equal cultural competence, everyone global health team when team members them- can and should be understanding and respectful selves may come from diverse medical back- of fellow team members and host country profes- grounds, institutions, and/or countries? The answer sionals. Never criticize individuals or medical lies in fi nding individuals that are competent and practices openly or publically. When in doubt, experienced in their disciplines, yet fl exible and ask questions. Also, never assume that everyone 5 Planning a Mission, Fundraising, and Building a Team 81 understands what is happening in a given encounter. same host country, along with new, fi rst-timers. If something doesn’t make sense or seems off, The team members who have participated on that is the time to discretely ask questions and try prior trips to the same area will know the people, to understand what is meant. When good prepa- the way things work, and can help new team ration assures that everyone on the team is com- members adapt. Plus, the more experienced team petent and skilled, then professionals should be members have a track record and the team leader allowed some leeway if using slightly different will know their strengths and weaknesses, par- approaches. ticularly if a formalized assessment tool is used Language barriers can pose problems in global to evaluate members at the end of the trip. It is contexts. It is important to have people on the important to bring new participants in order to team who are medically conversant in the target get new insights, and to be on the lookout for new language or to make certain that there are skilled talent and leadership. An ongoing global health translators on hand. Undoubtedly some doctors program should expand and grow and bringing in the host country will probably speak English; new people is part of that process. however, it is very important for visiting team Building a diverse team is also a great way to members to speak slowly and use simple lan- strengthen home relationships with colleagues at guage to communicate. It also helps to write work, acquaintances at other institutions, and things down while speaking because many will even other NGOs. By broadening the base from read English but may miss the point during con- where team members are recruited, it also gets versation. Another component to a successful the message out about a program or global health team is to blend team members who have been on organization and increases its visibility. Building previous medical missions, particularly in the a team can also refer to the people who keep a

Fig. 5.23 Photo courtesy of Kybele, Inc. Each volunteer of Einstein College of Medicine in New York teach an brings a particular skill set that can be used to achieve the ultrasound course on newly donated equipment in Ghana. mission’s goals. ( a ) Dr. Mandisa Jones-Haywood of Wake ( c ) Dr. Mandisa Jones-Haywood of Wake Forest Forest University teaches monitoring in Ghana. (b ) Dr. University teaches a course in CPR in Ghana Maria Small of Duke University and Dr. Kafui Demasio 82 M. Owen and H. Akinc

Fig. 5.23 (continued) program or organization running on a daily basis. of the pain I am going to feel. After having the Typically, there will be employees, staff members, epidural, I am convinced that it helped me and or volunteers who take care of daily operations. eased my baby’s way into this world. It helped It takes special people and careful planning to me to live the most beautiful event of my life with assemble a global health team that works. The enough strength to fully enjoy in it. Finally, I was time and effort spent, however, can be immensely lucky to have the competent and humane anes- rewarding when a program is planned well and thesiologist who was there for me, and whom I executed for success (Fig. 5.24 ). felt was my sister to be with me and my son there.” In the sentiment of a motivated host: “I’m in touch with my colleagues at the host hospitals Conclusion almost every day. We are preparing epidural protocols which will be introduced in all hospitals. In summary, planning and executing a successful I think that is very important. It is the fi rst time global health mission can improve the lives of that anesthesiologists in my country are working many, including patients, host country physi- together. Can you image that there are no guide- cians, and participants. Simple expressions of lines about any fi eld of anesthesia. I’m trying to gratitude as well as measured positive outcomes change it.” Finally, refl ections of a changed signal that a program has been well conducted. participant: “Thank you so much for including In the words of a grateful patient: “I didn’t want me. The trip was very satisfying—personally and to be alone. I was afraid that something may go professionally—and has given me much momen- wrong and nobody would notice. I was also afraid tum to make this type of development part of my 5 Planning a Mission, Fundraising, and Building a Team 83

Fig. 5.24 Nonproﬁ t organization Keysto success. These document samples are the property of Kybele, Inc. If you use these or any part of these materials in publication, kindly reference that the materials were developed by Kybele, Inc.

career as well. Thank you for doing an amazing 4. Fisher QA, Politis GD, Tobias JD, Proctor LT, Samandari-Stevenson R, Samuels P. Pediatric anes- job setting up the support structures for this and thesia for voluntary services abroad. Anesth Analg. making a difference.” 2002;95:336–50. Dare to dream. Strive to serve. 5. Schneider WJ, Politis GD, Gosain AK, Migliori MR, Cullington JR, Peterson EI, Corlew DS, Wexler AM, Flick R, Van Beek AL. Volunteers in plastic surgery Acknowledgment The authors would like to acknowl- guidelines for providing surgical care for children in edge the hundreds of medical professionals who have vol- the less developed world. Plast Reconstr Surg. 2011; unteered with Kybele. We would like to thank Dr. Joe 127:2477–86. Tobin, chairman, and the department of anesthesiology at 6. Reference for tool for situational analysis: http:// Wake Forest University for support. www.who.int/surgery/publications/ QuickSitAnalysisEESCsurvey.pdf . 7. Kopic D, Owen MD. Survey of obstetric anesthesia References practices in Croatia. Anesthesiology. 2004;100 Suppl 1:A67. 8. Kopic D, Sedensky M, Owen M. The impact of a 1. Schneider WJ, Migliori MR, Gosain AK, Gregory G, teaching program on obstetric anesthesia practices in Flick R. Volunteers in plastic surgery guidelines for Croatia. IJOA. 2009;18:4–9. providing surgical care for children in the less devel- 9. Ninidze N, Bodin S, Ivester T, Councilman L, Clyne oped world: part II. Ethical considerations. Plast B, Owen M. Advancing obstetric anesthesia practices Reconstr Surg. 2011;128:216–22. in Georgia through clinical education and quality 2. Buse K, Harmer AM. Seven habits of highly effective improvement methodologies. Int J Gynecol Obstet. global public-private health partnerships: practice and 2013;120:296–300. potential. Soc Sci Med. 2007;64:259–71. 10. Peters JL, Boakye G, Harris M, Nsiah-Asare A, 3. Petroze RT, Mody GN, Ntaganda E, Calland JF, Antwi-Kusi A, Jabir AR, McAllister B, Hale D. Riviello R, Rwamasirabo E, Ntakiyiruta G, Anesthesia teaching in Ghana: a 10-year experience. Kyamanywa P, Kayibanda E. Collaboration in surgi- Int Anesthesiol Clin. 2010;48(2):23–37. cal capacity development: a report of the inaugural 11. Wong EG, Trelles M, Dominguez L, Gupta S, meeting of the strengthening Rwanda surgery initia- Burnham G, Kushner AL. Surgical skills needed for tive. World J Surg. 2013;37:1500–5. 84 M. Owen and H. Akinc

humanitarian missions in resource-limited settings: 15. Aliu O, Corlew SD, Heisler ME, Pannucci CJ, common operational procedures performed at Chung KC. Building surgical capacity in low- Medecins Sans Frontieres facilities. Surgery. resource countries: a qualitative analysis of task 2014;156:642–9. doi: 10.1016/j.surg.2014.02.002 . shifting from surgeon volunteers’ perspectives. Ann 12. Srofenyoh E, Ivester T, Engmann C, Olufolabi A, Plast Surg. 2014;72:108–12. Bookman L, Owen M. Advancing obstetric and 16. Mellin-Olsen J. Varieties of teaching programs neonatal care in a regional hospital in Ghana via matched to country needs. Int Anesthesiol Clin. 2010; continuous quality improvement. Int J Gynaecol 48(2):9–21. Obstet. 2012;116(1):17–21. 17. Fisher QA, Nichols D, Stewart FC, Finley GA, 13. Stephen C, Daibes I. Deﬁ ning features of the practice Magee WP, Nelson K. Assessing pediatric anesthesia of global health research: an examination of 14 global practices for volunteer medical service abroad. health research teams. Glob Health Action. 2010; Anesthesiology. 2001;95:1315–22. 3:1–9. 18. Campbell A, Sullivan M, Sherman R, Magee WP. The 14. Kwok R. Two minutes to impress. Nature. 2013;494: medical mission and modern cultural competency 137–8. training. J Am Coll Surg. 2011;212(1):124–9. Developing Anesthesia Equipment for Low-Resource Environments 6

Angela Enright

remain unused and neglected when the anesthesia Abbreviations providers are frequently struggling to give anesthetics with minimal resources? This chapter WFSA World Federation of Societies of will review and discuss issues involved in devel- Anaesthesiologists oping safe and appropriate anesthesia equipment LMICs Low- and middle-income countries for such environments. Hz Hertz HICs High-income countries UAM Universal Anaesthesia Machine Anesthesia Resources UPS Uninterruptible power supply ISO International Standards Organization Michael Dobson in his book Anaesthesia at the WHO World Health Organization District Hospital says “good anaesthesia depends AAGBI Association of Anaesthetists of Great much more on the skills, training and standards Britain and Ireland of the anaesthetist than on the availability of HSPH Harvard School of Public Health expensive and complicated equipment.” [ 1 ] All NGOs Nongovernmental organizations anesthesia providers wish to give safe anesthesia V Volt to their patients. However basic infrastructure, taken for granted in wealthy environments, is often not available in economically challenged Introduction areas. This means that special consideration has to be given to the suitability of anesthesia equip- Anyone who has visited an operating room in a ment for such regions. hospital in a resource-poor region will have seen In 2007, Hodges and colleagues studied the anesthesia equipment sitting unused in corridors resources available in Uganda using a specially and store rooms, taking up space and serving as designed questionnaire given to 97 participants at repository for assorted detritus (Fig. 6.1 ). The a Ugandan anesthesia conference [2 ]. The obvious question is why does good equipment response rate was 100 %. The survey requested information on equipment and drugs considered necessary to administer anesthesia to an adult for A. Enright (*) a laparotomy, to a child under 5 years for an Department of Anesthesia , University of British appendectomy, and to a pregnant mother requir- Columbia , Royal Jubilee Hospital , Victoria , BC , Canada ing anesthesia for cesarean section. Only the most e-mail: [email protected] basic equipment was included such as oxygen,

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 85 DOI 10.1007/978-3-319-09423-6_6, © Springer International Publishing Switzerland 2015 86 A. Enright

Fig. 6.1 Anesthesia machine used for storage

suction, pulse oximeter, blood pressure cuff, countries (LMICs) which contained information laryngoscope, endotracheal tube, and essential from 52 hospitals. The results are contained in drugs. Twenty three (23 %) of the respondents Tables 6.1 and 6.2 . had what they required to give safe anesthesia to Electrical problems occur not just due to power an adult; 13 % could give safe anesthesia to the outages but also due to variations in voltage. child and only 6 % could safely give general or A 240 volt (V) mains supply can come in as low spinal anesthesia for the cesarean section. This as 180 V. Most western anesthesia equipment is situation is not unique to Uganda but is reﬂ ected designed to function with only a 5 % variation in in studies from many other countries [3 – 6 ]. voltage above or below the rated level. Dropping Looking at a basic element such as a reliable the voltage by this amount will cause most elec- electricity supply, the World Bank developed trical and electronic equipment to stop working. some key performance indicators for Sub- Equipment that continues to function may over- Saharan Africa [ 7 ]. Factors such as number of heat because the cooling fan runs more slowly. outages per year and capacity of the system were With microprocessors, a fall in mains voltage included. Eastern and Southern Africa were may cause the machine to reboot thus interrupt- doing better than Central and Western Africa in ing function for as long as the reboot takes, often terms of capacity but the number of outages was several minutes. Higher incoming voltages may highly variable from a low of 6 per annum in cause overheating or prompt fuses to blow. South Africa to a high of 407 in Guinea. These Mains frequency presents a bigger problem ﬁ gures are borne out by information from pub- than voltage irregularities. In North America a lished studies [3 , 8 ] and particularly by a study 110 V, 60 Hertz (Hz) system is used, which done by Michael Dobson for the World Federation gives equivalent power to 240 V, 50 Hz but is of Societies of Anaesthesiologists (personal com- safer in relationship to the risks of electric munication). He contacted anesthesia providers shocks. Many poorer countries use 110 V, 50 Hz in 122 countries requesting information on elec- systems. It is virtually impossible to convert trical supply and oxygen availability. Responses 60 Hz equipment to run on 50 Hz mains. were obtained from 23 low- and middle-income Transformers only work on voltage and not on 6 Developing Anesthesia Equipment for Low-Resource Environments 87

Table 6.1 Availability of electricity and oxygen in Africa frequency. Therefore any equipment using an Mains Oxygen Oxygen electric motor will not function for long and, electricity piped cylinder after a few hours, the motor will be irreparably Country TH RH DH TH RH DH TH DH RH damaged. Generating companies with inadequate Botswana F – – G – – G – – mains supply will often reduce the frequency Cameroon F F O F O O P P O which has the effect of reducing power to all Egypt F F P G G O G G G appliances and can result in damage. Kenya P – – G – – G – – Oxygen shortages and cost problems are G P P G O O G F P shared by both large and small hospitals in – G – – G – – – – LMICs. It may not be possible to distribute cyl- F F P G – – G G F inders because of poor road conditions which G – – G – – G – – can deteriorate in rainy conditions. This is par- G – – G – – G – – Nigeria F – – F – – F – – ticularly likely in small, district hospitals. Costs F P P G O O G O O vary from country to country but oxygen sup- P – – O – – G – – plied in cylinders is much more expensive in – F – – G – – G – LMICs than in industrialized countries, often by P – – G – – – – – a factor of ﬁ ve to ten times more [ 9]. Nitrous Rwanda F – – O – – G – – oxide can be ﬁ ve to ten times more expensive per South G G G G G G G G G liter than oxygen. Because big hospitals use Africa large amounts of oxygen, bills are often unpaid G G F G G F – – G and the oxygen supply may be cut off. Some G F P G G F G G G hospitals have been equipped with pipeline sys- G – – G – – – – – tems but many of these do not function because – F – – G – – G – of the lack of trained people to maintain them. Tanzania F F O – – – – – – Using oxygen concentrators can reduce oxygen Tunisia G F F G O O G G P costs by about 60 % [10 ]. Uganda F – – – – – – – – F P – O O O G P P So what is the relevance of this information to anesthesia equipment? In high-income countries Key : G good availability, F fair (usually available), P poor (sometimes available), O unavailable, Dash no data (HICs), anesthesia machines are high-tech work- received, TH tertiary hospital, DH district hospital, RH stations which require a stable electrical platform rural hospital and compressed gases without which they cannot function. They contain sophisticated controls, Table 6.2 Availability of electricity and oxygen in Asia monitoring, and alarm systems and can deliver a Mains Oxygen Oxygen wide range of anesthetics to the patient. In addi- electricity piped cylinder tion, they have complex ventilators which can Country TH DH RH TH DH RH TH DH RH ventilate the lungs of even the sickest patient from India F F P G O O – G F intensive care. But this equipment needs highly Laos G F P G O O G G P trained and skilled biomedical technologists for Myanmar F – – G – – G – – service and maintenance. In the world where elec- Nepal G F P G F P G G G tricity is variable, and compressed gases are rare Philippines G – – G – – – – – or nonexistent, these machines cannot function. G F F G G – G G P Therefore the anesthesia provider must depend on F – – G – – – – – a different type of anesthesia equipment to meet – G – – G – – – – his needs. Unfortunately this fact is either Sri Lanka F F F F O O – G F unknown to, or ignored by, well-meaning donors Vietnam – G – – G – – – – or even purchasing agents in hospitals or minis- Key : G good availability, F fair (usually available), P poor tries of health. Hence the common situation arises (sometimes available), O unavailable, Dash no data received, TH tertiary hospital, DH district hospital, RH of good anesthesia equipment in one environment rural hospital being totally useless in another. 88 A. Enright

has a safety mechanism that would prevent delivery How Do We Address This Issue? of an hypoxic mixture of gases if the oxygen supply failed. Nitrous oxide cannot be delivered In “Innovations,” a quarterly journal published by in the absence of the oxygen monitor. This moni- the Massachusetts Institute of Technology [11 ], tor is electrically powered and has a rechargeable Timothy Prestero describes two approaches to battery backup which should last for 2 h. Both solving design problems: the invention approach UAM and Glostavent® only use cylinders as and the design approach. In the invention backup in the event of a power failure thus reduc- approach, the inventor sees a problem, designs ing costs for the provision of oxygen. technology to fi x the problem, and then goes in The major advantage of both of these machines search of a user who can and will use the technol- is that they can be used for draw-over or ogy. In the design approach, the inventor works continuous- fl ow anesthesia. A draw-over system is with the end user to defi ne the problem and the one where the patient breathes spontaneously solution that will be usable in that context. through a circuit which enables him to “draw” the Prestero notes; “a common failure of defi ning the air through the circuit [1 ] (Fig. 6.2 ). The concen- technology before we have defi ned the user is that tration of oxygen is never less than room air minus the approach puts the burden of adaptation on the the fractional concentration of the inhaled agent. user.” Unfortunately, this is exactly how much The essential requirements of a draw-over anesthesia equipment has evolved. However there system are a low-resistance vaporizer (a draw- are exceptions to this where the designers have over) and tubing which goes from the vaporizer worked with the end users and have themselves to the patient. A one-way valve so that the patient experienced the environments where their equip- does not breathe back into the vaporizer must be ment will be used. The Glostavent ® anesthetic incorporated. Generally there are further addi- machine is one example; the Universal Anaesthesia tions to this basic circuit: reservoir tubing Machine (UAM) is another. upstream of the vaporizer, with an inlet for oxy- Although both of these machines were designed gen, and a self-infl ating bag or bellows, which by different anesthesiologists and engineers, and must be placed downstream of the vaporizer to have some notable differences, they have much in permit manual ventilation of the patient. This is common. Both are robust, easy to use, easy to ser- the simplest and cheapest of anesthesia circuits. vice, and relatively low cost [12 – 14]. Oxygen is It is not perfect as it is a little cumbersome and supplied by an oxygen concentrator which can pro- may not be suitable for small infants although duce oxygen concentrations over 90 %. An oxygen pediatric modifi cations are available. Nevertheless concentrator is a fairly simple apparatus that it is safe, reliable, and does not need compressed requires little servicing and maintenance, and pro- gases. duces oxygen from room air. Because voltage can Both Glostavent® and UAM also permit use of vary greatly, the Glostavent® incorporates an unin- a continuous fl ow system which is used in all terruptible power supply (UPS) unit that can work high-tech anesthesia workstations. There is a with voltage variations as high as 30 %. The UPS is continuous fl ow of carrier gas through the vapor- a microprocessor-controlled battery backup unit, izer. It requires compressed gases especially oxy- able to supply replacement alternating current gen as there is the potential for hypoxia to occur. automatically in the event of the mains power sup- The ability to switch between one method and the ply either being interrupted or being of inadequate other is a major feature of these two machines. quality. Following power failure, the UPS will sup- If compressed oxygen is available, then a ple- ply approximately 20 min of reserve electricity. num system is very nice to use but, if oxygen Different sized UPS units are available to suit bud- supplies are low, then a draw-over system is safe get and circumstances. and simple. The UAM is designed to be able to deliver One of the differences between the Glostavent® nitrous oxide or air as well as oxygen. It therefore and the UAM is the presence of a ventilator on 6 Developing Anesthesia Equipment for Low-Resource Environments 89

Fig. 6.2 Schematic of a draw-over circuit (M. Dobson)

the Glostavent® [12 ]. The Glostavent is gas- driven. anesthesia workstations used in wealthy countries, It can run on compressed air produced by the making them much more affordable for hospitals oxygen concentrator, on oxygen from a cylinder, with very limited budgets. or from a central supply. The volume of driving gas necessary is just one sixth of the minute ventilation. The oxygen used to drive the ventilator is Standards then returned to the breathing system thus increasing economy by using the same gas twice—once There are two types of standards that need to be as a power source and then again as respired gas. addressed in terms of anesthesia provision any- For long cases, it can be tiring ventilating the where in the world—standards for equipment patient by hand so the ventilator is very useful but and standards for anesthesia practice. In 2011 not essential. the International Standards Organization (ISO) These two anesthesia machines meet the cri- issued well thought out standards for anesthetic teria of good design. They are effi cient and machines suitable for low-income countries effective in a low-resource setting. By using [ 15 ]. The importance of these principles is that oxygen concentrators, they reduce the cost of manufacturers now have a value to which they providing oxygen and the organizational system should adhere when producing machines that required to provide it on a continuous basis. can function without electricity or compressed They can be used as draw-over or continuous gases. The ISO standard for high-tech anesthesia fl ow systems depending on the patient and situ- workstations [ 16 ] is not at all appropriate in ational requirements. They need a minimum of these circumstances. ISO is also in process of maintenance which the local team can be read- producing a standard for a draw-over vaporizer ily trained to do. Finally both purchase and (Mr. T. Longman personal communication ISO operating costs are signifi cantly lower than the TR 18835). These highly technical documents 90 A. Enright are most easily understood by engineers. In order specifi cations drawn up for a suitable oximeter. to assist anesthesia providers, the WFSA pro- By the calculations of Funk et al. [22 ], 77,000 duced a document outlining essentials for anes- operating rooms in the world lack pulse oxim- thesia machines for LMICs that was approved by eters. Anesthesia providers in low-income areas the General Assembly of the WFSA (122 coun- would like to have access to this technology. tries) at the World Congress in Buenos Aires in Lifebox Foundation® developed a full-service 2012. An updated version of these recommenda- oximeter, suitable for use in diffi cult circum- tions is now available on the WFSA website. stances and meeting all international standards The second type of standard is for anesthesia [ 23]. The oximeter will function on mains practice. The WFSA published its guidelines in electricity, with rechargeable or disposable 2010 [18 ] and includes recommendations for batteries. education, facilities, drugs, equipment and moni- Cost and education are the main factors reduc- toring, and organization of the profession. Of ing use of equipment in low-resource areas. The particular interest here are the recommendations Lifebox Foundation® ensured that its oximeter for monitoring of patients. There is universal was made available at a very reasonable cost and agreement that the best monitor is the full atten- that it was accompanied by an education pack- tion of a trained anesthesia provider [18 – 20 ]. age. In fact, through the efforts of the Lifebox However all anesthesia providers need the assis- Foundation® more than 8,000 oximeters have tance of appropriate monitoring equipment. been delivered to anesthesia providers in over 90 The WFSA categorizes such equipment into countries [24 ]. Education about oximetry and the highly recommended, i.e., essential, recom- surgical safety checklist has been provided by mended, and suggested. The authors note that Lifebox volunteers in association with the local, highly recommended monitors are the minimum regional, and national anesthesia societies thus requirements for elective surgery even in making the program sustainable. resource-poor settings. In emergency cases, The project has been taken up enthusiastically where life or limb is threatened, it may be accept- by anesthesia societies, both receiving and donat- able to proceed without these monitors. ing, and nongovernmental organizations (NGOs) all over the world because knowledgeable people recognize that the oximeter is designed for use in Oximetry diffi cult conditions, and will continue to function in spite of loss of electricity. Moreover it is One of the highly recommended pieces of moni- available at low cost and thus fi ts Prestero’s rec- toring equipment is a pulse oximeter. This equip- ommendations for design (i.e., it was designed ment came into general use in high-income and manufactured explicitly for the intended countries in the early 1980s. The World Health users). The Glostavent® and Universal Organization (WHO) Surgical Safety Checklist Anesthesia Machines share the same design and requires the presence of a functioning pulse cost benefi ts. oximeter on every patient [21 ]. However the cost of an oximeter is high and generally prohibitive for anesthesia providers in LMICs. Probes can The Future cost over $100 each and have a use expectancy of only 6 months. Slowly the need for anesthesia equipment suit- With this in mind, the WFSA, the Association able to low-resource areas is being recognized. of Anaesthetists of Great Britain and Ireland New technology will bring improvement. (AAGBI), the WHO, and the Harvard School of The miniaturization and modernization of moni- Public Health (HSPH) embarked on a project to tors will change the way things are done. develop a low-cost, full-service oximeter suit- Currently there are trials of a pulse oximeter able for use in diffi cult circumstances. To this using a smartphone [25 ]. Increasing use of cap- end, the Lifebox Foundation® was formed and nography in the fi eld will bring the development 6 Developing Anesthesia Equipment for Low-Resource Environments 91 of less expensive capnographs. Perhaps increas- Acknowledgement I would particularly like to thank Dr. ing use of pumps for total intravenous anesthesia Michael Dobson for his help in preparation of this chapter. His encyclopedic knowledge of anesthesia equipment and will bring about changes in the anesthesia of working in low-resource areas were invaluable. He also machine as we know it. There will still be a need created the schematic of the draw-over system. to provide oxygen- enriched air and to ventilate the lungs but vaporizers may become redundant. The need for trained biomedical personnel References who can maintain and service anesthesia equipment is recognized. As other areas of hospitals 1. Dobson MB. Anaesthesia at the district hospital. 2nd ed. Geneva: World Health Organization; 2000. in low-income regions procure better equip- 2. Hodges SC, Mijumbi C, Okello M, McCormick BA, ment, that too will require maintenance and Walker IA, Wilson IH. Anaesthesia services in devel- repair. Some suggest that fully trained biomedi- oping countries: defi ning the problems. Anaesthesia. cal engineers are not necessary [26 ] but that, 2007;62:4–11. 3. Chao TE, Burdic M, Ganjawalla K, Derbew M, given proper training, resources, and facilities, Keshian C, Meara J, McQueen K. Survey of surgery local technicians can provide most of the ser- and anesthesia infrastructure in Ethiopia. World J vice required. With modern communication, it Surg. 2012;36:2545–53. should be possible for a remote expert to lead a 4. LeBrun DG, Dhar D, Sarkar MIH, Imran TMTA, Kazi SN, McQueen K. Measuring global surgical dispari- local technician through a repair. However ties: a survey of surgical and anesthesia infrastructure manufacturers must recognize their obligation in Bangladesh. World J Surg. 2013;37:24–31. to provide training and follow-up for the prod- 5. Knowlton LM, Chackungal S, Dahn B, LeBrun D, ucts they sell. It may even be possible to design Nickereson J, McQueen K. Liberian surgical and anesthesia infrastructure: a survey of county hospi- equipment without a service requirement. The tals. World J Surg. 2013;37:721–9. development of this type of technology would 6. Choo S, Perry H, Hessy AAJ, Abantanga F, Sory E, go a long way toward solving the problems cur- Osen H, et al. Assessment of capacity for surgery, rently posed by the lack of trained technicians obstetrics and anesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Trop Med Int Health. in LMICs. 2010;15(9):1109–15. 7. Tallapragada V.S.N. P, Shkaratan M, Izaguirre AK, Helleranta J, Rahman S, Bergman S, 2009. Monitoring Conclusions performance of electric utilities: indicators and benchmarking in Sub-Saharan Africa. World Bank, Washington, DC. © World Bank. https://openknowl- There is a huge need for cost-effective, suitable edge.worldbank.org/handle/10986/13030 License: equipment for anesthesia providers in low- CC BY 3.0 Unported. Accessed 19 Mar 2014. resource areas. The challenges of variable elec- 8. Linden AF, Sekidde FS, Galukande M, Knowlton LM, Chackungal S, McQueen K. Challenges of sur- tricity supply and quality, heat, cold, dust, and gery in developing countries: a survey of surgical and humidity need to be considered in design. anesthesia capacity in Uganda’s public hospitals. Anesthesia equipment should be straightforward World J Surg. 2012;36:1056–65. to operate and have safety features built in. Lack 9. Howie S, Hill S, Ebonyi A, Krishnan G, Njie O, Sanneh M, et al. Meeting oxygen needs in Africa: an of biomedical technicians frequently necessitates options analysis from the Gambia. Bull World Health that the anesthetist maintain and service the Organ. 2009;87:763–71. machine. Education of the end users is para- 10. Friesen RM, Raber MB, Reimer DH. Oxygen mount. Without suitable education, even the best- concentrators: a primary oxygen supply source. Can J Anaesth. 1999;46:1185–90. designed equipment will not function well and 11. Prestero T. Better by design: how empathy can lead to will shortly be consigned to the equipment grave- more successful technologies and services for the yard. It behooves manufacturers to realize that poor. Innovations. 2010; 105–119. there is a huge market to be opened up if the cost 12. Beringer RM, Eltringham RJ. The Glostavent: evolution of an anaesthetic machine for developing coun- and design of equipment, and the education and tries. Anaesth Intensive Care. 2008;36:442–8. follow-up, are suitable for the locale in which it 13. van Hasselt G, Barr KG. The fi rst universal anaesthesia will be used. machine: an evaluation. JAP. 2011;4:128–34. 92 A. Enright

14. Rana RB, Agrawal JK, Manandhar ML, Shrestha 20. Association of Anaesthetists of Great Britain and N. An observational study of the Universal Anaesthesia Ireland. Recommendations for standards of monitor- Machine in Nepal. PMJN. 2011;11:36–41. ing during anaesthesia and recovery. 4th ed. 2007. 15. International standard 8835-7. Inhalational anaesthe- p. 4. http://www.aagbi.org. Accessed 19 Mar 2014. sia systems: part 7 anaesthetic systems for use in areas 21. World Health Organization. Surgical safety checklist. with limited logistical supplies of electricity and Revised 1/2009. http://www.who.int/patientsafety/ anaesthetic gases. Geneva: International Standards safesurgery . Accessed 19 Mar 2014. Organization; 2011. 22. Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry 16. International standard 80601-2-13-2011. Medical AF, Enright AC, et al. Global operating theatre distri- electrical equipment—part 2-13: particular require- bution and pulse oximetry supply: an estimation from ments for basic safety and essential performance of an reported data. Lancet. 2010;376:1055–61. anaesthetic workstation. Geneva: International 23. Dubowitz G, Breyer K, Lipnick M, Sall JW, Feiner J, Standards Organization; 2010. Ikeda K, et al. Accuracy of the Lifebox pulse oximeter 17. World Federation of Societies of Anaesthesiologists. during hypoxia in healthy volunteers. Anaesthesia. Guidelines for tendering for anaesthesia machines. 2013;68:1220–3. doi: 10.1111/anae 12382 . http://www.wfsahq.org/our-work/safety-quality . 24. Lifebox. Saving lives through safer surgery. http://www. Accessed 20 Oct 2014. lifebox.org/projectupdates/ . Accessed 20 Oct 2014. 18. Merry AF, Cooper JB, Soyannwo O, Wilson IH, 25. Petersen CL, Chen TP, Ansermino JM, Dumont Eichorn JH. International standards for a safe practice GA. Design and evaluation of a low-cost smartphone of anesthesia 2010. Can J Anaesth. 2010;57:1027–34. pulse oximeter. Sensors (Basel). 2013;13:16882–93. 19. Merchant R, Chartrand D, Dain S, Dobson G, Kurrek 26. Malkin R, Keane A. Evidence-based approach to the MM, Lagace A, Stacey S, Thiessen B. Guidelines to maintenance of laboratory and medical equipment in the practice of anesthesia—revised edition 2014. Can resource-poor settings. Med Biol Eng Comput. J Anaesth. 2014;61:47–71. 2010;48(7):721–6. Materials Management and Pollution Prevention 7

Jodi Sherman and Dorothy Gaal

Humanitarian medical service efforts in Introduction underserved areas in the last few decades have resulted in delivery of health care to hundreds of Medical progress has driven the development of thousands of individuals who otherwise may not new technologies and safer practices in health have been able to afford it. Facets of surgical care. Ironically, modern industrialized medicine mission efforts have been examined, such as the unintentionally contributes to environmental long- and short-term impact on the individual factors that threaten human health on individual, patient and healthcare system, quality assurance, community, and worldwide scales. The health- and ﬁ nancial models. The well-meaning, altruis- care sector in the United States (US) alone is tic anesthesia provider can contribute even more responsible for 8 % of national greenhouse gas to the health of the host environment and the (GHG) production [1 ]. Anesthesiologists typi- planet by weighing in on the ecological impact cally fail to consider the ecological implications various elements of the humanitarian efforts of manufacturing, transporting, and disposing make. Mission teams must be cautious not to of drugs and devices employed in their prac- abandon or export trash, nor to model wasteful tices. Hospitals, especially as regards periopera- behaviors to other parts of the world. In addition tive care, are the leading energy consuming and to humanitarian rewards, mission work affords an waste-producing elements within the healthcare opportunity to learn how to import a conservation system. Only through understanding the interre- mindset back to the U.S. latedness and contribution of modern anesthesia Lead organizations and individuals recognize practice to environmental issues can physicians that success of these humanitarian efforts with work toward aligning commitment to patient care regard to safety and quality requires some degree with community and ecological health [2 ]. of standardization. Recent publications [3 – 6 ] endorsed by the American Society of Anesthesiology (ASA) and American Society of Plastic Surgery extensively describe fundamental components of service efforts. In this chapter, the focus of materials management is on aspects J. Sherman , M.D. (*) • D. Gaal , M.D. that impact the environment. Several stages are Department of Anesthesiology , Yale University School of Medicine, New Haven , CT , USA recognized when management and control of e-mail: [email protected] transported materials must be considered.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 93 DOI 10.1007/978-3-319-09423-6_7, © Springer International Publishing Switzerland 2015 94 J. Sherman and D. Gaal

past due. Defi brillators may not be suited for Pre-trip Planning, Device infants. Suction may be nonexistent. Other times Procurement, and Transportation the equipment may be newer and well maintained. Some charitable organizations choose to Planning be safe and bring all basic equipment; however these efforts can lead to increased shipping costs Who will participate in a mission and where the and transportation pollution. patient care will be delivered impact how much Local, on-site anesthesia machines are fre- resources are consumed and pollution created by quently used by visiting anesthesiologists with transportation. There is recognition that an indi- great caution because they are often poorly main- vidual nongovernment organization (NGO) can- tained, and lack automation and modern safety not act in a silo and neglect the efforts of others. features such as disconnect alarms, and oxygen Potential services may be duplicated within a proportioning systems. On one mission, for short time frame, with some teams having too example, a near miss event occurred due to the few patients. Involving the local talent, rather accidental delivery of pure nitrous oxide (N 2 O). than transporting an entire, self-suffi cient, inde- The anesthesia machine predated standard posi- pendently operating medical team, strengthens tioning of the oxygen fl ow meter and the inter- diplomatic efforts and local participants’ confi - linking of the O 2 -N2 O fl ow meter knobs. dence. This effort may include physicians, nurses, Additionally, an adult pulse oximeter was ill- medical students, technicians, and translators. fi tting to the infant and functioned intermittently. Extremes of anesthesia supplies for missions Poor room lighting hindered physical examina- range from a haphazardly fi lled duffl e bag with tion of skin color. Fortunately, a free/facilitating assorted equipment to excessive numbers of anesthesiologist happened by and immediately boxes. Thoughtful teams recognize the need for a diagnosed the problem prior to a hypoxia-induced happy medium. Pre-trip planning with local hosts cardiac arrest. Only after this near miss did the is essential to ensure availability of required team appreciate the need for transportation of a equipment for safe and effective anesthesia care. portable defi brillator and appropriately sized It maximizes use of skilled human resources for probes. Transportation of a portable anesthesia provision of services to the greatest number of machine might also have to be considered. patients. Proper preparation also ensures preven- Anesthesia machines minimally have an oxy- tion of shipment of unusable equipment and sup- gen source (often portable) or concentrating plies that take up precious cargo space, waste fuel capability (as may be added to the portable on transportation, and lead to exportation of Glostavent® (Fig. 7.1 )), a vaporizer, and a vari- unnecessary medical waste and pollution. able fresh gas fl ow meter. It is not uncommon for Site visit, trip evaluation forms from prior the waste anesthetic gas (WAG) to be vented years, and close communication with host staff directly and passively out an operating room win- (physicians, nurses, hospital administrators, and dow. While the surgical team may be protected operations support) are essential to shed light on from the pharmacologic effects of these agents, facility conditions and equipment availability. the environment is not. Waste anesthetic gases Once on-site facilities are assessed, anesthesia are potent greenhouse gases (GHGs) [7 ], and an teams can more easily establish the equipment and essential pollution prevention and cost saving supplies that must be acquired. The sophistica- strategy is through strict attention to use of lowest tion, capabilities, and needs (education/physical) fl ow anesthesia [8 ]. Scavenging systems with of the various sites are variable and evolving. carbon dioxide (CO2 ) absorbents permit semi- The age and condition of anesthesia machines, closed circuits, reduce the total volatile agent defi brillators, autoclaves, and intensive care unit used, and greatly reduce environmental impact; (ICU) ventilators, for example, are often below however, many host sites lack this technology. US standards. Calibration of vaporizers may be Portable machines may be brought on select trips 7 Materials Management and Pollution Prevention 95

pediatric use. NGO supplied monitors may permit team anesthesiologists to provide the same standard of monitoring that a patient at home receives. The type of proposed surgeries, number of operating rooms (ORs) and operating days, patient population, and ages need to be known or carefully speculated to determine types and amounts of supplies. While purchasing local supplies can save shipment space and costs, or extend care when transported supplies run out, caution must be taken. Local safety control measures and oversight may be lacking, and labeling in a different language can be problematic. Teams should plan amounts of supplies as if single-use disposables will be used only once, though some devices may be safely reused. Fig. 7.1 Glostavent ® portable anesthesia machine; oxygen concentrating capacity may be added on Well-established organizations will have equipment and supply lists that include basic anesthesia equipment, as well as mission-specifi c lists that vary according to type of surgery and location. Specifi c types of missions may require all general anesthetics (GA) with breathing tubes (e.g., cleft lip/palate), while others may rely heavily on neuraxial techniques with GA backup (e.g., gynecologic surgery). Yet others may rely heavily on peripheral nerve blocks, such as is suitable for hand surgery. As much as possible, bringing individual procedure supply components instead of procedure kits can drastically cut down on the amount of waste [9 ]. Proper planning for type and number of anesthetics will ensure adequate supplies are on hand to maximize human resources, and prevent shipping of unnecessary Fig. 7.2 G.A.S./U.V.S. portable anesthesia unit, with supplies which may or may not be useful to the two vaporizers, variable fl ow meter, and CO2 scavenging capability to permit semi-closed circuit host team. Table 7.1 provides a sample basic anesthesia equipment list that may serve as a starting point for planning. by the team (Fig. 7.2) and should be strongly considered if CO2 absorbent capability is lacking in host countries. Regardless, backup non- Device Procurement rebreathing circuit systems must always be available although reliance on these systems wastes Medical devices may be obtained for medical both oxygen and volatile anesthetics. missions in a variety of ways, including pilfering Similar to the anesthesia machine situation, from home institutions (not recommended), local physiologic monitors may not be as con- collecting opened but unused items from one’s temporary as desired. Lacking capnography and own hospital, appealing to manufacturers for pulse oximeter probes for small children, they donations of capital equipment and supplies, may be unsuitable for general and especially fundraising to purchase materials, and through 96 J. Sherman and D. Gaal

Table 7.1 Basic equipment recommended for a surgical missiona (adapted from Politis [6 ]) Type of equipment Speciﬁ c equipment Anesthesia • Anesthesia machine with calibrated vaporizer delivery • Machine circuits

• CO2 scavenging supplies • Gas analyzer • +/− continuous drug infusion pumps • +/− portable ultrasound machine

Monitors/lab • Standard ASA: continuous pulse oximetry, end-tidal CO2 , automated noninvasive blood pressure, and multilead ECG (with lead pads); temperature monitoring and probes available • Twitch monitor • +/− invasive hemodynamic monitors • Point-of-care blood analyzer with adequate cartridges (caution: require refrigeration) Airway • Facemasks, assorted sizes management • Anesthesia circuits, appropriate size • Laryngoscope, blades, assorted sizes • Batteries, light bulbs • Video laryngoscope, blades, stylets assorted sizes • ETTs, stylets, assorted sizes • LMAs, assorted sizes • Bougies, assorted sizes • Ambu bag, appropriate size

• EtCO2 disposable detector • Suction tubing and instrument • Oral airways, nasal airways, assorted sizes • Nasal cannula, non-rebreather masks • Hydrogel Vascular access • IV catheters, assorted sizes • Tape and occlusive dressings • Tubing, appropriate type and size • Syringes, assorted sizes • Stop cocks • Alcohol swabs or alcohol solution and cotton swabs • +/− invasive Emergency • Ambu/self-infl ating bag equipment • Cricothyrotomy kit • Intraosseous needle • Defi brillator, pads appropriate sizes • Portable oxygen tank • LMAs, assorted sizes • Bougie • Stat laboratory for point-of-care testing • Flashlights and batteries • Portable fi beroptic bronchoscope Regional • Ultrasound gel anesthesia supplies • Stimulatable needles, assorted sizes • Spinal and epidural needles, assorted sizes • Sterile drapes • Sterile prep • Sterile cotton • +/− spinal, epidural, PNB kits (Note: kits generate more waste than components) Equipment/ • Portable autoclave, indicator strips maintenance • Cleaning solutions, waste neutralizer • Bottle brushes • Tools • Repair kits a Not intended as a comprehensive list 7 Materials Management and Pollution Prevention 97 organizations that collect and manage larger Transportation of Supplies scale medical equipment and supply donations to facilitate effi cient and reliable distribution for Substantial advanced planning is required to those in need. ensure surgical and anesthesia supplies arrive US hospitals generate more than 5.9 million intact and in a timely fashion. Supplies are gath- tons of medical waste each year [ 10 ]. Much of ered from donors, sorted, and then boxed. that waste consists of unused medical supplies Historically, airlines used to be very generous that are opened and unused but no longer sterile with providing shipping. Boxes could be sent by even if they have never contacted patients. Due general carrier with or without the team, free of to legal concerns and Food and Drug charge. Gradually that largesse has disappeared. Administration (FDA) regulations, these sup- Some organizations have been able to piggyback plies are not usable or resalable in the U.S. but supplies with the shipments of willing companies may be enthusiastically accepted by many that regularly do business in the host country, US-based charitable organizations for use in the allowing both economy and effi ciency. In general, developing world where they are so desperately the bulk of supplies travel with mission team needed. Supplies in opened packaging are re- members, who must maximize opportunities to sterilized and repackaged by donor institutions, check supplies as personal luggage. Additional then collected for distribution. R.E.M.E.D.Y. supplies are shipped separately, and overall thou- [ 11 ], Recovered Medical Equipment for the sands of dollars are now commonly spent on ship- Developing World, founded by Dr. William ping of supplies for each mission. As a result of Rosenblatt in 1991, was the fi rst such not-for- shipping expenses, fewer dollars exist for NGOs profi t organization dedicated to actively promoting to fulfi ll their annual mission goals. Mission the recovery of unused medical supplies for the groups have been forced to reconsider their model purpose of global aid, pollution prevention, and for materials procurement, and to look hard for cost-effectiveness. In addition to R.E.M.E.D.Y., what can be safely and reliably sourced locally. many other not-for-profi t medical equipment and Not only do these types of efforts save money, but supply organizations exist, including MedWish, they also reduce pollution by reducing shipping, MedShare, Procure, Afya Foundation, Intervol as well as reducing manufacturing, use, and dis- RUMS, IMEC International Medical Equipment posal of excess supplies. As noted, local procure- Collaborative, and AWH Advocates for World ment must proceed with caution. Health. Some organizations focus on acquisition For materials that will travel with the team, of supplies, and others on repurposed capital shipping arrangements should consider the tim- equipment [12 ]. ing, possible delays, and meticulous documenta- The bulk of equipment and supplies for medi- tion for customs agents. Endorsement letters cal missions are procured through not-for-profi t from government agencies or internationally rec- donation organizations. Institutions and manu- ognized charities may facilitate transit through facturers are often approached to fi ll supply customs. Materials beyond their expiration dates gaps. It is possible to solicit donations of refur- should not be shipped, and open packages should bished equipment from manufacturers, or bor- be avoided because the discovery of even one row equipment from them for specifi c missions, may provoke confi scation of the entire shipment. such as portable ultrasound machines or echo Similarly, controlled substances should not be machines. Mission groups typically house a cen- mixed with equipment supplies. Strict guidelines tral supply space from which all trips are stocked. also exist regarding shipment of fl ammable and Responsibility is with the mission organization explosive substances, which must be sourced to arrange and pay for shipment to fi nal locally. If shipments are not timed appropriately, destinations. mission teams may be forced to scramble “on the 98 J. Sherman and D. Gaal ground” to purchase local materials at increased however caution must be taken to prevent the expense and waste of transportation and supplies exportation of wasteful behaviors that are com- that may not be usable without the mission team. monplace in the U.S. Once the supplies arrive in the host country, with or without the team, they are brought to the hospital and stored. Advanced planning for secured Reduce transportation and storage locations is required to avoid theft, damage, loss, and waste. The primary resource conservation strategy both at home and abroad starts with opening and using less supplies whenever feasible. While humanitar- Equipment Maintenance ian organizations noted above thrive on the excesses and Cleaning for Responsible Reuse of the US health system as a source of medical supply donation and equipment refurbishment, waste There is growing concern regarding the amount reduction strategies in the U.S. must not be avoided of waste generated in the ORs, which indirectly to support their cause. When REMEDY was fi rst impacts public health and healthcare costs to instituted at Yale, OR nursing staff reported the society. Upwards of 1/3 of the 5.9 million tons of program raised awareness of wasteful practices and annual hospital waste in the U.S. originates in staff consciously worked to open fewer materials ORs [2 , 9 ]. Strategies to reduce waste are critical while successfully collecting supplies. Over time, to protect society from illness stemming from however, they anecdotally reported that they pollution, and to prevent the production of green- reverted to original wasteful habits and rationa- house gas formation through burning of fossil lized, “I’ll just donate excess supplies so they won’t fuels for resource extraction, de novo manufac- go to waste.” Unfortunately, only select supplies turing, and through waste incineration. Strategies are desired by equipment donation organizations that reduce waste save money directly in purchas- and so this attitude is misguided. Typically, medi- ing costs, and indirectly through prevention of cal missions provide an excellent opportunity to illness and loss of productivity [2 , 13 – 15 ]. learn how to provide safe care with fewer supplies, Use of single-use disposable medical equip- and conservation practices ought to subsequently ment is proliferating in the U.S., faster than impact behaviors at home institutions. anywhere else in the world. The reasons are mul- In addition to clinical waste, another important tifactorial, and typically include cheaper pur- opportunity for mission teams to reduce usage is chase price though this neglects to consider that through implementation of reusable food and higher upfront costs of reusables are offset by beverage containers. One NGO provided each numbers of reuse. Other reasons for selection of team member with a reusable coffee mug with disposable devices include concern for infection the organization logo on it to help reduce waste, prevention. For highly infectious patients, and encourage conservation mindedness, and as a for hard to clean items such as needles and IV mission keepsake. tubing, disposables are warranted. However, indiscriminate broad use of disposables appears unwarranted as there is a paucity of evidence to Reuse support reduction of infection rates over properly cleaned reusables. The biggest reason for the Besides employing reusable devices when possible, trend toward disposables likely is due to the con- an option that can lower environmental impacts is venience of throwing used supplies away rather through the reprocessing of single-use devices than cleaning them [16 ]. Upholding high stan- (SUDs). Volunteers may be alarmed to discover dards of infection prevention during administra- that reuse of disposable items is commonplace tion of anesthesia in underserved areas is critical; in the developing world. Faced with fi nancial 7 Materials Management and Pollution Prevention 99 restraints both in shipping and purchase, NGOs consider accepting these practices; however local standards of care must be honored as host regulations and customs may or may not permit reuse. There is precedent for SUD reuse practice in the U.S., and a growing industry around third-party reprocessing. The label “single use” is a manufacturer designation, and not an FDA designation. In 2000, the FDA issued a guidance document, “Enforcement Priorities for Single-Use Devices Reprocessed by Third Parties and Hospitals” to achieve standards and quality control [ 17 , 18 ]. In addition to cost savings from waste stream diversion, third-party reprocessed devices in the U.S. may be sold to hospitals with as much as a 50 % discount [9 , 13 ]. Substantial environmental savings can be achieved through reducing de novo manufacturing, transport of repeated quantities of single-use devices, and reducing disposal handling. While the same standards may be impossible to achieve in the developing world, reprocessing of simple SUDs such as supraglottic Fig. 7.3 airways (SGA) and endotracheal tubes (ETT) on Single-use disposable SGAs and Masks, drying after decontamination. Photo courtesy of Dr. Gabe Pitta trips is routine, and efforts must be made by mission teams to attain high cleaning standards (Fig. 7.3 ). There is no limit to the number of times an airway device may be reused as long as it has contamination rates [ 19]. Circuits are typically been decontaminated and the cuff is in good reused on missions, and it behooves the team to working order. Many teams include an equipment uphold these high standards of reuse. decontamination and sterilization specialist, and travel with a portable autoclave. In the U.S., anesthesia breathing circuits are Refurbished Equipment discarded after every use (and in some institutions, after any OR case even unused). In Europe US hospitals discard outdated equipment on a and elsewhere, breathing circuits are routinely routine basis, as newer models and technology changed less frequently, ranging from once a day become available. Some will stipulate that vendors to once a week except in select cases of known or of new equipment take old equipment back to presumed infectious patients. Circuits are then facilitate disposal; however few hospitals realize often decontaminated for reuse, or discarded. To that it is indeed possible to contractually arrange achieve safe reuse between cleanings, small for vendors to repurpose or responsibly recycle microbial fi lters are placed in line with the circuit take-backs. Nonetheless, many vendors will try to and discarded between patients, and condensate salvage parts, and will donate refurbished or unused is routinely emptied after each use. McGain et al. older models when asked, as part of organizational found prolonging the interval between anesthesia social responsibility. Some NGOs specialize in breathing circuit decontaminations in this fashion reclaimed equipment, though vendors also may be results in fi nancial, energy, and water savings, approached directly to satisfy mission needs and without any increase in signifi cant microbial for permanent donation to hosts. 100 J. Sherman and D. Gaal

Cleaning of bio-burden, items may then undergo the next steps to achieve disinfection or sterilization Infection prevention and control is of utmost pri- depending on their level of infection risk. ority, whether at home or abroad. Cleaning of Autoclaving entails applying high pressures medical devices can be particularly challenging and heat to either sterilize or high-level disinfect in portable, foreign settings. Disinfectants have equipment. Autoclaving at high temperatures is environmental impact themselves. All are inten- routinely employed to sterilize stainless surgical tionally toxic to destroy microorganisms, and steel equipment. Autoclaving at lower tempera- while currently none is deemed “green,” when- tures and durations can be used for high-level dis- ever possible, least harmful approaches must be infection [20 ], e.g., laryngoscopes and for classic employed [20 , 21 ]. reusable SGAs that are primarily silicone based. Classifying levels of infection risk must be Device manufacturer guidelines should be care- matched with antimicrobial potency of disinfec- fully reviewed. Single-use disposable SGAs and tion materials and processes, to ensure care that is ETTs may or may not be able to withstand HLD effective and safe for patients as well as limiting from autoclaving. All device cuffs must be fully unnecessary exposure to staff, communities, and defl ated prior to treatment, and function must be the environment through waste. Medical devices tested prior to each use. Portable tabletop auto- classifi ed as critical (invasive, contacting sterile claves are available in electrical or solar powered tissue) require sterilization. Semi-critical devices options, and some versions do not require water (contacting mucous membranes or non- intact main hook up—helpful for mission work. skin) including laryngoscopes, ETTs, and SGAs Temperature sensitive test strips must be used to require high-level disinfection (HLD). Noncritical ensure quality control. devices (contacting intact skin) such as pulse Glutaraldehyde is a HLD frequently used for oximeter probes and noninvasive blood pressure heat-sensitive equipment, and therefore has broad cuffs require low-level disinfection (LLD) [20 ]. application for missions. Glutaraldehyde is not a Fisher et al. [2 ] describe at length several meth- human carcinogen; however, several health ods for HLD that are approved by the FDA [ 20 ]. effects have been reported amongst exposed These include glutaraldehyde 2–3.5 % (Cidex® and healthcare workers including airway irritation others), ortho-phthalaldehyde 0.55 % (Cidex- and acute asthma exacerbation, eye irritation, OPA® and others), and hydrogen peroxide 2.5 % nosebleeds, headaches, contact dermatitis, and with 2-furoic acid (Resert XL HLD). Always, staining of skin. Handling in a well-ventilated devices intended for reuse must be checked for area is advised, and if that is not possible, a por- manufacturer recommendations for cleaning table hood with charcoal fi lter is recommended. compatibility. Autoclaving can achieve either Ortho-phthalaldehyde (OPA) is a chemically high-level disinfection or sterilization, depending related alternative that aerosolizes much less and on temperature, pressure, and time applied. is less irritating to the airway; however it can be All cleaning starts with physical removal of diffi cult to rinse off of equipment and is a potent excess bio-burden (body fl uids and tissue) with skin sensitizer. Further, OPA is considered toxic detergent and water prior to disinfection and ster- to aquatic life. Hydrogen peroxide is an oxidizer ilization. For many anesthesia airway items, and suspected animal carcinogen with unknown soaking in a bath of detergent and water and then human cancer potential. It can be a simple respi- scrubbing the lumen with a bottle brush can be ratory irritant but is not associated with any aller- effective in removing organic matter. Care should gic response. In all cases, non-latex nitrile gloves be taken to evacuate the accumulated condensate and goggles are advised, and equipment must be in breathing circuits between patients and before rinsed prior to patient use. Proper disposal of soaking; disposal is appropriately handled by sterilant and disinfectant waste includes binding sewage drain as with urine. After initial removal with a neutralizer [20 – 24 ] (see below). 7 Materials Management and Pollution Prevention 101

thousands of medical incinerators in the U.S., as Waste Segregation, Disposal, alternative safer treatment methods were and Minimization of Incineration enforced. Safer disposal methods include decontamination of biohazardous waste through auto- Waste Stream Segregation claving, then subsequent landfi lling as MSW. Some blood products, chemicals, pharmaceuti- Waste management by and large is a neglected cals, and pathology specimens still do require issue, and ought to be of concern for responsible incineration; however this should only amount to mission teams. It is essential to dispose of all waste about 3 % of total hospital waste generated in the safely, and in compliance with or exceeding coun- U.S. [ 13]. Many mission sites may lack autoclave try legislations. Proper waste management is an capacity suffi cient to handle treatment of the vol- especially important area to educate hosts about. ume of OR waste, and sadly, incineration may be According to the WHO [25 ], a maximum of 20 % the principle method of disposal. Strict attention of hospital trash is comprised of biohazardous to waste minimization and proper segregation of waste (regulated medical waste or RMW in the trash is critical to minimize unnecessary burning, U.S.). In the OR setting, it is possible to achieve and hosts ought to be encouraged to set goals of 10–15 % RMW in the U.S. and also abroad. The increasing autoclaving capacity [2 , 9 , 10 , 13 – 15 , remaining 80 % of medical waste is nonhazardous, 21 , 23 – 25 ]. including paper, plastic, metal, glass, and food products, and is suitably handled as municipal solid waste (MSW) and ought to be landfi lled. It is Sharps Waste essential to keep hazardous waste out of the MSW stream to prevent occupational and community Mission teams ought to carry disposable sharp exposure. It is also important to avoid placing bins from home to the destination site. It is dan- MSW into the hazardous waste stream since not gerous and illegal to return this biohazardous only is hazardous waste signifi cantly more waste back to the U.S., and so sharps bins are left expensive to dispose of, but its special treatment behind for hosts to dispose of. Sharps disposal in methods liberate potent toxins. Pollution preven- the U.S. entails fi rstly heating at high tempera- tion practices therefore emphasize proper waste tures to achieve disinfection, and then “rendering stream segregation [10 , 14 , 15 , 21 – 25 ]. unrecognizable,” e.g., through shredding or crushing; this waste is then safely destined for landfi ll [ 23]. Unfortunately, such high standards Hazardous Waste for sharps handling may be unachievable at host sites. Simple disposable containers may be easy Incineration had been the most popular disposal to open, and sadly many stories of locals sorting method of hazardous waste in the U.S. in the through sharps waste for reuse exist. To avoid past, and remains so in many developing coun- reuse, some locations rely on sealable drums and tries. Dioxins, furans, and heavy metals are some concrete pits. Mission teams must work with of the most notorious toxicants liberated into the hosts to abide by local regulations and to con- atmosphere through medical waste incineration, sciously uphold the highest standards possible, particularly through burning polyvinyl chloride while educating on best practices. (PVC) plastic that is ubiquitous in disposable medical devices, including IV tubing, ETTs, and LMAs. Dioxins, even in very small quantities, Pharmaceutical Waste are potent carcinogens and up until recently, healthcare incineration was the single largest Pharmaceutical waste in the OR is handled either source of dioxins in the world. Newer emissions in a combined sharps/drug waste container or in a regulations in the 1990s led to the closure of dedicated container for liquids with a binding 102 J. Sherman and D. Gaal and solidifying agent. The combined sharps/drug life once the pH has been adjusted and may be waste container ought to be handled as with any disposed of to drain [20 –23 ]. As always, all local sharps waste, by high heating to decontaminate regulations must be honored; however if stan- and then shredding or crushing to render unrec- dards are low it behooves the mission team to edu- ognizable. The container with solidifi ed drug cate local staff about environmental concerns and waste can be heat treated, or disposed of in land- uphold higher standards. fi ll depending on the hazardous classifi cation. In the U.S. many states require unused narcotics be wasted into sinks out of concern they might Lessons Abroad and at Home get extracted from solidifi ers [26 , 27 ]. Humanitarian medical service is incredibly rewarding work. Responsible mission work includes Recycling efforts to minimize wasteful practices and to prevent pollution, while providing safe and productive Within nonhazardous municipal solid waste, care. Several effective anesthesia equipment much could be diverted to recycling if facilities management strategies exist to minimize the are present. Surprisingly, even in some develop- environmental impact of care. Waste prevention ing countries there is a burgeoning market for begins with pre-trip planning in collaboration recyclables. If the opportunity exists, it behooves with hosts to determine required team members mission staff to collect both clean, non- and equipment to minimize unnecessary trans- contaminated clinical waste such as simple card- portation. Procurement is primarily through orga- board and paper packaging, and high-quality nizations specializing in reclaimed medical plastic such as saline bottles, as well as personal supplies and refurbished equipment. Waste anes- waste such as beverage containers, and work with thetic gases must be minimized; and CO2 absorbent hosts to ensure recyclables make it to the appro- capacity is critical to permit low fresh gas fl ows. priate facility. What is recyclable varies with loca- A decontamination and sterilization specialist is tion, technology advancements, and marketplace an essential team member for safe and responsible for materials and so communication is required reuse of equipment. Proper waste disposal starts with local facilities [9 , 28 ]. Great care must be with strict attention to waste segregation. Care taken to avoid contamination of recyclables by must be taken to avoid mixing of hazardous and hazardous materials. Not only is this responsible nonhazardous waste, to keep sharps safe, to bind behavior for visitors, but it also sets an example pharmaceutical waste, and to neutralize cleaning for host facilities. solutions prior to disposal. Special attention must be given to minimize incineration, and to support long-term autoclave capacity. Lessons learned not Disposal of Sterilant and Disinfectant only benefi t the local community, but they also Wastes can be employed at home to reduce the environmental impact of anesthesia practice on the global Unused disinfectant concentrates may be consid- community. ered hazardous waste in the U.S., and the assump- tion in the mission setting is that sewage treatment facilities are incapable of handling these solu- References tions. A simple and effective method of neutral- izing OPA or glutaraldehyde is through addition 1. Chung JW, Meltzer DO. Estimate of the carbon foot- of a glycine-based neutralizer (e.g., Glute-Out® ) print of the US health care sector. JAMA. 2009; prior to dumping in sewage. Acid stabilized 302(18):1970. 2. Sherman J, Ryan S. Ecological responsibility in hydrogen peroxide solutions have a low pH and as anesthesia practice. Int Anesthesiol Clin. 2010; such may need to be neutralized before drain 48(3):139–51. Lippincott Williams & Wilkins, disposal. These solutions are not toxic to aquatic Philadelphia, PA. 7 Materials Management and Pollution Prevention 103

3. Fisher QA, Politis GD, Tobias JD, Proctor LT, 16. Eckelman M, Mosher M, Gonzalez A, Sherman J. Samandari-Stevenson R, Roth A, et al. Pediatric anes- Comparative life cycle assessment of disposable and thesia for voluntary services abroad. Anesth Analg. reusable laryngeal mask airways. Anesth Analg. 2002;95(2):336–50. 2012;114(5):1067–72. 4. Schneider WJ, Politis GD, Gosain AK, Migliori MR, 17. FDA guidance document, “Enforcement Priorities for Cullington JR, Peterson EL, et al. Volunteers in plas- Single-Use Devices Reprocessed by Third Parties and tic surgery guidelines for providing surgical care for Hospitals”. August 14, 2000. http://www.fda.gov/ children in the less developed world. Plast Reconstr MedicalDevices/DeviceRegulationandGuidance/ Surg. 2011;127(6):2477–86. GuidanceDocuments/ucm107164.htm . Accessed 6 5. Schneider WJ, Migliori MR, Gosain AK, Gregory G, June 2014. Flick R, Committee of the American Society of 18. United States Government Accountability Offi ce. Plastic Surgeons; Plastic Surgery Foundation. Report to the Committee on Oversight and Government Volunteers in plastic surgery guidelines for providing Reform, House of Representatives. Reprocessed sin- surgical care for children in the less developed world: gle-use medical devices: FDA oversight has increased, part II. Ethical considerations. Plast Reconstr Surg. and available information does not indicate that use 2011;128(3):216e–22. presents an elevated health risk. Washington, DC: 6. Politis GD, Schneider WJ, Van Beek AL, Gosain A, United States Government Accountability Offi ce; 2008. Migliori MR, Gregory GA, et al. Guidelines for pedi- http://www.gao.gov/new.items/d08147.pdf . Accessed atric perioperative care during short-term plastic 6 June 2014. reconstructive surgical projects in less developed 19. McGain F, Algie CM, O’Toole J, Lim TF, Mohebbi M, nations. Anesth Analg. 2011;112(1):183–90. Story DA, Leder K. The microbiological and sustain- 7. Sherman J, Le C, Lamers V, Eckelman M. Life cycle ability effects of washing anaesthesia breathing circuits greenhouse gas emissions of anesthetic drugs. Anesth less frequently. Anaesthesia. 2014;69(4):337–42. Analg. 2012;114(5):1086–90. 20. FDA issued a guidance document, Medical devices: 8. Feldman JM. Managing fresh gas fl ow to reduce envi- sterility review guidance K90-1. August 30, 2002. ronmental contamination. Anesth Analg. 2012;114(5): http://www.fda.gov/MedicalDevices/ 1093–101. DeviceRegulationandGuidance/GuidanceDocuments/ 9. Practice Greenhealth. Greening the OR™. https:// ucm072783.htm . Accessed 6 June 2014. practicegreenhealth.org/initiatives/greening- 21. Green Guide for Health Care. The Green Guide operating-room . Accessed 6 June 2014. Version 2.2 operations section. 2008 revision. www. 10. Practice Greenhealth. Waste. https://practicegreen- gghc.org . Accessed 6 June 2014. health.org/topics/waste . Accessed 6 June 2014. 22. Practice Greenhealth. Sterilants and disinfectants. 11. R.E.M.E.D.Y.: Reclaimed Medical Equipment for the https://practicegreenhealth.org/topics/chemicals/ Developing World. http://www.remedyinc.org/ . sterilants-disinfectants . Accessed 6 June 2014. Accessed 6 June 2014. 23. EPA medical waste. http://www.epa.gov/osw/nonhaz/ 12. American Medical Association. Medical supply recy- industrial/medical/index.htm . Accessed 6 June 2014. cling programs. http://www.ama-assn.org//ama/pub/about- 24. EPA hospital pollution prevention. http://www.epa.gov/ ama/our-people/member-groups-sections/medical- region9/waste/p2/hospart.html . Accessed 6 June 2014. student-section/community-service/medical-supply- 25. World Health Organization. Waste from healthcare recycling-programs.page . Accessed 6 June 2014. activities. November 2011. http://www.who.int/ 13. Hunke TK, Ryan S, Hopf HW, Axelrod D, Feldman J, mediacentre/factsheets/fs253/en/ . Torrillo T, et al. American Society of Anesthesiologists, 26. Environmental Protection Agency, Management of Environmental Task Force. Greening the operating Hazardous Waste Pharmaceuticals, 2014. http://www. room manual. 2012. http://www.asahq.org/For- epa.gov/osw/hazard/generation/pharmaceuticals.htm . Members/Clinical-Information/Greening-the- Accessed June 6, 2014. Operating-Room.aspx . Accessed 6 June 2014. 27. Managing pharmaceutical waste: a 10-step blueprint for 14. World Health Organization. Health-care waste man- healthcare facilities, Practice Greenhealth. August 2008. agement. October 2011. http://www.who.int/media- http://www.hercenter.org/hazmat/tenstepblueprint.pdf . centre/factsheets/fs281/en/ . Accessed 6 June 2014. 28. McGain E, Hendel SA, Story DA. An audit of poten- 15. Health care without harm. https://noharm.org/ . Accessed tially recyclable waste from anesthetic practice. 6 June 2014. Anaesth Intensive Care. 2009;37(5):820–3. What Do Patients and Communities Expect 8 of a Medical Mission?

V. Lekprasert , S. Pauswasdi , and B. M. Shrestha

The expectations and thus success of medical Introduction missions depend on many factors including quality and safety factors [1 , 2 ], international collabo- Every one wishes to live a healthy life. Many ration, an understanding of the ethics and culture people worldwide are not so lucky. People of the host region and establishment of a means become sick for many reasons and access to to ensure sustainability and continuity. Recently, health care, which is a basic human right, may increasing public awareness of global health con- not be available. Those who can access these ser- cept has led various organizations to create global vices may not be able to afford the cost. Any collaborations in the form of medical missions [3 ]. resources which they have might have been spent The challenges of providing successful medical on basic primary needs like food, water, and shel- missions in underserved communities are multi- ter. There is nothing left for health care. This situ- factorial [4 ]. However, considering the princi- ation occurs more in less affl uent countries. ples of human rights, a conceptual framework International studies has shown that commu- can be summarized into three domains (quality, nities with low income, even those in affl uent ethics and cultural relevance, collaboration) countries, have greater exposure to health dam- sharing the same goals of continuity and sus- aging risk factors and thus have poorer health tainability (Fig. 8.1 ). causing more illness and shorter life span. Governments do plan to provide basic need and health care to their people but most of the Quality and Safety time in developing countries, the plan is limited to paper only. Unstable and corrupt governments, Quality and safety are multifaceted issues. The lack of infrastructure, lack of understanding of Institute of Medicine (IOM) has identifi ed six priorities, and poor economy all play a part. aims of quality medical care [5 ]: • Safety : Providers must ensure that the medical care intended to benefi t patients is not V. Lekprasert , M.D., M.S. (*) • S. Pauswasdi , M.D. causing harm. This requirement is particu- Department of Anesthesiology, Ramathibodi larly applicable as many developing coun- Hospital, Mahidol University , Bangkok , Thailand tries do not yet have safety standards built e-mail: [email protected]; [email protected] into their health care systems, and medical B. M. Shrestha , M.B.B.S., D.A., F.R.C.A.T. providers are often asked to practice outside Department of Anaesthesia and lntensive Care , Kathmandu Medical College Teaching Hospital , of their expertise, which is both unsafe and Sinamangal, Kathmandu , Nepal unethical.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 105 DOI 10.1007/978-3-319-09423-6_8, © Springer International Publishing Switzerland 2015 106 V. Lekprasert et al.

Table 8.1 Types of resources needed for quality and safety in anesthesia Human resources Nonhuman resources • Manpower • Equipment/tools • Education/knowledge • Monitors • Skills • Drugs • Experiences • Blood supply

Ideally, people throughout the world should gain access to quality health care. However, there are considerable challenges in resources and Fig. 8.1 A conceptual framework of the expectation of a organization to achieve all six key components. medical mission (The pillars of successful medical The World Federation of Societies of missions) Anaesthesiologists (WFSA), which was founded in 1955 aims to make available the highest stan- • Effectiveness : Medical treatments must be based dard of anesthesia to all peoples throughout the on scientifi c knowledge, and must produce world [7 , 8 ]. The international standards recom- benefi cial, measurable results. mended by the WFSA are aimed at anesthesia pro- • Patient-centered : Care must be tailored to fessionals everywhere to improve and maintain the individual patient preferences, needs, and quality and safety of anesthesia care. For some values. Patients should have authority over countries, these standards have already been imple- their own medical care, and their input must mented but for many countries or different areas in guide clinical decision-making. the same countries, these standards may repre- • Timeliness : Patients requiring medical atten- sent a future goal. Nonetheless, the goal is always tion should have access to timely health care the best possible care and ongoing improvement and follow-up care to avoid potentially harm- for the safe practice of anesthesia [8 ]. ful delays in treatment. Quality health care is about getting the right • Effi ciency: Quality health care avoids wasting care to the right patient at the right time, and fi nances, time, equipment, and energy. achieving the best possible outcome. Although it Effi ciency maximizes the impact of global sounds simple, quality may vary for many rea- health organizations. sons. Advanced technologies offer the promise of • Equitability : The quality of medical care improving health, increasing life span, and reduc- must be consistent across all patient types, ing pain and suffering. However, working in mul- irrespective of gender, ethnicity, socioeco- ticultural areas requires knowledge of cultural nomic status, and other personal characteris- differences and beliefs. What is considered the tics. Similarly, visiting medical providers best care in one region may not be the best in many must hold themselves to the highest standards other, even adjacent, areas. The quality issue of quality care, as they would in their home becomes even more complicated when facing a countries. huge patient need and demand. In many areas Developing countries have poor economies worldwide, there is a problem of provider volume and poor resources, which should not be a deter- and density. When the ratio of patients to providers rent to providing quality care. Patients do wish to is overwhelming, the need is often determined by have quality care. a combination of triage and weighing of risks and While low quality health care may be primarily benefi ts for each patient. a refl ection of inadequate fi nancial resources, there Provision of quality anesthesia care requires is evidence that quality can be enhanced in a both human and nonhuman resources (Table 8.1 ). number of ways even in the absence of additional Human resources include manpower, education, resources [6 ]. knowledge, skills, and experience of both physician 8 What Do Patients and Communities Expect of a Medical Mission? 107

Table 8.2 Three phases in the WHO surgical safety checklist [9 ] Sign in : Before starting anesthesia Time out : Before starting surgery Sign out : At the end of surgery • Patient identifi cation • Confi rmation of team members • Confi rmation of the performed • Surgical marked site • Confi rmation of the patient, procedure, procedure • Allergy and incision site • Complete counts of instrument, • Diffi cult airway or aspiration risk • Antibiotic prophylaxis within the last sponge, and needles • Bleeding risk and planned 60 min • Correct specimen labeling intravenous fl uid therapy • Anticipated critical events to surgeon, • Addressing any equipment • Readiness of anesthesia machine, anesthesiologist, and nursing team problems medications, pulse oximeter • Availability of essential imaging • Key concerns for patient recovery and management and non-physician anesthesia providers. In global warming, and depletion of limited natural addition, the multiple disciplines involve in the resources. In other words, a “global mind-set” various components of safety must be consid- must be emphasized [ 11 ]. Although advanced ered. Therefore, multidisciplinary aspects of care anesthesia machines and equipments have pro- through team training are vital. The World Health vided better care for patients, overreliance on Organization (WHO) has introduced a surgical them may cause hidden problems and dangers. safety checklist in 2009, as a mean to improve Evidence shows that many operating rooms in surgical patient safety through multidisciplinary the developing world are littered with an accu- communication. The checklist was fi rst launched mulation of well-meaning mission donations in in June 2008, and has been translated into at least the form of unrepaired ventilators, and anesthesia six languages (Table 8.2 ). WHO 2009 surgical machines, often labeled with the name and date checklist comprises vital checks in three phases: of the mission [12 ]. Instead of modern and high- sign in (before starting anesthesia), time out tech anesthesia machines, a simple medical ven- (before starting surgery), and sign out (at the end tilator such as the Bird respirator may be more of surgery) [9 ]. The use of a checklist can be practical in an area where electricity is not widely locally modifi ed to suit the individual hospital or consistently available (Fig. 8.2 ). setting. Recent studies show the benefi ts of oper- In addition simpler anesthesia machines and ating room teamwork and communication, equipment may be easier for local staffs to main- including reductions in morbidity and mortality tain in working order. The literature reveals that among surgical patients in a diverse group of hos- short-term medical missions have improved the pitals [ 9 , 10 ]. lives of patients in resource-limited area, but the Nonhuman resources include equipments, ability to make a meaningful and lasting effect in tools, monitors, anesthetic drugs, and blood sup- the developing world is diffi cult [12 ]. ply. Provision of these resources is as important as medical logistics to support medical missions. The logistics of pharmaceuticals, medical and sur- Ethics and Cultural Relevance gical supplies, devices and equipments are also essential for the continuity of care. In the resource- Behavioral and cultural differences are signifi cant poor setting, this issue remains challenging. barriers when working in different locations A well-developed infrastructure is necessary worldwide. Many models have been developed to to manage these resources for long-term use. cope with this problem. Rassiwala et al. reported Well-thought out strategic plans are required to two models of educational engagement: a 1-week make effi cient use of limited resources. program and a 4-week program for medical stu- Considering the health of all as interconnected dents [3 ]. Two physicians from the same univer- and closely linked to economic forces, resources sity supervised the short program, while the must be used with the awareness of ongoing longer program was coordinated by the nonprofi t widespread poverty, world population growth, organization that worked with local health care 108 V. Lekprasert et al.

negative information with Navajo patients in 34 Navajo informants [15 ]. There were three categories of informants: patients, traditional healers, and Western biomedical health care providers. The study suggested a four-stage approach to facilitate the bridging of cultural differences. The ﬁ rst stage is a patient assessment to assess the willingness and appropriate timing for any discussion. The next step is a preparation, which entails cultivating a trusting relationship, the involvement of family members, and facilitating the involvement of traditional healers if needed. The third stage is communication in a caring, kind, and respectful manner. Finally, the follow- through should be completed for the continuation of care.

International Collaboration and Sustainable Quality Health Care Fig. 8.2 Bird respirator at Ramathibodi hospital in Bangkok, kept in well-functioning condition for learning Several issues are essential to maintain sustainable and teaching purposes health care through international collaboration; 1. Education: in-country vs. oversea training providers [3 ]. A longer duration program provided programs; more time to develop good rapport, language and 2. Service: short-term vs. long-term and ethnic learning that bridges the cultural and ethi- 3. Research: routine-to-research methodology cal gaps between visiting medical students and the local population. The model of a longer duration of global health educational program helped Education medical students to incorporate their knowledge to better suit a resource-limited setting and also to In the developing world, education systems are build a better patient-provider bond. The same poorly developed or nonexistent. Many peoples positive impact in terms of better collaboration are uneducated and carry on with the traditional and understanding of a cultural and social context “cures” they received for generations when they was evident by senior physicians who may be able were sick. To maintain good health free from to stay in a place for long-term missions [13 ]. many diseases, good hygiene is necessary—a Despite good intentions, many international concept that is also foreign to many in underde- medical missions are unsuccessful. One of the veloped countries. major problems comes from cultural differences. But even educated people in these countries Regardless of race or location, communication often have very low expectations of the health should proceed in a caring, and respectful man- care system—they experience cycles of health ner to reduce culture-related communication crises and do not maintain good health. An envi- problems, not only to the patients but also to ronment in health care must be created so that local physicians on the basis of respect for their these people can also look for care when they skills, knowledge, and traditions [ 13, 14 ]. need it, and not wait for the situation to become Carrese et al. studied strategies for discussing acute or critical. Most of the time these educated 8 What Do Patients and Communities Expect of a Medical Mission? 109 mass also do not trust the modern health care system downward spiral, particularly in developing and prefer to be treated by local medicine men. countries.” [17 ] For example, Dhami Jhakri are the Nepalese An earlier paper by Yancey reported “Health words for shamans who are local healers and care providers are reminded at intervals that rich consulted by the local community. They are and poor, educated and illiterate people react found in Nepal, parts of India, not only in remote similarly to excellent, considerate health ser- villages but also in cities. Similar mediums, who vices. Practice does not make for perfection in practice often by spirit possession, are prevalent medicine; only excellent practice permits a close in other groups and tribes. approximation to perfection. Poor people know Poverty and lack of education, along with of the presence and accessibility of the public other social determinants, are proven barriers to teaching hospital in their community, yet they health care. Various measures of health quality, report to the hospital later than the higher income, including low life expectancies and high mortal- private hospital individuals for care” [18 ] ity rates, correlate to low levels of education [16 ]. And fi nally Clark reporting on volunteers in People living in poverty usually have not been Ghana wrote: “Even though people are gener- educated as to when, why, and where to access ally poor they still want to preserve their dig- health care. Many mistakenly believe that their nity. Valuable/expensive things offered on a affl iction is irreversible and permanent or the silver platter tend to lose their value and have result of some wrongdoing on their part or the the tendency to be abused. Thus it is always infl uences of evil spirits, and they are unaware of advisable to let people bear some responsibility. medical treatments that can treat or cure their This is why some communities have to pay a condition. Additionally, general public health token fee for some of the services or medica- education is lacking, such as knowledge of proper tions. No matter how meager a fee paid, it is hygiene and water treatment. It is the role of enough to let one value whatever is offered. If global health organizations to fi ll these educa- something very expensive is being offered for tional gaps. By training health workers and com- free, the notion is that it is meant to be thrown munity members to raise awareness about good away; and that is why it is being given to them. health practices and opportunities to access med- They may even feel belittled by the totally free ical care, global health organizations can produce offer.” [19 ] far-reaching positive results. Indeed, global health disparities and inequita- The developed world needs to be educated and ble access to health care in developing countries made more aware of poverty-induced health cri- should be an ongoing concern for many if not all ses across the globe. Though general health edu- physicians [20 ]. cation is readily available in affl uent countries, Thus evidence and research underscore that education and advocacy about poverty-induced education is the key to sustainable changes in health crises throughout the world are necessary developing countries. Bidirectional education to spur developed nations to action. between low and high-resource countries can be Strasser described it well: “Despite the huge benefi cial to both sides. Low-resource countries differences between developing and developed gain knowledge, advanced clinical skills, and countries, access is the major issue in rural health infrastructure organizing skill to meet their local around the world. Even in the countries where the needs. Students and faculty from high-resource majority of the population lives in rural areas, the countries also gain medical knowledge, clinical resources are concentrated in the cities. All coun- skills, cultural sensitivity, adaptability, fl exibility tries have diffi culties with transport and commu- and have more appreciation for public health and nication, and they all face the challenge of socioeconomic factors. The knowledge and expe- shortages of doctors and other health professionals riences gained from working in low-resource in rural and remote areas. Many rural people are countries can have long lasting benefi cial effects caught in the poverty–ill health–low productivity on their career paths [7 , 21 , 22 ]. 110 V. Lekprasert et al.

The World Federation of Societies of College of Anesthesiologists of Thailand (RCAT). Anaesthesiologists (WFSA) has provided train- RCAT feels the obligation to promote better ing opportunities in many areas around the world, global anesthetic care, apart from serving anes- both in-country training programs and overseas thesiologists in Thailand and cooperating with training programs. Candidates for oversea train- colleges/societies of anesthesiologists from vari- ing must commit to return home to practice. ous countries. Therefore, a 1-year WFSA- BARTC The main advantage of overseas training pro- program was started in 1996, with Prof. Thara gram is the opportunity for the trainee to see the Tritrakarn (Thailand) as the ﬁ rst director and sup- system and infrastructure support of anesthesia port from Prof. Mitsugu Fujimori (Japan), Dr. from the inside. The graduates can use knowl- Kester Brown (Australia), and Dr. Haydn Plerndt edge and experience to organize infrastructures, (Australia). To date, WFSA-BARTC has 60 grad- improve anesthesia practice, and even become uates from surrounding countries such as Laos professional leaders in their homelands. However, PDR, Myanmar, Mongolia, Vietnam, Cambodia, local investments for infrastructure support and and Bhutan. Feedback from the graduates empha- continuing education, as well as political com- sizes the great values of the program. In addition, mitments are essential to attract physicians and WFSA-BARTC refresher courses have been con- non-physician staff and retain those trained anes- ducted regularly in different countries where thesia providers in the areas of need. Studies those graduates reside for continuing education reveal barriers to recruitment and retention of as follows: anesthesia providers that include poor working environment and limited appeal of health care 1991 Hanoi, Vietnam jobs. These critical issues must be acknowledged 1993 Ho Chi Minh City, Vietnam and remedied in order to reduce the complex 1995 Ho Chi Minh City and Hue, Vietnam 1998 Vientiane, Laos PDR problem of “brain drain” [23 ]. In low-income and 1998 Haiphong, Vietnam middle-income countries, well trained anesthesia 2004 Phnom Penh, Cambodia providers, as well as other health care workers 2006 Ulaan Baatar, Mongolia are very poorly paid. Thus, they either move to 2007 Yangon, Myanmar higher paying jobs locally or migrate to better- 2010 Yangon, Myanmar paid jobs abroad. In the past, the most commonly 2011 Ulaan Baatar, Mongolia used strategy to retain those valuable health care 2012 Ubonratchatani, Thailand personnel was compulsory rural service bonds 2013 Yangon, Myanmar and mandatory rural service for admission into postgraduate training programs. However, the There are also short-term training programs new strategies including well-balanced work- sponsored by the WFSA in different countries as force management policies, incentives, incre- local health needs are identiﬁ ed, such as mental improvement in public health facilities, Romania, Israel, India, and South Africa. Many better residential infrastructure, and local health of these training courses have been extended to care provider recruitment have shown promising be of longer duration with additional subspe- impacts [23 , 24 ]. cialty training [7 ]. At present the WFSA offers basic anesthesia At Ramathibodi Hospital in Bangkok, there is training in two places: Bangkok Anesthesia an additional a 1-year training program for Regional Training Centers (BARTC) in Thailand Bhutan nurse anesthetists (Fig. 8.3 ). The program and Cluj-Napoca in Romania [7 ]. The center in originally sponsored by the World Health Romania, which is supported by the WFSA and Organization (WHO) was started in 2002 and the European Society of Anaesthesiology’s continued for 5 consecutive years, with 21 gradu- National Anesthesia Societies Committee ates. After the graduates returned to Bhutan and (NASC) commenced in 2002. BARTC was estab- practiced for sometimes, many requested to come lished in 1996 with the collaboration of the Royal back for additional short courses in areas such as 8 What Do Patients and Communities Expect of a Medical Mission? 111

Fig. 8.3 A group of Bhutan nurse anesthetists graduated from Ramathibodi hospital, Mahidol University in 2003—Rinzin Dorji, Champa Sharma, Dr. Varinee Lekprasert, Dr. Surirat Sriswasdi, Dorji Gyeltshen, and Changlo

pain, intensive care, and cardiopulmonary resus- culturally irrelevant care. In addition, there are citation. WFSA-BARTC graduates also asked for many lessons learned from various organizations, the same courses, including anesthesia for special which have programs relying only on visiting vol- procedures such as kidney transplantation and unteers to provide health care. For example, when laparoscopic surgery. Such actions clearly dem- the visiting surgeons leave the community and onstrate the life-long learning mind and the great there is no surgeon to provide follow-up care or attitude of professional development in these treat infections that may arise, serious complica- alumnae to pursue quality health care in their tions may result. Such poor surgical outcomes homeland. can be avoidable if there is a continuity of care Every effort should also be done to recruit by local physicians. Thus, the impact on local trainees into the specialty of anesthesia and to medical systems could cause signifi cant harm retain them locally. Thus, the continuity and sus- and hinder the success of the mission [25 ]. tainability of quality health care can be achieved. These global health activities use the form of short-term medical missions that may undermine the local health care system, and could cause sig- Service nifi cant harm and adversely affect the success of the mission [24 ]. Researchers have documented a Ideally, long-term medical missions can allevi- number of reasons for these failures, including ate the problems of short-term medical missions the economic situation of the country, hospital and involving unfamiliarity with sociocultural differ- national politics, personality confl icts, and con- ences, communication, and lack of follow-up tinued lack of resources. In addition, language care. It also can cultivate trusting relationship differences between the team and the host coun- with patients and communities. However, long- try add another challenge. Wolfberg emphasized term medical missions have higher costs, sched- the importance of developing strong relation- ule constraints, and more complex logistics. ships with local physicians with respect for their Therefore, many global health activities use the skills and traditions, so that follow-up care could form of short-term medical missions that could be achieved when the visiting staff left the com- undermine the local health care system, by unfa- munity [13 ]. Gorske discovered considerable risk miliarity with the local medical needs, diagnos- for medical errors from short-term medical mis- tic and management algorithm, and providing sions such as lack of understanding of the critical 112 V. Lekprasert et al. issue of the short-term medical mission setting resources, population growth, demographic itself and the increased risk of serious patient changes, and environmental and biological dan- harm, lack of knowledge of the individual patient, gers threaten us all. Research should be con- and inadequate time for obtaining accurate and ducted even in underserved communities to complete history [26 ]. improve quality health care and ascertain the Errors originated from lack of adequate health effective use of limited resources. records, poor-setting infrastructure, and language In under-resourced locations, high technol- barriers [25 ]. The nature of short stays in limited ogy research with surrogate outcome such as medical missions also causes complications due laboratory testing may not be relevant. However, to insuffi cient patient screening, and lack of fol- research in these areas should involve various low- up care. Extended medical missions clearly global health programs as a means to improve provide better outcomes, but the cost of such mis- health care quality. It is also vital to create sions can be prohibitive. In addition, the current learning community services through continu- global burden of surgical disease is still high, and ing quality improvement projects or clinical well-planned and organized short-term medical research. Most international health service missions may be more cost-effective and cover a research is facing the problem of bringing larger scope of world population health. Every research solutions into practice [29 ]. An effective possible means to bridge the gaps of cultural dif- way to get research into practice uses a differ- ferences, ethical values and endemic barriers ent approach by formulating research questions should be mobilized in order to achieve high from challenges in routine service or work. The quality in short-term medical missions. Without so-called “Routine to Research” (R-2-R) has been stable, collaborative partnerships with local phy- described by Professor Vicharn Panich, director sicians and community workers, it is diffi cult to of the Knowledge Management Institute (KMI) enact sustainable improvements in health care in Thailand and has been shown to solve ser- quality from even well-intended missions. vice/work problems while improving working Within Nepal, one of the authors (BMS) has quality at the same time (personal communica- helped organize surgical and medical camps in tion). Many models have been used to measure remote areas (Fig. 8.4 ). In these parts there is the success of R-2-R projects, such as quality, minimum equipment and drugs which sometimes timeliness, and cost reduction. For example, a have to be transported on the backs of donkeys. group of doctors and nurses from Siriraj hos- Oxygen cylinders are too heavy to be transported pital in Thailand noticed that after percutane- so most work is done with oxygen concentrators ous coronary intervention (PCI), patients often [27 ]. As there is no electrical power in remote experienced pain due to being immobile for up areas generators are used. Other equipment such to 10 h after the procedure. To alleviate the pain, as portable halothane vaporizers, Ambu bags, they described the “Siriraj Leg Lock” to confi ne foot suction (occasionally electrically powered), the hip while allowing patients to freely move portable pulse oximeters, and other drugs and other parts of their body without compromis- tubes is available. Esophageal stethoscopes are ing the postprocedural wound [30 ]. The study used as cardiac and respiratory monitors. result showed signifi cant less pain and more Modifi ed Bain circuits are available when an patient satisfaction without increasing wound air–oxygen–halothane mixture is needed [ 28 ]. complication. Local communities tend to participate and cooperate well with research solutions since the Research working staffs that experience the problems conduct the research. The cycle of Continuous In this twenty-fi rst century, the health of people Quality Improvement (CQI) in communities can in the world is more closely linked than ever as be sustained by the support of the program, on a we are all interconnected. Problems of limited national scale. In Thailand, four large organizations 8 What Do Patients and Communities Expect of a Medical Mission? 113

Fig. 8.4 Surgical camps in the Himalayas. Maharjan SK, Anaesthesia for cleft lip Surgery—Challenge in rural Nepal. K.U. Med. J. 2004: 2(2): 89–95

(Ministry of Health, Siriraj hospital, Thai Health Expectations from a Medical Promotion Foundation, and the National Health Mission Security Offi ce) signed the Memorandum of Understanding (MoU) for the support of R-2-R The Patients’ Perspective in August 2008. Walley et al. suggested from their experience that these research and develop- The fi rst thing the patient expects from any medical ment programs should be linked and adapted for team is that he/she will be well looked after and successful expansion [29 ]. will be cured of his/her disease. While expecting 114 V. Lekprasert et al. these results, patients may have many other doubts and cultural attachments there is one voice which about the team, perhaps related to previous makes it easier for a medical team to function. experiences. But it is not always so. A community that is spec- Questions raised include: Will he/she be lis- ifi ed geographically will have many ethnic tened to and heard properly and be seen by a groups with a variety of social customs or beliefs. properly qualifi ed physician? Most of the time A politically demarcated community will have a due to the large number of patients examined and party volunteer and work at the direction of the treated and the short duration of stay of the medi- party affording benefi t only for that particular cal team, there may be inadequate time to realize party community. these ideals. Doubts may arise and with whatever Expectation differs across cultural, racial, and sincerity the treatment was advised, the patient ethnic groups. Even then the community has many may not accept it. Patients believe that the team common expectations from a medical team. will respect his/her social and economic back- • Good intention—Serve for the benefi t of the ground. Any unnecessary remarks or comments local community without any self-interest. from the team hurt their feelings and provoke • Qualifi ed—Volunteers have appropriate medi- resentment. Again, problems may occur for an cal training as well as accountability. otherwise successful medical mission. Patients • There is no interference in religious views, who come for treatment are of different religious social activities, and beliefs of the community. background. They may not like for any sugges- • The ability to provide therapies that address tion or misinterpretation of their religion from a the root causes exists. visitor. • The team should not impose burdens on local Similarly there are often local beliefs and health facilities: they should provide relevant customs in the society integral and even unique to care and not leaving behind medical waste. them. To get away from unnatural beliefs and cus- • There should be no negligent care. toms, it takes time and proper convincing. A med- • Current standards of health care delivery or ical team visiting for short periods, may fi nd it public health programs should be appropri- very odd but these belief must be taken into ately followed [31 ]. account. • Due permission and clearance should be Now more and more patients based on past obtained from the concerned authorities experiences know that they must be treated by before initiating medical work. qualifi ed physicians and expect an ethical practice Some medical missions believe that providing from them. They like to be given a proper explana- some care is better than providing none at all. tion about their disease process, treatment, options Drs. Bishop and Litch, codirectors of the Kunde and expected outcome. In more serious cases they Hospital in Nepal, have explained why this phi- may or may not want families to be involved in losophy is misguided: decision making for treatment and surgery. • “ It is inappropriate arrogance to assume that Patients do expect that the information about them anything that a Western doctor has to offer his will be confi dential and protected. less developed neighbor is progress. These [Western physician] tourists are often working outside their trained specialty or have little Community Expectations concept of how that specialty applies to Nepal. They frequently don’t understand local illness Community involvement plays a great role in presentation, culture, or language. They often achieving success or failure of medical missions. offer inappropriate treatment because they Normally the community has common denomi- think they ‘must give something.’ The consul- nators: a specifi c geographical area may have an tations are often one off, with little possibility organized government plan or be bound by social for follow up and the local health providers or cultural tradition. Usually with similar social are left to pick up the pieces with no record of 8 What Do Patients and Communities Expect of a Medical Mission? 115

the consultation. If an unregistered doctor Professor Babu Raja Shrestha, Professor of Anesthesia on holiday in the United Kingdom offered and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal for his assistance in the prep- general medical consultations in a shopping aration of this chapter. centre there would be a public and professional outcry.” [32 ] References

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Miguel Trelles , Patricia Kahn , Jason Cone , and Carrie Teicher

value in reducing mortality, morbidity and disabil- Introduction ity and improving quality of life [ 2 , 3 ]. In working to translate this notion into practice, we and others Médecins Sans Frontières/Doctors Without have also learned that—contrary to a common Borders (MSF) is an independent medical humani- view of surgery as unrealistically expensive and tarian organization formed in 1971 by a small complex for diffi cult settings—basic surgical care group of French doctors and journalists with the provided at the low-cost district hospital level can aim of providing emergency care to populations in be surprisingly cost-effective, and “might compare danger. The underlying principle is that this assis- favorably with selected primary health interven- tance is offered based solely on need, irrespective tions in terms of cost-effectiveness” [4 –6 ]. of race, religion, gender or political affi liation. What is also clear from our work in emergency/ Surgical programs have been part of this response low-resource settings is that surgeons and anaes- in some settings since the early 1980s [ 1 ]. With thetists need to discard preconceived notions of an MSF now active in more than 70 countries, these inevitable link between the technical complexity surgical activities are undertaken in a wide array of surgical and anesthesia techniques and the abil- of contexts, ranging from confl ict zones such as ity to reduce morbidity and mortality. On the con- Afghanistan, Democratic Republic of Congo, and trary, we have found that keeping our interventions Syria, to natural disasters (e.g., the earthquake in simple, accessible and sustainable within a given Haiti and Typhoon Haiyan in the Philippines) to context is often the most effective way to best low-resource but more stable environments such as serve the needs of the many. In MSF-Belgium India and Burundi. projects, the focus is on providing access to quality A key conclusion from this experience is that surgical and anesthetic management in programs basic surgery should always be considered as an that are well adapted to each context and to the integral part of medical care, even in the most needs of the local population. remote and impoverished settings, given its proven

M. Trelles (*) MSF-Belgium , Brussels , Belgium Overview of Surgical e-mail: [email protected] and Anesthesia Activities P. Kahn • J. Cone MSF-USA , New York , NY , USA The countries and contexts where MSF-Belgium C. Teicher had surgical missions at the end of 2013 are Epicentre , New York , NY , USA shown in Table 9.1 . All but two are in either

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 117 DOI 10.1007/978-3-319-09423-6_9, © Springer International Publishing Switzerland 2015 118 M. Trelles et al.

Table 9.1 Ongoing Country Project Context Program description surgery projects, 2013 Afghanistan Kabul Confl ict Obstetrics, general surgery Khost Confl ict Obstetrics Kunduz Confl ict Obstetrics, general surgery Burundi Gitega Post-confl ict Obstetrics (fi stula repair) Kabezi Post-confl ict Obstetrics DRC Masisi Confl ict Obstetrics, general surgery Niangara Confl ict Obstetrics, general surgery Haiti Tabarre Stable Orthopaedics, general surgery India Mon Stable Obstetrics, general surgery Mali Douentza Confl ict Obstetrics, general surgery Mauritania Bassikounou Confl ict Obstetrics, general surgery Pakistan Timurgara Confl ict Obstetrics, general surgery Philippines Guiuan Natural disaster Obstetrics, general surgery Sierra Leone Bo Post-confl ict Obstetrics South Sudan Gogrial Confl ict Obstetrics, general surgery Gumuruk Confl ict General surgery Somalia Burao Confl ict Obstetrics, general surgery Syria Jabal-Akkrad Confl ict Obstetrics, general surgery

Table 9.2 Overview of surgical activities, 2010–2013 Indicator (#) Total 2013 2012 2011 2010 Patientsa 59,824 14,199 14,583 19,296 11,746 Casesb 77,048 19,395 19,145 22,964 15,544 Proceduresc 83,004 21,774 20,865 24,101 16,264 Main surgical indicators Violent traumad 4,767 (xx %) 1,445 (10.2 %) 1,277 (8.8 %) 1,086 (5.6 %) 959 (8.2 %) Accidental trauma 10,283 (xx %) 3,808 (26.8 %) 3,075 (21.1 %) 1,927 (12 %) 1,473 (12.5 %) Obstetricale 25,719 (xx %) 6,337 (44.6 %) 6,785 (46.5 %) 7,644 (47.5 %) 4,953 (42.2 %) Other pathologies 15,876 (xx %) 2,609 (18.4 %) 3,446 (23.6 %) 5,460 (34.0 %) 4,361 (37.1 %) Total 56,605 14,199 14,583 16,077 11,746 CK 56,646 No. of projectsf 18 22 21 19 a Number of new cases b Number of Operating Room. visits cNumber of surgical procedures performed during an intervention. MSF data tools allow reporting up to three procedures. For data analysis, only the fi rst entry is considered because not all projects reported multiple procedures in one surgical intervention d Violent trauma cases as cause for intervention (only new cases) e Percentage of Caesarean sections uses patient number (new cases) as the denominator f Number of active projects during 2013 emergency settings (confl ict or natural disaster) or or limb is at stake and surgery must be done as post-confl ict regions. soon as possible, usually within hours. Essential The core activity at these projects is the provi- surgery addresses conditions that may not imme- sion of lifesaving and essential surgery that diately affect health or life but will considerably requires only low technology and is based in dis- impair the quality of life or present a serious trict hospitals or in the subset of primary health future health threat, and that are amenable to a centers with surgical capacity. Lifesaving surgery proven surgical treatment. is defi ned as any procedure performed in response Table 9.2 gives an overview of the main surgi- to an acute state in which the patient’s life, organ, cal activities in these and 10 other (no longer 9 Anesthesia in Resource-Poor Settings: The Médecins Sans Frontières Experience 119

Table 9.3 Types of 2013 2012 2011 2010 anesthesia used at surgical Type of anesthesia # % # % # % # % projects, 2013 Spinal 7,208 37.2 7,294 38.1 7,797 39.7 5,224 33.6 General 7,945 41.0 7,971 41.6 7,961 40.5 7,033 45.2 Intubated 2,183 11.2 1,933 10.1 2,110 10.7 1,636 10.5 Local/regional 1,417 7.3 1,383 7.2 1,191 6.1 1,139 7.4 Combined/others 642 3.3 564 3.0 585 3.0 512 3.3 Total 19,395 100.0 19,145 100.0 19,644 100.0 15,544 100.0

Table 9.4 Ketamine doses and administration at MSF- Spinal anesthesia (SA) is indicated for surgery Belgium surgical projects below the umbilicus, i.e., lower limb surgery, sur- Parameter Anesthesia Analgesia gery of the inguinal area and amputations; for Route IM/rectal IV IM IV Caesarean sections we use hyperbaric bupivacaine. Dose (mg/kg) 8–10 1–2 2–4 0.3–0.8 Neither adrenaline nor opioids are added to our Onset (min) 5 1–2 5 1–2 protocols, as we see no clear advantage. Duration (min) 20–30 10–15 – – Maintenance (mg/kg) 5 0.5–1 – – Frequency (min) 20–30 15–20 – – Principles in MSF Field Anesthesia Practice active) surgery projects during the years 2010– 2013 [7 ]. Focusing on the 14,199 patients treated A key fi rst principle in our surgical missions is in 2013, the most common indication for surgery that it is feasible, although challenging, to do was obstetrical (44.6 % of all patients), 79 % of safe anesthesia with basic tools and infrastruc- which were Caesarean sections (data not shown). ture: after all, millions of episodes of anesthetic Accidental trauma was second (26.8 %), fol- administration are performed safely around the lowed by violent trauma (10.2 %). At the same world every year in relatively low-technology time, certain projects involved more complex, settings. Clearly this requires anaesthetists with specialized types of surgery, for example, high- certain critical skills, but a trained anesthesiolo- standard orthopedic procedures such as osteosyn- gist should know how to deal with the types of thesis and obstetric fi stula repair. emergency situations (such as hemorrhagic shock In terms of anesthesia practice, around 90 % or polytrauma), which happen everywhere. So in of all surgeries in 2010–2013 used either gen- this sense there should be no essential difference eral or spinal anesthesia, as shown in Table 9.3 . between anesthetic practices in Western versus General anesthesia in most MSF contexts uses resource-poor settings; the difference is in prac- the intravenous agents ketamine and thiopental tical implementation stemming from context- as well as the inhalation agent halothane. We specifi c constraints. consider ketamine an excellent choice for fi eld The fundamental principles we apply to fi eld settings due to its ease of use and safety profi le anesthesia are: and its widespread uptake throughout middle- • Primum non nocere —patient safety comes and low-income countries (Table 9.4 ). (However, fi rst. To achieve this, projects that use ketamine must have resuscita- • Simpler is often safer. We therefore keep pro- tion material available, due to the known risk tocols, equipment, etc. as basic as possible, of respiratory arrest.) Drugs used for muscular which helps us implement relaxation and intubation include depolarizing • The best practices for the majority of patients agents (suxamethonium) and non-depolarizing (“the best for most”). To achieve this, agents (vecuronium, atracurium). • Flexibility is key to effectiveness. 120 M. Trelles et al.

On a practical level, MSF surgical/anesthesia where we work, only males can provide consent, activities follow these basic principles: so for female patients we need approval from the • Privacy and respect for the patient. husband or father. Sometimes the issues around • Consent of the patient, or, if she/he is unable to obtaining consent delays surgery, and the medi- consent, his or her representative must do so. cal team might sometimes consider going ahead • Surgery is intrinsically linked to anesthesia, in exceptional cases if there is urgent medical and vice versa. need but the family could not be briefed on the • Surgical and anesthesia providers have a formal severity of the patient’s condition. However, qualifi cation or MSF validation. especially in contexts with high security con- • Surgery and anesthesia arsenals (techniques, straints, it may be better not to proceed under equipment, and drugs) are safe, simple, and these circumstances, because the reaction if a effective, allowing in most cases a low depen- patient dies may be incomprehension, blame or dence on sophisticated technology. even violence. • Tight collaboration between the surgical and A situation we faced in one project after anesthetic providers is assured. a natural disaster illustrates this problem. A • Before the start of new projects, a number of 9-year-old girl arrived at a neighboring hospi- defi ned prerequisites must be in place. tal (run by another international organization) • Surgery and anesthesia care encompass that was treating pediatric patients. They called preoperative, intraoperative (perioperative), our surgeon to consult, and he determined that and postoperative care. the child had acute abdominal pathology and • Quality control is assured by following MSF urgently needed surgery. But when the anes- policies, guidelines and protocols; and by thetist arrived and asked for the child’s parents, appropriate record-keeping of patient fi les, he learned that they had gone to the market to including anesthesia/surgical information and buy milk for the child. The surgeon was in a other relevant clinical data. quandary about whether to proceed, but after • Emergency preparedness is essential, ensuring some discussion he accepted the need to wait. the maintenance of skills; the permanent avail- The medical team could not anticipate how the ability of minimum materials, well-functioning parents might react if they returned to fi nd their sterilization facilities, and regular review; and child in the operating theatre; if the child died, updating of a Multiple Casualty Plan. they might think that the operation killed her. Since we were in a very violent neighborhood, it was conceivable that someone might have a Key Challenges weapon, or come back later to kill the surgical and How MSF Adapts team. Fortunately the parents returned quickly and gave consent, and the surgery proceeded Adapting to the Local smoothly. But the story illustrates a risk that Cultural Context affects our decision-making. Beyond informed consent, cultural norms Although perhaps not evident at fi rst glance, related to modesty also affect our work. If an cultural issues are essential to the way we work anesthetist wants to perform spinal anesthesia but as fi eld anesthesiologists. Informed consent pro- the (female) patient arrives completely covered vides a good example. Consent is important not and refuses to even show her back, the medical only as an administrative procedure but, much team needs to be fl exible, innovative and yet cau- more—especially in settings where many people tious. In our projects we work on the premise that cannot read—as a way of explaining to the patient everyone has the right to make decisions about (or family) what will happen during the surgery, their own body regardless of whether they are what outcome(s) to expect and what diffi culties knowledgeable about medical issues or share our and complications might arise. In many settings beliefs. 9 Anesthesia in Resource-Poor Settings: The Médecins Sans Frontières Experience 121

Table 9.5 Gender 2013 2012 2011 2010 distribution of surgical Gender # % # % # % # % patients, 2010–2013 Female 8,698 61.3 9,072 62.2 10,498 65.3 7,323 62.3 Male 5,501 38.7 5,511 37.8 5,579 34.7 4,423 37.7 Total 14,199 100.0 14,583 100.0 16,077 100.0 11,746 100.0

2000 1800 1600 1400 1200 1000 800 600 400 200 0

Female Male

Fig. 9.1 Age distribution by gender at MSF-Belgium surgical projects, 2013

Adapting to the Patients’ they may need money for the journey, or a means Profi les and Pathologies of transport. We therefore receive many patients who delayed leaving home when they became ill, Working in war-affected and underdeveloped or spent several days traveling to the hospital. countries with largely broken health systems Many have been treated by a traditional healer means treating patients with very different pro- before coming to our hospital. Over the few days fi les and pathologies than those in a typical of these delays, an easily treatable pathology Western hospital [8 ]. such as appendicitis can become life-threatening Although most of our surgical missions acute peritonitis. receive trauma patients, the majority of whom are The most common pathologies in our surgical male, overall more than 60 % of our surgical patients are obstructed labor, acute abdomen and patients in 2010–2013 were women, as shown in fractures (trauma), although this varies widely Table 9.5 . They were also overwhelmingly young among projects. For obstetrical patients, a typical (see 2013 data in Fig. 9.1 ), with a mean age of 28 scenario is obstructed labor leading to a ruptured years old for women and 27 for men. Another uterus, so the patient arrives in shock with the baby characteristic of the patients who reach our facili- in her belly. We also see many cases of postpartum ties is that they typically have an acute pathology, hemorrhage, as well as eclampsia and preeclamp- such as appendicitis, obstetric emergency, or sia. Our general surgery projects frequently strangulated hernia, since people with diseases receive patients with visceral abdominal patholo- like cancer or heart failure usually die in these gies, such as peritonitis, often stemming from settings due to lack of care. The decision to seek obstructed hernia. The number of trauma cases is care is often diffi cult for our patients, because highly dependent on the setting: for example, a 122 M. Trelles et al. project at a distant hospital in rural Congo may see Clarity About Our Role fewer trauma cases because patients die before and the Patient Population We Serve they reach the hospital. Most projects receive many patients with limb injuries, who tend to sur- Anesthetists working in Western countries usually vive the initial trauma, as well as patients with rely heavily on technology for evaluating and blunt trauma of the liver or pancreas. monitoring patients, and typically want the same A common challenge these trauma cases pres- machinery to be available at our missions. ent for anesthesiologists is the need to deal with However, this is often not feasible or wise, as the hemorrhagic shock even when blood supplies are examples below illustrate. In practice, decisions extremely limited. Under these circumstances it is on whether and what technology to transfer to sometimes necessary to use autologous hemotrans- the fi eld, and what protocols to follow, go to the fusion, a procedure that—while not well-known in heart of understanding our role and how to best Western countries—has saved many lives in MSF serve the most underserved patients—and have settings. Teams experienced with this procedure led MSF to the principles, mentioned earlier, of often perform autologous hemotransfusion from prioritizing simplicity and working towards hemothorax and ectopic pregnancy. At the same sustainability [10 ]. time, the use of tourniquets, quick-clot gauzes, and For example, should we use an electrocar- intraosseus access with drill is common. Ketamine diograph in our surgeries? While the answer is anesthesia has proven to be a good solution for this obvious for Western settings, consider a rural kind of pathology [9 ]. hospital in a remote region of a low-resource Despite this profi le being heavily skewed country where we work with and train local towards acute pathologies, 95 % of our surgical staff. First, the nurse anesthetist must learn patients in 2013 were considered to have a stable what an electrocardiogram is and in what situ- physical status prior to surgical intervention, ations we use it. Then she/he must learn about since they received scores of ASA1 or ASA2 on the different arrhythmias, how to distinguish the American Society of Anesthesiologists them, and the drugs needed for each one—and, (ASA) scale. This scoring system subjectively to be worth this considerable effort, all these categorizes patients into six subgroups based on drugs should be available locally. At the same preoperative physical fi tness. It makes no adjust- time, intensive care facilities are scarce in these ment for age, sex, weight, or pregnancy, nor does settings. Maintaining and repairing electrocar- it refl ect the nature of the planned surgery, the diograph equipment presents yet another set of skill of the anesthetist or surgeon, the degree of problems. For these reasons, we have found it preoperative preparation, or facilities for postop- safer and more feasible in practice to rely on erative care, and thus may not provide the infor- simpler monitoring protocols, which MSF mation best suited for our populations. At the developed based on the minimal standards for same time, poor general health of our patients is different levels of health care facilities as estab- another factor surgeons and anesthetists must lished by the World Health Organization (WHO) often consider. For example, many patients in (2003). MSF standards call for the availability low-resource settings have chronic anemia, with of equipment that is simple, safe, and easy to levels of hemoglobin that are astonishingly low understand and maintain–at a minimum, oxygen by Western standards and that potentially com- (mainly with oxygen concentrators) and basic plicate any surgical intervention: we have seen monitoring equipment (stethoscope, sphygmo- cases of women arriving at our facilities with manometer, pulse oximetry) must be on hand at hemoglobin levels of 5 g/dl, well below the 12 g/ all MSF missions with surgical activity. In addi- dl which defi nes anemia in adult women, and tion, sites must have adult and pediatric resus- even below MSF’s threshold for proceeding to citation bags, suction device (which may be as transfusion, i.e., 7 g/dl. simply as a foot sucker), laryngoscope set and 9 Anesthesia in Resource-Poor Settings: The Médecins Sans Frontières Experience 123 intubation material, Magill forceps, anesthesia Managing Human Resources masks of different sizes, pressure infusion bag, for Field Anesthesia and a standard list of drugs and consumables. Another aspect of this basic-versus-high tech- Anesthesia providers in MSF medical structures nology issue to consider is its potential impact on are drawn from a range of personnel that includes the patient population we serve. For example, our anesthesiologists, nurse anesthetists, other types obstetrical surgery projects mainly prioritize of physicians or nurses, and anesthesia techni- Cesarean sections and other obstetrical emergen- cians. At the fi eld level, the choice of anesthetist cies. Expatriate medical personnel arriving at depends upon the human resources (HR) avail- these projects sometimes suggest installing incu- able, the type of project, whether or how much bators for premature babies. But there are usually training is conducted, and the quality and quantity very few such facilities in the region—so having of surgical interventions. HR constraints, in these incubators would transform our projects turn, are shaped by both the quality and back- into the most advanced maternal centers far and ground of the anesthesia provider (anesthesi- wide, which in turn could end up drawing the ologist vs. nurse anesthetist; expatriate vs. country’s elite as patients, rather than the local national staff). populations we came to serve and who otherwise Expatriate anesthetists, especially those who have little access to care. are new to the fi eld, are likely to face several A related issue that infl uences our way of challenges, starting with the fact that she/he may working, including the choice of equipment not be trained to work under adverse conditions and protocols, is sustainability, given that MSF or in very basic settings, or to use basic drugs missions typically last from periods ranging such as ketamine [7 ]. from several months (e.g., after a natural disas- The types and status of anesthesia equipment ter) to 4–5 years, and occasionally longer. For at surgical projects varies widely, but the standard example, we could bring sophisticated anesthe- equipment is usually very basic and high- standard sia drugs used in the USA and elsewhere into biomedical devices are rare. Operating Theaters our missions. But if we base protocols on these may lack monitors and/or defi brillator equipment, drugs, what happens when we leave? First, it and anesthesia machines with ventilators are also will be diffi cult or impossible for the host coun- uncommon (Ambu-type self- infl ating bags offer try, institution or patients to access and afford one solution). Oxygen cylinders are not often these medicines. Second, there will be few staff available; in this case oxygen concentrators are a trained in their use beyond those who worked useful alternative. There must be a pulse oximeter with MSF. So instead we focus on medications that measures the saturation and pulse, as called that are commonly used in the region, that local for by the WHO-recommended standards and staff know how to use, and that are affordable. followed by MSF [9 ]. We do not use central When a project closes, we endeavor to leave venous catheters or central venous access due to behind a functional unit that can continue pro- the diffi culty of assuring good-quality care of viding at least some basic care. Whether this is these devices in the fi eld and to the need to avoid possible depends on many local factors, includ- serious complications, especially infection, ing security, availability of drugs and consum- related to incorrect use. ables, and the skill level and training of local This means that anesthesiologists at MSF staff (see following section). It also depends projects usually have to rely mostly on clinical greatly on the circumstances of our departure, parameters, using their eyes, ears, and knowledge and is often impossible if we are forced to to make diagnoses without access to an arsenal of leave unexpectedly due to a host government tools or tests, and to follow patients during sur- withdrawing permission for us to work, or to gery without advanced monitoring devices. She/ increased security risks. he will probably need to take a blood pressure 124 M. Trelles et al. measurement with a cuff every 5 min during sur- knowledge and skills. In other settings, we gery, because typically no automatic machine is encounter staff with no training at all in anesthe- available. Without all the customary technology, sia. So for example, at some projects in the the anesthesia provider’s clinical skills are criti- Democratic Republic of Congo (e.g., Masisi), we cal. Moreover, she/he is alone and fully in charge, worked alongside local staff for several years, and may even have to multitask—for example, teaching them the very basics at fi rst and pro- functioning as a circulating nurse who hands sup- gressing all the way to intubation; now they are plies to the surgeon. working independently. Such skills are not easy to fi nd: surgeons and Occasionally we do training in more advanced anesthesiologists are scarce, and those who func- technologies for specifi c projects. One example tion well in resource-limited settings are even is a peripherally inserted central catheter (PICC). rarer. For this reason, training is an important These can only be used in selected projects, since core activity of MSF-Belgium surgical missions. in most settings they could do more harm than Different training schemes target different type good. But we introduced them at two projects of specialists, taking into consideration their designated as trauma centers: Kunduz, in north- skills and knowledge, as well as the skills and ern Afghanistan, which has an intensive care unit knowledge needed for implementing MSF’s and where we trained local physicians on using medical strategies and protocols. PICC lines; and Tabarre, in Port-au-Prince, Haiti, Another important HR task is to train local where we trained nursing staff, who already have staff. The need to do this may not be obvious, good training and strong skills. since some international organizations work by bringing in all essential personnel from outside— an approach that usually produces good outcomes Interacting with Local Staff from the project’s beginning [11 , 12 ]. However, it also means that the hospital usually closes at the Expatriates usually account for only a small pro- end of the mission, since there is insuffi cient local portion of staff at our surgical projects, with capacity to continue its work. At MSF-Belgium national staff typically comprising up to 95 % of we try to avoid this approach and instead to incor- personnel. Our experience is that workplace inter- porate local staff development into our activities. action between these two groups often brings A few years ago this often meant a “task shifting” some predictable challenges, given the likelihood model, especially in countries where there were of a language gap and sometimes the very minimal simply not enough educated, highly trained peo- skill level of local health workers. In some coun- ple to meet the need for anesthesia services [13 ]. tries where we work, nurses study for only In practice, task shifting meant turning over 6 months, and may not know how to perform basic anesthesia to someone without much education arithmetic calculations or to correctly provide and who would work independently. This was nursing care. Consequently, when an expatriate MSF’s approach in Somalia (e.g., in Guri’el, doctor asks a nurse to do something, the potential where we trained auxiliary nurses in safe anes- for misunderstanding and error is enormous. For thesia, which in this setting meant only ket- example, in one of our projects, an anesthesiolo- amine and perhaps spinal anesthesia but not gist asked the nurse to give a patient “10 mor- intubation [14 ]). phines” for postoperative pain. The order was then Where possible, we now look to “task sharing” translated by a (non- medically specialized) trans- —for example, by going into hospitals to coach lator; not long afterwards the patient went into and work alongside national staff for an extended respiratory depression. It emerged later that the period of time [ 15]. Sometimes we work with nurse had understood the doctor’s order to mean local staff who are certifi ed nurse anesthetists but 10 ampules of morphine rather than 10 mg (i.e., have not been trained to a high standard, sending one ampule), as the doctor had intended. So the doctors to work with them and improve their patient got 10 times the intended dosage. 9 Anesthesia in Resource-Poor Settings: The Médecins Sans Frontières Experience 125

This unnecessary complication served as a ing paracetamol, diclofenac, ibuprofen (Level reminder that our protocols should be designed 1), codeine, tramadol (Level 2), and morphine with the lack of trained staff in mind, by return- (Level 3). Morphine is the opioid of choice and ing to principles of operational simplicity and is preferable to fentanyl (short duration) or pethi- sustainability. Our protocols now call for giving dine/demerol (weak effect). However, it is difﬁ - as much medication as possible by mouth, and in cult to use in the ﬁ eld because few of our staff the fewest possible doses. members are trained to recognize morphine’s It is also crucial for expatriates to remember complications. So we usually advise using and that local staff are salaried workers with families following WHO recommendations, which distin- and communities nearby, and often cannot match guish three level of pain management beginning the intensive work schedule of outsiders present with paracetamol and using morphine only at a in the country for a short-term mission focused last resort. Since the dosage requirement of indi- on doing humanitarian work. viduals varies, the use of pain scores and clinical examination is mandatory.

Helping Patients Manage Pain Pragmatic Outcomes Pain management is especially challenging in and Future Directions MSF surgical projects for several reasons, starting with limitations on the types of medications In typical MSF fi eld contexts, where the popula- available. Another factor is that patients may tion’s basic health needs are usually not being met, have a cultural expectation that pain is part of the issue of quality is often neglected. This neglect life, which can mean that that they do not com- stems largely from the common misperceptions plain about or even mention their pain. In our set- that placing priority on the expansion of coverage tings, we train the local staff that pain is also a inevitably means less focus on quality, and that vital sign. Therefore, patients should be system- improving quality requires adoption of more atically asked during ward rounds about the pain expensive measures, leading to ever- escalating they are feeling, based on the use of scales. We costs. In our experience, reality is much less mainly use the Face Rating Scale, where a range black-and-white. Ensuring quality at our mis- of different faces (from a big smile to a crying sions begins with the availability of clear institu- face) is showed to the patients. tional policies, relevant guidelines and strict Pain can be treated most effectively if it has protocols, all of which (as discussed throughout been properly evaluated, although we recognize this chapter) should be well-adapted to the specifi c that the patient is the only person who can truly context. It also extends to providing the best pos- know his/her pain intensity. The use of an evalua- sible work conditions for the surgical- anesthesia tion scale is mandatory in our projects, with results teams and requiring that they follow institutional recorded as for other vital signs. Protocols for pain practices to assure compliance and consistency in management are based on the following practices: patient care. • The sooner treatment is initiated, the better. In terms of monitoring quality, we use intraop- • It is advisable to give medication before the erative mortality as a proxy for the delivery of pain becomes intense. safe anesthesia care. In 2013 MSF-Belgium • Prescriptions should be systematic and taken reported 44 deaths related to its surgical interven- regularly at fi xed times. tions (cases = 19,395), an overall ratio of 0, 2 %— • Oral dosing should be used as much as an outcome which demonstrates that it is possible possible. to provide quality surgical-anesthesia care in fi eld • Preference must go to multimodal analgesia. contexts. However, assessing certain other aspects In the MSF context, the analgesics avail- of surgical care is more challenging, since the dif- able are WHO level 1, 2, and 3 drugs, includ- fi culty of following up with patients once they 126 M. Trelles et al. leave the hospital impedes the measurement of 4. Grimes CE, Henry JA, Maraka J, et al. Cost- post-discharge outcomes. This issue is a well- effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg. 2014; recognized challenge in the fi eld of global sur- 38(1):252–63. gery; hopefully in the future, we and others will 5. Gosselin RA, Maldonado A, Elder G. Comparative identify feasible ways to evaluate longer-term cost-effectiveness analysis of two MSF surgical surgical outcomes and quality. trauma centers. World J Surg. 2010;34(3):415–9. 6. Spiegel D, Gosselin R. Surgical services in low- On a broader level, while it is widely recog- income and middle-income countries. Lancet. 2007; nized that there is an acute need for surgeons to 370(9592):1013–5. deliver specialized services in low-income coun- 7. Wong EG, Trelles M, Dominguez L, et al. Surgical tries, the even greater need for anesthesia provid- skills needed for humanitarian missions in resource- limited settings: common operative procedures per- ers is often not highlighted [ 16]. In some formed at Médecins Sans Frontières facilities. humanitarian organizations, this gap is fi lled by Surgery. 2014;156(3):642–9. expatriate anesthesia providers (specialized med- 8. Debas HT. Disease control priorities in developing ical doctors and nurses), who make invaluable countries. In: Jamison D et al., editors. Disease control priorities in developing countries. New York: contributions to their programs and patients. Oxford University Press; 2006. p. 1245–60. However, it is also a reality that the growing gap 9. World Health Organization. Pulse oximetry training between the so-called Western anesthesia prac- manual, Geneva. 2011. www.who.int/patientsafety/ tices and the requirements and limitations of fi eld safesurgery/pulse_oximetry/tr_material/en/ . 10. Luboga S, Mcfarlane SB, von Schreeb J, et al. anesthesia make it increasingly diffi cult to fi nd Increasing access to surgical services in Sub-Saharan broadly trained anesthesia specialists with the Africa; priorities for national and international agen- capacity to be suffi ciently adaptable and fl exible, cies recommended by the Bellagio Essential Surgery and to rely mostly on clinical skills rather than Group. PLoS Med. 2009;6(12):1–5. 11. Chu KM, Ford NP, Trelles M. Providing surgical care biomedical devices. A big challenge for the fi eld of in Somalia: a model of task shifting. Confl Health. anesthesiology (and humanitarian organizations) 2010;5:12. doi: 10.1186/1752-1505-5-12 . over the coming years is therefore to improve the 12. Ginzburg E, O’Neill WW, Goldschmidt-Clermont PL, local anesthesia capacity in low- income countries et al. Rapid medical relief—Project Medishare and the Haitian earthquake. N Engl J Med. 2010;362:e31. and to train developed country specialists in the doi: 10.1056/NEJMp1002026 . practice of fi eld anesthesia. 13. Mavalankar D, Sriram V. Provision of anaesthesia services for emergency obstetric care through task shifting in South Asia. Reprod Health Matters. 2009; 17(33):21–31. References 14. Chu KM, Trelles M, Ford NP. Quality of care in humanitarian surgery. World J Surg. 2011;35(6): 1. Chu K, Rosseel P, Trelles M, et al. Surgeons without 1169–73. borders: a brief history of surgery at Médecins Sans 15. Dawson AJ, Buchan J, Duffi eld C, Homer CS, Frontières. World J Surg. 2010;34(3):411–4. Wijewardena K. Task shifting and sharing in maternal 2. Meara JG, Hagander L, Leather AJM. Surgery and and reproductive health in low-income countries: a global health: a Lancet Commission. Lancet. 2014; narrative synthesis of current evidence. Health Policy 383(9911):12–3. Plan. 2014;29(3):396–408. 3. Lavy C, Sauveen K, Mkandawine N, et al. State of 16. Marchbein D. Humanitarian surgery: a call to action surgery in tropical Africa: a review. World J Surg. for anesthesiologists. Anesthesiology. 2013;119(5): 2011;35(2):262–71. 1001–2. Quality of Care: Maintaining Safety Through Minimum Standards 10

Kathryn Chu and Monique James

Introduction Safe Surgery and Quality of Surgical Care One of the greatest challenges in executing effective surgical missions in low and middle resource “Surgical care is defi ned as any procedure that countries (LMICs) is creating conditions that reduces physical disability and premature death meet surgical and anesthetic standards of patient by treatment of a surgical condition.” [2 ] In safety and quality care. When surgical teams recent years, the safety and quality of surgical from high income countries (HICs) perform care have gained much attention. With increased operations in LMICs, they make use of existing reporting of surgical outcomes, efforts have hospitals or in emergency settings, sometimes been made to minimize complications ranging establish makeshift clinical facilities [1 ]. from wrong-site surgery to preventable periop- Replicating HIC conditions would be impossible erative mortality. Patients also have a vested given technical and fi nancial restraints. However, interest in provider-dependent outcomes when even with resource limitations and time con- choosing a physician [3 ]. Safety in surgery straints, establishing minimum standards of care includes minimizing adverse perioperative is possible and necessary. Proper planning can events such as 30-day mortality, surgical site maximize the quality of care in both elective and infections, cardiac and respiratory complica- emergency surgical missions. tions. It also entails providing the conditions to improve quality of care. There are three pillars of quality of surgical care: structural inputs, processes of care, and direct outcomes measures [3 ]. Structural inputs include the availability and use of infrastructure and essential material or human resources. A safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, anesthetics and analgesics, and qualifi ed surgical and K. Chu , M.D., M.P.H. (*) Eerste River Hospital , Eerste River , South Africa anesthesia providers are the implements of care e-mail: [email protected] and the conditions in which the care is provided. M. James , M.D., M.P.H. Processes of care include protocols and surgical Icahn School of Medicine at Mount Sinai, Mount checklists, in other words, the way things get Sinai Hospital, New York , NY , USA done in a health care system. Direct outcomes

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 127 DOI 10.1007/978-3-319-09423-6_10, © Springer International Publishing Switzerland 2015 128 K. Chu and M. James measures include, at minimum, data on morbidity payment systems. In contrast, patients in LMIC and mortality, which are ideally used in process have little choice where they receive surgical and structural improvements [3 ]. services; however, their providers should still strive to deliver high quality care.

Quality of Care in Resource-Rich Settings Quality of Care in Resource-Limited Settings In high income countries, multiple well-established systems are in place to measure and improve The World Health Organization (WHO) estimates quality. For example in the USA, the Joint the frequency of worldwide perioperative events Commission is an organization that evaluates to be 3 % and surgical mortality to be 0.5 % with health care organizations and provides accredita- deaths and complications occurring dispropor- tion and certifi cation [4 ]. As of 2010, all US hos- tionately in LMICs [12 ]. Some countries in Sub- pitals were required to report compliance with Saharan Africa (SSA) have reported perioperative 57 process measures [5 ]. In addition, various mortality as high as 5–10 % [13 , 14 ], and high hospitals use the American College of Surgeons anesthesia-related mortality rates have been National Surgery Quality Improvement Program reported in Malawi (1:500), Zimbabwe (1:500), (ACS-NSQIP), a nationally validated, risk- and Togo (1:133) [15 – 17] which is signifi cantly adjusted, outcomes-based program that has been higher than in HIC (1:200,000) [18 ]. Most of these shown to decrease length of stay, complication deaths are avoidable and due to lack of available rates, mortality, and health care costs [ 6 – 9 ]. The blood products or inadequate or absent periopera- American Society of Anesthesiology’s Anesthesia tive monitoring such as lack of pulse oximetry Quality Institute (AQI) maintains a database of [ 15 –17 ]. perioperative outcomes and quality measures The quality of surgical care in LMICs is also through the National Anesthesia Clinical Outcome diffi cult to measure. Human resources are limited Registry (NACOR) and regularly develops best and collecting routine outcome data is challeng- practice guidelines for anesthesia practice through ing. Longitudinal outcomes such as 30-day mor- evidence-based medicine and consensus panels bidity and mortality are particularly diffi cult to [10 ]. Adverse events are reported and available track when patients cannot return for follow-up for later analysis through the Anesthesia Incident and/or do not have contact information. Currently, Reporting System (AIRS). Another program most LMIC hospitals are not required by any reg- which uses incentive payments to encourage ulatory body to report patient outcomes or imple- reporting is the Patient Quality Reporting System ment quality process measures. National quality (PQRS) which evaluate adherence to process systems like NSQIP, AIRS, and PQRS and hospi- measures such as pre-incision prophylactic antibi- tal accreditation organizations such as the Joint otic administration and perioperative temperature Commission do not usually exist. monitoring [11 ]. International organizations such as the WHO In addition, patients themselves are invest time and others that deliver surgical care in LMICs and money in fi nding hospitals and providers have begun to recognize this lack of oversight. In that give the best care available in the health care 2007, the World Health Organization (WHO) marketplace [ 3]—they seek the highest quality launched the Safe Surgery Saves Lives Project care through personal recommendations, national aimed at “improving the safety of surgical care hospital rankings, and Internet rating sites such around the world by ensuring adherence to as Doximity. Patients have the ability to choose proven standards of care in all states.” [19 ] among providers because there is a high physi- Acknowledging that anesthesia providers on cian- and specialist-to-patient ratio and they have medical missions will be practicing in areas with access to transportation and single- or third-party variable local quality standards, the remainder of 10 Quality of Care: Maintaining Safety Through Minimum Standards 129 this chapter focuses on the challenges of and Essential Surgical Care [ 20 ]. Developed in strategies for providing safe and quality surgical 2007 as part of The WHO Global Initiative on care in LMICs including ways to implement Emergency and Essential Surgery Care minimum standards on location. (GIEESC), the 152-item questionnaire evaluates infrastructure, human resources, procedures currently performed, and the availability of Minimum Standards for Surgical emergency equipment and supplies for resuscita- Missions tion. It was developed for LMIC and can be used by local and international organizations alike. Pre-trip Assessment Coordination with local health authorities must be clearly established prior to the mission. Surgical missions in LMICs may be conducted in In elective missions, collaboration with a local a variety of settings. Often, a team from a HIC is partner organization and use of a preexisting hos- invited by a LMIC government hospital or a pital is likely. How the surgical mission will fi t private organization to perform elective or semi- into the hospital’s routine service delivery must elective operations. In other instances, a be discussed with the appropriate management. humanitarian surgical team will set up surgical Surgical missions can disrupt routine health care care in a post-disaster setting such as a hurricane delivery but local staff may be reluctant to speak or an earthquake, or during a confl ict and perform out because they do not want to seem unapprecia- emergency procedures where no preexisting structive. In emergency missions, no functional hospi- ture or local partner is available [ 1]. In all instances, tal may exist. Obtaining permission from local a pre-trip assessment is essential to quantify avail- health authorities, such as the Ministry of Health, able resources. This can be done remotely but to deliver care is important. Assuming that surgical more ideally by a site visit prior to the start of the intervention is welcome without an invitation from mission. In an emergency, the assessment can be local health authorities is an arrogant attitude and done expeditiously before the entire surgical team can result in poor coordination and duplication of is mobilized, and should be conducted by the team services, especially in large disasters with many member(s) most experienced in surgical care for humanitarian teams [21 ]. the specifi c setting. This assessment refi nes mission objectives based on resources that are readily available or Minimum Intraoperative able to be mobilized. The specifi c role and capac- Standards and Quality Surgical ity of local partners, surgical providers, nursing Care in LMIC and support staff and the existing infrastructure, equipment, and supplies must be defi ned to meet In order to maintain safety and quality of care, the needs identifi ed in the assessment. The types surgical missions should strive to establish mini- of procedures that can be safely performed must mum standards. After large natural disasters, also be determined and team members briefed many humanitarian surgical mission teams are before the mission of these limitations. For eager to provide care. However, the safety and example, if the LMIC setting does not have the quality of care of some of the teams have been postoperative monitoring or nursing ratio for car- questioned by the general public and other surgi- diothoracic surgery, these procedures must not be cal teams. For example, after the 2010 earth- allowed even if surgical providers have the skills quake in Port-au-Prince, many amputations were to perform them. Recognizing when not to oper- performed by surgical missions and criticism ate is as important in a low resource setting as from other surgical teams arose regarding knowing when to operate. whether some of these were preventable if there A useful assessment instrument is the Tool for had been higher quality of care or standardized Situational Analysis to Assess Emergency and protocols [ 22 ]. 130 K. Chu and M. James

Structural Inputs

Médecins Sans Frontières (MSF), a medical humanitarian organization that has provided care in resource-limited settings for over 40 years, has established minimum criteria for structural inputs needed before humanitarian surgery can be delivered. These standards include a safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, anesthetics, analgesics, antibiotics, and qualiﬁ ed surgery and anesthesia providers [ 21 ]. Elective surgical missions should also adhere to these requirements [ 23 ]. While HIC resources such as intensive care units, invasive intraoperative arterial monitoring and computed tomography scan are not always available, basic structural, process, and outcome conditions should be established.

Fig. 10.1 In 2008, three hurricaines struck the island Safe Structure nation of Haiti. The Arbonite region was most severely afffected with the only hospital fl ooded and unusable. Surgical care must be delivered in a safe building. Medecins Sans Frontieres, a humanitarian organization, created a hospital in a warehouse in a few weeks. This In 2008, extensive fl ooding ruined the local hos- hospital had an emergency department, inpatient wards, pital in the Arbonite region of Haiti. During the outpatient clinics and an operating theatre pre-mission assessment MSF emergency coordinators determined the existing hospital could not be salvaged and a warehouse was converted Electricity into a temporary hospital with inpatient wards, an emergency department and an operating theater Surgical care requires electricity to power anes- within a few weeks [1 ] (see (Fig. 10.1 ). After the thesia machines and surgical equipment such as 2010 earthquake in Port-au-Prince, over 200,000 operating room lighting, electrocautery, and suc- persons died, thousands more were injured, tion. It is also helpful (but not necessary) to steril- and many buildings were structurally damaged ize equipment using autoclaves, clean linens, and including La Trinité, a MSF trauma hospital [24 ]. maintain refrigeration for the cold chain of medi- Alternative structures, including some govern- cations and laboratory reagents. In LMICs, elec- ment hospitals that were structurally safe but had tricity is a precious commodity that is not readily not been providing surgical care, were identifi ed available at all times. Some hospitals use back up and utilized. MSF also organized an infl atable generators during electricity shortages. Surgical tent hospital and eventually established a hospi- missions must be prepared for these conditions tal in a container that included operating rooms by purchasing gasoline for host generators, bring- and surgical wards [ 24 ] (see Fig. 10.2 ). These ing portable lighting, and using surgical and examples demonstrate that buildings that already anesthesia equipment that are battery-operated. in place, repurposed locations, or purpose-built In response to the lack of reliable power sources portable structures can all serve as hospitals in LMICs, many manufacturers have created when required. medical technology that does not rely on electricity. 10 Quality of Care: Maintaining Safety Through Minimum Standards 131

Fig. 10.2 A safe structure is needed for surgery. When a hospital or existing infrastructure is not available, alternatives are needed. Medecins Sans Frontieres has inﬂ atable tents for emergencies which have several departments including emergency, inpatient wards, operating theatres, and even an intensive care unit. These tents have been recently used in the 2010 Haiti earthquake

Fig. 10.3 Clean water is an essential right and access is a Millennium Development Goal. An estimated 15–20 L/person/ day is needed for personal use and consumption but hospitals need up to 150–200/L/person/day for surgical procedures. Children collecting clean water at a common water point at an internally displaced camp, Masisi, Democratic Republic of Congo

Anesthesia machines with manual ventilators, Clean Water oxygen compressors/concentrators with battery power capability and portable operating room Clean water is needed to provide safe and quality lights, are just a few examples of equipment surgical care. Routine hand washing by providers available for resource-limited settings [25 ]. For reduces wound infections and cross contamina- example, the Universal Anaesthesia Machine, tion and the spread of infection [ 27 ]. One of the manufactured by Gradian Health Systems, has a Millennium Development Goals is to halve the manual ventilator and oxygen concentrating number of persons living without drinking water mechanism that does not require compressed and safe sanitation [28 ] (Fig. 10.3 ). The Sphere gases and can function in areas with unreliable project, a volunteer initiative for humanitarian power sources [26 ]. agencies has established minimum standards in 132 K. Chu and M. James humanitarian response and recommends 40–60 L of clean water/day/hospitalized patient [ 29 ]. For surgical care more is needed and used for cleaning and sterilizing surgical instruments and anesthesia machines, washing linens, and irrigating wounds. MSF recommends 100–300 L/patient/ surgical procedure [30 ]. Sufﬁ cient water should be stored on the premises to ensure a steady and uninterrupted supply. If clean water is not available then water and sanitation experts should be a part of the surgical mission to supply or to chlorinate existing sources [31 ] (see Fig. 10.4 ).

Blood Bank

Preoperative, intraoperative, and postoperative hemorrhage can be life threatening. The ability to transfuse a surgical patient with safe blood can save his or her life. In [29 ] LMICs, national transfusion services rarely exist and regional hospitals must rely on local blood banks with limited Fig. 10.4 Clean water is a minimum standard of care in resources [32 ]. Each mission should have a humanitarian surgery because it is required for sanitation transfusion protocol since blood is a precious and sterilization. Photo by Pascale Choquenet commodity and should not be wasted. Elective surgical missions should identify the nearest sions, the real risk of not transfusing must be blood bank. Emergency missions may have to set weighed against the risk to the patient of con- up their own system. tracting a transfusion transmitted illness (TTI) Organization should be aware that, at the from an unscreened family member and the risk minimum, blood banks must perform ABO typ- (or perceived risk) to the family member of con- ing and screening for human immunodeﬁ ciency tracting a TTI from the implements of blood col- virus (HIV), hepatitis B, hepatitis C, and syphilis lection [35 ]. Because of the complexities of [ 33 ]. Often the ability to store more than a few providing safe banked or donated blood in a low units of blood is limited by storage capacity and resource setting, a protocol for blood conserva- electricity. A list of prescreened potential donors tion, intraoperative normothermia, and, if possi- with known blood types can be maintained espe- ble, pretreatment of existing anemia should also cially for elective surgical procedures. If an effec- be in place for any surgical mission. tive blood cold chain does not exist, the transfusion of fresh, whole blood should be used [ 34 ]. More details on how to set up a blood bank Sterilization Equipment can be found in the WHO manual, Blood Cold Chain [34 ]. In order to safely perform surgery in any setting, Campaigns for voluntary unpaid donors are sterilization equipment is needed. Simple auto- the ideal and safest way to maintain a blood bank; claves can be powered by wood burning, gas, or however, during short-term medical missions this electricity and sterilize surgical equipment through can be both costly and time-consuming [33 ]. high pressure steam at 121 °C for approximately When relying on family replacement donors for 15–20 min. MSF uses several different models whole blood during humanitarian surgical mis- some pictured here (see Fig. 10.5 ). 10 Quality of Care: Maintaining Safety Through Minimum Standards 133

Fig. 10.5 Proper sterilization is a minimum standard for care for all surgical missions. Autoclaves can be small and basic like this 39 L wood burning one, which does not need electricity. Photo used with permission from Pascale Choquenet

Pharmaceutical Agents the WHO Model Lists of Essential Medicines are useful guides that can be tailored based on the Depending on the surgery general, regional, or clinical conditions and cases anticipated [38 ]. local anesthetic agents and analgesics are required. For general anesthesia, inhaled anesthetics such as halothane, isofl urane, and sevofl u- Anesthesia Monitoring rane may be used in functional anesthesia and Equipment machines with vaporizers based on availability of agents and equipment. If these are not available, The use of pulse oximetry for intraoperative total intravenous anesthesia can be provided with monitoring saves lives. It is recommended as a anesthetics such as propofol, ketamine, thiopen- minimum standard of monitoring by the WHO, tal, opioids, and benzodiazepenes [36 ]. In limited yet over 70,000 operating rooms worldwide lack resource areas that do not have reliable oxygen this essential equipment [39 ]. The WHO Patient supplies, regional and neuraxial anesthesia with Safety Pulse Oximetry Project aims to improve local anesthetics may help to limit alterations in the safety of surgical care by training surgical baseline patient physiology [ 37 ]. When providing providers how to use pulse oximeters [40 ] and any type of anesthesia care, access to resuscitation works with organizations like Lifebox who medications such as vasopressors, chronotropes, donate pulse oximeters to LMIC hospitals that do and ionotropes is imperative. Antibiotics cover- not have them [41 ]. Although pulse oximetry ful- ing a broad spectrum of gram-positive, gram- fi lls the minimum standard for anesthesia moni- negative, and anaerobic organisms are needed for toring, a noninvasive blood pressure cuff and perioperative treatment and prophylaxis. If these thermometer can be helpful for preoperative basic medications are not available in the LMIC assessment as well as intraoperative and postop- hospital where the surgical mission is to take erative monitoring. Anesthesia care should place, then they must be brought in or sourced always be provided under the supervision and and managed on site (see Fig. 6 ). When consider- vigilance of a trained professional assigned to the ing medications needed for a medical mission, care of each surgical patient [42 ]. 134 K. Chu and M. James

Fig. 10.6 A pharmacy that stocks essential medications such as anesthetic agents, antibiotics, and analgesics is needed in any surgical mission. If the local hospital does not have one, this must be created. Importing medications, even for humanitarian use, must be cleared with the appropriate authorities ahead of time

In emergency surgery, general anesthesia is use of portable ultrasonography or nerve stimula- often the appropriate anesthetic technique. tion can provide adequate operative anesthesia, Certain equipment and monitoring are needed to as well as postoperative analgesia for patients in safely anesthetize patients. Airway management hospitals with limited access to analgesic medi- requires both oxygenation and ventilation. cations or limited postoperative patient monitor- Oxygen sources include wall supplies, oxygen ing [45 , 46]. It is important to say that the rescue cylinders or oxygen compressors. Positive pres- airway equipment mentioned above should sure ventilation can be applied with a bag valve always available in case of complications such as mask with positive end expiratory pressure caudal spread of a neuraxial anesthetic or local (PEEP) valve or with a ventilator. In preparation anesthetic toxicity. for medical missions, anesthesia providers should carry functional laryngoscopes and endotracheal tubes in a variety of sizes, supraglottic airways, Postoperative Recovery Unit (PACU) oral airways, oro/nasogastric tubes and suction. These supplies allow for the adequate oxygen- The immediate postoperative period can be a ation and positive-pressure ventilation of a dangerous time if hypotension, hypoxia, hyper- patient while decreasing the risk of aspiration. carbia, or ischemic events occur in unmonitored In LMIC hospitals, regional and neuraxial patients. If these life-threatening conditions are anesthesia are invaluable anesthetic techniques. not accurately and quickly identifi ed, they can- Routine use of regional and neuraxial anesthesia not be treated appropriately and death may fol- allows providers in low resource settings to avoid low quickly. Some LMIC hospitals do not have many of the economic and hemodynamic pitfalls enough physical or human resources to have a and challenges that exist with routine use of gen- dedicated PACU and patients are sent back to the eral anesthesia [43 , 44 ]. Spinal anesthesia can be postoperative surgical ward immediately after a used for a variety of lower extremity, pelvic, and procedure. This practice is especially risky after abdominal surgeries particularly when oxygen is general anesthesia or in the face of respiratory or in limited supply. Regional anesthesia with the cardiac disease. Humanitarian surgeons should 10 Quality of Care: Maintaining Safety Through Minimum Standards 135 ensure a PACU exists at the hospital they are using, else one must be established. Experienced Processes of Care PACU nurses need to be part of the team if the pre-trip assessment shows a lack of qualifi ed The most important measure shown to improve local personnel. quality of care is adherence to processes of care [3 ]. Basic protocols such as administration of perioperative antibiotics, the use of pulse oximetry Qualifi ed Surgical and Anesthesia for intraoperative monitoring, and checklists are Providers processes than can be established on surgical missions. This might require pre-trip training of One of the main reasons the unmet burden of sur- team members or on site training at the beginning gical disease in LMICs is so great is the lack of of the mission with local staff. surgical providers [47 ]. Surgical providers include all personnel involved in the delivery of surgical care including surgeons, anesthesiolo- Perioperative Antibiotic Protocols gists, PACU and surgical ward nurses. HIC surgical providers can play an important role in Appropriate use of prophylactic antibiotics reducing the LMIC surgical burden through sur- reduces postoperative infections [54 ]. Some gical missions. However, they should only pro- patients will also need a course of postop- vide care (including performing surgery and erative antibiotics especially for contaminated administering anesthesia) in LMIC for which conditions. Antibiotic protocols for common they are qualifi ed. If a surgeon cannot perform an procedures, such as single dose prophylaxis for amputation safely in the USA, then s/he should Cesarean sections can greatly reduce wound not be allowed to perform that operation other infections and endometritis [ 55 ]. Surgical mis- countries. If an anesthesia provider has not prac- sions should establish protocols for the proce- ticed pediatric cardiac anesthesiology since fel- dures they perform. Antibiotic regimens may lowship, s/he should not be allowed to do so have to be adapted for the LMIC setting as there during a mission. will be fewer choices of agents, but evidence Unfortunately, some surgical missions have based medicine should be practiced in humani- given humanitarian surgery a bad reputation by tarian surgery just as pertains in HIC settings. adopting the attitude that LMIC patients can be “practiced upon” or that “any care is better than no care” [48 , 49 ]. Surgical and anesthesia resi- Checklists dents should not be allowed to operate or provide anesthesia without appropriate supervision Checklists save lives by standardizing basic regardless of the setting. Currently, no specifi c safety checks and preparation for complex tasks. credentials are needed for HIC surgeons and The airline industry has demonstrated this anesthesiologists to work in surgical missions. unequivocally with pre-fl ight checklists [56 ]. Studies in high-income countries have shown Checklists improve surgical quality by changing that surgical quality is directly related to sur- the culture of practice and ensuring that processes geon experience [50 – 53]. Surgeons and anes- of care are followed [ 57 ]. In 2009, WHO pub- thesiologists planning to go on elective or lished a 19-item surgical checklist that reduces emergency missions should receive special train- morbidity and mortality in HIC and LMIC [58 ]. ing to be better prepared for working in resource- This checklist can be modifi ed for each setting; limited settings. MSF and the International its main purpose is to ensure that processes of Committee for the Red Cross provide additional care are adhered to for each individual patient. trauma training for their surgeons to work in war An adaptation of this surgical safety checklist for zones. humanitarian surgery is shown in, Table 10.1 [ 1 ]. 136 K. Chu and M. James

Table 10.1 Surgical checklist adapted for humanitarian Smile, an organization which repairs cleft palates surgery (adapted with permission from World Journal of in LMICs, followed over 700 patients during a 4 Surgery, Chu [1 ]) week period in 19 countries giving individual 1. Perform anesthesia pre-operative evaluation surgeons feedback regarding complications and 2. Pulse oximetry is available and working identifying areas of program improvement [ 63 ]. 3. Procedure explained to patient and written consent signed While these studies demonstrate the feasibility of 4. Confi rm patient identifi cation data collection in resource limited settings, ongoing 5. Mark operative site routine outcome data collection has not been 6. If signifi cant fl uid/blood loss expected, obtain reported by any humanitarian surgical agency. appropriate intravenous access and ensure Moreover, since internationally standardized availability of fl uid/blood products databases for humanitarian surgery do not exist, 7. The appropriate surgical instruments are available interpretation and comparison of data from various to perform procedure agencies are diffi cult [64 ]. 8. Antibiotics have been given if wound is/expected to be contaminated Humanitarian surgery missions should be 9. Postanesthesia care is available required to routinely collect data on structure, 10. Postoperative care protocol is established process, and outcome indicators. Local funding 11. In a mass casualty, the procedure performed, date and human resources are often too scarce to of dressing change or re-intervention are written conduct patient follow-up so surgical missions on the bandage should ensure their budget allows the short-term 12. Patient and surgical data entered into a database employment of a local provider to track short and long term outcomes once the mission is over. Importantly, the surgical mission should Checklists can greatly benefi t surgical mis- analyze this data and give feedback to the host sions by improving communication between team hospital or local agency. This information can members from different institutions and local be used to improve the quality of surgical care and international providers who speak different in future LMIC missions. When HIC providers primary languages. carry out other public health interventions in LMIC such as maternal and neonatal care, HIV prevention, and vaccination programs, they are Data Collection and Outcomes required by local ministries of health to submit Assessment data for routine monitoring and evaluation to improve program policy and protocols. There Most surgical missions do not collect outcome should be similar requirements for surgical mis- data and therefore morbidity and mortality rates sions. One proposed way to begin measuring for humanitarian surgery are largely unknown. surgical/anesthesia safety and increase aware- For example, numerous agencies performed ness of avoidable perioperative complications in thousands of procedures during the 2010 earth- LMICs is the implementation and mandatory quake, but death and infection rates were not reporting of a postoperative mortality rate reported [59 –62 ]. This resulted in undetected (POMR). POMR is defi ned as the number of patient morbidity and mortality and an inability perioperative deaths in ASA Classifi cation I and to improve the quality of care delivered. Some II patients per 100,000 people [ 30]. This data is organizations collect patient demographic and a basic part of any operating room log and can procedural information and have conducted stud- lead to further evaluation and comparison of ies to determine morbidity and mortality. For surgical outcomes between countries. In addi- example, MSF, using a standardized database tion, reporting of preventable mortality can help containing nearly 20,000 procedures, reported an to stimulate action on the national and interna- operative mortality rate of 0.2 %. Operation tional levels. 10 Quality of Care: Maintaining Safety Through Minimum Standards 137

resources to provide oversight. As HIC surgical Oversight and Regulation and anesthesia providers increasingly become involved in surgical missions, the need to estab- As surgical missions become more commonplace, lish a framework for quality surgical delivery is an international regulatory body should be created more pressing. to provide oversight. While HIC standards cannot Surgical missions must prepare for their trip be completely translated to LMIC settings, as in several ways. First, a pre-trip needs assessment detailed above, minimum safe standards can be must be conducted to assess existing resources and applied. Host LMIC or the HIC initiating the mis- identify gaps in minimum standards in structural sion should require humanitarian surgeons and inputs, processes of care and outcome measures. anesthesiologists to provide minimum standards A safe structure, electricity, clean water, steriliza- through infrastructures such as appropriate medi- tion equipment, a blood bank, a PACU, and appro- cations and human resources, adherence to proto- priate medication and surgical providers are needed. cols, use of checklists, and simple databases to Certain processes of care such as protocols and follow short and long term outcomes. An interna- checklists should be decided upon ahead of time. tional regulatory body could maintain a central A database should be established capturing patient repository with standardized databases created for demographics, procedural data, and outcomes. The humanitarian surgery such as the clinical trials mission and local administrators should decide repository [65 ]. This regulatory body would which indicators can be realistically captured and receive post-mission reports from all humanitar- how they will be collected especially longer-term ian surgery missions and analyze complications in outcomes. A well-deﬁ ned mechanism for reporting order to improve care. In the meantime, other data to local and international program directors resources exist. For example, the American and mission participants is needed; results should College of Surgeons has a free online case log always translate into process or structural change. system and members who conduct humanitarian At the end of the surgical mission, local and inter- surgery can enter their cases [66 ]. national team members should give feedback and suggestions for improvements. All aspects of care, even structural inputs can be improved, especially Way Forward if the project is a long term one. Humanitarian surgeons and anesthesiologists must strive to provide Interest in global surgery is increasing exponen- quality care and can be ambassadors for a new cul- tially [67 ]. It is estimated that surgical missions ture of safety in global surgery. perform at least a quarter of a million procedures in LMIC; however, this is an underestimation since many missions do not publish their surgical activity References [ 30 ]. Elective and emergency missions can help address the global burden of surgical disease. More 1. Chu KM, Trelles M, Ford NP. Quality of care in importantly, they can improve the quality of care at humanitarian surgery. World J Surg. 2011;35(6):1169– 72. discussion 1173–1164. LMIC host hospitals by introducing protocols, 2. Bickler S, Ozgediz D, Gosselin R, et al. Key concepts checklists, and a new culture of safety in global sur- for estimating the burden of surgical conditions and gery. Such efforts demonstrate to local staff what the unmet need for surgical care. World J Surg. can be achieved even in resource-limited settings. 2010;34(3):374–80. 3. Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg. 2004;198(4):626–32. Summary 4. The Joint Commission. http://www.jointcommission. org . Accessed 1 May 2014. 5. Chassin MR, Loeb JM, Schmaltz SP, Wachter The quality of surgical services in humanitarian RM. Accountability measures—using measurement settings is rarely assessed. Most LMIC countries to promote quality improvement. N Engl J Med. are grateful for surgical care and do not have the 2010;363(7):683–8. 138 K. Chu and M. James

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42. Chackungal S, Nickerson JW, Knowlton LM, et al. a systematic review. J Urol. 2008;180(3):820–8. dis- Best practice guidelines on surgical response in disas- cussion 828-829. ters and humanitarian emergencies: report of the 2011 54. Bratzler DW, Houck PM. Antimicrobial prophylaxis Humanitarian Action Summit Working Group on for surgery: an advisory statement from the National Surgical Issues within the Humanitarian Space. Surgical Infection Prevention Project. Am J Surg. Prehosp Disaster Med. 2011;26(6):429–37. 2005;189(4):395–404. 43. Inipavudu B, Mitterschiffthaler G, Hasibeder WR, 55. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for Dunser MW. Spinal versus epidural anesthesia for cesarean section. Cochrane Database Syst Rev. vesicovaginal ﬁ stula repair surgery in a rural sub- 2002(3):CD000933. Saharan African setting. J Clin Anesth. 2007;19(6): 56. Weiser TG, Haynes AB, Lashoher A, et al. Perspectives 444–7. in quality: designing the WHO Surgical Safety 44. Surgical care at the district hospital. http://www.who. Checklist. Int J Qual Health Care. 2010;22(5): int/surgery/publications/en/SCDH.pdf?ua=1 . 365–70. Accessed 27 May 2014. 57. de Vries EN, Prins HA, Crolla RM, et al. Effect of a 45. Allcock E, Spencer E, Frazer R, Applegate G, comprehensive surgical safety system on patient out- Buckenmaier 3rd C. Continuous transversus abdomi- comes. N Engl J Med. 2010;363(20):1928–37. nis plane (TAP) block catheters in a combat surgical 58. Haynes AB, Weiser TG, Berry WR, et al. A surgical environment. Pain Med. 2010;11(9):1426–9. safety checklist to reduce morbidity and mortality in a 46. Buckenmaier 3rd CC, Lee EH, Shields CH, Sampson global population. N Engl J Med. 2009;360(5):491–9. JB, Chiles JH. Regional anesthesia in austere environ- 59. Ginzburg E, O’Neill WW, Goldschmidt-Clermont PJ, ments. Reg Anesth Pain Med. 2003;28(4):321–7. Marchena E, Pust D, Green BA. Rapid medical 47. Ozgediz D, Hsia R, Weiser T, et al. Population health relief—Project Medishare and the Haitian earthquake. metrics for surgery: effective coverage of surgical ser- N Engl J Med. 2010;362(10):e31. vices in low-income and middle-income countries. 60. MacIntyre NR, Jeffcoat DM, Chan DB, Lorich DG, World J Surg. 2009;33(1):1–5. Helfet DL. The experiences of a surgical response 48. Gilbert BJ, Miller C, Corrick F, Watson RA. Should team in Haiti. Am J Orthop (Belle Mead NJ). trainee doctors use the developing world to gain clini- 2010;39(4):172–201. cal experience? The annual Varsity Medical Debate— 61. Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. London, Friday 20th January, 2012. Philos Ethics The Israeli ﬁ eld hospital in Haiti—ethical dilemmas Humanit Med. 2013;8:1. in early disaster response. N Engl J Med. 2010; 49. Ramsey KM, Weijer C. Ethics of surgical training in 362(11):e38. developing countries. World J Surg. 62. Peranteau WH, Havens JM, Harrington S, Gates JD. 2007;31(11):2067–9. discussion 2070-2061. Re-establishing surgical care at Port-au-Prince 50. Bilimoria KY, Phillips JD, Rock CE, Hayman A, General Hospital, Haiti. J Am Coll Surg. 2010; Prystowsky JB, Bentrem DJ. Effect of surgeon train- 211(1):126–30. ing, specialization, and experience on outcomes for 63. Bermudez L, Carter V, Magee Jr W, Sherman R, Ayala cancer surgery: a systematic review of the literature. R. Surgical outcomes auditing systems in humanitar- Ann Surg Oncol. 2009;16(7):1799–808. ian organizations. World J Surg. 2010;34(3):403–10. 51. Dimick JB, Birkmeyer JD, Upchurch Jr GR. Measuring 64. Chu KM, Ford N, Trelles M. Operative mortality in surgical quality: what’s the role of provider volume? resource-limited settings: the experience of Medecins World J Surg. 2005;29(10):1217–21. Sans Frontieres in 13 countries. Arch Surg. 52. Rogo-Gupta LJ, Lewin SN, Kim JH, et al. The effect 2010;145(8):721–5. of surgeon volume on outcomes and resource use for 65. ClinicalTrials.gov. http://clinicaltrials.gov . Accessed vaginal hysterectomy. Obstet Gynecol. 2010;116(6): 11 May 2014. 1341–7. 66. ACS Case Log System. http://www.efacs.org . 53. Wilt TJ, Shamliyan TA, Taylor BC, MacDonald R, Accessed 11 May 2014. Kane RL. Association between hospital and surgeon 67. Wall AE. Ethics in global surgery. World J Surg. radical prostatectomy volume and patient outcomes: 2014;38(7):1574–80. Legal and Ethical Issues in Global Health: A Trip Through 11 the Vagaries of Truth and Culture

Jeffrey S. Freed

it is for us to integrate lessons that have been Introduction learned at high cost into societies that have perhaps not yet identifi ed the advantage of these Legal and ethical issues in global health should principles to every individual, man and woman. be considered a direct extension of those identi- These efforts are meant not to be paternalistic. cal issues and principles we appreciate as an inte- They are meant to bring justice to those who may gral part of Western medicine and healthcare not have a voice, leveling the playing fi eld no delivery. At no time should we consider the pro- matter what the economic or social environment vision of healthcare or medical research in the is in their world. Let us fi rst examine the magni- developing world as outside the ethical and legal tude of the problem and the roots of these ethical standards to which we adhere. This ideal often is and legal values in order to better understand how at loggerheads with the practical realities of the and why the medical community in the devel- developing world. However, as one who may oped world has come to the beliefs and proce- well be or is an interloper in that world, one must dures to which we have agreed to adhere. This take diligent care to preserve ethical and legal examination will also identify the complex issues principles without trampling on established local that are faced when attempting to create ethical cultural mores. Certain specifi c issues are unique and legal guidelines in the healthcare structure of to the developing and underdeveloped world. developing countries (Table 11.1 ). However, in no way will they, or should they, be addressed as deserving a lesser standard of ethical and legal observance. This, of course is a The Problem noble concept. But if one does not at least consider these principles prior to taking action, there The problems encountered when delivering medi- will never be a coalescence of developed and cal care in low- and middle-income countries developing world thought as well as behavior. (LMICs are myriad). They range from a lack of It is not for us to impose our ethical and legal tangible resources (e.g., anesthesia machines) to concepts on those in the developing world. Rather, the infl uence of local culture on the ability to deliver that same medical care (Figs. 11.1 and 11.2 ). When a 9-year- old presented to our hospi- J. S. Freed , MD, MPH, FACS (*) tal in Liberia with a gunshot wound to the abdo- Department of Surgery , men, the obvious question was how it occurred. Icahn School of Medicine at Mount Sinai , New York , NY , USA The mother, initially without much emotion, e-mail: [email protected] became irate when asked about the mechanism of

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 141 DOI 10.1007/978-3-319-09423-6_11, © Springer International Publishing Switzerland 2015 142 J.S. Freed

Table 11.1 Determinants for evaluation of problems in developing countries

Fig. 11.1 Our home away from home

Fig. 11.2 Antiquated anesthesia equipment

the injury, speciﬁ cally how a 9-year sustained a gun- ents were not required to give explanations about shot wound. This information was signiﬁ cant in their children’s condition. It was a startling intro- diagnosis and planning of treatment for the injury. duction to the local mores and an initiation into We were forced to proceed without the informa- our understanding of ethical concepts in the tion when a local physician informed us that such developing world. These local mores are just questions were inappropriate. Apparently chil- another obstacle in the provision of adequate dren were considered parental property and par- operative services in LMICs. 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 143

Surgery and anesthesia, referred to for practi- eases are the principle cause of the signifi cantly cal purposes as operative services, are two of the decreased life expectancy in the LMICs as most needed and most neglected areas of global compared to developed countries. Contrary to health and two areas most often affected by legal popular opinion, available data demonstrate that and ethical issues. It has been estimated that nearly 80 % of all non-communicable disease operatively treatable diseases account for 11 % (NCD) deaths occur in low- and middle-income of the global burden of disease and more than 25 countries and these diseases are the major cause million disability-adjusted life-years [ 1 ]. This of mortality in these countries [7 ]. NCDs are the rough estimate includes injuries, malignancies, leading cause of death globally, killing more peo- congenital anomalies, and complications of preg- ple each year than all other causes combined. The nancy, some of which may be cured if the affected World Health Organization, explaining the rea- populations had access to skilled surgical and son for this, stated that the resources to prevent, anesthesia services. Unfortunately, the burden of diagnose, and treat these diseases are glaringly these diseases disproportionately affects LMIC; absent in LMICs. They further stated that NCDs overall it is estimated that only 3 % of the world’s are caused, to a large extent, by multiple behav- operations are performed in LMICs [2 ]. In many ioral risk factors that are pervasive aspects of LMICs, operative services are concentrated in economic transition, rapid urbanization and cities and only available to citizens who can twenty-fi rst-century lifestyles: tobacco use, afford them [ 3]. Several studies have shown that unhealthy diet, insuffi cient physical activity, and operative care can be delivered in a cost-effective the excessive use of alcohol and drugs, like khat manner in small hospitals [4 ]; however the current chewing in Yemen [8 ]. The greatest deleterious burden of disease in LMICs is not being adequately effects of these risk factors are increasingly managed by the patchwork of surgical services observed in LMICs, especially foisted upon supported by federal governments, international poorer people within all these countries, mirror- non-governmental organizations, and limited- ing the international underlying socioeconomic resource surgical “mission trips.” It is estimated determinants. When examining these populations that relief organizations perform nearly 250,000 with great need, one identifi es a repetitive cycle operations in LMICs annually [5 ]. of poverty that exposes people to behavioral risk In 1996, Paul Farmer echoed in print what was factors for NCDs while the resulting NCDs may known in the surgery/anesthesia community for become an important promoter for the downward some time; that surgery was the “stepchild” of spiral that leads families toward poverty [9 ]. global health [3 ]. Two billion people annually At present, there is no universally accepted lack access to emergency or essential operative defi nition of “access to health services” [10 ]. For care and 175,000 anesthetics are delivered the purposes of this treatise, the defi nition by without even pulse oximetry, recognized as the Peters et al. [ 11], which implies “the timely use standard of care in the developed world [6 ]. of service according to need,” will be operative. An estimated 500,000 mortalities per year in the Utilization of healthcare is applied as an opera- developing world could be avoided were ade- tional proxy for access to healthcare. Access has quate surgical and anesthesia resources available. four dimensions: availability, geographic acces- This is not just a medical problem. It is an ethical sibility, affordability, and acceptability [ 12 ]. and moral problem that has not received the When considering ethical and legal issues in attention it should by developed countries that global health, acceptability becomes the most have the resources not only to deliver the neces- important barrier to successful deliverance of sary care, but also to educate and mentor sur- healthcare, as it must deal with local cultural geons and anesthesiologists in LMICs creating issues, social issues, gender issues, and all the the skills to care for their own. mystical and mythical issues observed and practiced A major public misconception, primarily in a society. This barrier is divided into tangible because of the universal emphasis on control of (e.g., monetary) or intangible (e.g., strongly held communicable disease (CD), is that those dis- religious or spiritual beliefs). 144 J.S. Freed

It is often diffi cult to understand and always medieval and early modern period, Islamic ethi- diffi cult to deal with the intangible. The tangible, cal medical doctrine was dispersed to the West. in accessing health services, can stem from the Writers like Ishaq ibn Ali al-Ruhawi, a Muslim demand and/or the supply side of the economic physician, scribed the fi rst complete book on the equation [13 ]. Demand-side determinants are topic of medical ethics, entitled, Conduct of a factors infl uencing the ability to use health ser- Physician. Muhammad ibn Zakariya ar-Razi, vices at the individual, household or community Jewish thinkers like Maimonides, Roman level, while supply-side determinants are factors Catholic scholastic thinkers including Thomas that interfere with the right of entry by individu- Aquinas, applied general rules and principles to als, households or the community. The need to questions of ethics and morals in order to resolve identify the demand-side from the supply-side them, referred to as casuistry (that is, having the barrier is required to develop the necessary strat- air of case law) in Catholic theology. These intel- egies to overcome the barrier. In fact, whether the lectual traditions continue in Catholic, Islamic barrier is tangible like money, or intangible like and Jewish medical ethics to this day [14 ]. an immovable cultural mores, the application of By the eighteenth and nineteenth centuries, ethical and legal principles should be the starting medical ethics emerged as a more self-conscious point for development of any solution. discourse. In England, Thomas Percival, a physician and author, crafted the fi rst modern code of medical ethics. He authored a pamphlet with the Historical Background code in 1794 and wrote an expanded version in 1803, in which he coined the expressions “medi- We see a landscape of a signifi cant portion of cal ethics” and “medical jurisprudence” [15 ]. In the world’s population having experienced, and 1815, the Apothecaries Act was passed by the continuing to experience an inadequate access to Parliament of the United Kingdom (UK). It intro- what the United Nations declared in 1946 to be a duced compulsory apprenticeship and formal “right to health.” What has also been witnessed is qualifi cations for the apothecaries of the day the developed world community’s multiple starts under the license of the Society of Apothecaries. and reverses in an attempt to correct that phe- This was the beginning of regulation of the medi- nomenon. The origins of these attempts date back cal profession in the UK. millennia, as does the roots of the concepts of In 1847, the American Medical Association medical ethics and jurisprudence. A brief journey adopted its fi rst code of ethics [16 ], based in large through the evolution of the development of part upon Thomas Percival’s work. While in the medical ethics and jurisprudence focuses on how nineteenth century secularized medicine borrowed the questions of ethics and legal issues were iden- largely from Catholic ethics, in the twentieth cen- tifi ed in global health. Shortcomings in obser- tury an approach articulated by thinkers such as vance of those issues and failure to adhere to Joseph Fletcher was distinctively liberal Protestant those rules and regulations enacted by multiple [ 17]. This liberalization led to the movement nations, countries, and agencies to enforce those toward the appreciation of ethical and legal behav- principles are identifi ed. ior throughout the developed world; however, it Historically, Western medical ethics, and the was the atrocities that occurred during the Second legal standards that evolved from these cultural World War that focused humanity’s attention on the principles, were inscribed by physicians in need to deal with that type of heinous human ancient documents like the Hippocratic Oath. experimentation, genocide and other crimes against The fi rst recognized code of medical ethics, humanity. The judgment by the war crimes tribu- Formula Comitis Archiatrorum , was published in nals at Nuremberg, in a new code that is now the fi fth century AD, during the reign of King accepted worldwide, established ten standards by Theodoric the Great, the Visigoth ruler of Italy. which physicians would have to conform when As Middle Eastern infl uence increased in the carrying out experiments on human subjects [18 ]. 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 145

This code established a new standard of ethical has often led to governments and nations being medical behavior for the post-World War II unable or unwilling to establish ethical and legal human rights era. Among other requirements, standards to which they would adhere when this document enunciates the requirement of dealing with the health of their population. voluntary informed consent of the human subject. Global health ethics and laws that nations have The principle of voluntary informed consent pro- enacted have inadvertently created parallel legal tects the right of the individual to control his own systems. Specifi cally, each individual country body. This code also recognizes that the risk must must approve the international ethical principles, be weighed against the expected benefi t, and that rights, and laws that have been created before unnecessary pain and suffering must be avoided. those principles are instituted within the borders Doctors should avoid actions that injure human of their own country. Also, a treaty not recognized patients. Also, the volunteer must be capable of by a country results in that treaty having no force understanding the nature of the research in which of law within that country. In view of the fact that he or she partakes, including the risks and bene- international law is developed as a “bargaining fi ts. The principles established by this code for evolution of theory,” it often results in a simplifi ed medical practice now have been extended into version of what was intended in order to be general codes of medical ethics [ 19 ]. It has also accepted by the multiple partners, both from permeated the principles under which the medical developed and undeveloped worlds, participating and research community should function when in the process. In other words, laws and doctrine working in the developing world. are created by compromise, often losing the initial intent and failing to accomplish hoped for goals.

Recent Developments Current Situations In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the dis- Even though the Global Health community course of medical ethics went through a dramatic accepted the “right to health,” especially in shift and largely reconfi gured itself into what we LMICs, it did not necessarily mean that the right now call bioethics [20 ]. Unfortunately, the legal to healthcare was accepted. In developing coun- discourse that followed progressed more slowly, tries without the resources to provide adequate with little teeth given to those codes and doctrine care, the desire to fulfi ll the goals of human rights that were advocated and even enacted during the in the healthcare arena is not often met. The intent latter half of the twentieth century. of international laws and the quest for ethical The goal of the memorialization of medical deeds in providing the right to health (care) are ethics and jurisprudence was to affect ethical based on ideas, but remains only an empty fantasy behavior through cooperation among nations without the political and fi nancial commitment of and by the creation of codifi ed agreements, the global community. The creation of these through the international law aspect of the humanitarian concepts is admirable. But very human rights efforts. Examining the levels of often something that should be progressively interventions and how health offi cials can make realized only refl ects promoters’ dreams by use of it allowed for the passage of laws direct- allowing the countries that most need these prin- ing the behavior of individuals and nations. Such ciples to escape any real pressure to enforce direction becomes a major undertaking when them. To bring suffi cient pressure to correct this dealing with LMICs when they themselves have problem, human rights assessments would be not necessarily set standards for ethical and legal necessary by unbiased observers and the results action. Many of these countries have undergone published so the facts would be universally appre- social and political upheaval, being referred to as ciated. Anticipation of human rights violations by confl ict or post-confl ict nations (e.g., Congo, certain governments is required so steps can be Liberia, and Nicaragua). The unrest sustained taken to circumvent abuses [21 ]. 146 J.S. Freed

The enforcement of global health laws and 4. Advocating for long term academic partnership ethics requires an understanding of the societies with hospitals and universities in countries of that we are supposedly assisting. Developed need. nations must fi rst establish that other societies are 5. Providing for collaboration of organizations, following the same rules and regulations that institutions, and initiatives with common they have deemed appropriate. Developed nations missions and philosophies. must understand what the underlying right might Humanitarian efforts like these are essential in be in any given society, and enforce the resolu- improving the state of health on a global stage. tion utilizing that right. Mechanisms to accomplish this goal are available such as international tribunals that have been successful in document- Research ing atrocities and calling to task those who have laid waste to established principles, laws, and One area of scientifi c pursuit in the developing ethics. Once the principles outlined above have world that is signifi cantly impacted by medical been introduced, the clinical setting in which ethics is scientifi c research. Even more than other they will function starts to impact the deliverance areas of healthcare in the LMICs, scientifi c of healthcare. research raises ethical issues, especially when When one looks at the practical requirements funded by external sponsors from developed of delivering “health” as established in the countries. Developing countries urgently need Declaration of Human Rights [22 ], the magni- research to help address the enormous burden of tude of that endeavor becomes clear. Perhaps disease. The disparities in resources previously even more than the need for surgical services in described between developed and developing the LMCIs, is a worldwide anesthesia crisis. countries can promote exploitation in the case of Most LMICs have less than 1 physician per externally sponsored research. Failure to under- 10,000 people and less than 1 anesthesiologist stand that external sponsors may differ in their per 100,000 people, leaving an immense gap in capability to appreciate different culture and edu- the safe performance of operative services [23 ]. cational status of the subjects in developing This void requires immediate attention to improve countries creates the need for signifi cant internal patient safety in low-income countries through and external oversight of research in LCMIs. education and support. Furthermore, in order to promote the ethical and legal climate for medical research, all countries should set national priorities related to their pro- Measures to Improve vision of healthcare. When externally sponsored Patient Safety research is proposed that does not address the national priorities of its host, the research must In order to address the marked disparity between demonstrate its relevance and be justifi ed to an the numbers of anesthesiologists in developed appropriate independent research ethics commit- versus LCMIs (i.e., one anesthesiologist per 260 tee. To enhance the capability of developing patients in the United States versus 1 anesthesi- countries to conduct and oversee research that is ologist per 55,000 patients in Ghana) the in their best interest, the inclusion of a component American Society of Anesthesia Committee on to improve the local expertise in country should Global Humanitarian Outreach is addressing this be a provision of any new healthcare and health- crisis in several ways: care research. The most diffi cult part of the cre- 1. Encouraging volunteerism. ation of this monitor would be to make it 2. Providing opportunities with reputable aid independent of both external and internal forces and mission organizations. that often have their own agendas. An indepen- 3. Supporting anesthesia education and training dent international organization without any direct in LMICs. interest in the results of the therapy or research 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 147 could be established to provide services equiva- It is fundamental that these obligations are lent to an Independent Research Committee respected when research is planned and conducted. It is essential to ethical research that these princi- (IRB) at any North American academic institu- ples be considered and that researchers take into tion. The committees would be comprised of account the context, social, cultural, and economic similar members as Western IRBs including status of the study community. Institution of these physician- scientists, ethicists, and lay people. principles will fulfi ll the minimum requirements to be considered ethical research [24 ]. The committee would function at arm’s length from those issues on which it is evaluating and An excellent example of research that has would be able to provide oversight while also been effective and changed behavior in the devel- performing an educational function for those in oping world, especially India, dealt with adoles- the host country. This IRB-type international cent health and development. The results of this committee would work hand-in-hand through research, presented as an analysis of data from every step of the process with a similar commit- six cross-national studies, representing 53 differ- tee in the LMIC that had requested its services. ent countries, found that the success or the The international community of developed absence of parent–child relationships is an indi- nations would fund the program with the intent of cator of the likelihood of early sexual initiation, its existence being self-limited until such time substance use, and depression among adoles- that any particular nation using it could afford its cents. The Child Development and Adolescent own independent organization. Health Center in New Delhi, India, has developed Externally sponsored research often must programs to better equip parents to manage cope with adverse and occasionally contradictory behavioral problems and to recognize mental directions as to what may be ethically suitable. health problems among their adolescent children. Finding an ethical framework for this situation Workshops were created to provide life skill edu- requires application of the ethical and often legal cation and promote mental health in secondary principles that might be an anathema to the local schools. They were designed to improve parents’ authorities. In LMICs, Western ethical and legal communication with their children and enhance conventions are occasionally seen as contradic- the capability of parents to prevent and identify tory to acceptable local social and cultural behav- common behavioral problems in adolescence. As ior. An example of this is what we refer to in the a result of parent participation, several schools West as female genital mutilation. In some coun- are now directly involving parents in mental tries on the African continent, this ritual is essen- health initiatives [25 ]. tial for a woman to be acceptable in her The diffi culties of managing the multiple fac- community and as a partner for marriage. Dealing tors that compose what we term ethical research with this type of cultural activity must be done are often beyond the capability of LMICs and with the utmost sensitivity. Providing such guid- result in negative external oversight actions. The ance and assisting in the education of those local situation cited above could be considered one of professionals and citizens involved is part of the “unethical ethics.” The term unethical ethics is obligation of researchers and clinicians in estab- invoked when researchers, even with the best lishing cohesive and mutually agreeable rules intentions, actions or policies that are believed to for the ethical review of research. The ethical promote ethical research standards inadvertently framework for this process that has become the cause serious damage to other important values, standard for global research is based on four like the right to self-determination and the right principles: to be compensated for damages incurred while 1. The duty to alleviate suffering. participating in a study. In this case, the drive to 2. The duty to show respect for persons. promote the welfare of research participants 3. The duty to be sensitive to cultural unfortunately created a situation where it could be differences. deemed diffi cult to conduct health related research, 4. The duty not to exploit the vulnerable. even if the research focused on important public 148 J.S. Freed health problems in that country. The preexisting Regardless of the setting, test, or procedure, when Indian regulations protecting human participants it comes to incidental fi ndings, President Barack involved in research were considered problem- Obama’s Commission on Bioethics (referred to as atic enough to necessitate the US National the Bioethical Commission or just Commission) Institutes of Health to cease all funding for bio- [28 ] has offered this recommendation: “anticipate medical research in India in 2013, and cautiously and communicate.” The Bioethics Commission re-institute it in 2014 with severe restrictions and recommended that all practitioners or research greater external oversight [26 , 27 ]. scientists anticipate and plan for incidental fi nd- The three core problems in the Indian study ings so that patients, research participants, and cited by the NIH were the following: those involved in a patient or subject’s care are 1. The research guidelines did not state how informed before an intervention is undertaken. injuries suffered by research participants were This recommendation holds true for all clinicians to be compensated by research institutions and researchers, including anesthesiologists. and did not delineate how they were to be Incidental fi ndings have been conventionally determined as “research related.” defi ned as those results that originate from a test 2. Protocol guidelines had an overly broad inter- or procedure that have not been anticipated, pro- pretation as to what counted as a research ducing an array of practical and ethical challenges related harm, including for example use of for the subject or patient as well as the clinician placebo in a placebo controlled trial. or researcher. These “secondary fi ndings” are not 3. The Indian ethics review committees and the primary objective of the test or the procedures licensing authorities had to help determine performed, but are additional information to be whether and to what extent compensation for considered and evaluated. These incidental and harm was warranted, but was unclear as to what secondary fi ndings may lead the physician/ relevant skills and resources were available researcher to discoveries that were not previously to do so. considered, but may also result in uncertainty and The researchers conducting the study were grief if no equivalent benefi t is derived and a making every effort to protect their study subjects. condition for which no available treatment is However, they failed to clearly defi ne what were found in that country. considered injuries to study subjects, the mecha- The great majority of the present literature, nism to identify those injuries and the method- that discusses incidental fi ndings, relates to ologies to be used to determine compensation. unforeseen genetic fi ndings during clinical test- As one cannot deduce the best efforts in this par- ing or research activities. In the developing world ticular situation to create an ethical environment the majority of external humanitarian activities for the study resulting in harm to the study sub- center round research and clinical care of infec- jects, the researchers and the project they were tious diseases. Recently, on a surgical mission to conducting with their best efforts to work within Phoebe, Liberia, a radiologist performed an ultra- the constraints of ethical research boundaries sound on a 5-year-old boy with massive spleno- were deemed unsatisfactory. These results megaly thought to be secondary to malaria. The refl ected the diffi culty a scientist or scientifi c Liberian doctors believed that the child devel- group unexpectedly faces even when the best oped splenomegaly because of his refractory ane- efforts are effectuated. mia. The sonogram revealed a massively enlarged The performance of ethical and legally accept- heterogeneous spleen, multiple defects in the able research or clinical care in LMICs is often liver and extensive adenopathy in the abdomen confounded when something unexpected is dis- and retroperitoneum compatible with lymphoma. covered. When a patient or subject undergoes a The surgical team had not prepared the family for routine test at the doctor’s offi ce or is participating the possibility of a diagnosis that was untreatable in a research study, a result that is surprising to and fatal in that setting. The lack of communica- the clinical personnel may be recognized. tion combined with the “incidental fi nding of 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 149

Table 11.2 ASA guidelines as to ethical behavior, based woman with a cancer obstructing her bowel, on AMA code of conduct there are times when an ethical decision must be 1. Patients’ interests are foremost, including made that is the opposite to the best medical care. self-determination in decision making (includes The physician must decide not to treat the patient minors in some situations) but to allow them to die. A lack of necessary 2. Monitor themselves and others 3. Maintain confi dentiality resources for these cases would result in an 4. Explain shared responsibility inability to salvage these patients after the best 5. No exploitive fi nancial advantages operative intervention. Every instinct the physi- 6. Provide care irrespective of ability to pay cian has to try save a life must be tempered by the 7. Cooperative and respectful relationships with realities of functioning in these countries. And colleagues every effort must be made to transfer the reasons 8. Timely consultations for your decision to the families and the local 9. Strive to change laws and improve community of it hospital staff who remain to care for these betters patients patients. Decisions based on long established 10. Secure controlled substances bioethical canons may well appear as abandon- 11. Maintain skills ment of the patient if those canons are not defi - nitely expressed to the local caregivers invested lymphoma” left the team emotionally disrupted in these patients. One has to have a strategy for and the family without hope for their child. dealing with these cases long before they appear This is a clear example of the need, especially in in order to prevent animus among those who suf- a setting where care is not available for “inciden- fer the loss. This process must start before any tal or secondary fi ndings,” to think ahead before specifi c case presents and is part of the obligation procedures are performed, and to prepare patients of any individual or team practicing or doing and their families for the chance of discovering research in these settings. an untreatable and possibly an incurable disease These recommendations, extensively debated process. This is our ethical obligation. and reviewed have become the basis of an approach The Bioethics Commission recommended that not only to care in the developed world but whether or not these incidental or secondary fi nd- hopefully in the developing world in the future. ings are identifi ed, the clinician or researcher The obligation of every physician, scientist or should proceed cautiously while following fi ve researcher approaching patient or subject interven- recommendations considered basic guidelines no tion in LMICs is to understand and appreciate the matter what the context of the fi nding. The guide- signifi cance of these guidelines and be willing and lines are outlined in Table 11.2 . The ultimate pur- able to carry out his or her duties while maintain- pose of these guidelines is to ensure that the ing these standards as best as possible in a differ- clinician or researcher, whether an anesthesiolo- ent cultural and social environment. The operative gist, other physician or non-physician scientist, team, often facing situations without authoritative fulfi lls the fundamental obligation to respect the solutions to complex medical problems based on subject’s or patient’s autonomy, benefi cence, and experience in their developed country, must make right to informed decision making [29 , 30 ]. decisions based on not only what is available in the The above tenets are an ideal. Commissions fi eld, but also on the ethical and legal issues come and go but the principles that evolve remain addressed above. These guidelines that were devel- unalterable. Yet there are times when the ideal oped by the Bioethics Commission apply not only cannot be met. On almost every mission to to incidental and secondary fi ndings, but also to all LMICs there is a moment when something is information about tests or procedures that might be identifi ed that challenges the principles. Whether sought or found in relationship to research study the birth of a child with an omphalocoele (a large or clinical therapy or testing. This ideal is truly a defect in the center of the baby’s abdomen with goal to which we can aspire, both in ethical and intestines protruding) or an elderly emaciated legal arenas (Table 11.3 ). 150 J.S. Freed

Table 11.3 Guidelines of the bioethics commission and rights; professionalism must be maintained at 1. Individuals must be informed that incidental fi ndings all times and those not adhering must be reported; can occur the law must be followed and efforts to improve 2. Professional groups develop unambiguous those laws sought; the rights of patients and health instructions for the categorization of these incidental professionals must be respected at all times and secondary fi ndings 3. Directed research should occur to defi ne the classes including their privacy; a physician will continue of and incidence of incidental and secondary fi ndings his own education and encourage and support the including the costs, benefi ts, and harms these of these education of others through interchange of knowl- fi ndings and preferences regarding the disclosure of edge; the physician maintains his independence the fi ndings as far as whom to treat (except in emergencies) 4. Preparation of educational materials to inform all stakeholders (patients, practitioners, IRBs, etc.) about and where to treat them; the betterment of the the ethical, practical, and legal implications of community shall be a constant goal of a physi- incidental and secondary fi ndings cian; responsibility to the patient as paramount 5. Affordable (and in some cases free) access to quality and: the physician shall support access to medical information must be available, both before and after care for all people. testing The practice of anesthesiology involves special problems relating to the quality and standards Ethical Guidelines of the ASA of patient care. Therefore, the ASA requires its members to adhere to the AMA Principles of The American Society of Anesthesiologists has Medical Ethics and any other specifi c ethical developed guidelines for the ethical practice of guidelines. It must be remembered that circum- anesthesiology that are applicable not only in the stances may arise when elements of the following USA but also in any intervention with patients or guidelines may not apply and wherein individu- subjects in LMICs [31 ]. alized decisions may be appropriate. This is of To quote from the Preamble to Society’s special import when practicing or doing research Guidelines for Ethical Practice, “Membership in in LMICs. The underlying principles, however, the American Society of Anesthesiologists is a must never be ignored. privilege of physicians who are dedicated to the The ASA has created a document to outline the ethical provision of health care.” The Society has fi ve areas in which an anesthesiologist must meet chosen to base these guidelines on the Principles ethical responsibilities. These areas include of Medical Ethics of the American Medical responsibilities to patients, colleagues, facilities, Association (AMA) [32 ]. communities, and themselves (Table 11.2 ). A brief The AMA, as described in the historical dis- summary will assist the reader to understand the cussion of ethics, was the fi rst organization in the goals of these individual tenets. United States to codify the concept of ethical The patient–physician relationship involves principles. Its beliefs were and still are that the special obligations for the physician that includes medical profession has “long subscribed to a placing the patient’s interests fi rst and foremost, body of ethical statements developed primarily faithfully caring for the patient and always being for the benefi t of the patient.” Any physician truthful. This includes respect for the patient’s practicing under the aegis of the AMA is required self-determination; protection of all patients to “recognize responsibility to patients fi rst and from disrespectful behavior and abuse from col- foremost.” While recognizing these principles, it leagues as well as themselves; maintenance of must be remembered that they are not law but confi dentiality; and guaranteeing of informed rather “standards of conduct that defi ne the essen- decision making and understanding of all parties tials of honorable behavior for the physician.” involved in the anesthesia and post-anesthesia The AMA Principles are divided into nine care. Also, anesthesiologists must not participate specifi c sections. To summarize, a physician is in exploitive fi nancial relationships, always pro- encouraged to provide competent medical care viding the same care for patients no matter their with compassion and respect for human dignity economic status. 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 151

The guidelines go on to speak of anesthesiolo- this advanced gynecologic malignancy. This des- gists maintaining professional interpersonal rela- perate woman was going to die from her disease. tionships with peers and non-physician staff and She should have been told that she had an untreat- students, never taking advantage of those persons able problem to allow her to make arrangements in their work roles or fi nancially even while still for her multiple young children. In spite of our monitoring the behavior and abilities of their desire to inform her, we were unable to do so peers. They must participate in their faculty’s because her husband was not traveling with her. activities, including education, while maintaining In the Niger culture only the husband could be a secure environment for the patient, staff, and told his wife’s diagnosis. The husband could not the drugs they use. All anesthesiologists are come from the distant village where he lived, pri- required to appreciate their responsibility for marily because of fi nancial issues. Therefore, our improving the community and the society in which doomed patient was neither going to receive ther- they participate, wherever their local facility apy nor be able to return home to prepare for her exists in the developing world. inevitable death. We were faced with an ethical These guidelines issued by the AMA or ASA or issue without a satisfactory answer. After long dis- any other agency or organization are meant to cussions with the Niger hospital staff, we decided direct the healthcare provider, no matter what the that it was more important to maintain the colle- rank or training, toward the consideration of the gial relationship with the local community than it patient or subject as the most important member of was to inform the woman of her diagnosis. This any interaction. Any patient or subject is to be pro- was done not only to respect the local tradition tected no matter what the circumstance. Ethical but just as importantly to protect the continuity of conundrums and legal confl icts will arise as a mat- our mission for the sake of those not yet treated. ter of course when treating or doing research or This compromise, although not ideal, was the only providing patient care. When the patient or subject way that many more women with a devastating is from an LMIC, the road is often fraught with condition could be returned to their normal lives. bumps and potholes because of the inability of Long mores trumped our best efforts to be ethical, the patient to participate in the decision making according to our own standards. process due to language or cultural differences. The diffi culties in patient participation for those residing in LMICs often are not just a mat- Global Health Law ter of understanding language or technical terms, but rather, culturally being in a position to be part As a consequence of rapid globalization, the need of the decision making process. Recently, a for a coherent system of global health law and patient presented at the hospital in Niger where a governance has never been greater. Hazards are fi stula team was doing surgery. Previously, think- posed by contemporary globalization on human ing that her bloody, foul-smelling vaginal dis- health and consequently there is an urgent need charge was secondary to a fi stula, a medicine for global health law to facilitate effective multi- man in her village had given her herbs. These lateral cooperation in advancing the health of homeopathic medicants failed to resolve the populations equitably. “Global health law” is an problem and upon hearing of our fi stula mission, emerging fi eld and there are many challenges to she decided to seek our help. This was as much a reaching its full potential to advance human medical decision as a cultural decision. Had she health in just and effective ways [33 ]. failed to resolve her problem, her husband would Only recently have scholars engaged in a have abandoned her and the villagers would have serious discussion of “public health law” [34 ], ostracized her. In fact, on examination, she did including a defi nition and theory of the fi eld. not have a recto-vaginal fi stula, but rather an The role of the state and civil society in health extensive, fi xed, ulcerated, necrotic cancer of her promotion and disease prevention within a coun- cervix, creating the offensive discharge. try must be defi ned. Literature on the interna- Unfortunately, in Niger, there is no treatment for tional dimensions of health is emerging but no 152 J.S. Freed similar systematic defi nition and exposition of a problems. A small sample of the most effective fi eld we call “global health law” is apparent. This organizations include the UN system, organiza- rapid and expanding globalization emphasizes tions with signifi cant involvement in health the need for a coherent system of international including the World Health Organization, the UN health law and governance [ 35 ]. According to Children’s Fund, the UN Food and Agricultural Taylor, a World Bank consultant and professor of Organization, the UN Environment Program, the public health law, “Although increasing global UN Population Fund, the International Labor integration is not an entirely new phenomenon, Organization and the World Bank. contemporary globalization has had an unprece- The need has also prompted nongovernmental dented impact on global public health” [36 ] and agencies to enter this arena including a wide is therefore responsible for the new challenges for variety of organizations coming at the problem international law and policy. It must be remem- from different perspectives such as religious bered that global health law is meant to facilitate groups, nongovernmental agencies and for-profi t effective cooperation between all nations for the corporations like the pharmaceutical industry purpose of advancing the health of populations with a powerful and signifi cant stake in interna- equally. tional health policy. Also included are the more Multinational corporations, in particular, have creative organizations like health research net- signifi cant infl uence and power over global con- works and, most signifi cantly, public–private sumption of food, tobacco, pharmaceuticals, con- partnerships, an arrangement that is rapidly sumer and healthcare products and services. The becoming commonplace. The need for more production and delivery of these goods and ser- effective collective action among governments, vices pose health hazards that span national bor- businesses, civil society and other entities ders, but often escape scrutiny under national increases daily as the infl uences on health are laws. The global community, therefore, needs to more and more affected by external local inter- develop effective ways to ensure the quality and national factors, including war or its many safety of goods and services that are exchanged equivalents, trashing of the environment, trade in international commerce. If this is not accom- or the lack thereof, investment both for internal plished, unethical practices and the “push and and external sources and crime. pull” of market forces will pressure not only the The seeds of the concept of global health law business community but also doctors and nurses have developed from public international law. in LMICs to make critical choices about the wel- The law is ultimately designed only, to protect fare of their patients, often resulting in the forfeit world health. The concepts are meant to protect of adequate resources needed for management of the individual national sovereignty that is mate- well-functioning healthcare systems [37 ]. rial in any international system. The subjects and Globalization is the driver of the considerably the sources of international law, therefore, have complex demand for effective mechanisms of been with specifi c intent, avoiding a “broad global health governance. Today, the health of any brush” approach to each issue. Global health law population, especially one that is compromised, is a living entity continually attempting to be cre- is not just determined by local facts, but rather is ative and non-intrusive in its attempts at global deeply affected by factors including the increas- health governance. Academicians have empha- ing integration and the internationalization of sized global health governance, in contrast to “the determinants of health.” This complexity has prohibitory or regulatory products of “govern- contributed to the swift decrease in the actual ment” because it allows easy movement across ability of nation-states to protect the health of their public/private boundaries of the state, markets, populations by their own actions alone. The phe- civil society, and private lives [ 39]. Rather than a nomenon has intensifi ed the need for interna- model of top-down social control, governance tional cooperation among states [38 ], leading to theory harnesses the creativity and channels the the rapid increase in international organizations actions, ideas and resources of multiple actors to try to establish legal codes to deal with these that affect health. 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 153

The moral ﬁ ber of global health law is justice. for fair distribution has arisen out of the concept This concept has been the consistent direction of that every life has value. It should be the mission the evolution of global health law and ethics. With of the community of nations to alleviate poverty, this goal of greatly cherished social justice, the the feeling of powerlessness and the needless deﬁ nition of global health law suggests that the suffering and death that harms everyone in the state of affairs for healthy populations should be world’s community by diminishing the public distributed fairly across social, racial, gender, trust and discouraging social cooperation. The economic, and geographic boundaries in all message delivered to those affected and to countries and regions. This is not to say that this everyone in general should not be that the basic justice must be rigidly equally allocated to every human needs of those less fortunate are of less nation and region, but rather some equitable concern than those who have the resources to method of health protection for every human attain their needs. “Social justice thus calls for being must exist. Social justice must at least in policies that promote human dignity for all part require reduction in socioeconomic dispari- members of the international community equita- ties within and among countries. This demand bly” (Fig. 11.3a,b ) [33 ].

Fig. 11.3 (a ) Doing what we do best. (b ) The lives we hope t o s a v e 154 J.S. Freed

rights, privileges and needs that any person in any Conclusion environment in the world has, and must be viewed with the same respect and justice that anyone any- The information provided in this chapter should where is treated. Following this dictum will lead allow the reader to begin to understand the com- to the humane handling of any problem no matter plexities of the ethical and legal issues that pres- what the ethical or legal issue. ent themselves when one is involved in healthcare in the developing world. These issues are further complicated by the requirement of functioning References within the same guidelines that control our activities while performing tasks in the developed 1. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: world. This latter requirement is sacrosanct, and Jamison DT, Breman JG, Measham AR, et al., editors. must be followed no matter what the context of Disease control priorities in developing countries. 2nd the situation encountered in LMICs. The guide- ed. Washington, DC: World Bank; 2006. Chap 67. 2. Ozgediz D, Chu K, Ford N, et al. Surgery in global lines and codes that we are encouraged to follow health delivery. Mt Sinai J Med. 2011;78(3): present an expansive group of problems as differ- 327–41. ent situations occur, while also providing an 3. Farmer PE, Kim JY. Surgery and global health: a view opportunity for reevaluation of the possibilities from beyond the OR. World J Surg. 2008;32(4):533–6. 4. Ozgediz D, Jamison D, Cherian M, McQueen K. The created by preexisting restraints. No two health- burden of surgical conditions and access to surgical care or medical decisions are generated by care in low- and middle-income countries. Bull World exactly the same circumstance, lending to the Health Organ. 2008;86(8):646–7. need for critical thinking when making decisions 5. McQueen KAK, Parmar P, Kene M, et al. Burden of surgical disease: strategies to manage an existing as to behavior in a particular setting. public health emergency. Prehosp Disaster Med. No single chapter can describe all the ethical 2009;24 Suppl 2:S228–31. codes and legal systems that have been formu- 6. Funk L, Weiser T, Berry W, Lipsitz S, Merry A, lated to try to deal with healthcare issues in Enright A, et al. Global operating room distribution and pulse oximetry for surgical care. Lancet. 2010; LMICs. However, this chapter is an introduction 376:1055–61. to those already in force, while also describing 7. Miranda JJ, Casas JP, et al. Non-communicable dis- several of the contexts from which these answers eases in low- and middle- income countries: context, to ethical and legal questions have evolved. In the determinants and health policy. Trop Med Int Health. 2008;13(10):1225–34. process of this evolution, many individuals from 8. Bulletin of the World Health Organization. Khat Hippocrates to Hitler have infl uenced what is chewing in Yemen: turning over a new leaf. Bull today considered ethical and legal. However, World Health Organ. 2008;86(10):737–81. these present answers are fl uid, with new problems 9. Alwan A. Diseases and mental health. In: Global status report on noncommunicable diseases. World and issues coming to the fore at a constant rate, Health Organization. 2010, p. vii. and sometimes at a critical pace. No group of 10. Penchansky R, Thomas JW. The concept of access: opinions or regulations can cover every possibil- defi nition and relationship to consumer satisfaction. ity, especially since every issue encountered has a Med Care. 1981;19(2):127–40. 11. Peters DH, Garg A, Bloom G, et al. Poverty and difference twist, in a different culture, in a differ- access to health care in developing countries. Ann N Y ent political atmosphere, and especially with dif- Acad Sci. 2008;1136:161–71. ferent actors evaluating and acting on the certain 12. Gulliford M, Figueroa-Munoz J, Morgan M, Hughes variable conditions. D, Gibson B, et al. What does ‘access to health care’ mean? J Health Serv Res Policy. 2002;7(3):186–8. When a reader becomes part of the scenario 13. Larson C, Williams J. Sociological context of and is faced with a set of circumstances not spe- TennCare: a public health perspective. J Ambul Care cifi cally covered by guidelines and rules, he or Manage. 2003;26(4):315–21. she must remember that LMICs are not test tubes 14. Jonsen AR. Short history of medical ethics. New York, NY: Oxford University Press; 2000. p. 28–32. in which to try a new and previously untried meth- 15. Percival T. Medical ethics. Manchester: S. Russell; odology. The people in LMICs have the same 1803. 11 Legal and Ethical Issues in Global Health: A Trip Through the Vagaries of Truth and Culture 155

16. American Medical Association [Internet]. Chicago: 28. Presidential Commission for the Study of Bioethical The Association; 2001. https://www.ama-assn.org/ Issues. Anticipate and communicate: ethical manage- ama/pub/physicians/medical-ethics.page . ment of incidental and secondary fi ndings in the clini- 17. Fletcher J. Morals and medicine. Princeton, NJ: cal, research, and direct-to-consumer contexts. 2013. Princeton; 1954. 29. Gutmann A. The bioethics commission on incidental 18. “Nuremberg Code” (PDF). U.S. National Institutes of fi ndings. Science. 2013;342(6164):1321–3. Health. Retrieved 20 Jun 2012. 30. Ma M. Bioethicists issue guidance on handling inci- 19. Kohler ED. The Nazi doctors and the Nuremburg dental fi ndings. JAMA. 2014;311(6):562–3. code: human rights in human experimentation, and— 31. American Society of Anesthesia Ethics Committee. cleansing the Fatherland—Nazi medicine and racial Guidelines for the ethical practice of anesthesiology. hygiene. Bull Hist Med. 1996;70(1):150–1. (Approved by the ASA House of Delegates on 20. Pellegrino ED. The origins and evolution of bioethics: October 15, 2003, last amended on October 19, 2011, some personal refl ections Kennedy Institute of Ethics. and reaffi rmed on October 16, 2013). Kennedy Inst Ethics J. 1999;9(1):73–88. 32. American Medical Association. Adopted June 1957; 21. Kuszler P, Kochis B, Atkins D. Ethics, International revised June 1980; revised June 2001. Law and Human Rights, Sanford. depts.washington. 33. Gostin LO, Taylor AL. Global health law: a defi nition edu/ihg/conference/ethicslawrights.doc. and grand challenges. Public Health Ethics. 2008; 22. United Nations General Assembly resolution 217 A 1(1):53–63. (III). 1948. 34. Martin R, Johnson L. Law and the public dimension 23. Linden AF, Sekidde FS, Galukande M, Knowlton of health. London: Cavendish; 2006. LM, Chackungal S, McQueen KA. Challenges of sur- 35. Fidler D, Gostin L. The new international health gery in developing countries: a survey of surgical and regulations: an historic development for interna- capacity Uganda’s public hospitals. World J Surg. tional law and public health. J Law Med Ethics. 2012;36(5):1056–65. 2006;33(4):85–94. 24. Nuffi eld Council on Bioethics. The ethics of research 36. Taylor A. Encyclo of public health. International law related to healthcare in developing countries. http:/ and public health policy. Elsevier. 2008. Nuffi eld bioethics.org. 2002, p. 126–34. 37. Lee K, Buse K, Fustukian S. Health policy in a global- 25. World Health Organization (WHO). Broadening the ising world. Cambridge: Cambridge University Press; horizon: balancing protection and risk for adolescents. 2002. p. 78–96. Geneva: WHO; 2001. 38. Hunter ND. Risk governance and democracy in health 26. Shukla S. India’s amended trials regulations spark care, Georgetown University Law Center. O’Neill research exodus. Lancet. 2013;382(9895):845–7. Institute Working Paper Series. 2008, p. 1–60. 27. Global bioethics BLOG: promoting refl ections on and 39. Gostin LO. Meeting basic survival needs of the world’s research issues in sub Saharan Africa. Research pro- least healthy people: toward a framework convention tections in India: a case of unethical ethics? 2001. on global health. Georgetown Law J. 2008;96:331–92. Part II Specifi c Case-Related Implementation Strategies for Patient Assessment and Scheduling 12

Laurent Jouffroy

Introduction General Considerations

In many developing countries, especially in rural The preoperative assessment of patient should areas, lack of appropriate supplies and equipment begin by taking the following into consideration: create special challenges for the visiting anesthe- 1. Many patients have never had medical care siologist. Electricity may be unpredictable, oxygen previously, and therefore a thorough history and medical gas supplies and up-to-date monitor- and physical examination are necessary to ing systems may be nonexistent and the level rule out preexisting medical conditions. of training of local health care providers can be Unidentiﬁ ed medical conditions such as con- variable [1 , 2 ]. genital heart disease may affect anesthesia Furthermore, in many places, the practice of care, especially in environments with limited anesthesia focused primarily on the intraoperative facilities for dealing with perioperative com- care of the patient while limited attention is given plications [3 ]. to comprehensive medical assessment prior to 2. Familiarity with locally endemic diseases and surgery. When visiting areas where medical care conditions is necessary to understand periop- is scarce, the anesthesiologist must be especially erative risk factors (e.g., parasitic infections: prepared to manage a range of conditions nor- malaria, dengue fever, HIV/AIDS) [4 ]. mally handled by a multispecialty team. By paying 3. Some anesthetic risks are unappreciated or careful attention to the preoperative process, unknown (e.g., difﬁ cult airway, natural rubber many potential serious complications related to latex allergy). Every attempt should be made anesthesia can be averted. to identify them ahead of time. 4. Depending on the hospital and the country, access to certain routine medications may be limited. 5. A language barrier may exist resulting in potential confusion and misunderstanding. 6. Access to preoperative laboratory work-up L. Jouffroy , M.D. (*) and imaging may be limited. French Society of Anesthesia and Intensive Care, 7. Where knowledge and technical means to Anesthesiology and Critical Care, Ambulatory Surgery Unit , Clinique du Diaconat, deliver regional anesthesia are limited, gen- Strasbourg , France eral anesthesia may be a more appropriate e-mail: [email protected] option [ 5 ] .

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 159 DOI 10.1007/978-3-319-09423-6_12, © Springer International Publishing Switzerland 2015 160 L. Jouffroy

Fig. 12.1 Waiting for pre-operative evaluation

Patient Assessment Table 12.1 Basic standards for preanesthesia care Committee of origin: standards and practice parameters The American Society of Anesthesiologists Task (approved by the ASA house of delegates on October 14, 1987, and last affi rmed on October 20, 2010) Force on Preanesthesia Evaluation defi nes pre- These standards apply to all patients who receive anesthesia as the process of clinical assessment anesthesia care. Under exceptional circumstances, these that precedes the delivery of anesthesia care for standards may be modifi ed. When this is the case, the surgery and for nonsurgical procedures [6 ]. circumstances shall be documented in the patient’s Preanesthesia evaluation includes the review record of medical records (laboratory and imaging) as An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of well as a compressive history and physical exam- anesthesia care ination (Table 12.1 ). The anesthesiologist, before the delivery of anesthesia Most patients should be assessed prior to the care, is responsible for: day of surgery, to allow adequate time for inter- 1. Reviewing the available medical record ventions such as preoperative testing or changes in 2. Interviewing and performing a focused examination medical regimen. For patients with low severity of of the patient to: disease or medium- or low-risk surgical proce- 2.1 Discuss the medical history, including previous anesthetic experiences and medical therapy dures, the preanesthesia assessment may be per- 2.2 Assess those aspects of the patient’s physical formed on the day of surgery. But in some cases, condition that might affect decisions regarding especially in regions where access to a medical perioperative risk and management facility is limited, it can be diffi cult to arrange a 3. Ordering and reviewing pertinent available tests and pertinent assessment prior to the day of surgery. consultations as necessary for the delivery of anesthesia care While the preoperative assessment should ide- 4. Ordering appropriate preoperative medications ally be completed by an anesthesiologist, in many 5. Ensuring that consent has been obtained for the cases a non-physician provider (e.g., trained anesthesia care nurse or anesthesia trainee) may be the most 6. Documenting in the chart that the above has been qualifi ed individual to provide anesthesia care. performed 12 Strategies for Patient Assessment and Scheduling 161

Table 12.2 American Society of Anesthesiologists tional capacity), and the magnitude and duration physical classifi cation [7 , 8 ] of the planned surgical procedure. In rural envi- ASA physical status classifi cation system ronments a number of factors can contribute to an ASA Physical Status 1 —a normal healthy patient increased risk of cardiac complications during ASA Physical Status 2 —a patient with mild systemic surgery. Examples include insuffi cient knowl- disease edge of the patient’s prior medical conditions ASA Physical Status 3 —a patient with severe systemic disease (especially as it may relate to endemic disease), ASA Physical Status 4 —a patient with severe systemic inadequate airway control, lack of appropriate disease that is a constant threat to life monitoring equipment, undetected hypoxia, and ASA Physical Status 5—a moribund patient who is not lack of resuscitation drugs and colloids and other expected to survive without the operation fl uids [11 – 13 ]. ASA Physical Status 6—a declared brain-dead patient A thorough assessment provides the clinician whose organs are being removed for donor purposes an opportunity to initiate medical therapy, coronary interventions, and specifi c surgical and anesthetic techniques tailored to each individual. Preoperative Testing Active or unstable cardiac conditions include unstable coronary artery disease, decompensated Preoperative testing, as a component of the heart failure, signifi cant arrhythmias, and severe preanesthesia evaluation, may be indicated for valvular disease. various purposes, including but not limited to: The Lee index is one of the most accurate indi- discovery or identifi cation of a disease or disor- ces for predicting cardiac risk in non-cardiac sur- der that may affect the perioperative course, veri- gery [14 ]. It emphasizes the value of clinical data fi cation or assessment of an already known in perioperative risk stratifi cation. The Lee index disease, disorder, medical or alternative therapy contains fi ve independent clinical determinants of that may affect perioperative anesthetic care, and major perioperative cardiac events: a history of formulation of specifi c plans and alternatives for ischemic heart disease, a history of cerebrovascu- perioperative anesthetic care. lar disease, heart failure, insulin- dependent diabe- After obtaining the patient history, performing tes mellitus, and impaired renal function. the physical examination and reviewing preoper- High-risk type of surgery is the sixth factor. All ative testing, the patient’s ASA status should be factors are equally weighted with one point given noted (Table 12.2 ). The ASA classifi cation iden- to each. tifi es patients according to the level of systemic The incidence of major cardiac complications illness. is estimated at 0.4, 0.9, 7, and 11 % in patients A patient’s poor medical conditions and inap- with an index of 0, 1, 2, and 3 or more points, propriate selection for surgery when matching risk respectively (Table 12.3 ). to procedure benefi t, and inadequate preoperative Cardiac complications after non-cardiac sur- preparation are factors associated with increased gery depend not only on medical risk factors but mortality in developing countries [9 , 10 ]. also on the type of surgery being performed, the urgency, magnitude, type, and duration of the procedure, as well as changes in body core tempera- Specifi c Clinical Considerations ture, blood loss, and fl uid shifts [ 15]. With regard to cardiac risk, surgical interven- Cardiac Risk tions can be divided into low-risk, intermediate- risk, and high-risk groups with estimated 30-day In general, cardiac risk factors are determined cardiac event rates (cardiac death and MI) less by the patient’s condition prior to surgery, the than 1 %, 1–5 %, and superior to 5 %, respectively prevalence of co-morbidities (as it relates to func- (Table 12.4). Although only a rough estimation, 162 L. Jouffroy this risk stratifi cation provides a good indication of be another essential component in preoperative the need for cardiac evaluation, drug treatment, cardiac risk assessment [17 , 18 ]. Functional capac- and assessment of risk for cardiac events [16 ]. ity is measured in metabolic equivalents (METs). Evaluation of functional capacity is considered to One MET equals the basal metabolic rate. Exercise testing provides an objective assessment of func- Table 12.3 LEE cardiac risk index [16 ] tional capacity. Without testing, functional capac- Classical Clinical ity can be estimated by the ability to perform a LEE risk LEE risk number of activities of daily living (Table 12.5 ). index Clinical risk determinants index When functional capacity is high, the progno- 1 Point High-risk surgical procedures Not • Intraperitoneal applicable sis is excellent, even in the presence of stable • Intrathoracic ischemic heart disease or risk factors (>4 meta- • Suprainguinal vascular bolic equivalents). On the other hand, when func- 1 Point History of ischemic heart disease 1 Point tional capacity is poor or unknown (<4 metabolic • History of myocardial infarction equivalents), consideration of other risk factors is • History of positive exercise test required to determine the patient’s risk for peri- • Current complaint of chest operative morbidity. pain considered secondary to myocardial ischemia • Use of nitrate therapy • ECG with pathological Q Pulmonary Disease waves 1 Point History of congestive heart failure 1 Point Preoperative pulmonary care involves identifying • History of congestive heart patients at high risk for postoperative pulmonary failure • Pulmonary edema complications and optimizing respiratory function • Paroxysmal nocturnal dyspnea for those with preexistent pulmonary disease [19 , • Bilateral rales or S3 gallop 20]. Postoperative pulmonary complications include • Chest radiograph showing atelectasis, bronchospasm, pneumonia, respiratory pulmonary vascular redistribution failure, and exacerbation of chronic lung disease. 1 Point History of cerebrovascular disease 1 Point Table 12.6 indicates conditions and risk fac- • History of transient ischemic tors that signifi cantly increase the risk of such attack or stroke complications. 1 Point Preoperative treatment with 1 Point Smoking cessation before surgery should be insulin initiated as soon as possible (at least 6–8 weeks 1 Point Preoperative serum creatinine 1 Point >2.0 mg/dL prior to surgery, 4 weeks at a minimum) [21 , 22 ].

Table 12.4 Surgical risk estimate: risk of myocardial infarction and cardiac death within 30 days after surgery Low risk <1 % Intermediate risk 1–5 % High risk >5 % Breast Uncomplicated abdominal Aortic and major vascular surgery Dental Carotid Peripheral vascular surgery Endocrine Peripheral arterial angioplasty Surgeries with major blood loss or ﬂ uids shifts involving the chest or abdomen Eye (cataract) Endovascular aneurysm repair Gynecology Head and neck surgery Dermatologic procedures and Neurological/orthopedic—major (hip and Reconstructive spine surgery) Orthopedic—minor (knee Thoracic, renal/liver transplant surgery) Urologic—minor Urologic—major (radical prostatectomy) 12 Strategies for Patient Assessment and Scheduling 163

Table 12.5 Estimated energy requirements for various Table 12.6 Surgical risk estimate: good evidence for activities postoperative pulmonary complications Functional Physical activity Estimated Patient-related Procedure-related risk Laboratory capacity METs without symptom surgical risk risk factor factor test High >10 Can participate to Advanced age Aortic aneurysm repair Albumin strenuous sport like level <30 g/L swimming, singles ASA class = or > II Vascular surgery tennis, basketball, or Chronic heart Thoracic surgery skiing? failure Good to 7–10 Can do heavy work Low Functionally Abdominal surgery very good around the house like dependent scrubbing fl oors or Chronic Neurosurgery lifting or moving obstructive disease heavy furniture Can participate in Obesity smoking Head and neck surgery moderate recreational Emergency surgery activities like golf, Alcohol abuse General anesthesia dancing, doubles tennis, Modifi ed from Smetana et al. [19 ] football, bicycling at a regular pace Can walk uphill? recent upper respiratory infection (coughing, Can walk on level ground at 4 mph sputum production) require particular atten- (6.5 kph)? Run a short tion and consideration. Major risk factors distance? include type of surgery, type and duration of Moderate 4–7 Can climb two fl ights anesthesia, general health status, and smoking of stairs? Can do light works history, rather than specifi c lung function around the house parameters [23 ]. (dusting, washing • Asthma [24 ]: Preoperative assessment of the dishes)? patient with asthma should focus on the Low <4 Can take care of Moderate to patient’s pulmonary status to determine the yourself? High Can eat, dress, or use level of respiratory dysfunction and to assess the toilet? the effectiveness of current therapy. A review of Can walk indoors baseline exercise tolerance, hospital visits due around the house? to asthma (including whether endotracheal Can walk a block or two on level ground at intubation or IV infusions were required), 2–3 mph (3–5 kph)? allergies, and previous surgical/anesthetic Not ? history is essential. The patient’s medication assessable regimen should be reviewed providing impor- kph indicates kilometers per hour, MET metabolic equiva- tant clues as to the level of disease severity. lent, mph miles per hour Asthma can be divided into four categories: Adapted from Fletcher et al. [18 ] 1. Mild intermittent disease (use of short-acting bronchodilators on an as-needed basis). Preoperative Assessment 2. Mild persistent disease (daily controller of Respiratory Disease medication such as low-dose inhaled corti- The most commonly encountered preexisting costeroid (ICS) leukotriene modifi er, or respiratory conditions of clinical relevance to the theophylline). anesthesiologist include chronic obstructive pul- 3. Moderate persistent disease (low- or medium- monary disease (COPD), asthma, and obstructive dose ICS with a long-acting bronchodilator). sleep apnea syndrome (OSAS). 4. Severe persistent disease (daily symptoms, • For COPD, clinical fi ndings of obstruction multiple medications such as high-dose ICSs, (wheezing, increased dyspnea), or a history of oral steroids, bronchodilators). 164 L. Jouffroy

This classifi cation should help to identify elevated body mass index, high-risk surgery, patients at risk for pulmonary complications and peripheral vascular occlusive disease, and chronic prepare the anesthesiologist to initiate therapy obstructive pulmonary disease necessitating for potential bronchoconstriction and to plan chronic bronchodilator therapy. The score is perioperative care to minimize the risk of acute applied as follows: exacerbations. • Class I (0–2 risk factors) is not related to a • Obstructive sleep apnea syndrome [ 25 , 26 ]: relative risk of acute kidney injury (AKI). OSAS poses a high risk factor for encountering • Class II (3 risk factors) is related to a relative a diffi cult airway and post operative respiratory risk of AKI from 4 %. obstruction. In addition to a through history • Class III (4 risk factors) is related to a relative and physical examination prior to surgery, a risk of AKI from 8.8 %. standardized questionnaire can be helpful in • Class IV (5 risk factors) is related to a relative assessing OSAS (e.g., Berlin questionnaire). risk of AKI from 16.1 %. • Class V (6 and more risk factors) is related to Pulmonary Function Tests a relative risk of AKI from 46.3 %. Preoperative spirometry and chest radiography are While a number of strategies have been sug- not predictive of postoperative pulmonary compli- gested to minimize nephrotoxic insults, there is cations and cannot be recommended on a routine limited evidence to support the value of prophy- basis [27 ]. Clinical fi ndings remain the most accu- lactic and therapeutic interventions in patients rate predictor of postoperative pulmonary compli- at high risk for developing perioperative renal cations. Aggressive treatment based on the use of failure [29 ]. bronchodilators, antibiotics, corticosteroids, physical therapy, smoking cessation, and correction of malnutrition may be benefi cial in reducing postop- Obesity erative pulmonary complications. The Overseas Development Institute (ODI) currently puts the number of overweight and obese Renal Disease adults in developing countries at more than 900 million. Moreover, the number of overweight and The patient with preexisting renal disease poses obese adults has risen from 250 million to nearly a particular challenge to the safe delivery of anes- a billion in the last 30 years [ 30]. The body mass thesia. Renal complications are more likely to index (BMI) is the most widely used classifi ca- occur in: tion. Patients are considered overweight with a 1. Patients with preexisting renal dysfunction. BMI between 25 and 29.9 kg/m 2 and obese with 2. Patients with chronic heart disease, chronic a BMI between 30 and 49.9 kg/m 2 . Patients with obstructive lung disease, peripheral occlusive a BMI of 50 kg/m 2 or greater are considered vascular disease, obesity. superobese. 3. Patients undergoing vascular procedures with Obesity is accompanied by co-morbidities aortic cross clamping, cardiopulmonary such as coronary artery disease, hypertension, bypass. OSAS and/or diabetes mellitus. Perioperative risk 4. Lengthy surgical procedures and/or procedure assessment should, therefore, focus on cardiac with major blood loss and major fl uids shifts. and pulmonary dysfunction as well as nutritional In non-cardiac surgery, the Kheterpal score is status [31 ]. useful for the identifi cation of patient at risk for Preoperative assessment of risk factors and postoperative renal impairment [ 28 ]. For patient clinical evaluation as well as ECG examination without preexisting renal dysfunction seven iden- is essential in obese patients. To identify patients tifi ed preoperative predictors of acute renal fail- at risk for diffi cult airway, a neck circumferences ure include age, emergency surgery, liver disease, of at least 43 cm as well as a high Mallampati 12 Strategies for Patient Assessment and Scheduling 165 score and male gender are predictors for diffi cult although nonpregnant women constitute the largest laryngoscopy and hence intubation [32 ]. group (468 million) [39 ]. Underlying causes for Preoperative testing is indicated in obese patients anemia are multi-factorial and largely prevent- in order to detect abnormal glucose/HbA1C levels able and include nutritional defi ciencies, infec- and/or anemia [27 ]. tions, multiple pregnancies, and hemoglobin disorders. Low preoperative hemoglobin levels and a Diabetes Mellitus high level of surgical intervention can predict the need for intraoperative blood transfusion and Diabetes mellitus is a growing public health issue potentially poor postoperative outcome. Low affecting people both in developing and devel- hemoglobin levels are associated with increased oped countries [33 ]: approximately 150 million perioperative morbidity in surgical patients, lon- people have diabetes mellitus worldwide, and this ger recovery from procedures that involve blood number may very well double by 2025. Much of loss, and a higher likelihood of postoperative this increase will likely occur in developing coun- infection. Depending on the hospital, and the tries. By 2025, while most people with diabetes lack of availability of routine blood tests, it may in developed countries will be aged 65 years or be benefi cial to bring the equipment required to more, in developing countries the age range is in measure hematocrit (a small portable device), the 45–64-year bracket during some of their most especially if procedures involving blood loss are productive years. anticipated. Given the risks and costs associated Patients with diabetes are more likely to with allogeneic blood transfusion and the low require surgery [34 ]. Elevated blood glucose in availability of blood for transfusion, strategies the perioperative period is a risk factor for have been developed for preoperative correction surgical site infection [35 ] and diabetic patients of anemia and prevention of perioperative blood are at greater risk for postoperative heart failure transfusion needs as preoperative iron supple- [36 ]. Both type I and II diabetic patients have a mentation which may be considered to correct higher rate of diffi cult laryngoscopy than non- preoperative anemia [40 ]. diabetic patients [37 ]. It is not necessary to test blood sugars routinely on all patients during the preoperative assessment. Substance Abuse and Addiction Screening for diabetes/risk of hyperglycemia can be based on history and examination or investiga- In many developing countries, alcohol and cigarette tions of glycemic control. Risk factors include use is rising rapidly and often at an earlier age. age, sex, family history of diabetes, low exercise Intravenous drug use, involving heroin, amphet- level, and obesity [38 , 27 ]. amine, and opiates, is on the rise [41 ]. Alcohol use disorders (AUDs) are associated with alcohol-related postoperative complications Anemia such as higher rates of wound infection, acute withdrawal and organ failure. For the preoperative Anemia is an especially important public health detection of AUDs, the combined use of a stan- concern in developing countries and is responsi- dardized questionnaire (e.g., CAGE question- ble for signifi cant morbidity and mortality. About naire) together with laboratory testing such as two billion people worldwide are estimated to GGT (g-glutaryl transferase) and carbohydrate- suffer from anemia and it is reported to account defi cient transferrin (CDT) is superior to either for more than 700,000 deaths per year in Africa one alone [42 , 43 ]. Alcohol abstinence for at least and Southeast Asia. The highest prevalence of 1 month has been shown to reduce perioperative anemia is in preschool-age children (47 %) complications from 74 to 31 % [44 ]. 166 L. Jouffroy

HIV/AIDS Preoperative Evaluation for HIV- Infected Patients [45 ] According to the 2007 WHO/UNAIDS estimates, at the end of 2007, more than 95 % of Preoperative evaluation of the HIV-infected patient HIV infections worldwide occur in developing is similar to that of the general population; how- countries with two-thirds occurring in sub-Saha- ever, comorbidities, active substance use, and the ran Africa where over 28 million people are liv- presence of methicillin-resistant Staphylococcus ing with HIV. Infection rates are lower in Asia aureus may be more prevalent in the HIV-infected and the Paciﬁ c, where over seven million are population (see Table 12.7 ). infected. However, since this syndrome is not In most developing countries, heterosexual speciﬁ c, it is rarely recognized, even when clini- transmission is the dominant mode of spread, cally apparent. and mother to child transmission of HIV is much

Table 12.7 Surgical management considerations for HIV-infected patients with comorbidities and other conditions Comorbidity risks Pre- and perioperative recommendations Hepatic dysfunction Recommendation • Increased prevalence of hepatic dysfunction • Assess for hepatic dysfunction preoperatively because of the from ART or from preexisting liver disease possible impact on dosing or selection of anesthetics, Surgical risk perioperative antibiotics, and other medications • Co-infection with HBV or HCV may predispose to increased bleeding risk due to coagulopathy or thrombocytopenia Renal dysfunction Recommendations • Increased prevalence of renal dysfunction from • Assess for renal dysfunction preoperatively because of the HIV - associated nephropathy (HIVAN ) and other possible impact on dosing or selection of anesthetics, causes perioperative antibiotics, and other medications • If there are renal function changes in the perioperative period, review ART regimen for agents that may require renal dose adjustment Coronary artery disease and cardiac abnormalities Recommendations • Increased prevalence of CAD from metabolic • Assess for coronary artery disease preoperatively. dysfunction due to HIV infection and / or ART Perform careful review of preoperative EKG results • QT prolongation or other cardiac abnormalities may occur in advanced HIV infection or in patients receiving certain medications a Respiratory complications Recommendation • Prevalence of underlying pulmonary disease is Carefully evaluate for respiratory complications in the increased due to the increased risk for bacterial perioperative period pneumonia and high prevalence of smoking in HIV -infected patients Surgical risk • Risk for postoperative pneumonia is increased in HIV-infected patients Thrombocytopenia and neutropenia Recommendations • Idiopathic thrombocytopenic purpura may • Consult with hematologist prior to surgical procedure when occur at any stage of HIV infection platelet counts approach 50,000 per μL Neutropenia is common in HIV -infected individuals • Routine use of G-CSF not recommended but in perioperative with severe immunosuppression b period may consider G-CSF c use to maintain absolute neutrophil count >1,000 cells/mm Hemophilia Recommendation • Coordination between surgical team and hematologist is recommended for transfusion of factor replacement in anticipation of surgery (continued) 12 Strategies for Patient Assessment and Scheduling 167

Table 12.7 (continued) Comorbidity risks Pre- and perioperative recommendations Substance use ( SU ) Recommendations • SU disorders are more prevalent in HIV - infected • Obtain detailed history of substance use individuals than in the general population • Consider obtaining urine toxicology screen, with patient Surgical risks consent • Increased risk for complications from surgery • For elective surgery, observe appropriate period of and anesthesia, notably cardiac complications abstinence with the use of substitute medications such as associated with cocaine use methadone or benzodiazepines as appropriate • Increased risk for withdrawal symptoms in the postoperative period for unrecognized alcohold, benzodiazepine, or heroin use Methicillin Resistant Staphylococcus aureus Recommendations (MRSA ) • Assess for a history of previous MRSA infection/ • Community -acquired MRSA infection is more colonization, particularly in MSMs common in MSM than in the general population • Use vancomycin instead of cefazolin for prophylaxis when indicated in patients with positive history of MRSA Drug allergies Recommendation • HIV -infection is associated with a higher • Obtain a careful history of allergies incidence of medication allergies HBV hepatitis B virus, HCV hepatitis C virus, MSM men who have sex with men, PI protease inhibitor, ZDV zidovudine a Anti-arrhythmics, methadone, PIs, antipsychotics, or macrolide antibiotics can cause QT prolongation or other cardiac abnormalities, especially if more than one such agent is administered concurrently b Neutropenia may be caused by medications (e.g., ZDV, TMP-SMX), HIV infection itself, bone marrow infi ltration from malignancy or systemic infection c G-CSF is recommended over GM-CSF due to theoretical concerns regarding potential stimulation of HIV replication by the latter, although the possible mechanism by which GM-CSF might affect HIV-1 replication remains unclear d Alcohol withdrawal may be life-threatening if symptoms are not recognized early more common. Transmission associated with injecting drug use is particularly frequent in parts Specifi c Considerations of South and South East Asia and Central and South America. Acquisition of infection from D i f fi cult Airway contaminated blood remains a problem, especially in parts of sub-Saharan Africa and South Airway assessment is paramount when assessing Asia. Women and children are at especially high anesthesia-related morbidity. Many unnecessary risk for transfusion transmitted HIV infection, deaths are a result of airway problems in healthy the former because of the high incidence of ane- young patient in developing countries [47 ]. mia and hemorrhage associated with pregnancy The American Society of Anesthesiologists and childbirth, and the latter because of malarial defi nes a diffi cult airway as the clinical situation anemia [46 ]. in which a conventionally trained anesthesiologist experiences diffi culty with facemask ventilation of the upper airway, diffi culty with tracheal Perioperative Medication intubation, or both [48 ] (Table 12.8 ). Management of HIV-Infected Patients No single predictive sign for diffi cult airway management is suffi cient by itself and the preanes- Clinicians should continue antiretroviral therapy thesia assessment needs to combine a number of (ART) in the perioperative period with as little validated evaluation criteria (Table 12.9 ). interruption as possible, particularly for patients Systematic multimodal screening for diffi - co-infected with hepatitis B virus (HBV) who are cult intubation should include the Mallampati receiving an ART regimen that also has activity classifi cation (Fig. 12.2 ), the thyromental dis- against HBV. tance (<3 fi nger breaths), the mouth opening or 168 L. Jouffroy interincisor distance (<3 cm), and the upper lip Particular attention to the evaluation for bite test (ULBT). possible diffi cult intubation should be paid in • The Mallampati classifi cation [49 – 51 ]. certain medical conditions such as obesity, large • The ULBT [52 ] consists of three classes: class I, the lower incisors can bite the upper lip, making the mucosa of the upper lip totally invisible; Table 12.9 Components of the preoperative airway physical examination class II, the same biting maneuver reveals a partially visible upper lip mucosa; and class III, Airway examination component Nonreassuring fi ndings the lower incisors fail to bite the upper lip. Length of upper Relatively long incisors Table 12.8 Current recommendations from the ASA for airway assessment preoperatively Relation of maxillary Prominent “overbite” (maxillary and mandibular incisors anterior to mandibular Recommendations for evaluation of the airway incisors during normal incisors) History . An airway history should be conducted, jaw closure whenever feasible, before the initiation of anesthetic care Relation of maxillary Patient cannot bring mandibular and airway management in all patients. The intent of the and mandibular incisors anterior to (in front of) airway history is to detect medical, surgical, and incisors during maxillary incisors anesthetic factors that may indicate the presence of a voluntary protrusion of diffi cult airway. Examination of previous anesthetic the lower jaw records, if available in a timely manner, may yield useful Interincisor distance Less than 3 cm information about airway management Visibility of uvula Not visible when tongue is Physical examination . An airway physical examination protruded with patient in sitting should be conducted, whenever feasible, before the position (e.g., Mallampati class initiation of anesthetic care and airway management in greater than II) all patients. The intent of this examination is to detect Shape of palate Highly arched or very narrow physical characteristics that may indicate the presence of a diffi cult airway Compliance of Stiff, indurated, occupied by mandibular space mass, or nonresilient Multiple airway features should be assessed Thyromental distance Less than three ordinary fi nger Additional evaluation . Additional evaluation may be breadths indicated in some patients to characterize the likelihood or nature of the anticipated airway diffi culty. The Length of neck Short fi ndings of the airway history and physical examination Thickness of neck Thick may be useful in guiding the selection of specifi c Range of motion of Patient cannot touch tip of chin diagnostic tests and consultation head and neck to chest or cannot extend neck

Fig. 12.2 (a ) Mallampati classifi cation modifi ed by Samsoon and young: Class 1—visualization of the soft palate, Class 2—complete visualization of uvula, Class 3—visualization of the base of the uvula, Class 4—soft palate is not visible at all; (b ) Laryngoscopy according to the classifi cation of Cormack and Lehane: Grade I—most of the glottis visible, Grade II—only the posterior extremity of the glottis visible, Grade IV— not even the epiglottis visible [6 ] 12 Strategies for Patient Assessment and Scheduling 169 neck circumference (more than 45 cm), OSAS, when patients should restrict the oral intake of diabetes, fi xed cervical spine, ENT pathologies, liquids or solids. and preeclampsia. A number of recommendations have been proposed related to the duration of fasting and the type of foods that should be avoided. For Pulmonary Aspiration Preoperative Fasting Status, the ASA guidelines suggest: Perioperative pulmonary aspiration is defi ned as 1. Adults: Clear liquids at least 2 h (e.g., water, aspiration of gastric contents (Practice fruit juices without pulp, carbonated bever- Guidelines for Preoperative Fasting) occurring ages, clear tea, black coffee). after induction of anesthesia, during a procedure 2. Children: Clear liquids at least 2 h; breast or in the immediate period after surgery [ 53 ]. milk at least 4 h; infant formula at least 6 h. Aspiration is a known risk of anesthesia and it is 3. Solids or nonhuman milk at least 6 h. avoidable with proper management strategies. 4. Fried or fatty foods or meat, additional fasting Preoperative assessment and identifi cation of time: at least 8 h or more. patients at risk for aspiration allow the clinician The European Society of Anesthesiology to initiate fasting, medication administration, guidelines suggest clinicians [54 ]: and appropriate anesthetic techniques to mini- • Increase the emphasis on encouraging patients mize the risk of pulmonary aspiration. In devel- not to avoid fl uids for any longer than is oping countries, higher risk of aspiration is necessary: related to inadequate airway management, lack “Adults and children should be encouraged to of awareness, and understanding of the anesthe- drink clear fl uids (including water, pulp-free sia providers. juice and tea or coffee without milk) up to 2 h Predisposing factors for increasing incidence before elective surgery (including caesarean of aspiration include: section)”. 1. Coexisting diseases or conditions that can • Offer practical, pragmatic advice on chewing affect gastric emptying or fl uid volume: e.g. gum, smoking and drinks containing milk: obesity, diabetes, hiatal hernia, gastroesopha- “Patients should not have their operation geal refl ux, neurological defi cit, emergency cancelled or delayed just because they are surgery (particularly in a trauma patient), chewing gum, sucking a boiled sweet or bowel obstruction, or opioid medication taken smoking immediately prior to induction of by the patient. anesthesia”. 2. Patients in whom airway management might • Consider the safety and possible benefi ts of be diffi cult, inadequate (light) anesthesia, or preoperative carbohydrates: the supine position. “It is safe for patients (including diabetics) to The primary method for reducing the risk of drink carbohydrate-rich drinks up to 2 h before aspiration is to ensure that the patient has an elective surgery”. empty stomach before induction of anesthesia, “Drinking carbohydrate-rich fl uids before particularly for elective surgical procedures. The elective surgery improves subjective well- routine request to fast patients prior to surgery has being, reduces thirst and hunger and reduces evolved with time to emptying the stomach prior postoperative insulin resistance”. to induction of anesthesia so that nowadays sev- • Fasting in obstetric patients: eral anesthesia societies suggest shorter fasting “Women should be allowed clear fl uids times with regards to liquids in fi t healthy patients. (as defi ned above) as they desire in labor”. Fasting is the recommended approach to reducing But “Solid food should be discouraged dur- the quantity of gastric contents. According to the ing active labor”. ASA defi nition, preoperative fasting is defi ned as These recommendations are of particular a prescribed period of time before a procedure importance in warmer climates where dehydration 170 L. Jouffroy

Table 12.10 Several therapeutic strategies have been • Patients with a history of possible latex applied to decrease the risk of aspiration allergy. Preoperative pharmacologic interventions • Children having had multiple surgeries, par- 1. Gastrointestinal stimulants (e.g., metoclopramide, ticularly those with spina bifi da and cisapride) myelomeningocoele. 2. Blockage of gastric acid secretion • Patients with a history suggesting allergy to a. Histamine-2 receptor antagonists (e.g., cimetidine, ranitidine, famotidine) vegetables, fruits or cereals known to have b. Proton pump inhibitors (e.g., omeprazole, frequent cross-reactivity with latex (such as lansoprazole) kiwi, banana, papaya, avocado, chestnut, 3. Antacids (e.g., sodium citrate, magnesium trisilicate) buckwheat). 4. Antiemetics (e.g., ondansetron, droperidol) Knowledge of any previous allergic reactions 5. Anticholinergics (e.g., atropine, glycopyrrolate) to medications and the nature of the reaction are 6. Multiple agents/drugs versus single agents/drugs critical information for the anesthesiologist as well as the other members of the perioperative team to obtain. For patients with hypersensitivity can post a signifi cant risk to the patient’s health to latex, exposure to even low amounts of latex- prior to surgery. containing particles is suffi cient to induce a Patients should be informed of fasting severe anaphylactic reaction. A latex-free operat- requirements suffi ciently in advance of their pro- ing environment, in which no latex gloves or cedures. Verifi cation of patient compliance with accessories are used should be established. fasting requirements should be assessed prior to the procedure. Nevertheless for patients at risk for aspiration, some preoperative pharmacologic Malignant Hyperthermia [56 , 57 ] interventions have been proposed (ASA 2011) (Table 12.10.) Malignant hyperthermia (MH) is serious condition characterized by acute hyperpyrexia developing during or immediately after general anesthesia. Allergy [55 ] Exposure of patients with mutations predisposing them to MH following exposure to vola- Substances most responsible for immediate allergic tile anesthetics, including halothane, isofl urane, reactions during anesthesia are neuromuscular enfl urane, desfl urane, and sevofl urane, or to a blockers (63 % of reactions), latex (14 %), hypnot- depolarizing muscle relaxant such as succinyl- ics (7 %), antibiotics (6 %), plasma substitutes choline, can precipitate life-threatening muscle (3 %), and morphine-like substances (2 %). Allergic contractures, increases in heart rate and body reactions to local anesthetics are very rare, espe- temperature, rhabdomyolysis, myoglobinuria, cially when one considers how often they are used. and metabolic acidosis. The mortality rate for To date no anaphylactic reaction to halogenated MH is 80 % in untreated patients but about 5 % anesthetic agents has been published. with timely treatment. The preanesthesia evaluation has to include a If malignant hyperthermia is suspected from a systematic search for potential hypersensitivity family history of adverse events with the admin- reactions, taking into account the great number of istration of anesthetics or when a patient has a drugs and devices to which the patient may be reaction suspicious for malignant hyperthermia, exposed during the perioperative period. a muscle biopsy is indicated but usually not Patients at risk for anaphylactic/anaphylactoid available. No physical fi ndings identify MHS reaction are the following: patients. • Patients with a documented allergy to one of Local or regional anesthetic techniques are the drugs or products likely to be used. good choices where possible. If general anesthe- • Patients with a history of possible allergic sia has to be used, avoidance of triggering agents reaction during a previous anesthesia. is advised and preparation of the anesthesia 12 Strategies for Patient Assessment and Scheduling 171 machine includes removing vaporizers, fl ushing should be reassessed in view of the nature and through the machine with 100 % oxygen and half-life of the medications. Many medications using a new breathing circuit. An anesthesiolo- are continued through the perioperative period, gist on a medical mission needs to be prepared with the last dose taken with a sip of clear liquid for malignant hyperthermia and must carry dan- up to 2 h prior to the procedure, and quickly trolene or make sure that it is available. resumed during recovery (Table 12.11 ).

Drug Interactions Medical Records

Routinely prescribed medications have many It is imperative that the anesthesiologist docu- potential interactions with drugs used during ments all ﬁ ndings related to the perioperative surgery, but few situations prohibit concurrent interaction in the patient’s record and insures its administration. The perioperative medical regimen accessibility to both the patient and the local

Table 12.11 Medications and their use or discontinuation during the perioperative period [58 , 59 ] Should be continued Should be discontinued Cardiovascular [60 ] Beta blockers [61 ] (e.g., metoprolol, Until and including the day of operation / atenolol, nebivolol) Ace inhibitors (ACEI ) Until the day before of operation On the day of the operation (general (e.g., captopril, lisinopril) anesthesia) Angiotensin receptor blockers ( ARB ) (e.g., losartan, candesartan) Calcium channel blockers [62 ] Until and including the day of operation / (e.g., nifedipine, diltiazem) Nitrates Until and including the day of operation / (e.g., nitroglycerin, isosorbide) Alpha-2 agonists Until and including the day of operation / (e.g., clonidine) Aspirin [63 , 64 ] Unless noted otherwise STOP at least 5 days prior to surgery in high risk of bleeding procedures Clopidogrel Unless noted otherwise STOP at least 1 week prior to surgery Oral anticoagulants Unless noted otherwise STOP at least 5 days prior to surgery In patients undergoing surgery with a In high - risk patients or in case of low risk of serious bleeding , such as surgical procedures with a high risk cataract or minor soft tissue surgery of serious bleeding , discontinuation ( carpal tunnel , dermatologic of medications and bridging therapy procedures ), continuation should be with LMWH are highly considered instead of instituting recommended for the perioperative bridging therapy period LMWH Until the day before of operation STOP 12 h before surgery – Prophylactic dose STOP 24 h before surgery – Half or full therapeutic dose Diuretics On the day of the operation (e.g., furosemide, hydrochlorothiazide) Cardiac rhythm management Until and including the day of operation / medications (e.g., digoxin, beta-blockers, quinidine, amiodarone) (continued) 172 L. Jouffroy

Table 12.11 (continued) Should be continued Should be discontinued Statins Until and including the day of operation / (e.g., atorvastatin, simvastatin) Cholesterol lowering medications Until the day before of operation On the day of the operation. CNS medications Anticonvulsants Until and including the day of operation / (e.g., phenytoin, tegretol) Antidepressants Until and including the day of operation / (e.g., imipramine, sertraline) Monoamine oxidase inhibitors STOP at least 2 weeks prior to surgery Antianxiety medications Until and including the day of operation / (e.g., diazepam, lorazepam) Antipsychotics Until and including the day of operation / (e.g., haloperidol, risperdal) Lithium Until and including the day of operation / Antiparkinson drugs Until and including the day of operation / (e.g., sinemet) Vitamins/nutritional supplements “Over-the-counter” vitamins STOP at least 10–14 days prior to surgery Herbal /alternative preparations [65 , 66 ] STOP at least 1 week prior surgery, (e.g., Ginseng, Garlic, Ginko, and 1 week after Echinacea, Ephedra) Pulmonary medications Asthma medications Until and including the day of operation / (e.g., theophylline, inhaled steroids) COPD medications Until and including the day of operation / (e.g., theophylline, ipratropium, inhaled steroids) Pulmonary hypertension medications Until and including the day of operation / (e.g., sildenaﬁ l, prostacyclin, others) Endocrine Insulin – Type 1 should take 1/3 the day of – Type 2 take none surgery – Insulin pump continued at the lowest basal rate Oral diabetic medications metformine Until the day before of operation On the day of the operation STOP 24–48 h before surgery Thyroid medications Until and including the day of operation / (e.g., synthroid, dessicated thyroid, propylthiouracil) Steroids (oral and inhaled ) Until and including the day of operation / (e.g., prednisone, cortef) Oral contraceptives Until and including the day of operation / Renal Phosphate binders, renal vitamins, Until the day before of operation On the day of the operation. iron, erythropoietin, others Gynecology / urology Prostate medications Until and including the day of operation / (e.g., terazosin, tamsulozsin) Hormonal medications Until and including the day of operation / Oral contraceptives Until and including the day of operation / (continued) 12 Strategies for Patient Assessment and Scheduling 173

Table 12.11 (continued) Should be continued Should be discontinued Analgesics Opiate containing analgesics Until and including the day of the / (e.g., vicodin, tylox, methadone) operation, without exception Nonsteroidal anti-infl ammatory STOP at least 5 days prior surgery compounds (e.g., ibuprofen, naproxen) Gastrointestinal Gastroesophageal refl ux (GERD ) Until and including the day of operation / medications (e.g., ranitidine, omeprazole) Antiemetics Until and including the day of operation / (e.g., ondansetron, metoclopramide) Autoimmune medications Methotrexate Until and including the day of operation / Unless risk of acute renal failure Etanercept (Enbral) STOP 2 weeks prior to surgery Infl iximab (Remicade) STOP 6 weeks prior to surgery Adalimumab (Humira) STOP 8 weeks prior to surgery

Table 12.12 Statement on documentation of anesthesia care Committee of origin: quality management and departmental administration (approved by the ASA house of delegates on October 15, 2003, and last amended on October 16, 2013) Documentation is a factor in the provision of quality care and is the responsibility of an anesthesiologist. While anesthesia care is a continuum, it is usually viewed as consisting of preanesthesia, intraoperative/procedural anesthesia and postanesthesia components. Anesthesia care should be documented to refl ect these components and to facilitate review. Documentation may be through a paper record, an electronic system, or a combination, as specifi ed by the practice and the facility where patient care is provided. CMS has separate detailed requirements for the contents of peri-anesthesia care documentation that should be addressed, if pertinent The record should include documentation of: I. Preanesthesia Evaluation A. Patient interview to assess: 1. Patient and procedure identifi cation 2. Verifi cation of admission status (inpatient, outpatient, “short stay”, etc.) 3. Medical history 4. Anesthetic history 5. Medication/Allergy history 6. NPO status B. Appropriate physical examination, including vital signs and documentation of airway assessment C. Review of objective diagnostic data (e.g., laboratory, ECG, X-ray) and medical records D. Medical consultations when applicable E. Assignment of ASA physical status, including emergent status when applicable F. Formulation of the anesthetic plan and discussion of the risks and benefi ts of the plan (including discharge issues when indicated) with the patient or the patient’s legal representative and/or escort.2 G. Documentation of appropriate informed consent(s) H. Appropriate premedication and prophylactic antibiotic administrations (if indicated) medical facility (Table 12.12 ). These records ers, surgeons and operating-room staff is help to discuss the best anesthetic strategies. At achieved. But in many countries, hospitals do not every stage of the process, appropriate coordina- maintain individual medical records and it is the tion between anesthesiologist, anesthesia provid- responsibility of each patient to carry his or her 174 L. Jouffroy own record. If this is the case, it is highly recom- in the case of minors, their family members—fully mended that the perioperative anesthesia record appreciate the risks specifi c to the delivery of anes- be created in the local language. In addition, a thesia and have an opportunity to address their copy or photograph of the anesthesia record concerns prior to the operation. Arrangements should be kept with the visiting medical team in must be made to communicate and obtain written the event paper records are permanently lost. consent in a language that is accessible to patients and their family members.

Information and Consent Patient Identifi cation Obtaining medical consent for anesthesia during outreach missions can be a signifi cant challenge as In many developing countries, patient identifi ca- a result of cultural and linguistic and logistical bar- tion is often more diffi cult because of the language riers. Very often, the high volume of patients and barrier, of the other race effect (diffi culty to recog- the logistics of the screening process can be such nize faces from other race), of the close similarity that the fi rst interaction with a patient occurs in the of names, or because of lack of familiarity with operating room. Whenever possible, every effort local names (Fig. 12.3 ). Here, as elsewhere in the should be made to arrange for a preanesthesia con- process, assistance by an interpreter is very help- sultation prior to the day of surgery. This meeting ful. In the author’s experience a useful method is can be done concomitantly with the surgeon(s) in to obtain Polaroid photography of the patient with a parallel fashion or separately. Anesthesiologists his or her name, date of birth, diagnosis, and must insist on having adequate time to evaluate treatment plan. The patient is then asked to and discuss surgical risks with patients and their present this identifi cation card upon entering the family members even if this assessment reduces operating room for verifi cation. Standard time- the number of potential surgical cases performed. out checklists are absolutely paramount to avoid The anesthesiologist must ensure that patients—or serious medical errors or oversights.

Fig.12.3 At induction 12 Strategies for Patient Assessment and Scheduling 175

improper preoperative assessment of the patient Scheduling continues to be the one the most signifi cant sources of morbidity and mortality. The visiting In scheduling cases, the anesthesiologist must anesthesiologist must not only be well prepared take into account a number of important elements for unexpected clinical challenges, but also strive including the nature and urgency of the operation to advance the education and training of local to be performed, the age and medical condition providers. It is only can short-term medical inter- of the patient, the availability of postoperative ventions can result in long-term sustainable care (monitoring and intensive care), the limita- change. tion of drugs and life sustaining equipment. It is recommended that the team including the surgeon, nursing staff, and anesthesiologist discuss References the order and priority of the cases on a daily basis to avoid any miscommunications that could result 1. Capello CS, Gainer VG, Adkisson GH. The safe in unnecessary cancelations, medical errors, or practice of anesthesia in developing countries. CRNA. prolonged fasting for patients. 1995;6:91–5. 2. Walker IA, Wilson IH. Anesthesia in developing countries: a risk for patients. Lancet. 2008;371: 968–9. Individual Considerations 3. Tobias JD, Kim Y, Davies J. Anesthetic care in developing countries: equipment and techniques. South Med J. 2002;95:239–47. As mentioned above, particular attention should 4. Misra S, Koshy T. Anesthesia in developing countries: be paid to certain anesthetic risks: one-way traffi c? Anesth Analg. 2009;108:674–5. • Diffi cult airway: A portable storage kit should 5. Jochberger S, Lederer W, Mayr VD, Luckner G, be adapted to the specifi c skills of the local Wenzel V, Ismailova F, Ulmer H, Hasibeder WR, Dünser MW, Helfen Berührt Study Team. Anesthesia practitioner and healthcare facility. In devel- in developing countries: one-way traffi c? Anesth oping countries, the minimum content Analg. 2009;108:675. includes: rigid laryngoscope blades, tracheal 6. American Society of Anesthesiologists Task Force on tubes of assorted sizes, tracheal tube guides, Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: an updated report by the supraglottic airway. More advanced equip- American society of anesthesiologists task force on ment such as videolaryngoscopes, fl exible preanesthesia evaluation. Anesthesiology. 2012; fi ber-optic intubation equipment or exhaled 116:522–38. carbon dioxide detectors are rarely available 7. Cullen DJ, Apolone G, Greenfi eld S, Guadagnoli E, Cleary P. ASA physical status and age predict morbid- unless brought along by the anesthesiologist. ity after three surgical procedures. Ann Surg. • Risk of anaphylaxis: Patients sensitized to 1994;220:3–9. latex must be scheduled at the beginning of 8. Owens WD. American society of anesthesiologists the day and in a latex free environment. physical status classifi cation system is not a risk classifi cation system. Anesthesiology. 2001;94:378. • Malignant hyperthermia: A patient with pre- 9. Bainbridge D, Martin J, Arango M, Cheng D, Evidence- disposition to malignant hyperthermia must be based Peri-operative Clinical Outcomes Research scheduled at the beginning of the day in order (EPiCOR) Group. Perioperative and anaesthetic- to avoid perioperative exposures to potential related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. gas contamination. 2012;380:1075–81. 10. Khan M, Khan FA. Anesthetic deaths in a developing country. Middle East J Anesthesiol. 2007;19:159–72. Conclusion 11. Jochberger S, Ismailova F, Lederer W, Mayr VD, Luckner G, Wenzel V, Ulmer H, Hasibeder WR, Dünser MW, Helfen Berührt Study Team. Anesthesia While great strides in technology and technique and its allied disciplines in the developing world: a have greatly improved the overall safety of anes- nationwide survey of the Republic of Zambia. Anesth thesia delivery worldwide, incomplete or Analg. 2008;106:942–8. 176 L. Jouffroy

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Curtis L. Baysinger , Ivan Velickovic , and K. A. Kelly McQueen

complications contribute to these problems is Introduction currently not known. A lack of trained personnel, inadequate The overall burden of surgical disease has a supplies, poor and not enough equipment, con- signiﬁ cant impact on global health. In 2013 a strained pharmaceutical access, and a woefully World Bank independent commission estimated inadequate infrastructure have all been touted as the magnitude to be 28 % of the total global bur- the major barriers for improving anesthesia care den of disease and that the burden of surgical in low income countries (LICs); however, in both disease is likely to eclipse that due to infectious low and middle income countries, the core prob- diseases by year 2016 [1 , 2 ]. In those countries lem may well be a failure of implementation of in which some data collection has been possi- medical knowledge. Implementation requires ble, preventable anesthesia deaths are very high bridging the gap between knowing what to do and aggravate the burden of surgical disease and actual application of the knowledge within a [3 – 5 ]. Postoperative complications are rarely system robust enough to deliver care. Changing followed in low and middle income countries the systems by which care is delivered by process (LMICs) once the patient leaves the operating improvement should be the major focus for qual- theater. This missing information impedes accu- ity improvement in anesthesia in LMICs [6 , 7 ]. rate conclusions on the role of anesthesia and Improving the processes by which postoperative surgical intervention in averting surgical disease care is delivered is critical to improving postop- burden. The extent to which postoperative erative quality and outcome. Quality improvement is a moving target—once achieved, effort is required to maintain improve- C. L. Baysinger , M.D. (*) ment. Successful quality maintenance following K. A. K. McQueen , M.D., M.P.H. short term surgical interventions requires a long Department of Anesthesiology , Vanderbilt University term commitment from both visitor and the host Medical Center , 1211 Medical Center Dr. , Nashville , TN 37232 , USA facility beyond that associated with the visit e-mail: [email protected]; itself. This long term commitment should include [email protected] a calendar of repeat short visits and ongoing I. Velickovic , M.D. interaction between the intervention team and the Department of Anesthesiology, State University of host facility in between visits. When short term New York Downstate Medical Center , University visits have been used to provide only proper Hospital of Brooklyn, 450 Clarkson Ave. , Brooklyn , NY 11203 , USA training of health care workers, this alone has e-mail: [email protected] been insufﬁ cient in most situations to effect

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 179 DOI 10.1007/978-3-319-09423-6_13, © Springer International Publishing Switzerland 2015 180 C.L. Baysinger et al. meaningful improvement in LMICs. Waldemar because “that which cannot be measured cannot et al. in a review of targeted training program for be improved” [12 ]. Data on perioperative mor- providers of neonatal resuscitation noted no bidity and mortality is lacking in most LICs and effect on neonatal mortality rates after training of some MICs. In those countries in which it is col- health workers who performed the resuscitation lected, the data almost never includes events out- [8 ]. Heitmann et al. noted a similar lack of skill side of the immediate intraoperative period [ 13 ]. retention in providers following Advanced In many LICs there is no written patient record of Cardiac Life Support training in Haiti [ 9 ]. Thus, surgical care beyond the ubiquitous surgical case if outcomes in LMICs are to improve and if qual- log in each institution, and accurate statistics are ity improvement occurring during short term vis- not recorded [ 14 ]. In most institutions, deaths its is to be maintained, it is insuffi cient to improve occurring within a 30 day period are not recorded only the training of a group of health care work- either. This makes the tracking of outcomes and ers or to increase the resources that are available mortality within a country nearly impossible in a system. Processes of care have to be improved (Fig. 13.1). Even if a system to collect health [7 ]. Targeted data collection continued by the information exists, the data are often incomplete host health care providers after a short term inter- and many times the outcomes are so discouraging vention team departs is the fi rst step. Distribution to the governing bodies having health care of this data to all members of a health care system responsibility that they go unutilized [13 ]. This to allow appropriate decision making is required situation is diffi cult for most visiting practitio- for change to be successful [7 ]. ners in high income nations to comprehend. Maintenance of quality improvement initia- Underreporting could be changed if the capture tives has the potential for great success at low of both intraoperative and postoperative surgical cost. Since resource scarcity is one of the most and anesthesia mortality rates became a global daunting aspects of providing health care in health priority [1 , 13 , 15 ]. As an example where LMICs, reduction in systems waste is essential recognition of a specifi c disease burden and its for expanding essential surgical services. Quality measurement lead to focused action and improve- improvement processes and changes in systems ment, maternal mortality was shown to be a procedures are proven to reduce in waste of valu- signifi cant contributor to overall world disease in able materials, and scarce resources can then be the 1980s. The adoption of mandatory reporting allocated more appropriately [7 , 10 ]. The changes of maternal mortality ratios (MMRs) by the in behavior from these improvements can be World Health Organization’s (WHO) focused accomplished at minimal cost and do not rely on world attention on the unacceptable high rates of the use of advanced technologies [10 ]. An empha- maternal mortality [16 ] and galvanized action to sis on vigilance in physical diagnosis by providers reduce it. The tracking of MMR allowed moni- of anesthesia care without use of advanced tech- toring of quality improvement programs aimed at nologies may be the most effi cacious approach its reduction and each country was then able to [ 11]. These and other successful quality mainte- track and compare its results with another country nance initiatives following short term interven- [13 ]. Tracking of the MMR also led to the inclu- tions require modifi ed use of implementation sion of the reduction of maternal mortality in the science techniques that have found success in high United Nations’ Millennium Declaration Goals income countries. (MDGs). As a result signifi cant progress has been made [17 ]. A similar worldwide initiative to focus on one easily measured surgical and anesthetic The Need for Adequate Data outcome might spur many initiatives to improve Collection anesthetic and surgical quality much like the MDGs did for maternal and child health. Quality improvement in surgery and anesthesiology Adoption of a perioperative mortality rate requires data collection and analysis so that steps (POMR) defi ned as the number of American to improve care can be outlined and implemented Society of Anesthesiologist (ASA) classifi cation 13 Perioperative Follow-Up and Quality Maintenance 181

Fig. 13.1 Countries registering cause of death by per- Health Organization Global Health Observatory Map centage of total deaths captured. Adpated with permission Gallery. http://gamapserver.who.int/mapLibrary/app/ from World Health Organization Statistics 2013, World searchResults.aspx . Accessed 14 April 2014

I and II deaths per 100,000 population or as the were contingent upon their collection. In many fraction of deaths divided by the total number of MICs whose health care systems have signifi cant operations recorded, could serve as the metric centralized control, data collection by subordi- which could galvanize the world’s efforts to nate hospitals occurs only if required by a central improve surgical outcomes. Separate ratios for health agency. Furthermore, the current surgical deaths within the immediate operative period and log books found in virtually all low and middle those occurring within 30 days should be income countries could be easily altered to col- recorded [18 ]. These ratios should be stratifi ed lect in-hospital postoperative data in addition to for ASA status focusing only on ASA I and II that recorded in the immediate surgical period patients. Although surgical procedures in LICs with minimal increase in effort on the part of are often performed on ASA I and II patients who health care providers. The WHO could report are trauma victims, many of whom would die in immediate and postoperative mortality ratios for the fi eld without care, ASA I and II patients each of its members along with the other data it should not die in the perioperative period in a currently reports. It could become an important system with reasonable surgical skill and anes- measure of a country’s public health and patient thetic delivery [ 13 ]. Although either of the above safety and spur the adoption of future MDGs suggested ratios is not specifi c to anesthetic aimed at improving surgical care. related death, both can be easily measured, are In the absence of centralized data collection, not reliant upon interpretation, and represent the the most available measure in the majority of overall quality of surgical care. LMICs is the frequency of adverse events in a Since most operating rooms in LICs record given health delivery facility following surgical intraoperative death, most often in a paper log of and anesthetic care, which is a rough measure of operative procedures, governmental agencies whether patients are helped or harmed. Although could be incentivized to collect and report the the argument is made above that expanded, data if funding of surgical improvement projects centralized reporting of mortality rates among 182 C.L. Baysinger et al. healthy patients is the best metric for measuring per capita income means many training positions quality improvement, the reduction in the fre- in LICs go unfi lled [15 ]. Moreover, reports on the quency of adverse events in a facility has great training providers receive for postoperative care value because successes and lessons can be trans- are unknown. Long standing programs created ferred to other facilities in a country. by the World Federation of Societies of Until there is an international mandate, imme- Anaesthesiologists (WSFA) and the Committee diate and 30-day perioperative mortality and the for European Education in Anaesthesiology rate of perioperative adverse events should be (CEEA) are initiatives that can serve as models tracked by the organizations that sponsor short for increased training in perioperative care by term surgical trips as they try to improve their own agencies external to a country [23 ]; however, outcomes. their overall impact in improving anesthesia and postoperative quality has not been determined [15 ]. Given the scarcity of providers and the Elements of Quality Improvement unknown extent of training in postoperative care, Programs for Postoperative there is always a role for visiting practitioners in Anesthesia and Surgical Care teaching postoperative care. As part of a 2 year development of a process road map for the The primary purpose of any quality improvement improvement of women’s care in a health care program is to improve patient care [12 ]. The cur- facility by the Kybele organization and Ridge rent model for improving health care quality in Hospital in Ghana (Fig. 13.2 ) [24 , 25 ], post- general follows the Donabedian framework in cesarean section care was identifi ed as a process which the physical and human structure of the for improvement and the visiting team developed system, the process by which care is delivered, and a program of education for post-cesarean care. outcomes of care delivered are assessed [19 ]. In many MICs resources exist to support training of an adequate number of providers, but standards to insure the quality of the training are System Structure often lacking. One focus for short term visit teams to MICs should be not only to provide edu- The Need for Adequate Numbers cation, but to partner with interested host facility of Trained Personnel personnel in creating training standards. During a The prevention of postoperative adverse events recent Kybele team visit to Serbia by two of the requires trained individuals. Many LICs and authors (CB and IV), the local host was engaged some middle income countries (MICs), have an in outlining a strategy for education of practitio- extraordinary lack thereof, the magnitude of ners outside of the host facility. A curriculum that which is not well understood due to lack of data could be standardized for wide spread use is on numbers of providers within many LICs [ 1 , 5 , being created. 15]. In Uganda, one of the few LICs from which In addition to production of trained individu- data has been collected, reports in 2008 noted als, the retention of trained practitioners is diffi - that there were only 14 anesthesiologists for a cult because the rate of pay for health care population of 30 million, giving a ratio of 1 pro- practitioners is very low. Once trained in their vider per 2.1 million population [ 1 , 20 , 21 ]. In home country, many anesthesia providers have neighboring Kenya there are only 13 anesthesi- the qualifi cations to work elsewhere and thus ologists that work in public hospitals serving a migrate to better paid positions outside their population of 32 million [15 ]. While joint educa- home country. A “brain-drain” is thus created tion projects between facilities within a LIC and [15 , 20 ] and the scarce resources used to train in- outside education organizations are ongoing in country providers are exported to more devel- some areas to improve the lack of trained pro- oped nations when those persons leave. The viders [22 ], the high cost of training relative to detrimental effect on postoperative care is probably 13 Perioperative Follow-Up and Quality Maintenance 183

Fig. 13.2 Kybele-Ghana Health Services/Ridge Hospital, neonatal care in a regional hospital in Ghana via continu- Accra process improvement map. Adapted with permis- ous quality improvement. Int J Gynaecol Obstet. 2012; sion from Srofenyoh et al. Advancing obstetric and 116:17–21 [ 25 ] signifi cant, but currently not quantifi ed. As a pro- facilities [3 ]. Equally dismal percentages for cess improvement, visiting teams could use morale adequate equipment maintenance and drug avail- improving measures to encourage and bolster ability were noted. Although adequate resources local practitioners; examples are noted below in do not translate into quality anesthesia provision, the section entitled “Workforce Morale.” provision of necessary resources is required. Donated equipment can be a useful means of The Need for Adequate Infrastructure improving physical resources, but it must meet and Supplies the need of the host facility otherwise it will be The prevention of adverse events requires ade- discarded and can then become a signifi cant quate infrastructure and supplies. The lack of environmental hazard to an individual facility as transportation for supplies and inadequate sup- waste disposal is almost non-existent in most port staffi ng compound the inability to provide LICs. The troubleshooting and subsequent dis- essential materials for safe anesthesia care of rea- posal of inappropriate equipment further drains sonable quality. Hodges et al., in their report of scarce resources and degrades quality care [26 ]. anesthesia services in Uganda in 2007 using a The WHO has published guidelines that chari- standardized survey tool, noted that only 23 % of table organizations could use for equipment hospitals surveyed could provide a safe general donations [ 27 ]. anesthetic for an adult, 13 % could so do so for a In contrast to surgical facilities in most wealthy child, 28 % could do spinal anesthesia safely, and western countries, virtually all facilities in LICs that resources to provide safe anesthesia for and most in MICs do not have a post-anesthesia cesarean delivery were available in only 6 % of care unit (PACU) attached to the operating room. 184 C.L. Baysinger et al.

Patients are most often returned to the regular spread adoption of pulse oximetry during the wards or sent to areas little different from them operative period [32 ]. As an initiative, visiting following an operative procedure. Recently teams could promote pulse oximetry use into the reported evidence from France reinforces that postoperative period regardless of patient loca- establishment of PACUs signifi cantly reduce tion and, with their host facility, adopt processes postoperative adverse events [28 ]. Unfortunately, to implement immediate care when hypoxemia is resources in most LMICs will likely not be avail- detected. able to provide such a specialized area in facilities in which it currently does not exist. Resources in LICs would probably be better spent on higher Process Improvement Systems priorities. In MICs, extensive facilities were often constructed with operating areas near patient In many LMICs, systems for care delivery have rooms dispersed throughout a facility without typically evolved slowly and the reasons for pro- dedicated PACUs. The creation of centralized cesses used are often not know by the current PACUs is unlikely in these settings as the cost of workers within the system. This leads to diffi - changing this infrastructure would be substantial. culty in introducing new ideas quickly. In many Quality improvement could focus on more exten- LMICs the problem being addressed has often sive preanesthetic assessment and preparation existed for so long that it has survived attempts in and alterations of intraoperative anesthetic tech- the past to solve it, has been cast off as a result of niques to reduce the possibility of anesthesia resource lack, and is approached by the workers related post-anesthesia complications. Since air- in the system as being unsolvable [7 ]. Improving way obstruction and respiratory complications workplace morale, changing workplace behavior are among the most frequent causes of postopera- and culture, and change implementation are tive morbidity [29 ], the use of regional anesthesia required for process improvement. as a strategy to reduce adverse events could be encouraged as a measure to improve quality. For Workforce Morale example, in a recent report of a Kybele sponsored Improving process to prevent of adverse events trip to Georgia, Ninidze et al. reported an increase requires good workforce morale. The poor infra- in the use of regional anesthesia for cesarean structure and lack of medical supplies noted delivery [30 ]. While specifi c effects on postoper- above are commonly found in LICs and some ative adverse events were not noted, the report MICs and lead to poor workforce morale [15 ]. was done in the context of improving total peri- Provider psychological reaction to the organiza- operative care in which increased use of regional tional structure in which the provider works has anesthesia was thought to improve maternal an almost equal effect. A recent systematic review outcomes. of studies examining factors contributing to poor Although the only randomized controlled trial health care worker morale in LICs, noted that examining the effects of pulse oximetry introduc- while fi nancial constraints and poor resource tion failed to show a reduction in adverse effects availability ranked near the top of factors associ- postoperatively [ 29 ], its widespread use to ated with poor morale (90 % and 80 % respec- improve patient outcomes during the immediate tively), lack of career development and lack of operative period is now part of the International recognition by the organization for worker con- standards for a safe practice of anaesthesia [31 ]. tributions ranked nearly as high (85 % and 70 %, Best practice guidelines vary considerably among respectively) [33 ]. In contrast, poor infrastructure organizations in all health systems, but virtually was reported by only 45 % of workers as contrib- all guidelines demand use of pulse oximetry and uting to low morale. As part of their ongoing compliance among practitioners for its use is improvement, the above mentioned Kybele– nearly 100 % when made available [31 ]. Currently Ghana partnership began a program recognizing The Global Oximetry project promotes the wide- individual nurse suggestions, implemented a 13 Perioperative Follow-Up and Quality Maintenance 185 monthly nurse recognition award, and sponsored Similarly an index of patient risk for postoperative an out of country educational trip to the United diffi culty could be generated using a combination States for those nurses who were recognized as of unstable intraoperative hemodynamics, exces- team leaders. Although the effects on overall sive surgical blood loss, and complexity of preop- morale were not measured, other improvements erative medical conditions. Postoperative care in work performance measures (decreased work givers could identify those patients with increased tardiness for example) were noted. risk vs. those with less and thus focus their scarce time preferentially. Workforce Behavior and Culture Team building will help change workplace The prevention of adverse events is likely to be behavior. Team building encourages participation incentivized by changes in behavior and culture. by all stakeholders in perioperative care. Regular As an example, the attitudes and practice habits of meetings ensure all persons have a say in the anesthesiologists and other anesthesia providers in change process that affects them. Ensuring that LMICs regarding vigilance have not been evalu- everyone can speak during meetings and using ated or studied. However, the behavior of local power elevating techniques allow individuals, anesthesia providers has been anecdotally noted including those who are low in the organizational by humanitarians, visiting physicians, and surgical structure to feel that that they have input [ 7 ]. teams providing care through nonprofi t organiza- Shortly after The Kybele-Ghana project began, tions. Often anesthesia providers will leave a both the visiting team and the facility hosts patient under anesthesia for a variety of reasons, agreed that monthly morbidity and mortality including caring for another patient, being called conferences and monthly service meetings to an emergency, and in the most shocking of situ- would occur. All stakeholders at the host facility ations, for a lunch break leaving no one else in participated, and everyone were encouraged to attendance. The process of providing a thorough have input. hand-off of care to persons who will care for a patient in the postoperative period is not often per- Implementation of Process Change formed. These practices were common place in Prevention of adverse events requires change to developed countries prior to 1950, but a culture of the processes and ways of doing work; “all vigilance and the availability of safety monitors change will not result in improvement, but any which demand continuous assessment has forever improvement will need to result in change” [7 ]. changed the standard of care for an anesthesia pro- Although the application of implementation sci- vider in the immediate and postsurgical period. ence to LIMC health care systems is in its infancy, However, for providers who have rendered pre- Ramaswamy and Barker [7 ] and Berwick [10 ] and post-anesthetic and surgical care for years and (based on his review of successful project imple- decades without monitors, and often with mini- mentation in an LIC [Peru] and an MIC [Russia]) mal resources, an emphasis on vigilance may suggest common factors that can lead to success- have waned. Vigilance in many LICs needs to be ful implementation and maintenance of quality reintroduced, and postoperative hand offs to improvement (Tables 13.1 and 13.2 ). These other health personnel need to be mandatory. authors state that successful implantation will Vigilance may be enhanced by the simple mea- often lead to higher quality with consumption of sure of identifying the sicker vs. the healthiest fewer resources and better quality care that often postoperative patient. The good success in reduc- costs less compared to the provision of defective ing maternal mortality reported by the Kybele- care [ 7 , 10]. The challenge of improving postop- Ghana experience may lie in separating the sick erative care relies upon consuming fewer from the less sick by screening for preeclampsia resources. Implementation of better processes and post-delivery hemorrhage. This action allowed needs to be the focus in LICs in particular that scarce and overworked care givers to focus their often waste many of the scarce resources that attention on those patients who needed it most. they can ill afford to lose [7 ]. 186 C.L. Baysinger et al.

Table 13.1 Factors for successful quality improvement facilitate acceptance of agreed measures to process implementation development. • Clear improvement goals Formulating clear aims to improve periopera- • Participation by all stakeholders tive anesthetic and surgical care upon which all • Defi ning measures to achieve goals stakeholders agree can be diffi cult because not all • All providers help build infrastructure and data will accept that a problem is everyone’s to solve collection means and or even whether solving a given problem is • All participate in generating change ideas necessary. Group meetings may require participa- • Education of learned successes to those outside a facility tion of large groups of people from the entire organization. Leadership has to emphasize the importance of the project and show unwavering Table 13.2 Team behaviors for successful quality improvement commitment to it. The aims should be couched in terms of measurable results that are easily opera- • Specify defi ned goals, understood by all stakeholders tionalized and understood to all who are participat- • Use team building during project development ing in the change [7 , 10 ]. For example, since • Build infrastructure, especially data collection adoption of pulse oximetry in the postoperative • Empower local leadership to move forward despite a larger changing policy environment period will likely improve outcome, the number of • Spread new improvements in stages patients who had low oxygen saturation readings and the number of interventions might be used as a metrics to monitor post-anesthetic care. Table 13.3 Common reasons for resistance to change by Work fl ow charts, which contain all partici- organizations pants in the system, have not often been used in • Lack of buy-in to need for change LMICs to diagram work processes; however, • Uncertainty about future career effects, position their use in other settings has often led to per- qualifi cations • Fear of learning new ways of doing things sonal insights that create individual ownership • Lack of trust in external suggestions for improvement [10 ]. Trade-offs between accu- • No participation in planning by stakeholders rate recording of those measures vs. ease in pro- • Perceived lack of communication by leadership ducing relevant data is often necessary [ 7 ]. • Fear of failure Display of the data to all stakeholders will keep interest in the quality improvement high and will lead to acceptance of change when progress is One core principle is how changes are intro- shown [ 7 , 10]. While advanced technology to duced to the stakeholders who they will affect; collect data, such as use of mobile phone devices either resistance will be encountered, or provid- which are common in LMICs is possible, it is ers will accept them and the implementation will important to focus on simplicity of data gathering more likely be successful [7 ]. Travis et al. and and presentation [ 7]. During the development of Ramaswamy and Barker et al. have outlined the process map used by the Kybele–Ghana part- common reasons for resistance to change among nership, individual intermediate improvement stakeholders within a system (Table 13.3 ) [ 7 , 34 ]. goals were identifi ed and progress toward each During the early evolution of the Kybele–Ghana goal was measured by a “colored smiley face” partnership, need for the routine involvement of (from a red frowning face meaning no progress an organizational systems consultant who had to a green smiling face meaning total implemen- worked with organizations in overcoming resis- tation). This chart was updated by the visiting tance to adoption of change by stakeholders was team and host partners at each repeat visit and identifi ed. Thus a non-medical person who ful- displayed where all stakeholders could easily fi lled this role was made a routine part of the see it. Although the effect of the device was not visiting team and met with small groups of quantifi ed, progress could be easily determined health providers during external team visits to by all in the facility. 13 Perioperative Follow-Up and Quality Maintenance 187

Spreading Local Successes changes to effect meaning full quality improve- Transferring change to other parts of the health ment will not come from sporadic visits from care system outside of a local system that has had either internal or external well-meaning health success requires spread to other parts of a coun- care organizations. Narrowly focused quality try. Many times that spread will be impeded as it improvement projects without building wide occurs in a country’s political climate where focused systems for monitoring and response overall health care policy changes are frequent will most likely fail [ 7 , 40]. External organiza- due to frequent political leadership changes [10 ]. tions interested in helping should thus be ready to Because virtually all LICs and most MICs have commit to a long term relationship with the facil- not had much experience with large scale quality ity or health system with which they interact. improvement programs, the most effective Trust between the leadership of the visiting team approach to disseminate a successful project and the host and a good working relationship is would be use of a deliberate timetable in which a critical for overall success. program is implemented in a health care district, With modern communication technology, and followed by ramping up through successive the availability of internet and wireless commu- regions of a country [7 ]. Workshops conducted nication in most LMICs, host team members can every 3–6 months, fi rst within a district involving communicate easily with their external counter- stakeholders from a health care facility, and then parts at almost no expense. The benefi t for moni- among stakeholders within a region would identify toring progress between team visits and the reasons for success and help remove barriers [7 ]. ability to better plan visits in greater detail is Recent success has been reported by the Institute obvious. for Healthcare Improvement (IHI) and by Berwick An ongoing relationship between visitor and who used this approach in improving care to host is one of the main reasons why the above patients with hypertension over large regions in mentioned Kybele–Ghana partnership reported Russia [ 10 , 35]. In many MICs, where a health care success in reducing maternal mortality and the delivery system may be under signifi cant central- rate of stillbirths through partnership with a ized control, change to an established procedure health care facility in Accra, Ghana. After initial may require permission by a higher level govern- site visits over a 2 year period of time by the mental organization. Centralized health ministries Kybele organization and establishment of their may view change to a long-standing policy as process improvement map, results in the major unnecessary and thus impede the dissemination of outcome variables were impressive: maternal local innovation. mortality declined 34 %, case fatality rates from preeclampsia and hemorrhage decreased from 3.1 % to 1.1 % and from 14.8 % to 1.9 % respec- Maintaining Outcomes tively, and stillbirths declined by 36 %. All of this occurred despite a 36 % increase in patient Few reports of success from LMICs in areas of admissions and a substantial increase in patient anesthesia related quality improvement exist acuity. Success was attributed to use of many of Reports from other areas of health care delivery, the implementation strategies mentioned above, primarily aimed at reduction in the burden of including a long term commitment by all parties infectious disease, are few as well, but show that to process improvement, formal support from by implementation and maintenance of quality the country’s senior health leadership, training by improvement programs using the tools outlined staff in quality improvement processes, participa- above can be effective [6 , 10 , 36 – 39 ]. tion by all parties involved at the health care What is very clear is that those programs that facility, identifi cation of local persons who take have been successful had ongoing visiting ownership of the process, and identifi cation of a program-host interaction during times when the measure of outcome that was easily obtained and visiting team is not on site. The necessary systems made known to all [24 , 25 ]. 188 C.L. Baysinger et al.

Fig. 13.3 World Health Organization Surgical Safety Surgical Safety Checklist. http://www.who.int/patientsafety Checklist. Adapted with permission from WHO Surgical /safesurgery/tools_resources/SSSL_Checklist_ Safety Checklist and Implementation Manual WHO ﬁ nalJun08.pdf . Accessed 14 April 2014

Similar success has been reported by another the WHO Surgical Safety Checklist (SSCL) in Kybele sponsored health care team in an LMICs (Fig. 13.3 ) [ 41 ]. When successfully MIC. Ninidze et al. recently reported on the suc- implemented, the WHO SSCL has led to signifi - cess of a similar collaborative quality improve- cant reduction in anesthetic and surgical compliment project to increase the use of regional cations. Bergs et al. in a recent systematic anesthesia for labor and for cesarean section in analysis of seven studies evaluating the imple- the nation of Georgia [30 ]. Over 3 years, four vis- mentation of the WHO SSCL in hospitals in its were made by an outside consulting group developed countries and LMICs noted an approx- who provided education in the use of regional imate 40 % reduction in any complication (30- anesthesia and introduced quality improvement day mortality, surgical site infection, excessive processes and measurement tools. The use of blood loss, unplanned emergency surgery, pneu- general anesthesia for cesarean delivery declined monia), a 23 % reduction in mortality, and a 43 % from approximately 80–30 % overall at partici- reduction in surgical site infection [ 42 ]. Weiser pating hospitals and the use of epidural analgesia et al. in a prospective study of the WHO SSC for labor increased from 20 % to approximately introduction in four hospitals in developed coun- 45 %; no changes were noted at control hospital tries, two hospitals in MICs and one hospital in a within the country. Reasons cited by the authors LIC, noted a one-third reduction in complications for success were similar to that noted by the a drop in overall surgery associated death from Ghana–Kybele partnership. 3.7 to 1.7 %, and increased compliance with six An example where quality improvement has essential safety measures (airway evaluation, use not been uniformly successful is in adoption of of pulse oximetry, IV access, prophylactic antibiotic 13 Perioperative Follow-Up and Quality Maintenance 189 administration, confi rmation of surgical site, and blood is infrequently planned for and rarely avail- sponge count verifi cation) from 19 to 51 % [ 43 ]. able outside hospitals providing the highest level However, the authors of this second study were of care in LICs. In fact, oxygen has only been unable to determine if the use of the checklist had recently added to the WHO Essential Medicine been retained after the study period. Indeed, list [27 ]. These realities anecdotally contribute to although Borchard et al. reported a 70 % overall a sense of futility in the poorest settings when the compliance with elements in a recent systematic list is modifi ed for the resource reality on the review of SSCL adoption in developed countries ground. [ 44], other studies have noted barriers to their adoption. One study from France noted wide variation in their adoption attributable to organi- Conclusions zational and cultural factors [45 ]. Widespread implementation in LMICs may be For the past two decades, the pressing needs of the unsuccessful. Alitoor et al. evaluated the imple- global HIV epidemic have shifted the focus of mentation of the SSCL in hospitals in Pakistan LMIC health care systems away from surgical and noted a lack of surgical site identifi cation in and anesthesia infrastructure, and, by extension, 13 % of the surveyed procedures, no antibiotic away from outcomes analysis and improvement prophylaxis in 38 %, and no recording of patient interventions. As LMICs build and improve surgi- allergies and instrument counts in 54 % and 21 % cal infrastructure to meet the growing surgical of the procedures, respectively [46 ]. SSCL adop- needs related to chronic disease, maternal and tion may be more critical in LMICs than in more child health, and trauma, it is essential to include developed countries as the largest decrease in processes for tracking, reporting, and benchmark- complications (74 % in one study) occurred in ing anesthesia and surgical outcomes. Recent LMICs as compared to high income countries advocacy for the perioperative mortality ratio (HICs) [41 ]. Levy et al. emphasized that effective including reporting of a separate ratio for postop- adoption of checklist elements in a hospital in a erative mortality presents a realistic opportunity developed country required the use of the ele- to evaluate and track patient safety and outcomes ments of implementation science noted in the dis- related to anesthesia and surgery. Systems-wide, cussion above [47 ]. Vivekanantham et al. noted infrastructure and cultural changes will be that barriers to adoption in LICs are cultural in required for the much needed quality improve- nature, and require education efforts and compliment in the postsurgical period in most LMICs ance monitoring in that setting [48 ]. and even as infrastructure lags behind. LMICs For the SSCL to be most effective in improv- should be encouraged that early implementation ing care, it is essential that safety equipment, res- of these processes will decrease postoperative cue medications and blood, which are emphasized morbidity and mortality. in the list, be available in the setting where implementation is desired. While the WHO and Safe Surgery Saves Lives researchers have recognized References that the SSCL will require modifi cation based on local infrastructure, the outcomes related to the 1. Dubowitz G, Detlefs S, McQueen KA. Global anes- check list have not been compared nor stratifi ed thesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes related to these local modifi cations. For instance, and unsafe practices. World J Surg. 2010;34: when the SSCL was initially evaluated, pulse 438–44. oximetry was not routinely available in a major- 2. 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Fiona Turpie and Ronald B. George

period as these women fi ght to reduce poverty, Introduction hunger, and threats to their environmental on a daily basis. In contrast, pain associated with labor The health and socioeconomic development of and delivery is the most important anesthetic- any country is dependent on the well-being of related concern for expectant mothers in high women. However, women are still dying in child- income countries [3 ]. Young girls and women in birth and from treatable conditions because they LMIC suffer the greatest ill-health consequences don’t have access to the most basic surgeries and from low status, poverty, and denial of basic perioperative care, including analgesia. Safe human rights [4 ]. anesthesia for cesarean delivery saves lives during obstructed births but, when not available, can lead to mortality for the mother and fetus. Human Rights and Inhuman Pain Whether it is a cesarean, childbirth, or any number of surgical procedures, they are immeasur- Pain is, in part, a learned experience. It does not able painful components of women’s lives. necessarily only refl ect the presence of a noxious Access to pain management is a human right. stimulus but refl ects interactions with a person’s However, less than 50 % of all patients with acute internal and external environment and her/his postoperative, chronic, or cancer pain are ade- learned behaviors from cultural experiences. Pain quately managed [1 ]. Unfortunately in low and is a complex milieu of physiology, psychology, middle income countries (LMIC) the incidence and sociological factors. When managed poorly, of pain is signifi cantly higher [2 ]. Following sur- pain also has major physiological, psychological, gery or childbirth, acute pain may limit the recov- economic, and social ramifi cations for patients, ery and function of women in the postoperative their families, and society [ 5]. Given the wide variety of cultural environments, countless variations in the experience and manifestations of pain F. Turpie , M.D., F.R.C.P.C., D.T.M.H. are to be expected. Regardless of its defi nition, Department of Anesthesiology, Pain Management, source, or infl uence from environmental factors, and Perioperative Medicine , Dalhousie University , the management of pain is a public health emer- Halifax , NS , Canada gency on a global scale. R. B. George , M.D., F.R.C.P.C. (*) Pain is defi ned as a physical suffering or discom- Department of Women’s & Obstetric Anesthesia , fort caused by illness or injury [6 ]. The International IWK Health Centre , 5850 University Ave. , Halifax , NS , Canada , B3P 0B7 Association for the Study of Pain defi nes pain as e-mail: [email protected] an unpleasant sensory and emotional experience

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 193 DOI 10.1007/978-3-319-09423-6_14, © Springer International Publishing Switzerland 2015 194 F. Turpie and R.B. George associated with actual or potential tissue damage, catecholamines, placing patients at risk of or described in terms of such damage [7 ]. myocardial ischemia, stroke, bleeding, and other Advocates for pain management have pointed complications. Unrelieved acute pain commonly out repeatedly that inadequate pain management elicits pathophysiologic neural alterations, includ- is a violation of human rights. Less than 50 % of ing peripheral and central neuronal sensitization, patients with acute, chronic, or cancer pain are that evolve into chronic pain syndromes [ 10]. adequately managed [1 , 8 ]. It was demonstrated Physically, these responses include reduced mobil- that pain impacts the quality of life for 20 % of ity and consequent loss of strength, disturbed adults and 50 % of the elderly [1 , 5, 8]. Pain sleep, an increased susceptibility to disease, related to untreated cancer effects more than 70 % dependence on medication, and codependence on of those 10 million diagnosed annually and the family members and other caregivers [ 5 ]. The psy- number of diagnosed cases is expected to exceed chological and likely societal ramifi cations of 20 million by 2020 [ 8 ]. In 2012 there were more chronic pain are profound. The WHO has revealed than 35 million people living with Human that mental illness is four times more likely to Immunodefi ciency Virus (HIV), creating a large affl ict those with chronic pain issues compared to burden of pain related morbidity as pain affects those without pain [5 ]. more than 60 % of those during their illness with HIV [8 ]. HIV has a particularly dramatic prevalence in developing countries, with more than Declaration of Montreal, 2010 70 % of diagnosed cases living in sub-Saharan Africa; 12 million are women over the age of 15 At the conclusion of the 2010 World Congress on [9 ]. Not only is pain a physiologic response but Pain, the International Association for the Study also a pathological response which increases of Pain hosted delegates to the International Pain both morbidity and mortality. It has an impact on Summit, comprised of representatives from 130 individuals’ quality of life. countries who gathered to address the tragedy of In LMIC, health care delivery is focused on unrelieved pain globally. At the conclusion of the high-level objective goals such as treating preva- Summit, the delegates adopted the Declaration of lent cancers and developing vaccinations and Montreal, which states that access to pain man- treatments effective against HIV and malaria. agement is a fundamental human right. Within While working towards these necessary goals to this declaration, it is stated that there is ‘inade- improve lives in developing countries we should quate access to the treatment of acute pain caused not lose focus on analgesia management, the pain by trauma, disease and terminal illness and fail- suffered by women, and the impact of pain on ure to recognize chronic pain is a serious chronic quality of life indicators. health problem akin to other chronic diseases In the past 30 years there has been expansive such as diabetes or chronic heart disease’ [11 ]. growth in our knowledge of the physiology and Reasons for this failing including: major defi cits psychology of pain. We now have numerous phar- in knowledge of health care professionals regard- maceutical and non-pharmaceutical interventions ing the mechanisms and management of pain, to aid our patients. However, the gap between our lack of national policies declaring pain manage- understanding of the biology of pain and our per- ment as a public health problem, inadequate vasive failure to implement effective pain man- levels of research funding, and severe restrictions agement strategies continues to grow. In LMIC, on the availability of opioids and other essential this gap is, for the most part, ignored despite pan- medications critical to the management of pain demic suffering from HIV and Acquired Immune [ 11 ]. The World Health Organization (WHO) Defi ciency Syndrome (AIDS), poverty, oppres- estimates that fi ve billion people have limited or sion and violence, and war and its aftermath [5 ]. no access to controlled medicines to treat moder- Untreated pain after surgery increases heart ate to severe pain [8 ]. Supporting this statement, rate, systemic vascular resistance, and circulating experts demonstrated that “every country in the 14 Women’s Rights to Pain Relief After Surgery and Labor Analgesia 195 world is now party to at least one human rights Each of the medications on the ladder, treaty that addresses health related rights as well as acetaminophen, ibuprofen, and morphine are other rights that relate to the conditions necessary found on the WHO List of Essential Medications for health” [1 ] ( Table 14.1 ). updated every 2 years and directed at the primary Pain is a ubiquitous throughout our lives and health care requirements of a population [ 1 ]. throughout our practice as anesthesiologists. The They are selected with regard to disease preva- mandate of the World Federation of Societies of lence, safety, effi cacy, and comparative cost- Anaesthesiologists (WFSA) is to maintain the effectiveness [14 ]. The Essential List advocating highest standards of anesthesia, pain medicine, the pharmaceutical needs of individuals allows trauma management, resuscitation, and preopera- each nation to expand on the list according to tive/critical care medicine to all peoples of the national health goals and individual needs. The world and advocate for improved pain manage- goal of the Essential List is to establish standards ment [12 ]. They have acknowledged that pain has of health care supplies and to improve national been both poorly managed and over looked both standards of care. in developed and developing countries [13 ]. The WFSA have adopted the three steps of the WHO analgesic treatment ladder starting with non- The Realities of Pain Management opioid adjuncts, secondly stepping up to low Among Women in LMIC potency opioids, and then if necessary the addition of a high potency opioid to manage moderate Women experience more severe pain, more recur- to severe pain (Fig. 14.1 ). rent pain, and longer duration of pain than men [15 ]. Moreover, pain affects a higher proportion of women than men and they are less likely to receive treatment compared to men [16 , 17 ]. Table 14.1 The Declaration of Montreal Upwards of 20 % of women may suffer from con- The Declaration of Montreal [11 ] tinued severe acute pain after labor and delivery Article 1. The right of all people to have access to pain of their children [18 ]. Since acute pain is a risk management without discrimination factor for chronic pain, it can be postulated that Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be the experiencing the pain of childbirth may shape assessed and managed a woman’s “pain future,” having a profound effect Article 3. The right of all people with pain to have access on her life. to appropriate assessment and treatment of the pain by Access to pain management is poor for all adequately people in LMIC, gender inequalities contribute to The 2010 Declaration of Montreal formalized the position the pain suffered women globally. This can be of the World Federation of Societies of Anesthesiologists (WSFA) on acute and chronic pain. Future global health due to various cultural, economic and political anesthesiology research and policy will be guided by the barriers. Pain from menstruation and/or childbirth Declaration is diminished by caregivers and deemed ‘natural’.

Fig. 14.1 World Federation of Societies of Anaesthesiologists modiﬁ ed analgesic ladder for acute pain [13 ] 196 F. Turpie and R.B. George

Women are among the most commonly cited management for acute pain caused by trauma, vulnerable groups along with children, the disease, or terminal illness without discrimina- elderly, patients living with HIV/AIDS or other tion. The pain of pregnancy is not caused by any chronic diseases, those with mental or physical of these injuries described but by the physiologi- disabilities, ethnic minorities, and socioeconomi- cal preparation of the uterus and cervix to expel cally disadvantaged groups [19 , 20 ]. A large the fetus through the vagina. Labor causes severe percent of the female population are potential pain for most women. The pain of labor for nul- mothers, and the detrimental effect of maternal liparous women was similar to the trauma of hav- death on household income, household producing a digit amputated [ 23]. There is no other tivity, and household disintegration has been circumstance where it is considered acceptable widely described [21 ]. During and after a disas- for an individual to experience untreated severe ter, women have to assume the role of head of pain, amenable to safe intervention, while under household. This may include management of a physician’s care [24 ]. The American College of household fi nances and food supply, in addition Obstetricians and Gynecologists together with to childcare and other responsibilities [20 ]. the American Society of Anesthesiologists have Pregnancy may be the defi ning period of a stipulated that in the absence of a medical contra- women’s life. In most parts of the world preg- indication, a women’s request is a suffi cient med- nancy can also be a life threatening condition. ical indication for pain relief during labor [24 ]. Access to safe and pain free surgical care during In China, most women in labor are primigravi- pregnancy is a critical prerogative for all women. das whose fear of labor pain leads them to request The ability to provide quality analgesia is likely cesarean deliveries rather than risk labor without an indicator of the level quality of care facility effective analgesia; their fears may be justifi ed as can deliver. In the opinion of the authors, the rate less than 1 % of women in labor are given analge- of death of women in LMIC could be improved sia [25 ]. As a result, the rate of cesarean deliver- by providing them with access to quality health ies is as high as 50 % in many hospitals in China. services such as analgesia. However, in reality, In these situations, more available labor analge- most women experience serious barriers to sia may reduce the rate of cesarean deliveries and accessing services. Even if they do reach them, resulting morbidity and mortality by reducing the services themselves are often of insuffi cient fear of labor pain. quality or effectiveness. The main components The logistics of pain management during are the health professionals within their ‘enabling labor are complex. There is the physiology of environment’ that comprise a functioning health both mother and fetal circulation to consider care system including effective transportation, and the choice of drug and delivery may have drugs, equipment and supplies [21 ]. A lack of impact one or both parties. Some methods of trained surgical providers is among the most sig- pain management, such as labor analgesia, can nifi cant barriers to essential surgical and postsur- be costly and labor intensive. Neuraxial labor gical care. LMIC have a crisis of human resources analgesia is the primary modality in high- where the workforce of surgeons, obstetricians, income countries. However, epidural analgesia and anesthesiologists is severely depleted [22 ]. uses numerous disposables and large volumes of This scarcity is due in part to a paucity of educa- medications. The ability to supply the medication, training, and economic opportunities for tions and disposable equipment must be consid- physicians and other health care workers. ered when planning to provide a labor analgesia service. All classes of drugs used traditionally on labor units for pain management of labor are Pain and Childbirth listed in the WHO List of Essential Medicines. This includes opioids, naloxone, local anesthet- In the advocacy of pain management as a human ics, and nitrous oxide [26 ]. Providing pain relief right, the Declaration of Montreal states that it is during labor is both necessary and feasible in the right of all people to have access to pain developing countries. 14 Women’s Rights to Pain Relief After Surgery and Labor Analgesia 197

Neuraxial analgesia is a highly effective Table 14.2 The United Nations Millennium Goals method of providing pain relief during labor [ 27 , The United Nations Millennium Goals 28]. Regardless of economic situation, some Goal 1. Eradicate extreme poverty and hunger women in labor wish to have analgesia for child- • Reduce extreme poverty by half birth. Unfortunately, access to epidural analgesia • Productive and decent employment during labor is limited in LMIC [29 ]. In a survey • Reduce hunger by half of women in LMIC, 85 % of respondents indi- Goal 2. Achieve universal primary education cated they would request labor analgesia if avail- • Universal primary schooling able but only 40 % received any form of analgesia Goal 3. Promote gender equality and empower women during childbirth [30 ]. Costs of staffi ng and sup- • Equal girls’ enrollment in primary school plies associated with providing neuraxial analge- • Women’s share of paid employment • Women’s equal representation in national sia can be prohibitive in LMIC [ 13 , 31 ]. With parliaments limited resources for epidural analgesia, spinal Goal 4. Reduce child mortality analgesia may be a useful alternative for relief of • Reduce mortality of children under 5 years of age labor pain [32 , 33 ]. by two-thirds Pain management during labor permits a calm Goal 5. Improve maternal health and stable environment for the infant’s delivery. • Reduce maternal mortality by three-quarters It will offer the workers the ability to demonstrate • Access to reproductive health compassion and empathy instead frustration. Goal 6. Combat HIV/AIDS, malaria, and other diseases Perhaps the learned behavior of pain and its • Halt and begin to reverse the spread HIV/AIDS needed endurance will be recognized as unneces- • Halt and reverse the spread of tuberculosis sary and bring these women to a supervised Goal 7. Ensure environmental sustainability skilled setting for delivery. Skilled delivery • Have proportion of population without improved drinking water would offer the women greater chances of • Halve proportion of population without sanitation survival and perhaps even reduce the complica- • Improve the lives of slum-dwellers tions affecting the neonate leading to longer-term Goal 8. Develop a global partnership for development survival of both mother and child. • Internet use To truly promote women’s rights and the right As discussed above, the Millennium Development Goals to pain relief, a greater investment in education and were created to help focus resources for the achievement health, including reproductive health and family of several universal human rights and global priorities by planning must be made [ 4 ]. Beyond diffi cult acces- the year 2015 sibility, women have limited access to health care in LMIC because of traditional beliefs surrounding include a right to: (a) respect as a person of value religion and ethnicity into which modern medical or worth, (b) security of person (safety), (c) pri- care does not fi t [34 ]. The authors postulate that vacy/confi dentiality, (d) food, nutrition, and exposure and education of women may have housing, (e) freedom from any form of discrimi- women ignore traditional beliefs and choose safe nation, (f) information and education, (g) benefi ts labor pain relief over cesarean delivery. The next of scientifi c progress, (h) freely informed con- section describes in more detail the international sent, (i) reproductive choices, and (j) equitable efforts to advance the health of women in the access to health services of good quality [4 ]. context of the Millennium Development Goals. To galvanize purpose and organize efforts toward the achievement of basic human rights for all people, at the turn of the twenty-fi rst century, The Millennium Development Goals the United Nations (UN) created an ambitious and Pain set of eight goals to be achieved by 2015 (see Table 14.2 ). When women are treated as objects and not as Although there have been great strides made fully human, they have few or no rights and their to improve conditions for the marginalized health suffers. Basic human rights generally minorities, for women and children under fi ve in 198 F. Turpie and R.B. George developing countries, the objective deadlines of The MDG each has gender biases directed the MDGs will not be met. Still more than 1 billion towards the improvement of marginalized women people live in extreme poverty, with a total of 385 and the children under their care in impoverished million still living on less than 1.25 dollars a day. and developing countries. Potential examples of There is still a huge gender gap for those these biases in LMIC include the preference for employed, with the gender-employment ratio male children, which may result in lower invest- resting at almost 30 % in Africa [35 ]. Women still ment of resources for female children. This leads fi ll positions of lesser employment [36 ]. Primary to women being disadvantaged in the battle to school education in developing countries has combat hunger. As women are responsible for reached 90 % [ 37]. A child under fi ve is twice as most work in the home, pregnant women perform likely to die if her mother has not had a primary heavy physical labor far into their pregnancies. school education [36 ]. For this reason, the UN is This signifi cant workload may contribute to pre- in the process of setting a post-2105 agenda for term delivery and fetal growth restriction, which continued work [38 ]. leads to decreased under-fi ve survival. Another The survival of children under fi ve (MDG 4) example: Women’s lives can be improved by and the reduction in maternal mortality (MDG 5) ensuring environmental sustainability and access may be key pain related goals. Reducing by almost to clean water near where people live. Since the half, the child mortality incidence has fallen 12.4 daily task of collecting water mostly falls to million in 1990 to 6.6 million in 2012 [ 39 ]. Despite female members of the household, clean acces- this fall in the child mortality rate, the rate of neo- sible water could mean more time to concentrate natal deaths is increasing [39 ]. Asphyxia is the on their own and their children’s health. Thus, cause of 9 % of the neonatal deaths. In dealing bringing an improved water supply to somewhere with the pain of the laboring woman, a reduction near residential concentrations can both improve in some of the complications of labor can result the health of a population and reduce the burden in successful instrumental delivery allowing of a particularly taxing and time-consuming form those infants to be delivered without serious mor- of labor. bidity or complications which would result in lower infant mortality rate [39 , 40 ]. MDG 5 addresses a woman’s right to maternal The Three Delays of Maternal health care. The original goal, to reduce the Mortality: Pain Delay maternal mortality ratio by two-thirds has had some success with a reduction in maternal deaths The conceptual details fi rst described by of 47 % from 1990 to 2010 [40 ]. Even though Thaddeus and Wade of the three delays relating there has been great progress, 50 million babies to maternal mortality in the developing world are are still born without skilled attendants present applicable to all aspects of women’s health care [ 40 ]. Postpartum hemorrhage is still a large con- in the developing world [41 ]. The woman must tributing factor to maternal mortality in much of fi rst recognize that pain may be key to an under- the developing world. lying pathophysiologic condition or simply to MDG 4 and 5 are unifi ed by the need to childbirth itself. It may require consultation with empower women both in poverty and in develop- other women in the village including a traditional ing countries, include objective measures of their birth attendant prior to the recognition of a prob- success. The goals include the need for education lem. If no problem is identifi ed when there is one on reducing the mortality of children under fi ve by present, the obstruction to skilled assistance is measuring mortality reduced by mortality rates postponed. Women, the earth over, place their and the reduction in the maternal mortality ratio. children and their commitments before their own Currently there is no consideration of a woman’s well-being (Fig. 14.2 ). suffering and pain and how that may affect work In rural communities, where the women have towards the achievement of the MDGs. both limited education and access to information 14 Women’s Rights to Pain Relief After Surgery and Labor Analgesia 199

Fig. 14.2 The Thadeus and Maine delay model [41 ]. of these phases is infl uenced by a web of social and cul- Thadeus and Maine describe the complex care seeking tural issues, transportation and geography of the local behavior of women in low resource settings as having health care landscape, and the quality of personnel and three phases; the decision to seek care, gaining access to a services in-country medical facility, and receiving the services needed. Each because of cultural and sociological constraints Availability of analgesics. Almost at the same they often must seek approval from a head of time as the Montreal Declaration, there was household to seek treatment. It is often that the another summit in the Netherlands, sponsored by male holds both the pecuniary support and social the International Federation of Health and Human approval needed to seek transport to that health Rights of which the British Medical Association care facility and more importantly the money to and the Amnesty International observing [42 ]. provide the care. If the male head has moved to an A resolution was passed by the World Medical urban center to support his family, seeking assis- Association General Assembly stating that indi- tance may delay a woman’s search for care. viduals in pain had the right to pain management. If both fi nancial support and permission are The WMA also declared that drug control poli- given, the next issue will be for the woman to fi nd cies should be reviewed. The goal of this review transport to the clinic or center, which may be was to ensure that drugs such as morphine were able to help her. She may need to walk, but with available in countries where there may be unnec- severely incapacitating pain that may not be pos- essary mechanisms of restriction in place. sible. She may need to fi nd public transport, which has an unpredictable schedule. When the The woman herself . Traditional beliefs religion need is urgent she may need to exercise the option and ethnic origin were identifi ed as reasons that of hiring a motor or a bicycle. The limited acces- the women would avoid hospital [ 34]. Birth was sibility may delay a woman from the needed care, perceived as a test of endurance. In Uganda women immaterial of the source of her pain. Finally are expected to deliver without fear but a multitude when she does arrive at the health care facility, of traditional therapies are offered, including back the doctor or other health care professional may massages, sitting submerged in water mixed with be unavailable to either assess her pain but performs of herbal medicine to clean, disinfect and haps more importantly manage her pain. Each ‘widen the birth canal’, spreading topical herbs step in the delay model prolongs the pain and its inside the vagina and herbal elixirs to deliver the impact on quality of life. placenta [43 ]. 200 F. Turpie and R.B. George

System issues . Once access to the drugs is management is a human right. But more will be secured, the patient needs access to an individual needed. Addressing the pain of women and their who will treat her pain. The closest medical care right to appropriate management in developing may be a clinic staffed only by nurses or other countries will take great effort by supporting the health care workers without the knowledge or the education of those who are to manage the pain as training to assess and treat her pain. Either by health care professionals and those who must systematic or self-referral she must seek out a ensure the supply of the drugs. These skills must physician who must then set aside their own be shared with the emphasis on both empathy and beliefs to treat the pain. There are many biases of compassion. Education is key. health care professional including concern about the patient’s needs for pain management and the balance of dependence and addiction. A broader References education amongst all health care professionals to teach empathy and compassion with appropri- 1. Cousins MJ, Brennan F, Carr DB. Pain relief: a uni- ate and necessary management of pain, which versal human right. Pain. 2004;112(1–2):1–4. may take on many forms during one’s life, is 2. Adams V, Worldwide Palliative Care Alliance. Access required globally [44 ]. to pain relief: an essential human right. A report for World Hospice and Palliative Care Day 2007. Help Mismanaged and under recognized pain has the hospices for the Worldwide Palliative Care huge implications on physiological, social eco- Alliance. J Pain Palliat Care Pharmacother. 2008; nomic, and social cultural levels irrespective of 22(2):101–29. women’s pain. Pain can have signifi cant, perva- 3. Carvalho B, Cohen SE, Lipman SS, Fuller A, Mathusamy AD, Macario A. Patient preferences for sive repercussions if not managed properly. It is anesthesia outcomes associated with cesarean delivery. associated with lost time of work, slower return Anesth Analg. 2005;101(4):1182–7. to activities of daily living, and reduced physical 4. Thompson JE. Poverty, development, and women: why recovery after the injury, be it surgical or other- should we care? J Obstet Gynecol Neonatal Nurs. 2007;36(6):523–30. wise. Improved relationships once pain is under 5. Brennan F, Carr DB, Cousins M. Pain management: a control have been documented, including in the fundamental human right. Anesth Analg. 2007; postpartum period after the delivery that improves 105(1):205–21. mother–infant bonding. 6. The Oxford English Dictionary. 2nd ed. Oxford: Oxford University Press; 1989. 7. IASP Taxonomy: International Association for the Study of Pain; 2014 [cited 2014]. Available from: Conclusion http://www.iasp-pain.org/Education/Content.aspx?Ite mNumber=1698&navItemNumber=576 - Pain . 8. Lipman AG. Pain as a human right: the 2004 Global Pain becomes a life-defi ning event for many Day Against Pain. J Pain Palliat Care Pharmacother. women in developing countries; be it the 2005;19(3):85–100. untreated and often ignored pain of child birth, 9. Global Health Observatory—Number of Women acute surgical pain, or even the disregarded pal- Living with HIV: World Health Organization; 2014. Available from: http://www.who.int/gho/hiv/ liative pain of end of life pathology. As health epidemic_status/cases_adults_women_children/en/ . care professionals, we must seek out strategies 10. Siddall PJ, Cousins MJ. Persistent pain as a disease and interventions to change this cycle. entity: implications for clinical management. Anesth Acknowledgement of pain and recognition of its Analg. 2004;99(2):510–20. table of contents. 11. International Pain Summit Of The International further impacts is only the fi rst step. Both our Association For The Study Of Pain. Declaration of increased acknowledgement and awareness of Montreal: declaration that access to pain management pain in women must be utilized for advocacy of is a fundamental human right. J Pain Palliat Care pain management in women. The Declarations of Pharmacother. 2011;25(1):29–31. 12. World Federation of Anaesthesiologists, WFSA Human Rights, the Millennium Development Constitution: World Federation of Anaesthesiologists; Goals and the Declaration of Montreal are inch- 2013. Available from: http://www.anaesthesiologists. ing us forward towards a future where pain org/guidelines/wfsa-constitution . 14 Women’s Rights to Pain Relief After Surgery and Labor Analgesia 201

13. Size M, Soyannwo OA, Justins DM. Pain manage- 29. Schnittger T. Regional anaesthesia in developing ment in developing countries. Anaesthesia. 2007;62 countries. Anaesthesia. 2007;62 Suppl 1:44–7. Suppl 1:38–43. 30. Imarengiaye CO, Ande AB. Demand and utilisation 14. Manikandan S, Gitanjali B. National list of essential of labour analgesia service by Nigerian women. medicines of India: the way forward. J Postgrad Med. J Obstet Gynaecol. 2006;26(2):130–2. 2012;58(1):68–72. 31. Viitanen H, Viitanen M, Heikkila M. Single-shot spinal 15. Alabas OA, Tashani OA, Tabasam G, Johnson block for labour analgesia in multiparous parturi- MI. Gender role affects experimental pain responses: ents*. Acta Anaesthesiol Scand. 2005;49(7):1023–9. a systematic review with meta-analysis. Eur J Pain. 32. Dyer RA, Reed AR, James MF. Obstetric anaesthesia 2012;16(9):1211–23. in low-resource settings. Best Pract Res Clin Obstet 16. Bartley EJ, Fillingim RB. 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Ebby Elahi and Natalie F. Holt

General Considerations Patient Evaluation

While many basic ophthalmic procedures may Ophthalmic surgeries are usually low-risk proce- be performed under topical or local anesthesia dures associated with little morbidity or mortality. provided by the ophthalmologist, others require They are most often performed on patients at the deeper sedation or anesthesia administered by extremes of age—the elderly and very young— an anesthesiologist. During intraocular surgery, both of whom merit unique considerations in the for instance, relaxation of the extraocular mus- context of anesthesia. Medical history is best cles and control of intraocular pressure (IOP) addressed using a systems-based approach, with a can be quite critical. Many anesthetic agents focus on the cardiovascular, pulmonary, and neu- and maneuvers have infl uences on IOP and rologic systems. A useful way to screen for occult therefore affect surgical conditions (Table 15.1 ). cardiovascular disease is to inquire about the In orbital surgery, the oculocardiac refl ex, sec- patient’s ability to exercise at 4 metabolic equiva- ondary to pressure on the optic nerve, may lead lents (METs) without dyspnea, chest pain, or to signifi cant bradycardia and hemodynamic lightheadedness. An example of an activity that instability. Finally, because microsurgical uses about 4 METs is climbing one to two fl ights maneuvers require immobility of the patient, of stairs. Pulmonary evaluation should take into intravenous sedation must be carefully titrated account recent upper respiratory infections, smok- to reduce head movement while maintaining ing history, and signs and symptoms suggestive adequate oxygenation. of obstructive sleep apnea (e.g., snoring, obesity). The neurologic evaluation should note any preexisting defi cits of the central or peripheral nervous system. The patient should also be screened for aspiration risk factors. For pediatric patients, preoperative evaluation should also include information about birth history (e.g., prematurity) and E. Elahi , M.D. (*) developmental history (e.g., diffi culty/failure The Icahn School of Medicine at Mount Sinai , reaching developmental milestones), asthma or 1034 Fifth Avenue, New York , NY 10028 , USA e-mail: [email protected] other respiratory problems, and recent infections. The patient’s mental status and ability to commu- N. F. Holt , M.D. Yale School of Medicine , 333 Cedar Street, TMP 3 , nicate adequately with the medical team is of P.O. Box 208051, New Haven, CT 06520 , USA critical importance, especially during conscious

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 203 DOI 10.1007/978-3-319-09423-6_15, © Springer International Publishing Switzerland 2015 204 E. Elahi and N.F. Holt

Table 15.1 Effect of anesthetic drugs and maneuvers on scores the fact that mild-to-moderate malnutri- intraocular pressure (IOP) tion is relatively common in developing countries. Agent Effect Therefore, it is best to use weight-based drug and Ventilation pattern Hypoventilation increases IOP, fl uid calculations [4 ]. hyperventilation decreases IOP Intravenous induction All decrease IOP except possibly and inhaled agents ketamine; etomidate decreases IOP but myoclonus upon Management of Anesthesia injection may be dangerous in setting of ruptured globe General Principles Narcotics Decrease IOP Succinylcholine Increase IOP In developed countries, safety standards, moni- (Suxamethonium) toring requirements, the availability of drugs and Nondepolarizing Decrease IOP neuromuscular supplies, as well as an adequate supply of well- blocking agents trained anesthesia providers are such that Hypertonic solutions Decrease IOP anesthesia-related mortality is extremely low— (dextran, mannitol) less than 1 in 100,000 in the USA [ 5 ]. By contrast, Acetazolamide Decrease IOP in developing countries, deaths attributable to anesthesia in the range of 1 in 133 [ 6 ], 1 in 144 [ 7 ], and 1 in 504 [ 8] have been reported. To maintain a sedation cases in which the patient’s ability to safe level of care, basic intraoperative monitoring remain motionless can be critical. Finally, it is should include means to assess oxygenation, important to elicit any personal or family history ventilation, and circulation. Since 2007, the WHO, of complications related to anesthesia. together with the World Federation of Societies Laboratory testing prior to ophthalmic surgery of Anaesthesiologists (WFSA), the Association of is not usually necessary. However, hemoglobin Anaesthetists of Great Britain and Ireland and bleeding time may be sought for more extensive (AAGBI), and others have supported the Global interventions such as oculofacial procedures in Oximetry Initiative to advocate the provision of which blood loss is expected or in patients on pulse oximetry as a minimum monitoring standard medications that might affect blood clotting. during the provision of anesthesia [9 ]. Pulse oxim- Recent evidence suggests that antiplatelet and etry offers the benefi t of establishing a basic mea- anticoagulant medications do not increase the sure of adequacy of tissue perfusion and occurrence of signifi cant bleeding complications oxygenation as well as providing a continuous dis- during cataract surgeries, even when regional play of heart rate. When general anesthesia is blocks are performed; therefore, these medica- administered, continuous capnography is the gold tions should be continued in patients who use standard for ensuring correct placement of the air- them chronically for cardiovascular conditions way and adequacy of ventilation. An esophageal or [3 ]. Patients with type II diabetes should be coun- precordial stethoscope provides an alternative seled to hold insulin and oral hypoglycemic means of assessing adequacy of ventilation when agents on the day of surgery. For patients with capnography is not available. The WFSA has pub- type I diabetes, a basal infusion of insulin should lished recommendations on international standards be continued once nil per os (NPO), and a for the safe practice of anesthesia based on avail- glucose-containing solution should be infused able levels of infrastructure (basic, intermediate, during surgery. A recent analysis by Operation optimal) [10 ]. This includes suggested minimum Smile International demonstrated that the major- drug requirements (Table 15.2 ). The WHO also has ity of children treated during its medical mis- a Model List of Essential Medicines [11 ]. sion had an age–weight ratio at or below the For ophthalmic procedures, maximizing the use Centers for Disease Control and Prevention’s of local and regional anesthesia offers the benefi t of (CDC) 50th percentile; however, the majority minimizing equipment and monitoring needs. It is had near-normal hemoglobin levels. This under- therefore an ideal approach for the majority of 15 Saving Sight in Developing Countries 205

Table 15.2 Recommended supplies and anesthesia drugs based on level of health care facility Rural hospital or health center (sparse operating room or minor Referral hospital with intensive procedure room only) District or provincial hospital (100–300 beds) care facilities (300–1,000 beds) Supplies Equipment: Capital Complete anesthesia, resuscitation and airway Same as Level 2 with these management systems including: additions per operating room and ICU bed: Adult and pediatric self-infl ating Reliable oxygen source ECG monitor breathing bags with masks Foot-powered suction Vaporizer Anesthesia ventilator, reliable electric power source with manual override Stethoscope, sphygmomanometer, Hoses and valves Infusion pumps thermometer Pulse oximeter Bellows or bags to infl ate lungs Pressure bag with IV infusion Oxygen concentrator or tank Face masks (size 00–5) Electric or pneumatic suction oxygen and draw-over vaporizer with hosesa Laryngoscopes, bougies Pediatric anesthesia system Oxygen analyzer Oxygen supply failure alarm, oxygen analyzer Thermometer or temperature probe Adult and pediatric resuscitator sets Electric warming blanket Pulse oximeter, spare probes, adult and pediatric Electric overhead heater Capnograph Infant incubator Defi brillator (one per OR suite/ICU) Laryngeal mask airways (sizes 2–4) ECG monitor Intubating bougies, adult and child Larygnoscope, Macintosh blades (1–4) Anesthetic agent (gas and vapour analyzer) Oxygen concentrator[s] cylinder Foot or electric suction IV pressure infusor bag Adult and pediatric resuscitator sets Magill forceps and/or bougie Spinal needles (25G) Nerve stimulator Automatic noninvasive blood pressure monitor Equipment: Disposable Examination gloves ECG electrodes Same as Level 2 plus: IV infusion/drug injection IV equipment and fl uids (normal saline, Ventilator circuits equipment Ringer’s lactate, dextrose 5 %) Suction catheter size 16F Pediatric giving sets Yankauer circuits and suckers Airway support equipment, Suction catheter size 16F IV infusion tubing including airways and tracheal tubes Oral and nasal airways Sterile gloves sizes 6–8 Disposable suction machines Nasogastric tubes 10–16F Disposables for capnography, oxygen analyzer (continued) 206 E. Elahi and N.F. Holt

Table 15.2 (continued) Rural hospital or health center (sparse operating room or minor Referral hospital with intensive procedure room only) District or provincial hospital (100–300 beds) care facilities (300–1,000 beds) Oral airway size 000–4 Sampling lines Tracheal tube size 3–8.5 mm Water traps Spinal needle size 22G and 25G Connectors Battery size C Filters—Fuel cells Drugs Ketamine 50 mg/mL Same as Level 1 but also : Same as Level 2 but also : Lidocaine 1 or 2 % Thiopental 500 mg/1 g powder or Propofol Propofol Diazepam 5 mg/mL or Suxamethonium bromide 500 mg powder Nitrous oxide Midazolam 1 mg/mL Morphine 10 mg/mL Pancuronium Various modern neuromuscular blocking agents Pethidine (Meperidine) 50 mg/ Neostigmine 2.5 mg injection Various modern inhalation mL agents Epinephrine 1 mg Ether, halothane, other inhalation agents Various inotropic agents Atropine 0.6 mg/mL Lidocaine 5 %, heavy spinal Various antiarrhythmic agents Bupivacaine 0.5 %, heavy or plain Nitroglycerine for infusion Hydralazine 20 mg injection Calcium chloride 10 % 10 for injection Furosemide 20 mg injection Potassium chloride 20 % 10 mL injection for infusion Dextrose 50 % 20 mL injection Aminophylline 250 mg injection Ephedrine 30/50 mg ampule Hydrocortisone ±Nitrous oxide Modiﬁ ed from Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Canadian journal of anaesthesia = Journal canadien d’anesthesie . 2010;57(11):1027–34. Table 1 aOxygen stored in cylinders is common in outlying hospitals. Tanks of various sizes are available, with difference capacities of oxygen storage. Type E cylinders hold 625 L oxygen; Type G hold 5,300 L oxygen; and Type H hold 6,900 L oxygen. While in the USA oxygen tanks are green, the WHO speciﬁ es that oxygen cylinders are white

cases. It should be recognized that although it is blocks or “minimal” sedation [ 12 ]; however, possible for a visiting medical mission group to this practice is controversial, and following the transport disposable supplies and drugs, the team ASA Practice Guidelines on Preoperative Fasting will often be dependent on the host nation for daily is the safest approach (Table 15.3 ) [13 ]. sterilization of equipment. Therefore, the quality of As with any anesthetic, it is useful to utilize a this sterilization equipment may be a limiting fac- pre-anesthetic checklist to ensure that basic pre- tor in terms of case turnover. It is advisable to pro- operative patient information and the necessary vision supplies for at least a full day of surgical anesthesia equipment is available prior to the procedures without needing to re-sterilize equip- start of each case (Table 15.4 and Fig. 15.1 ). ment. Carrying disposable back-up instruments can also provide a safety net in the event reusable instruments become unavailable. Regional Blocks In some countries, traditional NPO guidelines are circumvented, especially for those patients who Topical local anesthesia and regional orbital are only expected to receive regional ophthalmic blocks may be employed for most intraocular and 15 Saving Sight in Developing Countries 207

Table 15.3 Summary of fasting guidelines to prevent periorbital procedures. The increased use of pulmonary aspiration phacoemulsifi cation for cataract extraction has led Minimum fasting to a greater use of topical anesthesia for cataract Ingested substance period (h) surgery, while most vitreoretinal procedures Clear liquids (water, carbonated 2 require a denser anesthesia provided by regional beverages, tea, black coffee) blocks [14 ]. Among the regional techniques Breast milk 4 Infant formula 6 available are the retrobulbar, peribulbar, and Nonhuman milk 6 sub-Tenon’s block. Relative contraindications to Light meal (toast, clear liquids) 6 regional ophthalmic block include blindness in Heavy meal (fatty foods) 8 the contralateral eye, signifi cant myopia, elevated Adapted from Practice guidelines for preoperative fasting IOP, and trauma or perforation of the globe [15 ]. and the use of pharmacologic agents to reduce the risk of Whether these blocks are performed by an anes- pulmonary aspiration: application to healthy patients under- thesiologist or ophthalmologist varies by institu- going elective procedures. Anesthesiology 2011;114:495 tion and experience of the provider. Regardless, it is the responsibility of the anesthesiologist to monitor the patient’s vital signs during the performance Table 15.4 Pre-anesthetic checklist of any regional anesthetic. Patient’s Name: Date of Birth: Retrobulbar and Peribulbar Blocks Weight: Procedure: Traditionally, the four rectus muscles of the eyes ASA Physical 1 2 3 Anesthetic resources were thought to form a distinct cone around the Status 4 5 E globe whose apex was at the optic foramen. Mallampati I II Airway ⃞ Class III – Masks ⃞ Retrobulbar blocks are performed such that local IV – LMAs, Tubes ⃞ anesthetic is injected directly into the intraconal – Working laryngoscopes ⃞ space, allowing for profound and rapid anesthesia – Bougies and akinesia (globe immobility) of the rectus Aspiration Risk? Yes Breathing ⃞ No – Circuit, leak-tested ⃞ muscles with a low volume of anesthetic. – Soda lime, no color Subsequently, it has been recognized that the con- change nective tissue around the rectus muscles is incom- Allergies? Yes Suction ⃞ plete. Therefore, local anesthetic injected outside No the orbital cone may diffuse into the intraconal ⃞ Important Drugs and Devices space and produce results similar to those Medications – Oxygen cylinder, full ⃞ (e.g., insulin, and off ⃞ achieved from a retrobulbar block with relatively seizure drugs) – Vaporizers ⃞ less risk. This is the principle behind the peribul- – Monitors, alarms on ⃞ bar block, which is theoretically safer owing to ⃞ – Based drugs labeled the position of the needle on injection more – Fluids available – Thermometer, removed from the optic nerve and other critical temperature probe brainstem structures. Relevant Emergency ⃞ The retrobulbar block is performed by direct- ⃞ Medical – Epinephrine ing a needle toward the apex such that local Problems (e.g., – Self- infl ating bag ⃞ diabetes, asthma) – Tilting table ⃞ anesthetic is injected into the intraconal space. – Succinylcholine The needle is inserted through the lower eyelid, History of just superior to the lateral third of the inferior anesthesia- orbital rim and advanced in parallel to the orbital related problems fl oor. Once the needle is inserted about half an Modifi ed from Merry AF, Cooper JB, Soyannwo O, Wilson inch, the angle of insertion is shifted medially IH, Eichhorn JH. International Standards for a Safe and superiorly allowing the needle to enter the Practice of Anesthesia 2010. Canadian journal of anaesthesia = Journal canadien d’anesthesie. 2010;57(11): intraconal space. Clinically, several confi rmatory 1027–34 “pops” can be felt as the needle penetrates fi rst 208 E. Elahi and N.F. Holt

Fig. 15.1 When relying on a local supply of medications, it is imperative to foresee a mechanism to identify each drug appropriately the skin, then the orbital septum, and fi nally the risk of needle passage beyond the ciliary ganglion. orbital cone. It is paramount to pull on the plunger For the retrobulbar block, a 1.25 in. (31-mm) needle prior to injection to avoid inadvertent intravascular is suffi cient; for the peribulbar block, a ¾ inch injection of anesthetic. (19-mm) needle is adequate. For the retrobulbar The peribulbar block is administered by block, a typical injection is 3–5 mL of anesthetic directing the needle parallel to the fl oor of the solution. For the peribulbar block, 5-mL to orbit. It may be given in a single inferior injection 12-mL of anesthetic solution is used, depending at the lower orbital rim; or a superior injection on whether the block is performed with one or may also be used, given nasally above the medial two sticks. canthus. For the inferior injection, the needle is inserted through the fornix below the lateral lim- Sub-Tenon’s Block bus or percutaneously through the inferior eyelid The sub-Tenon’s block involves injection of local and directed back, laterally and slightly down- anesthetic into the episcleral (sub-Tenon’s) space, wards. If a second injection is used, the needle is which then spreads circularly, providing anesthe- advanced between the caruncle and medial can- sia to the entire globe. It is sometimes performed thus in a medial direction, away from the globe. as an adjunct to a retrobulbar or peribulbar block, Studies suggest there is no particular benefi t to or it may be used by itself for cataract or short vit- one approach versus the other in terms of anes- reoretinal surgeries. Relative to topical anesthesia, thesia, akinesia, or the development of severe sub-Tenon’s block provides superior pain relief to complications [16 ]. patients undergoing cataract surgery [17 ]. Basic supplies required include sharp small However, for many patients, placement of the gauge needles (typically 24–26G) and 5- or 10-mL block is the most painful part of the procedure, syringes. Various needle lengths are available. with nearly half of patients reporting pain on injec- The use of shorter needle lengths decreases the tion [18 ]. In contrast to the retrobulbar or peribulbar 15 Saving Sight in Developing Countries 209

Table 15.5 Complications of regional orbital blocks To prevent a rise in IOP due to squeezing of the Symptom Causes eyelids, temporary paralysis of the orbicularis Bradycardia Oculocardiac refl ex oculi is sometimes required for cataract or other Superfi cial hemorrhage Circumorbital hematoma ophthalmologic procedures. Because of the large Chemosis (conjunctival Anterior spread of local volume of local anesthetic applied extraconally, swelling) anesthetic (more common after paralysis of the orbicularis oculi is often a sec- peribulbar and sub-Tenon’s block) ondary consequence of peribulbar block. Loss of vision Retrobulbar hemorrhage However, a retrobulbar block leaves the facial Intraocular injection nerve untouched. Central retinal artery occlusion The facial nerve arises from the stylomastoid Trauma to the optic nerve foramen and passes into the substances of the Diplopia, strabismus Extraocular muscle injury parotid gland. Various methods for blocking the Convulsions Intra-arterial injection orbicularis oculi have been described, including Unconsciousness, Injection of local anesthetic the methods of O-Brien, Van Lint, Atkinson, and muscle paresis, into the cerebrospinal fl uid due Nadbath-Ellis. The O’Brien method is fairly pop- cardiopulmonary to perforation of the meningeal collapse sheath surrounding the optic ular owing to its easy landmarks and high effi - nerve cacy. It aims to block the nerve at its proximal Hypertension, Epinephrine toxicity trunk through injection of local anesthetic at the tachycardia, angina condyloid process of the mandible, which may be Wheezing, Allergic reaction, e.g., located by asking the patient to open and close hypotension, hives ester-type local anesthetic his or her mouth. After infi ltration of the skin with local anesthesia at the site of injection, a 25G 1-in. needle should be passed directly to the block, the sub-Tenon’s block is usually performed periosteum. Injection of 2–3 mL of local anesthesia using a specially designed blunt cannula rather is usually suffi cient to provide paralysis of the than a needle. After placing topical anesthesia, a orbicularis oculi within 5–10 min. The use of this buttonhole incision is made into the conjunctiva block warrants close attention to the status of the and Tenon’s capsule usually in the inferonasal eyelids following surgery, as the normal blink quadrant using spring (Westcott) scissors. response is suppressed. A compressive eye patch Anywhere from 2 to 5 mL of local anesthetic may generally can prevent corneal exposure until eyelid be injected via this incision, with the degree of function returns. sensory and motor block produced proportional to the amount of volume of anesthetic utilized. Chemosis (conjunctival swelling) and subconjunc- Topical Anesthesia tival hemorrhage are relative common complications with this block; the application of gentle Topical anesthesia involves installation of local pressure is helpful and neither generally causes anesthetic eye drops onto the eye surface. This intraoperative problems. The sub-Tenon’s block approach has several advantages including avoid- may also be performed using a needle, but this ing the risks associated with regional blocks, as approach is associated with more complications. well as reducing case turnover time. However, When performed by experienced providers, cases that require globe immobility or interven- regional ophthalmic blocks are safe procedures. tions beyond limited corneal incisions generally A summary of potential complications is provided require denser anesthesia. Furthermore, the in Table 15.5 . patient must have suffi cient linguistic and cognitive skills to follow directions and maintain Orbicularis Oculi Block steady gaze during the procedure. Topical anes- The muscles of the eyelids are controlled by the thesia is ideal for standard phacoemulsifi cation orbicularis oculi, a division of the facial nerve. procedures performed by experienced surgeons. 210 E. Elahi and N.F. Holt

Options for eye drops include the shorter-acting duration. Other local anesthetic agents used agents such as proxymetacaine 0.5 %, and oxy- include 2-chloroprocaine 2–3 %, mepivacaine buprocaine (benoxinate) 0.4 %; and longer-acting 1–2 %, bupivacaine 0.25–0.75 %, levobupiva- drugs such as lidocaine 1–4 %, bupivacaine 0.5– caine 0.25–0.75 %, prilocaine 3 %, ropivacaine 0.75 %, and tetracaine 0.5–1.0 %. All topical 0.75 %, and articaine 2–4 %. Table 15.6 provides local anesthetics sting on application owing to a comparison of the properties of the local anes- their acidic pH; the longer-acting anesthetics are thetics commonly used for anesthetic surgery relatively more painful on instillation, so some [22 ]. Table 15.7 provides typical anesthetic solu- providers use a combination of short-acting drops tions used for the most common regional and fi rst followed by longer-acting agents to reduce topical ophthalmic blocks. patient discomfort [19 ]. The intracameral injection of a small volume (0.1–0.3 mL) of 1 % preservative-free lidocaine is an option for Table 15.7 Typical anesthetic solutions for regional and enhancing the analgesia provided by topical topical ophthalmic blocks drops [20 ]. An alternative to drops is the use of Technique Solution anesthetic gels, including lidocaine 2.0 %. The Retrobulbar/ Lidocaine 2 % gel may be mixed with dilating medications, peribulbar/ Lidocaine 2 % + Bupivacaine 0.5 or antibiotics, and nonsteroidal anti-infl ammatory sub-Tenon’s 0.75 % in a 50:50 mixture drugs and applied before surgery [21 ]. Lidocaine 2 % + Ropivacaine 0.5 or 1 % in a 50:50 mixture Topical Oxybuprocaine alone OR with Tetracaine or Lidocaine for longer procedures Local Anesthetics Viscous lidocaine 2 % or tetracaine 4 % gel ± 4 gtts tropicamide, 4 gtts 1 % The choice of local anesthetic depends on the cyclopentolate, 10 % phenylephrine, 10 requirement for onset of action, desired duration gtts moxifl oxacin, 4 gtts ketorolac of anesthesia, and degree of akinesia required by Intracameral Lidocaine 1 % (preservative- free) + Bupivacaine 0.5 % eye drops the procedure. Lidocaine 2 % and bupivacaine (preservative free) 0.5 % are the two most commonly used local Adapted from Malik et al. Local anesthesia for cataract anesthetics; sometimes used in a 50:50 mix to surgery. J Cataract Refract Surg 2010;36:133–152. combine the benefi ts of quicker onset and longer (Table 2, page 135)

Table 15.6 Local Agent Onset Duration Toxicity anesthetics commonly used Procaine Slow Short Low for ophthalmic surgery 2-chloroprocaine Rapid Short Low Tetracaine Slow Intermediate Intermediate Cocaine Slow Long Very high Oxybuprocaine Slow Short Intermediate Bupivacaine Slow Long High Levobupivacaine Slow Long Intermediate Lidocaine Rapid Intermediate Low/intermediate Ropivacaine Intermediate Long Intermediate Etidocaine Rapid Long High Articaine Rapid Long Low Proxymethacaine Rapid Intermediate Low Prilocaine Rapid Intermediate Low Mepivacaine Rapid Intermediate Low Modiﬁ ed from Malik et al. Local anesthesia for cataract surgery. J Cataract Refract Surg 2010;36:133–152 and Jackson et al. 2006 15 Saving Sight in Developing Countries 211

Several additives may be used to modify the Table 15.8 Classifi cation of local anesthetics effect of local anesthetics. Epinephrine 1:200,000 Ester Amide (5 μg/mL) may be added to increase the duration Procaine Lidocaine and quality of the block by causing local vasocon- Tetracaine Mepivacaine striction; this effect is most prominent with bupi- Chloroprocaine Bupivacaine vacaine. However, it should be avoided in patients Cocaine Ropivacaine with coronary artery disease and has been impli- Benzocaine Levobupivacaine cated in retinal artery thrombosis secondary to Oxybuprocaine Etidocaine vasoconstriction. Sodium bicarbonate is thought Prilocaine to speed the onset of action of bupivacaine and Articaine may help reduce pain on injection. Hyaluronidase (15 IU/mL of local anesthetic) is an enzyme that helps facilitate the spread of local anesthetic ing agent should be removed or discontinued if thereby decreasing the amount needed to achieve a possible and additional assistance should be desired effect and improve the quality of the block. summoned. Initial attention should focus on the Its use remains controversial since rare, but serious airway, breathing, and circulation. The patient allergic reactions have been reported [23 , 24 ]. should be placed in a recumbent position with the legs elevated to offset vasodilation and maximize perfusion to vital organs. Intravenous Allergic Reactions to Local access should be obtained as soon as possible. Anesthetics Supplemental oxygen should be administered by face mask. Ideally, the patient should be Although uncommon, allergic reactions to local monitored with continuous electrocardiogram anesthetics occur and may be caused by (1) the (ECG) and pulse oximetry as well as routine local anesthetic or its metabolite; (2) the methyl- blood pressure and heart rate assessment. paraben preservative used in multidose vials; or (3) Pharmacologic treatment usually includes antioxidants added to some formulations of local administration of histamine-1 and histamine-2 anesthetics. There are two classes of local anes- antagonists such as diphenhydramine 25–50 mg thetic based on chemical structure: esters and IV (1 mg/kg for patients <40 kg) and ranitidine amides (Table 15.8 ). Esters are associated with a 50 mg (1 mg/kg for patients <40 kg), respec- relatively higher incidence of allergic reactions due tively. Albuterol nebulizers or inhalers are use- to one of their metabolic by-products—para- ful in the treatment of bronchospasm. Refractory amino-benzoic acid (PABA), which is structurally bronchospasm or hypotension is best treated similar to methylparaben. Amide local anesthetics with epinephrine. Epinephrine may be adminis- do not metabolize to PABA; therefore, patients tered intramuscularly in the outer thigh. When allergic to the ester local anesthetics are generally administered intramuscularly, a concentration able to tolerate the amide local anesthetics. of 1 mg/mL (1:1,000) is used, and the dose is However, even with amides, methylparaben is used 0.3–0.5 mg per dose (0.01 mg/kg per dose in to preserve the multidose vial and patients who are patients <50 kg). Epinephrine may also be given allergic to PABA will have reactions. Sulfi tes are intravenously in a concentration of 0.1 mg/mL another potential allergen used in some formula- (1:10,000), usually as a continuous infusion tions of local anesthetic solutions, notably those 2–10 μg/min, titrated to blood pressure. Owing containing vasoconstrictors such as epinephrine. to their long onset of action, glucocorticoids are Therefore, in patients with a known sulfi te allergy, not useful in treating the initial symptoms of an it is best to avoid solutions containing additives allergic reaction; however, they may be given to such as sodium bisulfi te and metabisulfi te. prevent late-stage responses. Typical treatment The fi rst step in treatment of an allergic reac- is methylprednisolone 1–2 mg/kg daily for a tion is recognition of its occurrence. The incit- maximum of 72 h. 212 E. Elahi and N.F. Holt

Monitored Anesthesia Care Table 15.9 Example of procedure-specifi c ophthalmic surgery preoperative orders Monitored anesthesia care (MAC) as an adjunct Extraocular procedures to local or regional anesthesia is a widely used – Check vital signs approach for ophthalmologic procedures. – Midazolam or Diazepam po or IV according to size of patient Supplemental oxygen is required, and the patient – Chloroprocaine gtt every 3 h until surgery should be monitoring for satisfactory respiratory – If patient to have general anesthesia: IV insertion effort—ideally with end-tidal carbon dioxide with 500–1,000 mL preload, if adult; weight-based monitoring. For patients requiring retrobulbar or for pediatric patients Intraocular procedures (cataract, lens placement) peribulbar block, a brief period of general anesthe- – Check vital signs sia using a bolus dose of propofol (30–75 mg) or – Midazolam or Diazepam po or IV pre-op according methohexital (30–75 mg) is frequently employed to size of patient just prior to performing the block. The patient is – Chloroprocaine gtt every 3 h until surgery then allowed to awaken spontaneously. Propofol – Diamox 250–500 mg pre-op μ – Dilating drops: mydriacyl or phenylephrine gtt pre-op as a continuous infusion (25–75 g/kg/min) is – Cyclopentolate gtt per MD orders sometimes used to provide deeper sedation in – If patient to have general anesthesia: IV insertion younger or more anxious patients. This technique with 500–1,000 mL preload, if adult; weight-based offers the benefi t of reduced awareness and anti- for pediatric patients emetic properties. Adapted from Moos DD. Perianesthesia nursing at an The main role of the anesthesiologist during ophthalmic hospital in the Middle East. Journal of perianesthesia nursing: offi cial journal of the American MAC for eye surgery is to monitor the patient’s Society of PeriAnesthesia Nurses/American Society of vital signs and attend to the patient’s comfort. PeriAnesthesia Nurses . 2005;20(2):83–91. Table 3 [27 ] Deep sedation is unnecessary and best avoided owing to the risk of airway obstruction with the A benefi t of these drugs is that they do not impair airway in the operative fi eld far from the anesthe- respiratory effort. However, they may cause car- siologist, prolonged recovery time and possible diovascular depression. Dexmedetomidine is also disinhibition or confusion, especially in the elderly expensive and unlikely to be available in hospitals population. Verbal reassurance is often all that is with limited resources. required; however, for some patients, a small dose Ketamine is a low-cost anesthetic with analge- of anxiolytic (midazolam 0.5–2 mg) is advanta- sic properties that has the benefi t of causing little geous. An oral or nasal dose of midazolam respiratory depression or hemodynamic instability. (0.5 mg/kg) may also be given to children (2–10 Therefore, it is theoretically ideal for MAC where years) prior to minor ophthalmologic procedures. resources are scarce. However, patients who receive Diphenhydramine, a histamine-1 antagonist that ketamine often suffer unpleasant psychomimetic has sedative, antiemetic, and anticholinergic prop- emergence reactions; in addition, they may develop erties is an alternative to midazolam. However, intraoperative hypertension. In small doses (10– owing to its long half-life (3–6 h), Diphenhydramine 20 mg), these side effects can usually be avoided. tends to prolong recovery times and may cause When higher doses are used, it is best to pretreat confusion in the elderly. with an anxiolytic such as midazolam. Occasionally, intravenous narcotics are used Table 15.9 provides an example of procedure- as a supplement for pain control; short-acting specifi c preoperative orders for extraocular and agents such as fentanyl (0.5–1.0 μg/kg), remifen- intraocular procedures. tanil (0.5 μg/kg), and alfentanil (3–7 μg/kg) are commonly employed. Owing to its lower potency and greater safety margin, fentanyl is the most General Anesthesia commonly use agent. Other less commonly used drugs include General anesthesia is usually reserved for pediat- clonidine and dexmedetomidine. Both are alpha- ric patients, adults who are unable to lie fl at or 2-agonists with anxiolytic and sedative properties. still, as well as for strabismus surgery and more 15 Saving Sight in Developing Countries 213 complicated oculoplastic procedures. General manipulation of the eye to induce bradycardia anesthesia is indicated for emergency procedures, (oculocardiac refl ex) and the relatively high inci- such as penetrating eye injuries (“open globe”). dence of postoperative nausea and vomiting The experience and skill of the anesthesiologist is (oculogastric refl ex). If bradycardia occurs often the limiting factor in smooth inductions and intraoperatively, the best approach is to ask the emergence. An endotracheal tube (ETT) is pref- surgeon to temporarily discontinue ocular erable in patients at risk for aspiration. manipulation; however, glycopyrrolate and atro- Specifi cally, a Right Angle Endotracheal (RAE) pine should be available as well. The avoidance Tube may be best as it protects the airway, facili- of narcotics helps to minimize the risk of postop- tates mechanical ventilation, if necessary, and erative vomiting, as does the use of total intrave- angles down towards the chest away from the sur- nous anesthesia with propofol; however, this gical fi eld. The installation of intratracheal lido- approach may be impractical in developing coun- caine (2–4 % solution; 1 mg/kg) or intravenous tries, owing to cost considerations. The nonste- lidocaine (1.5–2.0 mg/kg) may be considered in roidal anti-infl ammatory agent ketorolac is a an attempt to reduce coughing on insertion or suitable alternative to narcotics for postoperative removal of the ETT. A supraglottic airway (e.g., analgesia. laryngeal mask airway) may be suitable for some The prophylactic administration of antiemetic ocular procedures. Compared to an endotracheal agents at induction has been shown to reduce the tube, insertion of a supraglottic airway may be incidence of postoperative vomiting. Droperidol associated with less of an increase in intraocular had been well-studied for this indication, though pressure (IOP). In addition, its use may reduce its use in the USA has decreased dramatically bucking on emergence. Spontaneous respiration since the Food and Drug Administration’s “black can be maintained during general anesthesia, box” warning concerning the risk of QT interval avoiding the need for a mechanical ventilator, prolongation. Alternative antiemetics include which may be in scarce supply in limited resources serotonin antagonists (e.g., ondansetron) and glu- areas. Ultimately, the choice of ETT versus LMA cocorticoids (e.g., dexamethasone, 0.25 mg/kg). should be left to the anesthesiologist. There is an increased incidence of malignant Inhalational anesthesia (e.g., halothane, sevofl u- hyperthermia in patients with strabismus. rane, isofl urane ± nitrous oxide) is most commonly Therefore, it is important to be vigilant about used for maintenance of general anesthesia, monitoring of temperature and end-tidal CO2 . although total intravenous anesthesia (e.g., propofol and narcotic infusion) may be used as well. Nitrous Open Eye Surgery oxide should not be used in procedures requiring Special considerations in the management of instillation of intravitreal gas. anesthesia for open eye injuries include the need to minimize aspiration risk and the desire to Strabismus Surgery avoid increases in IOP that could cause extrusion Strabismus surgery is most commonly performed of vitreous contents from the damaged eye. While on pediatric patients although it may be indicated succinylcholine offers the safest option for rapid in the adult population as well. Strabismus sur- intubating conditions, concern exists over its gery typically requires general anesthesia. Muscle potential to temporarily increase IOP. High-dose relaxation may be requested by the surgeon to rocuronium (1.0 mg/kg) is an alternative to suc- reduce tone in the extraocular muscles. Non- cinylcholine, but due to its intermediate duration depolarizing agents are preferred to succinylcho- of action, the use of rocuronium may be danger- line because the latter interferes with the forced ous in patients with known or unrecognized dif- duction test (FDT), an intraoperative maneuver fi cult airways. It is also often not available in that helps distinguish the cause of impaired eye developing countries. In a patient with a known muscle function. diffi cult airway, options are limited to awake Special considerations during strabismus fi ber-optic laryngoscopy, topical or regional surgery include the propensity for surgical anesthesia. Fiber-optic laryngoscopy requires 214 E. Elahi and N.F. Holt skill as well as expertise in anesthetic airway more rapid vision recovery, which is important in blocks to obviate increases in IOP. The fi ber- patients with poor vision in both eyes [24 ]. optic scope is expensive, fragile and requires Most pediatric patients undergoing ophthal- sophisticated processing for sterilization; there- mic procedures will have uneventful recoveries. fore, it is not likely to be available on a mission. Postoperative breath-holding and episodic brady- The management decisions for this type of emer- cardia may be a problem in procedures performed gency should be made in consultation with the on preterm infants (e.g., surgery for retinopathy ophthalmologist and decisions made based on the of prematurity). Close monitoring is warranted in probability of saving the injured eye. these patients. It is prudent to administer an H2-receptor antagonist such as ranitidine prophylactically prior to general anesthesia in the non-fasted Documentation patient. Given intravenously, ranitidine is effec- and Communication tive within 60 min and lasts for up to 9 h. Non- particulate antacids, such as 0.3 M sodium citrate Documentation raise gastric pH within 15–30 min, and are therefore also useful for patients presenting for emer- In order to achieve the humanitarian objective of gency surgeries. Metoclopramide, a dopamine medical missions, it is fundamental to maintain antagonist that increases gastric motility and gas- administration and documentation standards. troesophageal sphincter tone may be considered. Each patient should be registered with a unique It is optimally administered via infusion within identifi er, and on the day of surgery, the patient 15–30 min of induction. Contraindications should wear that identifi er at all times. Digital include patients with a bowel obstruction and photography can be especially useful to maintain should be used with caution in the elderly, a centralized visual identifi er of patients and their because of possible side effects such as confusion chart. Furthermore, photographs can easily be and drowsiness. printed and used as a means to verify patients’ identities and treatment plans. The WHO recommends the use of a surgical safety checklist to Postanesthesia Recovery ensure availability of necessary equipment, confi rmation of patient, procedure and surgical site, In many developing countries, there is no desig- and review of anticipated critical events, etc. [25 ] nated postanesthesia recovery area and no direct Basic components of a surgical medical record nursing or medical oversight for recovering should include: (1) preoperative assessment; (2) patients. Instead, on emergence, the patient is consent in the local language; (3) operative note; transferred from the operating table to a stretcher (4) anesthesia record; (5) postanesthesia recovery and moved to an area outside the operating the- record; and (6) discharge plan. All patients should atre; and the anesthesia provider remains respon- be assessed postoperatively and a treatment plan sible for recovering the patient, even as he or she needs to be established by the surgical team that prepares for or begins another case. allows for a practical transition of care to local Recovery from an uneventful cataract surgery health personnel. should take less than 20 min. The degree of An anesthesia record should be completed for postoperative recovery is directly related to the every procedure. This should include the surgical sedation given during the procedure. When post- procedure and its length, interval recordings of operative care resources are limited, it is benefi - oxygen saturation, heart rate, respiratory rate, cial to minimize sedation required to provide a blood pressure, as well as the length and type of satisfactory patient experience. Compared with a anesthesia, and drugs and fl uids administered [ 26 ]. regional block, topical anesthesia also allows for This record should also note any unusual intraop- 15 Saving Sight in Developing Countries 215 erative events, such as intubation diffi culties, and (b) rare serious conditions for which local hypotensive episodes, etc. An appropriate hand- know-how or available equipment may be lacking off should be given to a care provider in the (e.g., orbital decompression). The authors have postanesthesia care unit (PACU), and this area found that a prescreening triage with priority should be supervised by an anesthesiologist. assignment allows patients and the local provid- Postanesthesia orders should include provisions ers to have clarity with regard to the nature and for pain medications as well as routine measure- scope of cases that are to be performed. ment of vital signs. Before incision, it is also useful to conduct a verbal “time out” to verify the patient’s identity, confi rm the procedure to be performed (including Communication, Ethical, and Cultural laterality) and any special equipment or prosthet- Considerations ics needed, determine antibiotics that need to be administered, and review any critical issues While obtaining surgical consent, it is impera- expected during the procedures. tive that the risks, benefi ts and alternatives to surgery be adequately explained in a language that is accessible to patients. Arranging for trans- Conclusion lation prior to the mission is useful in order to avoid misunderstandings that can lead to cata- Providing anesthesia support to ophthalmic strophic outcomes. Consent documents should surgeries presents both unique challenges and be read to patients in consideration of high rates opportunities. With adequate preparation and of illiteracy. foresight, life-transforming operations can be Ideally, medical missions are performed in safely provided to millions of individuals in need. conjunction with local specialists who may In places where healthcare infrastructure is scarce, assume postoperative care of the patients when the anesthesiologist must not only be able to the visiting team departs. If such local support is improvise with limited means but also continue to lacking, patient selection should be limited to remain intimately involved in the patient’s recov- those who can be treated with limited aftercare. ery outside the operating room. For example, cataract surgery can be performed with minimal follow up in most cases whereas glaucoma surgery requires frequent follow-ups References and close monitoring. In cases where no after care support is available locally, it may be more 1. Nouvellon E, Cuvillon P, Ripart J. Regional anesthe- appropriate to help transfer the patient to a differ- sia and eye surgery. Anesthesiology. 2010;113(5): 1236–42. ent facility rather than risking visual complications 2. McQueen KA, Magee W, Crabtree T, Romano C, due to inappropriate postoperative care. Burkle Jr FM. Application of outcome measures in Planning for a medical mission presents international humanitarian aid: comparing indices unique challenges to the medical team. Patient through retrospective analysis of corrective surgical care cases. Prehosp Disaster Med. 2009;24(1):39–46. selection often depends on a number of factors 3. Li G, Warner M, Lang BH, Huang L, Sun LS. including the availability of local support, the Epidemiology of anesthesia-related mortality in the nature and diffi culty of the operation and the util- United States, 1999–2005. Anesthesiology. 2009; itarian value of a particular intervention. In the 110(4):759–65. 4. Ouro-Bang’na Maman AF, Tomta K, Ahouangbevi S, authors’ experiences, two types of operations are Chobli M. Deaths associated with anaesthesia in ideally suited for medical missions: (a) Surgery Togo, West Africa. Trop Doct. 2005;35(4):220–2. for common conditions that can be treated by the 5. Hodges SC, Mijumbi C, Okello M, McCormick BA, local physicians with minimal capacity building Walker IA, Wilson IH. Anaesthesia services in developing countries: defi ning the problems. Anaesthesia. and knowledge transfer (e.g., cataract surgery) 2007;62(1):4–11. 216 E. Elahi and N.F. Holt

6. Hansen D, Gausi SC, Merikebu M. Anaesthesia in 16. Jeganathan VS, Jeganathan VP. Sub-Tenon’s anaes- Malawi: complications and deaths. Trop Doct. thesia: a well tolerated and effective procedure for 2000;30(3):146–9. ophthalmic surgery. Curr Opin Ophthalmol. 2009; 7. Thoms GM, McHugh GA, O’Sullivan E. The Global 20(3):205–9. Oximetry initiative. Anaesthesia. 2007;62 Suppl 1:75–7. 17. Kumar C, Dowd T. Ophthalmic regional anaesthesia. 8. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Curr Opin Anaesthesiol. 2008;21(5):632–7. Eichhorn JH. International Standards for a safe 18. Ezra DG, Allan BD. Topical anaesthesia alone versus practice of anesthesia 2010. Can J Anaesth. 2010; topical anaesthesia with intracameral lidocaine for 57(11):1027–34. phacoemulsiﬁ cation. Cochrane Database Syst Rev. 9. World Health Organization. 2013. WHO Model List 2007;3, CD005276. of Essential Medicines. Available: http://www.who. 19. Cass GD. Choices of local anesthetics for ocular int/medicines/publications/essentialmedicines/en/ . surgery. Ophthalmol Clin North Am. 2006;19(2): Accessed 26 Jan 2014. 203–7. 10. Sanmugasunderam S, Khalfan A. Is fasting required 20. Jackson T, McLure HA. Pharmacology of local anes- before cataract surgery? A retrospective review. Can J thetics. Ophthalmol Clin North Am. 2006;19(2): Ophthalmol. 2009;44(6):655–6. 155–61. 11. American Society of Anesthesiologists. Practice guide- 21. Kumar CM, Dowd TC. Complications of ophthalmic lines for preoperative fasting and the use of pharmaco- regional blocks: their treatment and prevention. logic agents to reduce the risk of pulmonary aspiration: Ophthalmologica. 2006;220(2):73–82. application to healthy patients undergoing elective pro- 22. Malik A, Fletcher EC, Chong V, Dasan J. Local anes- cedures: an updated report by the American Society of thesia for cataract surgery. J Cataract Refract Surg. Anesthesiologists Committee on Standards and Practice 2010;36(1):133–52. Parameters. Anesthesiology. 2011;114(3):495–511. 23. World Alliance for Patient Safety. 2008. Surgical 12. Vann MA, Ogunnaike BO, Joshi GP. Sedation and anes- Safety Checklist. Available: http://www.who.int/ thesia care for ophthalmologic surgery during local/ patientsafety/safesurgery/ss_checklist/en/ . Accessed regional anesthesia. Anesthesiology. 2007;107(3):502–8. 27 Jan 2014. 13. Kallio H, Rosenberg PH. Advances in ophthalmic 24. Chackungal S, Nickerson JW, Knowlton LM, Black regional anaesthesia. Best Pract Res Clin Anaesthesiol. L, Burkle FM, Casey K, et al. Best practice guidelines 2005;19(2):215–27. on surgical response in disasters and humanitarian 14. Alhassan MB, Kyari F, Ejere HO. Peribulbar versus emergencies: report of the 2011 Humanitarian Action retrobulbar anaesthesia for cataract surgery. Cochrane Summit Working Group on Surgical Issues within the Database Syst Rev. 2008;3, CD004083. Humanitarian Space. Prehosp Disaster Med. 2011; 15. Davison M, Padroni S, Bunce C, Ruschen H. Sub- 26(6):429–37. Tenon’s anaesthesia versus topical anaesthesia for 25. Moos DD. Perianesthesia nursing at an ophthalmic cataract surgery. Cochrane Database Syst Rev. 2007;3, hospital in the Middle East. J Perianesth Nurs. CD006291. 2005;20(2):83–91. Cardiothoracic Anesthesia and Intensive Care: What Is 16 the Role of Missions?

Peter M. J. Rosseel and Carrie L. H. Atcheson

developed through teaching and mentorship. Introduction Cardiothoracic anesthesiology is well covered in other texts,1 and within the fi eld there is a circum- Some might say practicing cardiovascular anes- scribed chain of surgical care. Thus, the expertise thesia and intensive care in a low-resource setting and evidence presented elsewhere should serve is overly ambitious and unrealistic and that having the provider well when adapted and implemented a chapter on cardiothoracic anesthesia in a book in a global health context. Intensive care is also a on anesthesia missions opens up many contradic- broad fi eld that is well described in other texts,2 tions and ambiguities. Addressing these contra- dictions and ambiguities is necessary, however, as hospitals in low- and middle-income countries 1 Suggested resources for cardiac anesthesiology (LMICs) across a variety of geographic and socio- include, but are not limited to: Kaplan ’ s Cardiac Anesthesia, A Practical Approach to Transesophageal economic contexts develop and expand surgical Echocardiography by A. C. Perrino, S. T. Reeves (ISBN- and anesthesiology services. 13: 978–1451175608), the updated clinical practice guide- The fi eld of cardiovascular anesthesiology in a lines maintained by The Society of Thoracic Surgeons global health setting touches on so many domains found at http://www.sts.org/resources-publications/ clinical-practice- credentialing-reporting-guidelines , the that it deserves a text of its own covering epidemi- Transoesphageal echocardiography e-learning certifi cation ology, prevention, accessibility to cardiac surgery course from the European Association of Cardiovascular and anesthesia, postsurgical care, supply chains, Anaesthesiologists http://www.eacta.org/education/eacad- and quality control, just to name a few. emy and the lecture series maintained by the Society of Cardiovascular Anesthesiologists at http://www.scahq.org/ Furthermore, the domains of cardiovascular anes- FellowshipCareerOpportunities/Adult Cardiothoracic thesiology and intensive care have developed so Anesthesiology Fellowships/FellowshipLectureSeries.aspx broadly that they cannot be rightly practiced with- (must be a member to access, and membership costs $40 out specifi c knowledge, expertise, and skills USD for fellows and residents). 2 Suggested resources for critical care medicine include, but are not limited to: Paul Marino: The ICU Handbook, fourth edition, ISBN 13–1451121186; Murry & Nadel’s Textbook P. M. J. Rosseel , M.D. (*) of Respiratory Medicine, the American Thoracic Society Department of Cardiothoracic Anaesthesia Reading List found at http://www.thoracic.org/career- and Intensive Care , Amphia Hospital , development /residents/ats-reading-list/, the treasury of Molengracht 21 , Breda 4818 CK , The Netherlands review articles in The Clinics series found at http://www. e-mail: [email protected] chestmed.theclinics.com/ , and—for procedures—the video C. L. H. Atcheson , M.D., M.P.H. library of the New England Journal of Medicine found at Oregon Anesthesiology Group, Department of http://www.nejm.org/multimedia/medical-videos and that Anesthesiology, Adv entist Medical Center , maintained by Cook ® Medical at https://www.cookmedical. Portland, OR , USA com/web/critical-care?id=Educational_Video .

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 217 DOI 10.1007/978-3-319-09423-6_16, © Springer International Publishing Switzerland 2015 218 P.M.J. Rosseel and C.L.H. Atcheson and therefore this chapter focuses on the special ologists who contributed their experiences and provisions and minimum standards of care reviewed this manuscript and want to pay their needed to provide appropriate intensive care for deepest respect to those who are practicing car- safe cardiovascular anesthesiology services. diothoracic anesthesiology and intensive care in Additionally, for many of the lowest income more difﬁ cult and less comfortable conditions. countries (LICs), the resources required to develop safe cardiovascular surgical and anesthesia services are too great. Therefore, in this chapter, we further Cardiac Surgery and the Global narrow the scope to focus on those countries where Burden of Cardiovascular Disease the conditions are somewhat more favorable, e.g., middle-income countries (MICs). Cardiovascular Global Burden of Cardiovascular disease is one of the greatest public health concerns, Disease even when limited to those forms that are amenable to surgery. Surgery has been called the neglected In a landmark article in 2001 Yusuf describes stepchild of global health because of its dependency how during the twentieth century the epidemiol- on a well-functioning hospital structure including ogy of cardiovascular disease has shifted from a laboratory and blood banking services [1 ]. This predominantly nutritional and infectious origin to applies especially to cardiac surgery. Short term, degenerative causes and how this shift paralleled self-contained surgical trips are described elsewhere socioeconomic development. In medical terms, in the text, but his chapter focuses on the building of cardiac surgical disease went from being pre- a sustainable service of cardiovascular anesthesiol- dominantly rheumatic in origin among a young ogy and intensive care, staying away from volun- population to ischemic coronary disease and tarism without a clear objective. degenerative valve disease causing heart failure This chapter brings together expertise from in middle aged or elderly patients (Table 16.1 ) cardiovascular anesthesiology and intensive care [ 2 ]. According to Yusuf et al., this disease pattern gained in High Income Countries (HICs) and the differs throughout the world, depending on the experience and knowledge of the humanitarian socioeconomic status and evolution of a particu- context of LMICs. Although practical clues for lar country or region, and a well-developed health organizing a mission will be provided, this chap- care system can regress due to a changing socio ter aims more to convey a way of thinking and economic event, e.g., war or natural disaster. The provide a framework that can be adapted to the following section traces the impact of socioeco- local situation. Explicitly the authors want to nomic status on cardiovascular disease and sur- thank the pediatric and adult cardiac anaesthesi- gery through three different scenarios.

Table 16.1 Adapted from (Yusuf et al. [2 ]). Mortality from Cardiovascular Disease and Infectious Causes in 1990, by region and gender (in thousands) Cardiovascular Infectious Cardiovascular Infectious Region causes in men causes in men causes in women causes in women India 611 429 481 240 China 576 158 439 89 Other Asian and Paciﬁ c Island 289 147 226 140 Commonwealth of Independent States 416 20 253 6 Sub-Saharan Africa 183 215 211 228 Latin America/Caribbean 186 62 147 48 Middle East Crescent 258 56 215 35 Established Market Economies 483 42 227 12 Total 3,028 1,128 2,201 798 In 2001, Yusuf and colleagues demonstrated in their landmark article series “The Global Burden of Cardiovascular Diseases” that, even in regions with the lowest per capita incomes, mortality from cardiovascular disease is high and growing. Only in sub-Saharan Africa did mortality from infectious causes exceed that from cardiovascular disease. 16 Cardiothoracic Anesthesia and Intensive Care… 219

50.000

40.000

30.000

20.000

10.000

0 Aantal hartoperaties / PCI = Cardiosurgical intervention / Percutaneous Coronary Interventions Openhartoperatie = Cardiac surgery 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Openhartoperatie PCI

Fig. 16.1 The increase in the absolute number of percu- Foundation). Black lines depict absolute number of annual taneous coronary interventions versus the number of open cardiosurgical intervention (open hart operaties) as heart surgeries from 1983–1985 to present. X axis: year. Y compared to the number of percutaneous coronary inter- axis: number of interventons. According to the 2013 ventions (PCI) represented by the red line report of the “Nederlandse Hartstichting” (Dutch Cardiac

Situation in Developed born in other countries with a higher incidence of Countries rheumatic fever in childhood. In the Netherlands, only 761 of the 17,293 cases of cardiac surgery The Netherlands is a country on the high end of were performed for children younger than development and income with an exemplary and 14 years. highly accessible health care system that focus on disease prevention. The number of cardiac surgeries is only slowly increasing while the Lowest Income Countries number of percutaneous procedures in octoge- narians remains stable due to increased life On the other end of the spectrum are the poorest expectancy (Fig. 16.1 ). countries that have few local, national, or private In 2012, 17,293 open heart operations were sector resources and are categorized by the World performed on a total population of 16.7 million, Bank as Low Income Countries (LICs). Sixty per- which represents 104 open heart operations per cent of the burden of cardiovascular disease is 100,000 inhabitants [3 ]. Fifty-fi ve percent of borne by LICs, and the epidemiology of cardiac these were isolated coronary artery bypass graft- surgical disease is different in these countries [4 ]. ing (CABG) and 42 % were isolated valve sur- According to the World Heart Federation gery. The remainder of the cases were for (WHF), the burden of rheumatic heart disease— combined valve with CABG surgery, or other which is a consequence of an untreated or less prevalent forms like repair of the thoracic undertreated streptococcal upper respiratory aorta, heart transplants, and congenital cardiac infection—falls disproportionately on the chil- surgery [3 ]. Most valve surgery is for degenera- dren and young adults in LICs. In LICs alone, tive valve disease, and the proportion of valve 15.6 million people are affected by rheumatic heart operations due to delayed consequences of rheu- disease, two million per year require hospitaliza- matic fever is scant and mainly among patients tion, and 233,000 deaths per year are attributable 220 P.M.J. Rosseel and C.L.H. Atcheson to end-stage rheumatic heart disease. In some parts services, and “impotent” because even if the cor- of sub-Saharan Africa, Latin America, and Asia rect diagnosis were revealed, resuscitation or and among the indigenous people of Australia curative operation was not possible because of a and New Zealand, as much as 1 % of school age total absence of equipment and tools. The num- children have symptomatic rheumatic heart ber of these cases that might be prevented by disease [5 ]. Though few international resources good primary health care or detected by an ade- are dedicated to it, an estimated 16–18 million quately functioning hospital and cardiology care people in LICs are infected with Chagas disease, is not documented. a parasite carried by a beetle that lives in mud and These three cases are representative of the dirt structures that eventually causes an infec- burden of cardiac surgery in the poorest coun- tious cardiomyopathy [6 ]. Though infectious eti- tries. To have an impact, congenital heart disease, ologies of surgical cardiac disease are not likely the treatment of rheumatic fever, and the causes to be eradicated in LICs in the near future, these of emerging degenerative cardiac disease such as countries are beginning to confront ischemic aging, urbanization, and lifestyle changes (smok- heart disease due to the obesity epidemic and ing, decreased physical activity, obesity, and ischemic heart disease is expected to grow more nutrition must all be addressed from a public quickly in LMICs than in HICs [6 , 7 ]. According health perspective. Goal oriented resource man- to the World Health Organization (WHO), in 2011 agement can only be achieved when adequate “Coronary disease killed more than 7 million data regarding existing health conditions are pro- people and stroke killed nearly 6 million. Most of vided for low- and middle-income countries [8 ]. the deaths were in developing countries” [ 4]. Thus, the burden of surgical cardiac disease will continue to fall disproportionately on the people Middle-Income Countries with the least access to medical care and surgical services. BRICS Countries This author (PR) can easily recall three cases In between these socioeconomic extremes, on the from Médecins Sans Frontières (MSF) emergency top of the bell curve, lie the middle-income coun- response humanitarian projects: tries. This group is too diverse to describe as a • In Somalia, a pregnant woman presented at the whole. On one hand there are the so-called emergency department in overt cardiac failure BRICS—Brazil, the Russian Federation, India, clinically diagnosed as aortic insuffi ciency. China, and South Africa—the countries repre- • In Liberia, a middle aged male visitor in the senting three billion habitants of our planet. This hospital suffered sudden cardiac death, preterm was fi rst coined in a white paper by a sumably from a myocardial infarction. Goldman-Sachs executive in 2001 to describe the • In Somalia again, a newborn infant remained investment opportunities in these up-and-coming cyanotic after birth, a condition that did not economies [9 ]. This group of countries holds a improve with oxygen by face mask and a clin- yearly international summit; Argentina, ical diagnosis was made of cyanotic heart dis- Indonesia, Turkey, Iran, Nigeria, Syria, and Egypt ease of unspecifi ed cause. are sometimes practically grouped in the same In these cases, as in many cases of cardiac dis- category, but do not take part in the BRICS eco- ease encountered in LICs, “clinically”, “presum- nomic summit [10 ]. ably” and “unspecifi ed” are the key words. As Though the level of health care is considerably this author did, visiting anesthesiologists and better than in the developing countries, it is far local practitioners alike fi nd themselves feeling below what would be expected in the G7 coun- ignorant and impotent in such clinical situa- tries, the most important differences being a tions—“ignorant” because the exact diagnosis marked disparity in the quality of health care pro- cannot be known without ECG and echocardiog- vided and even more important unequal access to raphy equipment and an appropriate laboratory health care [11 ]. The disparity in access occurs for 16 Cardiothoracic Anesthesia and Intensive Care… 221 a variety of reasons such as a lack of universal be of interest to all health care practitioners. social security system as in India and China or a Health care professionals universally face the marked urban–rural quality of life disparity as in changing landscape created by the global eco- South Africa and Brazil. Lack of health insurance nomic crisis and can subsequently implement providers in countries like India and China is also these measures in their home country. a primary cause of unaffordability in treating cardiac surgical cases [12 ]. Still many hospitals and Other Middle-Income Countries: university centers in BRICS nations may provide The Target Group? advanced medical care including advanced car- At the lower end of the MIC group, are the coun- diac surgery at a standard of care comparable to tries that have less immediate economic potential that offered in so-called developed nations. The or are lagging behind in development as com- case mix is different from what may be seen in the pared to these BRICS countries. Very probably developed countries with a substantial proportion realpolitik will drive the majority of cardiac surgi- of valve surgery due the late consequences of cal missions to these countries where primary and rheumatic fever and a much younger population of secondary care is suffi ciently developed to be able CABG patients owing to unhealthy lifestyle and to consider doing cardiac surgery (Fig. 16.2 ). “iceberg phenomenon” of diabetic patients [11 ]. BRICS countries have the personnel and expertise to improve the quality of their cardio- Congenital Cardiac Surgery surgical care and the political potential to improve accessibility, but cooperation between Discussing cardiac surgical disease is incomplete practitioners and institutions in BRICS countries without mentioning congenital cardiac heart dis- and HICs can still be fruitful. For host countries, ease. Structural heart disease affects infants and these partnerships sharpen new techniques and adults in high-, low-, and middle-income coun- improve academic rigor, and the visiting practitio- tries with relatively the same genetic preva- ners profi t from the rewarding teaching and learn- lence—8–12 cases/1,000 live births, with the rate ing experience of helping a growing anesthesiology depending on the method of detection—but the department or cardiac surgical program. Indeed burden of disease falls disproportionately on the the creative and innovative solutions employed by lowest income countries [ 13 – 15 ]. This disparity practitioners and health care systems in BRICS in exists not only because of lower per capita order to invest limited resources effectively will income to support expensive care but because

Fig. 16.2 Peeping through the window of the cardiac OR in Suriname. Suriname is considered an upper middle income country by the World Bank, which means the Academisch Ziekenhuis of Paramaribo, the academic hospital, has suffi cient resources to support a cardiac surgical mission 222 P.M.J. Rosseel and C.L.H. Atcheson higher fertility rates in LICs translate to more minimal level of primary and secondary health cases of congenital heart disease per wage earner care will be necessary in order to be able to [13 ]. Although only a small proportion of cardiac deploy a cardiac surgical development program. surgical care in any setting is provided to infants For more comprehensive review the reader is and children, the effect of treatment can provide referred to an excellent article of Pezzella et al. 20–50 Disability adjusted life years (DALYs) 3 [18 ] In the next section, we discuss the task of per case treated in the population in question assessing capacity, forming partnerships, and [ 16]. Timely detection followed by curative surgi- making goals for a cardiac surgical program. cal treatment may normalize life expectancies as well as improve neurodevelopmental outcomes for a considerable proportion of congenital cardiac Cardiac Surgical Mission Goals malformations as well as cardiac disease due to and Preparation infectious causes [15 , 17 ]. The problem of congenital heart disease must be addressed from Goals and Modalities of a Cardiac several angles with increased attention for mother Surgical Mission and child survival campaigns, improved capacity of medical and diagnostic services, and fi nally When one is choosing to participate in a humani- improved access to cardiac surgical services [6 ]. tarian surgical mission, it is a good idea to think As we discuss below, for successful treatment of about how one’s personal goals and the goals of any cardiac surgical disease—including congeni- the organization align. Especially for a cardiac tal heart disease—several layers of care and capa- surgical mission, the goals of the trip will dictate bility must be in place to detect congenital cardiac the daily activities and responsibilities, which malformations in an early stage, provide timely may range from simply providing the anesthetic treatment, and to propose appropriate follow-up to helping plan the case schedule to providing programs. postoperative ICU care. These can also include teaching a team of local practitioners how to expand their practice to implement the new pro- Summary cedures performed. Defi ned goals of cardiac surgical missions Cardiovascular disease has a huge impact on the may include: global burden of disease, an impact that will con- • Bringing patients with advanced disease from tinue to grow in particular among the populations LMICs to a cardiac surgical center in HIC and of LMICs, who are not only affected by infec- repatriating the patient after recovery. tious cardiac disease, but have an increasing inci- • Performing cardiac surgery and anesthesia in dence of ischemic and degenerative disease. a well-equipped but temporary structure, e.g., Although the largest impact in many countries an empty wing of a hospital. will come from a focus on primary prevention, • Performing cardiac surgery and anesthesia in cardiac surgical care is an indisputable part of a local facility in conjunction with local public health concern. The particular burden of practitioners. disease and capacity to build surgical services • Assisting in setting up or planning a new car- will be different in every country and how that diac surgical facility. should be organized will very much depend on • Providing education for local practitioners, the specifi c context of the country. Typically a residents, fellows, nurses, or perfusionists. Participants should look for programs where the host institution has a voice in the design and 3 See the chapter in this text entitled “Comparative implementation of the program. Reputable pro- Economics of Anesthesia Care and the Global Anesthesia Workforce” for a thorough discussion of the Disability grams will also be recognized by the host country Adjusted Life Year (DALY) measure. Ministry of Health (MoH) and host national 16 Cardiothoracic Anesthesia and Intensive Care… 223

professional associations. Often local or interna- Dr. Castañeda’s work is one of the best exam- tional nongovernmental organizations (NGOs) ples of holistic surgical service capacity building. will play a role in the organization and logistical Since 1997, the Fundación Aldo Castañeda has support. The technical expertise can come from facilitated growth of the Paediatric Cardiac international specialty associations (in anesthesia Surgical Unit of Guatemala, expanding the and surgery). Regardless of who the players on capacity for outpatient consultation, echocar- the ground are, looking for an organization that diography diagnostics, preoperative, intraopera- emphasizes sustainability and self-suffi ciency of tive, and postoperative care of cardiac surgical the host team and training of specialists as patients, and graduate medical education [20 , 21 ]. opposed to substitution of roles will ensure the As of 2012, the Paediatric Cardiac Surgical Unit best experience for the visiting practitioner, host of Guatemala had tripled the number of surgeries institution, and ultimately the population of the performed annually, had become an international host country. referral center for pediatric cardiology, and had begun to train subspecialist physicians in pediatric cardiac anesthesiology, pediatric cardiology, The Premise of a Mission pediatric critical care, and cardiopulmonary perfusion [ 20 ]. Whether it is through “developing a Making Voluntarism Meaningful functioning, independent local effort” [ 19 ] as Dr. and Impactful Castañeda has done in Guatemala and as Surgeons Many authors in this text have spoken out against of Hope® has done in Nicaragua, through ongo- medical tourism in its many forms. That argu- ing collaboration between university departments ment will not be repeated here; however, it is in HICs and LICs, or by a establishing a mean- worth noting that more than any other subspe- ingful, long term education program, enhancing cialty care, the treatment and care of cardiac sur- the ability of local practitioners to safely care gical diseases requires long-term care from a for the needs of their community should be the team of health care providers including: cardiolo- ultimate goal. gists, cardiac surgeons, cardiothoracic anesthesi- The most explicit example of this philosophy ologists, perfusionists, intensivists, operating is described by the organization Children’s room technicians, and last but certainly not least HeartLink® , which was founded by Drs. Frank nurses with experience in the OR, ICU, post- Johnson and Joseph Kaiser cardiovascular sur- anesthesia care unit (PACU), and clinic. geons at Swedish Hospital in Minneapolis, Dr. Aldo Castañeda4 noted in his address to Minnesota. In the early 1990’s, Children’s the World Society for Pediatric and Congenital HeartLink® transitioned from providing care for Heart Surgery (WSPCHS) in Antigua, Guatemala children from LMICs in the USA to partnering in 2010, “occasional visits of traveling teams per- with local hospitals and practitioners. Currently forming a few diagnostic tests, interventions, and Children’s HeartLink® practices a well- delineated operations…will not solve the permanent needs process of local surgical capacity building with its of a cardiac unit in a developing country” [19 ]. sites; during this 6- to 10-year process they call the “Phased Support Approach,” they work with 4 Aldo Casteñeda, MD is a humanitarian and a pediatric sites on three continents to achieve a state where cardiac surgeon of unparalleled achievement who has local practitioners are able not only to perform contributed over 400 scholarly articles and advanced the surgeries with acceptably low complication rates, fi eld of pediatric cardiac surgery in the areas of heart-lung transplantation and neonatal correction of complex car- but to train other practitioners [22 , 23 ]. diac malformations. He is the William E. Ladd Professor The transition from service substitution to Emeritus of Child Surgery at the Children’s Hospital of independence often evolves organically without a Boston. Since his retirement from Harvard Medical well set plan, as in the example of the experience School and the Children’s Hospital of Boston, he has worked as founder and leader of the Fundación Aldo of one of the authors (PR) with the setup of a Casteñado centered in Antigua, Guatemala. cardiac surgery program in Suriname. Until the late 224 P.M.J. Rosseel and C.L.H. Atcheson nineties Suriname cardiac patients were operated opportunity to direct a fully functional cardiac in The Netherlands, through a program which surgical unit in his native country. was fi nanced by the Dutch Government. When this agreement was stopped for political reasons, Partnering for Sustainability one German and three Dutch cardiac surgical Unless the organization’s mission is explicitly departments joined efforts with the Academic dedicated to cardiac surgery—as is the case with Hospital of Paramaribo to organize three to four several organizations mentioned above—local 3-week missions per year. During these missions, nongovernmental organizations (NGOs) often an average of 35 patients were operated upon; have profound knowledge of the local context but these patients were pooled in advance by lack specifi c expertise in cardiac surgery. The Suriname Cardiologists. The effort required to advantage of partnering with local NGOs is that keep up this frequency of missions was chal- the surgical team gains entrée into the community. lenging and required dedicated perseverance in In the experience of the author (PR), the disadvan- particular from a single cardiac surgeon (GJ tage is that local NGOs will be driven by their Kootstra) from Breda, The Netherlands, funding streams, which are tied to achievement of Gradually more coordinated efforts for collabo- short- and medium-term goals with high impact ration and training of cardiac anesthesiologists or great visibility. Partnering with local NGOs and perfusionists were introduced involving three may mean an open time schedule if no interest one-year fellowships in Amphia Hospital, sup- exists in fi nalizing funded project. ported by a grant from the European Association Hospitals have access to all of the supply of Cardiothoracic Anaesthesiologists (EACTA). chains and structural implements for surgical This additional training bolstered the ICU, phar- missions, but administrators often lack knowl- macy, and organization of the cardiac surgical edge of the larger national context as they are mission (Fig. 16.3 ). focused on maintaining private practices, serving Through 10 years of collaboration with the patients in need, and keeping the doors open. Surinam Hospital management and cardiologists, In working with any hospital, one also must deal what started a volunteer-based and externally with the microcosm of personalities and habits fi nanced project ended in a fully independent governing health care business as usual. cardiac surgical department in Suriname fortuitously As successful university collaborations and staffed by a Dutch cardiac surgeon eager for the NGOs such Children’s HeartLink® , Surgeons of

Fig. 16.3 A mixed surgical team at work on a coronary artery bypass graft (CABG). Local OR nurses are harvesting the venous graft while the visiting surgeons prepare the arterial target sites. This is an example of the middle stages of transition from a substitution team to a fully trained local team 16 Cardiothoracic Anesthesia and Intensive Care… 225

Hope® , and Fundación Aldo Castañeda have Table 16.2 WHO Objectives of Safe Surgery demonstrated, the ideal situation may be the Objective hybrid approach of connecting a host hospital 1 Operate on correct patient and site where practitioners are ready to build a program 2 Use anesthetic methods known to prevent harm and with a functional team of practitioners with the treat pain support of an NGO or professional association. 3 Be prepared for airway emergency or respiratory failure The Surinam example shows that this can be 4 Avoid or appropriately treat adverse drug reactions done without an NGO, but considerable effort 5 Recognize and treat large volume blood loss will be need to overcome administrative and 6 Minimize risk of surgical site infections logistical hurdles. 7 Prevent retention of surgical instruments or With all of this in mind, physicians and nurses implements who are inspired to serve need not wait for the 8 Label all specimens correctly ideal situation to act or volunteer on a cardiac 9 Communicate effectively for the exchange of surgical mission—many anesthesiologists have critical information had very fulﬁ lling volunteer experiences in the 10 Establish and participate in routine surveillance at the hospital system level absence of one or more of the conceptual elements described here [ 24 – 26]. No volunteer The WHO Safe Surgery Saves Lives campaign encourages hospitals around the world to use the WHO Safe experience, even a surgical mission, comes with Surgery Saves Lives Checklist (SSLC) to help hospitals the guarantee of success and future productive and practitioners meet these ten basic objectives. academic relationships. Not all sites will become fully functioning independent adult or pediatric heart centers. But in order to help patients, one Donabedian described in 1988 how the quality does need to know that minimum standards of of medical care could be assessed and assured in quality and safety will be met. These standards a three dimensional model [29 ]. He described are discussed in the next section. three criteria that should be addressed to achieve an acceptable level of quality: structure, process and outcome criteria.5 In order to discuss speciﬁ - Cardiac Anesthesia: Providing cally the minimum standards for cardiac anesthe- Optimal Care in Low Resource sia, the Donabedian model will be used. Settings

In 2008, the World Health Organization (WHO) Structure published guidelines identifying multiple recommended worldwide safe surgical practices (see The Regional Context Table 16.2 ) [27 ]. In order to be able to practice The socioeconomic environment will have some any type of surgery in LMICs, these minimum bearing on the type of cardiac surgical care that conditions need to be fulfi lled. In 2010, the World can be provided. Given the nature and the extent Federation of Societies of Anaesthesiologists of the investment needed in cardiac surgery, local (WFSA) updated the existing international stan- cardiologists must have infrastructure in place to dards for a safe practice in anesthesia and corre- be able to identify patients in suffi cient numbers, lated these standards with the three levels of a prepare them for surgery, and support them after hospital structure as defi ned by the WHO [ 28 ]. visiting practitioners leave. Often this will imply Although the WFSA guidelines were created for that a cardiac surgical mission is best planned in anesthesia for non-cardiac surgery, a cardiac an urban area. In particular staff, equipment anesthesia unit or visiting medical team should comply with all grades of suggestions and rec- 5 See the chapter in this text “Quality Care: Maintaining ommendations applicable for a level 3 hospital Safety through Minimum Standards” for an in-depth structure (see Table 16.3 ). discussion. 226 P.M.J. Rosseel and C.L.H. Atcheson

Table 16.3 Standards for infrastructure, supplies, and departments, affi liation with a university or teach- anesthesia at the Referral Hospital Level ing hospital should be actively sought out. It is Level 3 (Should meet at least highly recommended , perhaps out of touch with reality to say that the recommended and suggested anesthesia standards) hospital should be well organized and func- Referral hospital tional—as there are so many hospitals in HICs A referral hospital of 300–1,000 or more beds with basic intensive care facilities. Treatment aims are the same as for that are not—but a thorough check on a secure Level 2, with the addition of: Ventilation in OR and ICU water supply, electricity, medical gasses and Prolonged endotracheal intubation waste management should be performed and Thoracic trauma care confi rmed to comply with minimal standards. 6 Hemodynamic and inotropic treatment An adequate number of qualifi ed medical and Complex neurological and cardiac surgery support staff from the host site should be available Basic ICU patient management and monitoring for up to 1 week : all types of cases, but possibly with limited around the clock. A reliable telecommunication provision for: multi-organ system failure system (within the hospital and outwards) needs Hemodialysis to be in place (Fig. 16.4 ). Prolonged respiratory failure The hospital should offer most major catego- Metabolic care or monitoring ries of specialty care (at minimum cardiology, Essential procedures internal and pulmonary medicine, general sur- Same as Level 2 with the following additions: Facial and intracranial surgery gery and paediatrics). Intensive care staffi ng and Bowel surgery work patterns for monitoring postoperative Pediatric and neonatal surgery patients may be considered adequate by the host Thoracic surgery team, but will not meet standards of care of the Major eye surgery Major gynecological surgery, e.g. vesico-vaginal repair visiting team [26 ]. Specifi c inquiries should be Personnel made to determine if intensivists needs to be Clinical offi cers and specialists in anesthesia and surgery added to the visiting team. Specifi cally for car- Drugs diac surgery, the availability of transesophageal Same as Level 2 with these additions: echocardiography (TEE) machines and probes Propofol and bronchoscopy equipment appropriately sized Nitrous oxide Various modern neuromuscular blocking agents for the surgical population needs to be Various modern inhalation anesthetics determined. Various inotropic agents In an ideal situation, cardiology department Various intravenous antiarrhythmic agents should be fully functional with a qualifi ed staff of Nitroglycerine for infusion Calcium chloride 10 % 10 i.m. injection interventional cardiologists, equipped with a car- Adapted from Merry et al. Can J Anesth/J Can Anesth diac catheterization laboratory and echocardiog- (2010) 57:1027–1034 (Springer) raphy equipment and expertise. A local These are the minimum standards recommended by the cardiologist must be available for postoperative WSFA for anesthesia for complex non-cardiac surgery, care and for emergency interventional proce- including thoracic surgery. The authors suggest these can also be considered as minimum standards for an institu- dures. Ideally, the hospital would have a dedi- tion hosting a cardiac surgical mission cated ICU and cardiac surgical ward with 24/7 nursing staff. If this is not available, provisions requirement and on-site logistical support will must be made so all cardiac surgical patients can necessitate good geographic accessibility (good be hospitalized and monitored preoperatively and roads, proximity to airport). postoperatively. If a ward or a smaller hospital will be repurposed for PACU, ICU, and ward, The Hospital this space should be equipped with ventilators, Cardiac surgery and anesthesia can only be oxygen saturation and invasive blood pressure performed in a qualifi ed hospital structure, preferably a referral hospital. As a cardiac surgical 6 See the chapter in this text “Planning a Mission, project or mission will create a spin-off effect Fundraising, and Building a Team: the Kybele experi- that might benefi t or draw on the resources other ence” for further discussion of site evaluation. 16 Cardiothoracic Anesthesia and Intensive Care… 227

Fig. 16.4 Even with a thorough site evaluation, one must always be ready for the unexpected change in the infrastructure. Here, for example, the whole team transports a patient—stretcher and all—one ﬂ oor downstairs from the OR to the ICU because the electricity and therefore the elevator had gone out

monitoring, a telemetry system, a central oxygen list should only contain drugs that have proven supply system, medical air and vacuum pipeline evidence-based effi cacy. It is tempting to import system for connecting suction drainage systems. an entire pharmacopeia to provide “optimal care,” but in the setting of global health, optimal Laboratory and Imaging Services care is the care that will be available when the A well-staffed laboratory that can perform chem- team leaves, so some consideration should be istry, hematology, and hemostasis tests will be given to using and training local providers to use needed providing service around the clock. the drugs most readily available. Substituting an accurate Point of Care (POC) laboratory unit for hemoglobin, glucose, blood gases Transfusion and Blood banking with electrolytes, and/or dynamic hemostasis may The Society of Thoracic Surgery (STS) identifi ed prove to be effective and effi cient. Radiology ser- three groups of patients who are at increased risk vices need to be available on a daily basis for of perioperative bleeding and transfusion during diagnostics [30 –32 ]. cardiac surgery: patients of advanced age, patients with small blood volume due to small Pharmacy Services body size, and patients having emergent or com- The local pharmacy should dispense a regular, plex operations [34 ]. Practitioners are unlikely to secure supply of essential drugs contained in encounter patients of advanced age or to under- WHO Model List of Essential Medicines for take emergent or redo procedures in a global adults or children, whichever is appropriate for health setting. Thus, aiming for a low transfusion the surgical population [33 ]. The surgical and exposure should be a primary objective of every anesthesia team can agree that a few drugs not on cardiac surgical program. the WHO lists need to be brought from the home The local blood bank should be able to guaran- institution or purchased in-country, e.g., different tee a secure supply of properly tested blood prod- synthetic opioids, subcutaneous heparin prepara- ucts according to the 2010 recommendations by tion for venous thromboembolism (VTE) pro- the WHO (Screening donated blood for trans- phylaxis, milrinone, phenylephrine, sevofl urane, fusion transmissible infections (TTI) [ 35 ]. This and hemostatic agents (protamine, antifi brinolytics, document describes universal and country- specifi c desmopressin) [24 – 26]. This expanded pharmacy requirement for screening. Blood products that 228 P.M.J. Rosseel and C.L.H. Atcheson should be available are packed cells (all blood advantages in a setting when electricity is not a groups), fresh frozen plasma (FFP), thrombocyte guarantee. Early extubation and “fast-track” pro- concentrate (TC) and maybe cryoprecipitate. grams have been implemented in LMICs where Component therapy—with a growing body of they were associated with decreased morbidity evidence—may be an effective solution to and mortality and should be implemented if pos- decrease the dependency on FFP and TC but sible (Fig. 16.5 ) [39 , 40 ]. probably depend on import [36 ]. With a growing For postoperative intensive care, one must arsenal of equipment required to maintain blood check the number and availability of up-to-date component therapy, a maintenance department bedside monitoring equipment including: two with qualifi ed biomedical engineers will be selectable ECG channels (fi ve lead system), needed by the hospital. invasive pressure monitoring (two channels), pulse oximetry, capnography (side stream or Intensive Care and Monitoring main stream). In addition, number and mainte- The staffi ng and capacity of host facility to pro- nance of artifi cial ventilators able to provide dif- vide intensive care may be variable, and even if ferent modes of ventilation (Volume and pressure intensive care services are readily available, the control and pressure support) should be deter- host institution may not have capacity to expand mined. Defi brillators, enteral and parenteral to accommodate the increase in volume from a nutrition should be routinely available. Dialysis week of cardiac surgery. Consideration should either intermittent or continuous hemofi ltration be given to including one or two intensivists (CVVH) should be available either as an in hos- and up to four critical care nurses with experi- pital use service or in agreement with a nearby ence caring for the surgical population on the dialysis centre. visiting team [ 24 , 25 ]. The extent of the requirement for postoperative ventilator support must The Operating Room and Extracorporeal not be overestimated. Mechanical ventilation has Circulation both indications and risks [37 , 38]. Most cardiac An equipped and functional OR including a anesthesiologists would prefer to ventilate their sterilization unit is a mainstay, and the function- patients for a few hours postoperatively but car- ality and reliability of electricity, OR table, lights, diac anesthesia can be performed with extuba- and climate control should be discussed. Specifi c tion in the OR, and this can have considerable equipment should consist of diathermy devices,

Fig. 16.5 The resources required for proper postoperative management and monitoring are substantial. Here the patient is mechanically ventilated, but “fast-track” anesthesia, which aims at extubation in the OR or in the immediate postoperative period is the goal in a global health setting 16 Cardiothoracic Anesthesia and Intensive Care… 229

OR tables, and a method of charting. Particular care should be given to the presence of a few sets of cardio-surgical instruments and disposables. At minimum, two identical cardiopulmonary bypass (CPB) machines for extracorporeal circulation (ECC)—one for use and one to serve for spare parts are essential, along with a suffi - cient supply of ECC circuit sets and disposables. A CellSaver ® for red cell salvage and autotrans- fusion, if available, will be of paramount importance. Historically the CPB unit was known as the Heart-Lung Machine (HLM) and is colloquially known as a “pump.” CPB has become safer and better controlled than ever, but with the incorporation of sophisticated electronics, it is particularly vulnerable in the context of LMICs. Biocompatible and prepacked sterilized low volume circuits including membrane oxygenators have rendered bubble oxygenators and blood priming obsolete, but machines with these features may still be in operation in LMICs Fig. 16.6 A simple but functional extracorporeal circula- (Fig. 16.6 ). tion (ECC) cardiopulmonary bypass machine run by a Monitoring for cardiothoracic surgery has local perfusionist in use during a coronary artery bypass evolved a great deal from the age of simple moni- grafting surgery toring to the advent and use of very invasive monitors and now a return to simplicity courtesy of technology. In addition to the standard monitors Newer and simpler noninvasive monitoring enumerated above, transesophageal echocardiog- concepts are being proposed and although their raphy (TOE) should be available. Mandatory pul- benefi ts are not proven yet may appear as inter- monary artery catheterization and measurement esting concepts in particular in low resource of cardiac output by thermodilution has been settings. Near-infrared spectroscopy (NIRS) abandoned in routine practice as benefi ts have monitoring may prove to become a reliable trend failed to be proven [41 , 42 ]. TOE is a superior monitor of cardiac output and mixed venous O2 monitor, providing more information and more saturation and may provide additional (limited) insight than pulmonary artery catheterization. information on brain saturation [43 , 44 ]. At this TOE equipment and profi cient use of it at an stage, disposables are expensive, and without a advanced level is essential in every cardiac surgi- strong industry partnership, are likely not yet cal program, but the purchase and maintenance practical in the global health setting. However, of TOE machines and probes may prove chal- one author (PR) has experience safely reusing lenging for the host institution. Visiting providers NIRS disposables; single use sensors provided may have access to probes in the host facility, but though by the manufacturer can be adhered to the maintenance and sterilization should be dis- forehead of several patients until the transducer cussed prior to arrival. If well-maintained equip- fi nally becomes defective. ment will not be available, vendors from the It is always best to use local equipment when home institution may be a good source of probes possible. The anesthesia machine should be a or equipment for loan and use during the surgical “modern” ventilator (different ventilations modes mission [ 24 ]. with PEEP and variable bypass vaporizers for, in 230 P.M.J. Rosseel and C.L.H. Atcheson order of increasing preference: halothane, isofl urane, Supplies: Assuring a Secure Logistical or sevofl urane). The availability of syringe and System infusion volumetric pumps should be in suffi - The diffi cult logistics of securing a reliable supply cient quantity and thoroughly checked. Two to chain for disposables and drugs is a conditio sine fi ve syringe pumps will be needed per OR. Again, qua non of a cardiac surgical mission. In devel- vendors from the home institution may prove to oped countries there is a whole system in place be helpful in obtaining donation or loan of such assuring used to well-functioning supply systems durable medical equipment. Temporary pace- in the hospitals and even if a shortage or stock makers and a defi brillator with internal pads will rupture occurs we can easily fall back on a reli- complete the list of essential equipment. One able commercial and industrial network. In the may discuss with the team the necessity of hav- LMIC countries such a backup network system is ing an intra-aortic balloon pump in the light of often lacking or not reliable. Furthermore, for lack of evidence, but in the likely absence of cardiac surgery, anesthesia, and intensive care, ECMO outside the OR, most cardiac anaesthesi- specifi c drugs and equipment are needed (valve ologist and surgeons would feel more comfort- implants, catheters, extracorporeal circuits) for able with having IABP at hand. which there is no other local market. Because of spatial and fi nancial impacts of Personnel: The Anesthesia Department maintaining high stocks and the potential for and the Cardiac Surgical Team diversion of supplies the common HIC practice Again the framework set forth by the 2010 of “having it available” is not practical. Creativity WFSA international standards for a safe practice and fl exibility will need to be employed with in anesthesia, though designed for anesthesia for respect to materials and supplies. Budgeting for non-cardiac surgery, is an excellent lens through and using the disposables from within the local which to evaluate the status of the host anesthe- hospital will strengthen the supply chain within sia department. In order to offer cardiac services, the host country. In the event that specifi c and a cardiac surgical unit should at least comply essential items are not available, they will need to with all recommendations for a level 3 hospital be secured from outside sources or imported structure [28 ]. prior to arrival. Supply and back up should be In the early stages of a mission, the cardiac secured. Expiration dates and shipping will need surgical team will be fl own in from abroad. to be taken into account [24 ]. The team should be carefully selected and con- Bringing in equipment and leaving it in the local sist of qualifi ed and experienced staff: at least one structure is a delicate proposition. Equipment from cardiovascular surgeon, one cardiac anaesthesi- the home hospital must work under the conditions ologist with one cardiac anesthesia resident or in the local hospital, it must be reliable and well nurse, one or two cardiac surgical scrub nurses or maintained equipment; and it must be delivered technicians, and between three and four nurses with essential spare parts. In donation, uniformity with critical care training experienced with the is the golden rule, and different types or brands of cardiac surgical population. This personnel is in equipment should be avoided. The equipment and addition to any needs for critical care physicians, monitors used in HICs is increasingly digital which critical care nurses, or cardiologists from the makes it more sophisticated, fragile and expensive local hospital required for safe preoperative and to maintain. Older equipment, such as that often postoperative care. The staffi ng will depend heav- found in BRICS countries, may have a more robust ily on the experience and comfort level of the host and suitable construction. practitioners, with staffi ng on the higher side for The process for obtaining the vast array of the initial visit of a paediatric cardiac surgical drugs and disposables for surgery, anesthesia and mission [24 –26 ]. perfusion begins with maintaining a detailed 16 Cardiothoracic Anesthesia and Intensive Care… 231

Table 16.4 Adopting the KISS principle a source of infection in regular hospitals. There Home institution Local project exists no international standard for disposal and Ventilators Sophisticated, Local brand, search there is a dire need of infectious waste disposal digital outside Europe or management. There is a trend for disposal of USA medical wastes in landfi lled sites which requires Opioids Remifentanil, Morphine sulphate strict quality control from the local health author- sufentanil Anesthetics Sevofl urane Halothane, ities and local health department [12 ]. isofl urane Pulmonary Different brands Skip, use NIRS, dilution catheters TOE Processes Intravascular 3–4 channels 1–2 channels pressure The processes include all medical and adminis- monitoring trative tasks performed during the cardiac surgi- Mixed venous Lab NIRS saturation cal mission. It involves the medical and surgical Classical APTT, PTT, Dynamic POC care from the preoperative period to the patient’s coagulation tests INR, fi brinogen coagulation testing discharge and recovery. Guidelines are readily Practitioners working in a global health setting will benefi t available, and evidence based care should prevail from applying the KISS (Keep It Simple Stupid) organiza- above personal convictions. The processes of tional principle to their pre-trip planning and in-country care are often presented or enumerated in written activities documents, usually called policies. Each policy should aim at providing effective surgical care, inventory and fi nding a reliable source for each where, as the adage goes “better” can be the item. Then the whole logistic chain from pur- enemy of good.” The challenge in global health is chase (often abroad) through use and disposal not only to respect the host practitioners’ opin- must be monitored and assured. The KISS prin- ions but to actually adapt to the local conditions. ciple (“Keep It Simple, Stupid”) should prevail at Visiting practitioners may feel secure in their all time. Some examples are given in Table 16.4 . own habits, and it is tempting for the visiting Securing a supply line offers some control of or team to impose their own ways, techniques, preparedness for fi nancial and administrative equipment and drugs. However, it is a sign of true hurdles that will inevitably come with planning a professionalism to respect the local perspective, cardiac surgical mission. help the host team to adapt evidence based rec- The FDA accepts the reuse of medical devices ommendations to local conditions (such as local and disposables under strict conditions [45 ]. In medication availability), and be prepared to learn August 2000, FDA released a guidance document new techniques in the process. on single-use devices reprocessed by third parties A major problem may arise when different or hospitals. In this guidance document, FDA host teams are involved who all might try to states that hospitals or third-party re-processors impose their particular habits (and drugs and will be considered “manufacturers” and regulated equipment). It is in the interest of the program to in the same manner [ 45 , 46 ]. Thus, reprocessing search for a modus vivendi to which all teams of medical equipment is possible but is a signifi - commit. cant undertaking that is probably outside the abilities of a single mission team. For a thorough Surgical Planning discussion, see the chapter on “Materials The determination of surgical indications differs Management” within this book. little in a low resource setting from the high resource Sorting and salvage of waste material is an setting of the home institution. The difference is in easily overlooked aspect of logistics. Though it the risk-benefi t analysis because the team must can be reliable in state-of-the-art hospitals, in determine if the risks within the local conditions LMIC countries appropriate waste disposal can be outweighed the benefi ts of the surgical intervention. 232 P.M.J. Rosseel and C.L.H. Atcheson

Fig. 16.7 A multidisciplinary case conference with representatives from all specialties and professions held prior to and after arrival in-country will help provide the most rational plan for the operating room

These are diffi cult decisions that are best made as cardiac events (MACE) occur after coronary a group. artery bypass grafting (CABG) than after percu- Many practitioners have described the value taneous coronary intervention (PCI) among of a multidisciplinary conference in operative American and European patients with three ves- planning for humanitarian surgery, especially for sel coronary artery disease [47 ]. However, this pediatric cardiac surgery [23 , 24 , 26 , 40 ]. This study has yet to be repeated in BRICS or MICs, multidisciplinary approach includes input from where surgical morbidity and mortality may be practitioners from cardiothoracic anesthesiology, higher than with percutaneous interventions. cardiac surgery, cardiology, critical care, nursing, In addition, CABG performed without ECC (a so and perfusionists who have access to the patient’s called “off pump” procedure) may be preferable history, imaging, testing, and context from the over a CABG with ECC (an “on pump” proce- primary care physician (see Fig. 16.7 ) [23 – 25 , dure) and may be particularly suited to the con- 40]. In global health, the proposed surgery will text in BRICS and MICs [48 ]. As another succeed or fail based not on technical skill or example, though recent data suggests there is no perioperative care but on issues like family situa- difference in outcome between mitral valvulo- tion, housing, and working environment, and plasty and mitral valve replacement [ 49], in the economic constraints. For example, a patient may global health context valvuloplasty may be the be an excellent candidate for valve replacement, preferable option in particular if there is no atrial but lifelong anticoagulant therapy might not be fi brillation as lifelong anticoagulation may be tenable for the patient who lives in a remote area. avoided. In the pediatric surgical population, Safety should prevail and alternatives offered. though a patient might benefi t hemodynamically Surgical technique will be meticulous and from a Fontan procedure, if there are no cardiolo- should aim at the safest global outcome. This gists in the country capable of medically manag- might mean that at times a simpler intervention ing such a patient postoperatively, it is not the best may prove “better” than the “best” or most com- operation [24 ]. plete treatment. Complications like the require- In order to provide evidence based surgical care ment for a permanent pacemaker or coagulopathy in a low resource setting, each individual practitio- from a long bypass time may jeopardize the ner on the surgical team must exercise not only global success for a given patient. good, experienced and individualized clinical In adult cardiac surgery, the SYNTAX trial judgment but a holistic approach to applying the has clearly shown that fewer major adverse evidence and making the surgical plan. 16 Cardiothoracic Anesthesia and Intensive Care… 233

Fig. 16.8 A novel use for a transoesophageal echo (TOE) probe cover keeps the mood light in the OR. TOE is an essential function of the cardiac anesthesiologist in all settings

Embracing Advances in Cardiac The indications and uses for (TOE) is constantly Anesthesia evolving and expanding, and these guidelines are Currently, progress in cardiac anesthesia by the well described elsewhere [55 ]. Many professional refi nement of anaesthetic techniques from deep anaesthesiology associations like the Society for anesthesia to high dose opioids and progressing Cardiovascular Anesthesiology (SCA), European to a balanced anaesthetic technique is not too dif- Association of Cardiothoracic Anaesthesiologists ferent from anesthesia for non-cardiac surgery. (EACTA) and the Asian Society of Cardiothoracic Fast-track anesthesia techniques can—depending Anesthesia (ASCA) offer certifi ed training pro- on the study—include utilization of a balanced grams at beginner, advanced and expert levels. anesthesia technique with short-acting opioid, One study of implementation of TOE in a early extubation in the OR or ICU, and rapid nor- low- resource setting concluded that the major malization of the patient with early mobilization challenges were “(1) limited availability of and removal of lines and tubes [40 , 50 – 52 ]. equipment and trained personnel in either the Meta-analysis has shown decreased complica- public or private facilities in the region (2) tion rates and larger retrospective studies have restricted movement of skilled manpower in the shown effi cacious resources (reduced duration of region to support enhanced service delivery and postoperative ventilation or decreased length of (3), low level of awareness of providers and stays in ICU and hospital) [53 ]. It is tempting to patients of the clinical utility of this procedure” attribute the merits of fast track anesthesia to the [56 ]. Beginning or enhancing a program for TOE use of ultrashort acting opioids, anaesthetics with in the host country is an excellent opportunity for speedy pharmacokinetics, and increasing avail- the visiting anaesthesiologist to work with local ability of intermediate-acting muscle relaxants, practitioners on this essential skill. though fast-track anesthesia can be provided with older pharmacologic agents [40 , 50 ]. Longer act- Patient Blood Management Programs ing and much cheaper drugs have been used suc- Patient Blood Management Programs (PBMP) cessfully (e.g. morphine or fentanyl, halothane or contributed substantially to the progress in car- isofl urane and pancuronium) [54 ]. diac anesthesia and surgery. Cardiac surgery An essential diagnostic skill for the cardiac used to consume an important fraction of blood anesthesiologists is transesophageal echocar- usage in developed countries. Nevertheless, the diography (TOE) monitoring (see Fig. 16.8 ). benefi ts of transfusion have not borne out in the 234 P.M.J. Rosseel and C.L.H. Atcheson evidence, while the data surrounding transfu- only rarely be necessary to optimize preoperative sion-related morbidity and mortality is accumu- hemoglobin. lating [57 , 58 ]. PBMP have proven to Intraoperatively, tranexamic acid and desmo- substantially decrease transfusion requirements, pressin, which are on the WHO Essential and have contributed to the safety and cost effec- Medications list, may be more available in LMIC tiveness of both adult or congenital cardiac sur- cardiac surgical units; this is less the case for gery [ 59]. This result was achieved without an fi brinogen and factor concentrates (prothrombin increase in morbidity and mortality and with a complex) [ 62]. Still many cardiac anesthesiolo- decreased cost on top, both being important rea- gist will be glad to have this at hand, especially sons to make PBMP a high priority of any cardiac with an insecure supply of platelets and fresh surgical unit. Modern patient blood management frozen plasma. If available, the use of a is focuses upon three axes: (1) optimizing the CellSaver ® as standard technique of a cardio- patient’s preoperative condition in particular surgical program, its absence resulting in a sub- hemoglobin and coagulation, (2) minimizing stantial increase in consumption of transfusion hemodilution, blood loss, and transfusion, and products [ 34, 63 ]. The surgical and anaesthetic (3) maximizing blood salvage. The evidence technique should be judiciously used as unre- based guidelines for blood conservation are well stricted use of cell salvage will result in a deple- summarized elsewhere [34 ]. tion of coagulation factors and platelets with a Having an appropriate algorithm for preopera- likely increase in blood loss. A Cell Saver ® will tive patient optimization, appropriate transfusion need disposable components but the reservoir of indications, minimizing blood loss, blood recu- the ECC circuit may be used for a dual purpose peration (red cell salvage), and point of care (POC) if appropriately adapted. dynamic coagulation are essential for a successful PBPM. If possible, POC testing should be imple- Perfusion Medicine mented as it provides considerable advantages Some would say cardiac surgery cannot be per- above the classical coagulation tests [34 ]. formed without a cardiopulmonary bypass (CPB) For a surgical mission, a blood conservation machine for extracorporeal circulation (ECC), policy can be agreed upon by the anesthesia and but in reality, these surgeries cannot be performed surgical team prior to travel. Efforts for blood without the services of a perfusionist. The safety conservation are an excellent opportunity to work and quality of ECC has improved dramatically with local practitioners to achieve a common over the last two decades because of rapid tech- goal, especially in the area of patient preparation. nologic developments, academic research into The prevalence of anaemia in LMICs is very the science of ECC, and the professionalization high—perhaps 30 % in some areas, and patients of perfusion medicine. with anaemia have a higher rate of requiring Perfusionists have a variety of professional transfusion during cardiac surgery [34 , 60 ]. backgrounds from paramedical training (nurs- Furthermore preoperative anemia signifi cantly ing, lab technicians), to a dedicated three-year contributes to postoperative morbidity [61 ]. postgraduate degree in perfusion medicine, to Collaborative effort will be required to identify medical school and anaesthesiology residency patients that are at risk, to provide goal-directed (as in France and in Poland). In most European treatment with vitamin K for an abnormal coagula- countries training of perfusionist is nationally tion profi le and/or iron supplementation for anemia regulated. National training institutes can apply in the weeks prior to surgery, to monitor for and for certifi cation on a European level by the treat any infectious aetiologies, and to assure European Board of Clinical Perfusionists that patients are monitored while discontinuing (EBCP). At this moment the EBCP applies with antiplatelet drugs preoperatively. Erythropoietin may the European Commission for recognition as a 16 Cardiothoracic Anesthesia and Intensive Care… 235

of the location or nomenclature of the facility where this care will be provided. The main objectives of this phase of care are to monitor, assure optimal hemodynamic stability, prevent complications (especially bleeding and coagulation disturbances), and facilitate an advantageous and quick return to the surgical ward and eventually home. Dynamic coagulation testing may be useful but coagulation test disturbances without bleeding should not be treated. Lactate measurements, NIRS and TOE may be useful techniques to respectively monitor hemodynamics. The Fig. 16.9 Local and visiting perfusionists work together to prime the ECC circuit for the next case. Perfusionists importance of early recovery and weaning of from different backgrounds will have different education controlled ventilation cannot be over stated as and training awake and alert patients provide excellent clinical clues to evaluate their hemodynamic and respiration. More over the needs for ﬂ uid load- separate specialty with its own requirements and ing and vasoactive drugs will be greatly reduced responsibilities (Fig. 16.9 ). in the awake and pain free patient as compared Whatever her/his background, the perfusionist to the sedated and artiﬁ cially ventilated patient will need to combine knowledge and understand- (Fig. 16.10 ). ing of the physics and physiology of ECC and a Complications of cardiac surgery will put wide array of technical skills to assure the ECC additional stress on the capability and capacity of machine is functioning and interfacing well with an ICU. Peri-operative myocardial infarction, human circulation and respiration. At times, the dysrhythmias, kidney disturbances or renal fail- perfusionist must recommend the appropriate ure, and respiratory complications may require cannulas to the surgeon, manage the CellSaver ® additional diagnostic and therapeutic interven- for blood conservation, perform point of care tions like heart catheterization, bronchoscopy, dynamic hemostatic testing, and assist with trans- hemodialysis or CVVH, and pleural drainage. fusion management. S/he will monitor the ECC Any cardiac surgical program needs to be capa- including going on and coming off bypass and ble of handling these challenges. One of the intervene if necessary in close collaboration with greatest opportunities of a cardiac surgical pro- cardiac anaesthesiologist and surgeon. Likewise, gram occurs in the relationship between the host- the cardiac anaesthesiologist should have a thor- ing team and the local critical care teams, which ough understanding of ECC because s/he is the can have a positive effect on the local ICU. physician ultimately responsible for maintaining oxygen delivery and homeostasis. Particular attention should be given to assure that the Outcome and Quality Control patient’s temperature is normal at the end of surgery, as hypothermia causes and exacerbates Every cardiac surgical program should monitor its coagulation abnormalities and increases postop- results and clinical statistics should be proactively erative morbidity. registered, monitored and analyzed and lead to further improvement according the “plan–do–check– Intensive Care and Recovery act or adjust” cycle proposed by Deming [64 ]. Cardiac surgical patients will almost invariably This should follow the Donabedian’s princi- need intensive care postoperatively, irrespective ples. Appropriate indicators for structure, process, 236 P.M.J. Rosseel and C.L.H. Atcheson

Fig. 16.10 A view on the cardiac surgical side of the ICU geneity of equipment, which was a mix of host institution of the University Hospital in Paramaribo (AZP) shows and donated equipment that all patients are awake. Also of note here is the hetero-

and outcome should be identifi ed and registered mediastinitis), transfusion and a description of for preoperative, intraoperative, and postopera- the patient’s condition at discharge. Finally, spe- tive phases. Preoperatively besides the normal cial attention may be needed to assemble data to patient identifi ers gender, age, weight, length, evaluate the fi nancial burden and impact of the preoperative blood count and creatinine, diag- project or mission. nostic descriptive elements should be recorded, and a recognized risk assessment should be used. The EuroSCORE is one of the most universally Conclusion used and best known risk assessment systems and can be found at www.euroSCORE.org ). In conclusion, setting up a cardiac surgical proj- Intraoperatively, data describing surgical technique ect positively impacts a local health care system and relevant processes like duration of clamp time, and population. Very likely a successful cardiac ECC time, use of special techniques, and transfu- surgical and cardiac anesthesiology project will sions given should be registered. result in unanticipated benefi ts to the whole local Postoperatively process indicators as length of hospital. However, it is highly demanding on the stay in intensive care and hospital, use of adju- expertise, fl exibility, and organizational power of vants (IABP, renal replacement therapy) should the visiting practitioners in collaboration with the be assembled together with outcome indicators local hospital and team. This chapter has outlined including crude and risk adjusted mortality, the specifi c clinical and logistic considerations morbidity (including renal failure, myocardial for this type of high yield global health project, infarction, re-intervention, surgical site infection, which are summarized in Table 16.5 . 16 Cardiothoracic Anesthesia and Intensive Care… 237

Table 16.5 Checklist for considerations for a pediatric or adult cardiac surgery humanitarian mission

(continued) 238 P.M.J. Rosseel and C.L.H. Atcheson

Table 16.5 (continued)

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Clifford Gevirtz

allow for simple and dramatic correction of these Introduction abnormalities by moving the pieces back into correct position. Similarly, cystic hygromas are The birth of a child with a facial deformity has a easily correctable with appropriate surgical man- devastating effect on both the child and its family. agement and small hemangiomas can also be In ancient history, such births were regarded as remedied in the LDC setting. warnings from the deities of ill portent. In mod- The anesthesiologist is an essential member ern times, the ability to repair these defects can of the surgical team that can transform these be life changing for both the child and family. children. By deciding who is an appropriate Where before the child might have faced social anesthetic risk, how the airway is to be secured ostracism and very limited prospects, now the during the procedure, maintaining perioperative child can be a fully active and productive mem- homeostasis, and providing adequate postopera- ber of society. tive analgesia, the anesthesiologist facilities the Fabricius and his student, William Harvey, surgical repair and screens out problems before spent countless hours dissecting fetuses and still- they arise. births, in which they observed the various stages In working in LDCs, a key principle is to of cleft lip and palate development. Using these avoid any complication that might require an observations, they developed the concept of increase in the level of care required, e.g., where arrested development. From these early observa- in developed countries, a patient might be tions, a more sophisticated understanding of the admitted to the ICU out of an abundance of cau- migration of fetal tissue and of the role of apop- tion; in the LDCs, such care might not exist or tosis has emerged. Using the knowledge of may slow the production rate of the entire team embryology, it was recognized that all of the by occupying a recovery room bed for an essential tissue for repair is present, but it is out extended period of time. The anesthesiologist of place. Advances in plastic surgical technique must be on guard for patients who are not optimized. For example, in the developed world, a patient with profound anemia would be submitted to surgery knowing that there was a com- C. Gevirtz , M.D., M.P.H. (*) plete blood bank available to support the care of Department of Anesthesiology , LSU Health Sciences Center , New Orleans , LA , USA the child. In the LDCs, the only option may be e-mail: [email protected] direct person to person transfusion, an option Somnia, Inc. , New Rochelle , NY , USA not to be undertaken lightly.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 243 DOI 10.1007/978-3-319-09423-6_17, © Springer International Publishing Switzerland 2015 244 C. Gevirtz

disease, diaphragmatic defect, inguinal hernia, Nomenclature and Meckel’s diverticulum 5. Cri du chat syndrome—microcephaly, micro- The nomenclature of congenital abnormalities gnathia, cleft palate, antimongoloid palpebral has relevance in that specifi ed diagnosis may sig- fi ssures, and strabismus. nal other associated abnormalities of anesthetic 6. Fraser’s syndrome—middle ear malformation, signifi cance. Useful terminology: defects in the ear pinna, cleft palate, laryngeal Malformation—a primary structural defect which deformities, and renal abnormalities. results from a localized error of morphogene- A cleft lip is defi ned as any defect in fusion sis, e.g., isolated cleft palate or cleft lip. that occurs anterior to the incisive foramen. This Anomalad —a malformation that results in subse- point can be easily located in the adult as a small quent morphologic changes, e.g., The Pierre depression in the anterior portion of the midline Robin anomalad of micrognathia, a U-shaped of the roof the mouth. A cleft palate refers to cleft palate, and glossoptosis. The proximate any defect from this point posteriorly. Thus a cause is the hypoplastic mandible which cleft lip may be anything from a minor incom- causes the tongue to occupy a higher position plete skin cleft to a complete interruption of the in the oropharynx which in turn leads to a fail- skin, gingiva, alveolar ridge, and part of the pri- ure of the palate to fuse in the midline. mary palate. Syndrome—a pattern of malformation arising from a common etiology, but resulting in more than one region being affected, e.g., trisomy 19. Epidemiology of Clefts Association —the occurrence of two or more morphologic patterns together with a fre- Cleft lip and palate is the most common congeni- quency greater than would be predicted by tal craniofacial anomaly and the fourth most chance, e.g., The VATER association: verte- common birth defect after congenital heart defor- bral defect, anal atresia, tracheoesophageal mities, spina bifi da, and limb deformities. In the fi stula, renal dysplasia. United States, cleft palate alone has a prevalence A child with any lesion more complex than a of 6.35 per 10,000. Cleft lip with or without cleft malformation should probably not be operated palate occurs in 10.63 per 10,000 [ 1 ]. There are on-site in an LDC. Evaluation and consideration distinct differences in the occurrence of cleft lip of transporting the child back to the more devel- and/or palate between various ethnicities, with an oped world where complex care is available are incidence of 1 in 1,000 live births in Caucasians, indicated. While it is disheartening to have to 3.6 in 1,000 in Native Americans, 2.1 in 1,000 in pass on diffi cult cases, such challenges can lead Japanese, and only 0.3 in 1,000 in African to catastrophes if undertaken without necessary Americans. The overall incidence of isolated sophisticated backup. cleft palate is 1 in 1,500 live births and shows no Examples of syndrome which are best oper- ethnic variation. ated in developed countries include: Two thirds of orofacial clefting involve the lip 1. Pierre Robin anomalad—micrognathia, cleft and/or palate, and nearly one third involve the palate, and glossoptosis palate alone. The majority of cleft lip and/or pal- 2. Merkel-Gruber syndrome—microcephaly, ate cases are unilateral (80 %), and are more cleft palate, cleft tongue and epiglottis, micro- common on the left side. Midline clefts of the gnathia, congenital heart disease, and renal nose and/or lip are rare deformities. Isolated cleft abnormalities palate occurs twice as often in females, while 3. Oral-facial-digital syndrome—micrognathia, cleft lip with or without a cleft palate occurs hypoplasia of the nasal alae, cleft lip, cleft more frequently in males. palate, and lobate tongue Tanaka et al. [ 2] studied the number of live 4. Trisomy 18 syndrome—malformed ear pinna, births with cleft lip or other congenital anomalies micrognathia, cleft palate, congenital heart by soliciting data from national and international 17 Anesthesia Considerations for Facial Deformity Repair… 245 organizations covering for American states and that the waste bags will probably be thoroughly 30 countries for the years 2002 to 2006. All data examined and scavenged by the local medical were normalized and reported per 10,000 live community. births. Descriptive statistics, in addition to corre- lation and regression, were used for analysis. Over the 5-year period studied the overall con- Settings Up the Preanesthetic Clinic genital anomaly rate increased in the United States and decreased internationally. The states First, the surgeon must evaluate the child to see if with the highest and lowest rates were Maryland he/she is a suitable candidate for repair and, (21.46 per 10,000) and West Virginia (2.59 per along with a logistics person, assess to see where 10,000), respectively. The United States cleft lip the case can be scheduled. If running a 4 table national rate averaged 7.75 per 10,000. setup (2 OR tables per room), a spreadsheet is Countries with the highest and lowest rates were created which lists the expected duration of sur- Japan (19.05 per 10,000) and South Africa (3.13 gery. The anesthesiologist with the most pediatric per 10,000), respectively. Internationally, the experience should manage the youngest cases. rate of cleft lip declined, with an average overall The duration of the operative schedule should not prevalence of 7.94 per 10,000. The trends exceed the endurance of the team. While the urge diverged over the 5-year period, as the rate was is to book as many cases as possible, the reality is stable in the United States and the international that after 10–12 h, vigilance decreases and risks rate declined. increase. There are other concerns in making the schedule, i.e., the success of the mission may be judged on the total numbers of cases done, and it Preoperative Evaluation is immaterial if there were 16 diffi cult cleft palates rather than 40 cleft lips. Only the total num- When a mission arrives on-site, there are several ber of cases performed counts. Since the duration priorities: of a palate may be two to three times the length of 1. Unpack and set up the anesthesia equipment. a cleft lip, if the case volume is of concern, then As much as possible, the setup needs to be it is defi nitely easier to do cleft lips and/or revi- identical in each anesthetizing location as per- sions than more palates. The adage that younger sonnel may shift or breaks given during the and sicker patients go earlier in the day certainly course of the mission. holds true here. Another consideration is timing 2. Medication stocks may need to be secured the OR carefully so that the children are not each night but it is best to forward-deploy fasted for prolonged periods, although that stocks as much as possible so that the com- should be less of a concern if current recommen- plete disposal inventory is used during the dations to drink clear fl uids up to 2 h before mission and any emergency drugs are read- anesthesia are met. ily available, i.e., it makes no sense to trans- If a pediatrician is available, he/she should be port medications back to the home base. the fi rst to screen for obvious signs of infection ACLS kits for pediatric patients should also while conducting a history and physical exami- be kept within the OR along with any nation. Birth history is a key factor. Those born defi brillators. before 37 weeks gestation, i.e., preterm have an 3. Waste fl ow is a diffi cult issue. In developed increased incidence of perioperative respiratory countries, single-use syringes, IVs, and complications. Many of these babies experience endotracheal tubes are the standard of care. episodes of idiopathic apnea (defi ned as cessation In LDCs, these disposable items are washed of breathing for 20 s or more) until approximately and reused even through there is clearly a risk 60 weeks post-conceptual age and therefore of disease transmission. While missions to require additional monitoring postoperatively. LDCs should adhere to the standards of the These apneic episodes can occur up to 12 h after developed world, it is important to be aware the completion of surgery. Since the resources for 246 C. Gevirtz post-op monitoring may be very limited in the with the use of vasoconstrictors. The decision to LDCs, surgery in premature babies may be prob- proceed requires careful discussion as the blood lematic and therefore best avoided. bank facility may be limited or nonexistent. The degree of maternal–child bonding should The physical examination of the heart must be also be assessed as this may be utilized during the carefully done. The presence of a murmur needs to induction period, i.e., the mother can hold and be discerned and a diagnosis made on-site as there calm the child while a mask induction is per- is often no other consultation or investigations formed. The mother also needs to be questioned available, i.e., no echocardiography or cardiology about feeding problems. In cleft palate cases, the consultation. The most common cleft lip/and or normal separation between food and air is palate-associated cardiac problem is a ventricular absent, resulting in the mixing and deposition of septal defect and less commonly, atrial septal food in the turbinates. This abnormality may defects. Other physical signs such as clubbing or impair nutrition, which in turn affects growth cyanosis may not be present in an infant. and development. The rest of the physical exam should be Dehydration may also be of concern and mani- devoted to looking for other congenital abnormal- fest subtly on physical examination. These chil- ities as up to 10 % of these patients also have a dren often do not suck well and may be relatively second signifi cant defect. dehydrated. In all but the mildest cases, the child should be fl uid repleted before starting the case. Chronic rhinorrhea, which is caused by the Fasting Guidelines for Children cleft palate, needs to be differentiated by history and physical examination from the new onset of The ASA standards for preoperative fasting were an infectious process. If the patient has a new recently updated [3 ]. The European Society of fever, is irritable, and has an elevated white blood Anesthesiologists (ESA) published guidelines [4 ] cell count, rescheduling the case until the process that closely mirror the ASA guidelines albeit with is winding down is judicious. measures of common sense added, e.g., chewing Carefully weighing the patient is important to gum or a cough lozenge is not a reason to cancel assure that accurate dosage calculations can be a case. These guidelines are summarized in made. The overall length and head circumference Table 17.1 . should be measured with the result plotted on It is appropriate to fast from intake of breast standard childhood development curves. Children milk at least 4 h before elective procedures who are below the 10th percentile in weight dem- requiring general anesthesia, regional anesthesia, onstrate signifi cantly delayed development and or sedation/analgesia. the cause needs to be determined prior to surgery. While it is very rare for the anesthesiologist to be the fi rst to recognize a previously unrecognized Preoperative Fasting Status: Infant syndrome in a child, it should be remembered Formula that the anesthesiologist in the LDC setting may be one of the few physicians to actually examine An evidence-based review [3 ] of preoperative the child and issues may have been missed by fasting was published by the ASA. While many other examiners. observational studies have been done, the evidence With respect to laboratory studies, a spun hematocrit is the barest minimum required since these patients are often anemic. If the patient has Table 17.1 A summary of fasting guidelines a hematocrit below 30 %, due consideration has Clear liquids 2 h to be given to the potential blood loss of the Breast milk 4 h proposed procedure. A cleioplasty rarely loses a Infant formula 6 h signifi cant amount of blood while a cleft palate Nonhuman milk 6 h repair can involve signifi cant blood loss even Light meal 6 h 17 Anesthesia Considerations for Facial Deformity Repair… 247 is equivocal regarding the impact of ingesting before elective procedures requiring general infant formula 4 h before a procedure on the risk anesthesia, regional anesthesia, or sedation/ of higher volumes or lower pH levels of gastric analgesia should be maintained. contents during a procedure. The literature is Both the consultants and the vast majority of insuffi cient to evaluate the effect of the timing of ASA members agree that for infants, fasting from ingestion of infant formula and the perioperative the intake of nonhuman milk 6 h or more before incidence of emesis/refl ux or pulmonary aspira- elective procedures requiring general anesthesia, tion. However, the literature suggests that 4 h is a regional anesthesia, or sedation/analgesia should commonly accepted time limit. be maintained. The consultants agree and the A poll of consultants and a large number of ASA members strongly agree that for children ASA members found agreement that for neonates and adults, fasting from the intake of nonhuman and infants, fasting from the intake of infant for- milk 6 h or more before elective procedures mula at least 6 h before elective procedures requiring general anesthesia, regional anesthesia, requiring general anesthesia, regional anesthesia, or sedation/analgesia (i.e., monitored anesthesia or sedation/analgesia should be maintained. care) should be maintained. Similarly, the expert consultants agree and the ASA members strongly agree that for children, fasting from the intake of infant formula at least Premedication 6 h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/anal- The need for premedication varies widely. gesia (i.e., monitored anesthesia care) should be A 6-month-old who is held in the mother’s lap maintained. will not need any premedication for cleioplasty. A 3-year-old who requires a 4th procedure may Preoperative Fasting Status: Solids benefi t from heavy sedation. If prior anesthetic and Nonhuman Milk records are available, (something which larger The evidence-based review also reviewed studies organizations returning to the same site year after with nonrandomized comparative fi ndings for year may have), these should be reviewed. Older children given nonhuman milk 4 h or less before children who can communicate effectively may a procedure compared with children who fasted express a preference for “blowing up the bal- for more than 4 h and found higher gastric vol- loon” or accept “just one shot.” If ketamine is umes and equivocal gastric pH. Another impor- being used as the anesthetic, a benzodiazepine tant study [5 ], which was observational only, and a belladonna alkaloid will minimize intraop- suggested that fasting for more than 8 h may be erative secretions and decrease the risk of postop- associated with hypoglycemia in children. So it is erative delirium. important to closely monitor the OR schedule, to Oral premedication with midazolam (0.5 mg/ avoid prolonged fasts in children. The literature kg p.o.) to a maximum volume of 20 cc is a conve- was found to be insuffi cient to evaluate the effect nient way of sedating an anxious child but it must of the timing of ingestion of solids and nonhuman be emphasized that the child must be carefully milk and the perioperative incidence of emesis or observed and monitored for signs of overdosage refl ux or pulmonary aspiration. during the preoperative period. Polling showed that the expert consultants Friesen et al. [ 6 ] have demonstrated that, at agree and the ASA members strongly agree that least for infants between 1 and 6 months of age, fasting from the intake of a light meal (e.g., toast intramuscular atropine administered within and a clear liquid) 6 h or more before elective 45 min of the procedure is associated with a procedures requiring general anesthesia, regional lower incidence of hypotension as compared with anesthesia, or sedation/analgesia should be main- those unmedicated. Above this age, there was no tained. Both the consultants and ASA members demonstrable effect. strongly agree that fasting from the intake of a A surprisingly large number of children ful- meal that includes fried or fatty foods 8 h or more fi ll the criteria of being at risk for pulmonary 248 C. Gevirtz aspiration of gastric acid (i.e., gastric contents Transfusion in Children with a pH of less than 2.5 and a volume of greater than 0.4 ml/kg). However, pulmonary aspiration While cleioplasty rarely requires transfusion, is an exceedingly rare event in routine pediatric cleft palate repairs can involve signifi cant blood cases and regular administration of histamine-2 loss. Guidance on transfusion in children can blockers, proton pump inhibitors, or metoclo- be inferred from three clinical trials evaluating pramide is not recommended. transfusion triggers. The fi rst trial [8 ] evaluated 100 preterm infants weighing between 500 and 1,300 g. The patients were randomly assigned Timing of Surgery to a restrictive or liberal transfusion algorithm that considered respiratory status and hemato- Closure of the cleft lip (cleioplasty) is usually crit level. Infants in the liberal group received performed at the age of 3 months or when the more RBC transfusions (5.2 ± 4.5 vs. 3.3 ± 2.9) child meets Musgrave’s rule of 10s. Musgrave [7 ] in the restrictive group. Infants in the restrictive reviewed his institution’s considerable experi- group were more likely to have intraparenchy- ence in cleft lip and palate repair. He published a mal brain hemorrhage and frequent apneic simple rule which seemed to avoid many compli- episodes. cations when considering the timing of cleio- The second trial [9 ] enrolled 451 infants with plasty. Indeed, not following any one element of gestational ages less than 31 weeks, ages less the rule increased the risk of serious complica- than 2 days, and weight less than 1,000 g. There tions fi vefold. The rule states the child is ready were no signifi cant differences in outcome. The for cleioplasty when the weight is greater than third trial [ 10 ] recruited 637 children in a pediat- 10 lb (4.5 kg), the hemoglobin is greater than ric ICU, randomly allocated to 7 g/dL or 9.5 g/dL 10 g percent, and the white blood cell count is thresholds. Again, there were no signifi cant dif- less than 10,000 per cubic mm. The combination ferences in outcome. Overall, the results of these of all of these elements seems to insure that the three trials in children suggest that a restrictive child has enough physiologic reserve to survive trigger of 7–8 g/dL is safe. the surgery. While the method of repair and the choice of anesthesia do not predict morbidity or mortality, the absence of infection, adequate oxygen carrying capacity, and suffi cient nutrition to Antibiotic Prophylaxis in Children achieve 10 lb of weight seem to predict an excel- with Coincidental Congenital Heart lent candidate for repair. Disease Cleioplasty during the neonatal period has also been described but is ill advised in the LDC If the decision is made that a child with con- setting. genital heart disease is to undergo cleft palate Soft palate repairs are often conducted repair in the LDC setting, then antibiotic pro- between 12 and 18 months of age while hard pal- phylaxis should be administered. The risk of ate repairs are performed as a series of fl aps start- bacterial endocarditis is a very real possibility, ing after 2 years of age. How many procedures since the oral cavity is heavily populated with are required depends on the size of the defect and pathogens such as Streptococcus viridans and the growth of the child. The goal is to have a Enterococcus species. While the antibiotics are functioning soft palate before the onset of speech. best administered 60 min prior to the start of It should be noted, however, that there is a wide surgery, the guidelines [11 ] suggest that if this is range of opinion about repairs in the neonatal not possible, they may be given up to 2 h after period and many advocate as early a repair as surgery. possible. In the LDC the risks of neonatal repair The current recommendations for prophylaxis appear to rule out its advisability. are shown in Table 17.2 . 17 Anesthesia Considerations for Facial Deformity Repair… 249

Table 17.2 Antibiotic prophylaxis in children with coin- danger lies. The potent inhalation agent is building cident congenital heart disease (adapted from AHA up, while there is no venous access in the child. guidelines) If an agent analyzer is present, watching the end Situation tidal concentration build will signal when it is Able to take oral Amoxicillin 50 mg/kg safe to cannulate a vein. Spontaneous ventilation medication ensures deepening anesthetic levels. Some Unable to take Ampicillin OR 50 mg/kg IM or IV oral medication Cefazolin or 50 mg/kg IM or IV experts suggest self-ventilation to a depth of 2 ceftriaxone MAC and then laryngoscopy without muscle Allergic to Cephalexina,b OR 50 mg/kg relaxation, thus avoiding the use of succinylcho- penicillins or Clindamycin OR 20 mg/kg line or the use of a non-depolarizing agent that ampicillin—oral Azithromycin or 15 mg/kg would need to be reversed. Others suggest using clarithromycin Allergic to Cefazolin or 50 mg/kg IM or IV only a non-depolarizing agent to perform the penicillins or ceftriaxonea OR 20 mg/kg IM or IV intubation, holding succinylcholine in reserve for ampicillin and Clindamycin emergencies. During induction there is an unable to take increased frequency of laryngospasm due to oral medication secretions and frequent upper respiratory tract IM indicates intramuscular, IV intravenous infections experienced by these children. A plan a Or other fi rst- or second-generation oral cephalosporin in equivalent adult or pediatric dosage needs to be in place should the laryngospasm not b Cephalosporins should not be used in an individual with respond to positive pressure. a history of anaphylaxis, angioedema, or urticaria with If an intracardiac shunt has been missed, it penicillins or ampicillin will often manifest itself at this point. Cyanosis in the presence of good breath sounds is the key to diagnosis. A sudden increase in right-to-left Induction and Maintenance shunt may occur when the systemic vascular resistance decreases. Trying to treat the cyanosis If the parent can be enlisted, the child can sit in by increasing frequency and depth of ventilation his/her lap or on the OR table with the parent at is a natural reaction of most anesthesiologists. the side. Upon entering the operating room, a But hyperventilation and increased intrathoracic pulse oximeter probe should be applied fi rst. pressure may worsen the shunt. The treatment of (Although pulse oximeters are not available in choice is to increase the afterload as well as many ORs in LDCs, missions that perform these decrease the inhaled agent. If a shunt has been surgeries are all so equipped.) This unobtrusive missed, the case should be cancelled and further device is usually readily accepted and is often a work-up performed. point of fascination for children as they look at In Fig. 17.1, three blades are illustrated: the their transilluminated fi nger. Induction is usually Robertshaw, the Oxford, and the Seward. These accomplished via mask induction with sevofl u- are designed to minimize the likelihood of having rane or halothane (still commonly available in the upright fl ange of the laryngoscope engaging LDCs). The mask may be fl avored with vanilla, the cleft palate causing injury to the membranes. cherry, orange, or bubble gum extracts which are readily available in Western supermarkets. A few drops applied to the inner surface of the mask Equipment Used for Drawover will greatly increase acceptance by the child. Anesthesia Using a Mapleson D, E or Bain circuit for infants or a circle system for the older child, the mask is In some locations, the anesthesia equipment may gently brought into proximity with the child’s be rather rudimentary based on drawover princi- face with the agent drifting over. As the child ples. These vaporizers work by drawing a carrier loses consciousness, the mask is secured over the gas over a volatile liquid for the purpose of add- nose and mouth. It is at this point where the most ing the vapor from that liquid to the carrier gas. 250 C. Gevirtz

Fig. 17.1 The Robertshaw blade (top ) has a 45° fl ange The goal of each of these designs is to minimize the likeli- which curves back upon itself, The Oxford blade (middle ) hood of engaging the cleft with the fl ange is tubular and the Seward blade has a low profi le fl ange.

This carrier gas/vapor mixture is then directed to potentially hazardous. Also, the cylinders in the patient by a circuit. In drawover systems the LDCs may be mislabeled or not carry medical carrier gas is drawn through the vaporizer either grade gas. Therefore, drawover systems have by the patient’s own respiratory efforts or by a obvious advantages in LDCs. self-infl ating bag or manual bellows with a one- An important consideration is the respiratory way valve placed downstream from the vapor- physiological effects of general anesthesia which izer. Drawover systems operate at less than or at tends to reduce minute ventilation and increase ambient pressure, and fl ow through the system is shunting of blood within the lung (V/Q mis- intermittent, varying with different phases of match). These changes result in hypoxia when inspiration, and ceasing in expiration. A one-way using halothane or isofl urane with spontaneous valve prevents reverse fl ow in the circuit. This ventilation (SV) in air, and supplemental oxygen system differs from conventional plenum (con- is necessary. The problem is reduced, but not tinuous fl ow) anesthesia in which the carrier gas totally abolished, by applying intermittent posi- is sent through the vaporizer at a constant rate. tive pressure ventilation (IPPV). Ether can be In plenum circuits the anesthetic is then collected delivered in air (without supplemental oxygen), in a circuit with a reservoir bag or bellows. in IPPV mode, presumably because it causes less Pressure fl uctuations in the circuit caused by V/Q mismatch, and tends to stimulate ventila- patient respiration do not affect the vaporizer. tion, rather than depress it. When ether is used Plenum systems operate at higher than ambient with just room air and spontaneous respiration, atmospheric pressure. desaturation may occur. Drawover systems are simple to assemble and In drawover systems supplemental oxygen is use, and can operate without fresh gas supplies. administered via a T-piece connection mounted to They are lightweight and portable. Plenum sys- the intake port of the vaporizer. To maximize the tems are much more technically complex, and inspired oxygen concentration a “reservoir tube” need a well-regulated, constant, positive pressure is attached to the T-piece. A 1 m length of corru- gas supply which may not be available in LDCs. gated tubing with an internal volume of 415 ml

They require a sophisticated anesthesia machine allows an FiO 2 of at least 0.3 % at an oxygen ﬂ ow to support them, which in turn needs regular pre- rate of 1.0 L/min, and 60 % at 4 L/min, at normal ventive maintenance. The transport of gas cylin- adult minute ventilation. Oxygen can be given ders for these systems is both expensive and from cylinders, or an oxygen concentrator. 17 Anesthesia Considerations for Facial Deformity Repair… 251

Fig. 17.3 The Oxford Miniature Vaporizer (OMV) in line with an EMO is used in a drawover system to provide anesthesia without requiring a supply of compressed gases. Atmospheric air is used as the main carrier gas and is drawn in by the patient’s inspiratory effort. The OMV may also be used as a stand-alone vaporizer Fig. 17.2 The Epstein-Macintosh-Oxford (EMO) vaporizer is designed to deliver ether in known concentrations irrespective of the temperature of the ether. Used with a bellows, it can deliver the ether in a safe predictable manner chords into view, and routinely using a stylet. Intubation with a straight blade with a low or If ether is used, absolutely NO cautery can be curve fl ange (see Fig. 17.1 ) should be used. Most used nor can there be any open fl ames in the cleft lip and palate repairs are performed using an vicinity. This precludes doing cleft palate repairs oral RAE (Ring-Adair-Elwyn) endotracheal tube. as cautery is a frequent requirement. Cleft lips The RAE tube is a preformed polyvinyl chloride however can usually be done without the need of endotracheal tube with a curve that fi ts easily into cautery. the natural curve of the pharynx. The RAE tube, The EMO (Fig. 17.2 ) and Oxford (Fig. 17.3 ) however, is susceptible to kinking and mucous drawover vaporizers have low internal resistance plugging at the curve. It is very important to reas- to gas fl ow and allow easy spontaneous ventila- sess ventilation after tube fi xation, oral packing tion, while vapor output is fairly constant for a and positioning, and after placement of a given dial setting over a wide range of minute Dingman mouth gag (Figs. 17.4 ). Frequent volumes and ambient temperatures. checking of tube position will quickly alert the Complete operating instructions EMO and practitioner to misplacement, disconnection, or Oxford systems are available online through the kinking. The fi nal position of the child’s head is World Anaesthesia Textbook. hyperextended with 15° of Trendelenburg and often the surgeon may have the head suspended from a Mayo stand by the Dingman mouth gag Common Anesthetic Complications with the occiput almost resting in the surgeon’s lap. At the start of the procedure, the throat is Diffi cult intubations are fairly common in cleft packed by a roll of sponges tied with a long tailed palate patients due to the high arch, but can be suture that will remain outside the mouth (to help managed successfully by the experienced provid- remember to remove the throat pack at the end). ers, careful monitoring of oxygenation and cap- As the throat pack is advanced, the tube may be nography, positioning the patients by use of a pulled along and a mainstem bronchial intubation shoulder roll to produce hyperextension, apply- may occur. Again, frequent checking of the ing external laryngeal pressure to bring the breath sounds is necessary. 252 C. Gevirtz

Fig. 17.4 The Dingman mouth gag in position for cleft palate repair. Note Well: The Endotracheal tube in located within the groove of the lower blade of the mouth gag. If the gag is rotated to gain better purchase on the incisors, the tube may become kinked. Similarly, if the gag is tilted from its normal blade, the endotracheal tube may advance or become kinked. (Reproduced with permission [17 ], Fig. 2 )

The surgeon will place a traction suture (tongue against gravity correlates well with adequate tie) in the infant’s tongue just before extubation. inspiratory strength. After completion of surgery, The ends of the suture are left long and tied in a the patient is transported to the recovery room loop that is easily grasped, providing an effective with the head turned to the side to allow the method of clearing the airway and at the same drainage of any blood or secretions. time providing a strong stimulus to breathe. Using Postoperatively, the most common cause of the tongue tie at the end of the case allows the airway obstruction after extubation is due to fail- anesthesiologist to verify the removal of the ure to remove the throat packing. This cause throat pack and to assess whether the oropharynx should always be considered and ruled out by needs further suctioning which should be care- laryngoscopy if needed. The nursing staff in the fully performed, midline, under direct laryngos- recovery room should be instructed on the use of copy to avoid disrupting the repair. the tongue to aid in airway management. Extubation is performed when the patient is The physiological changes that occur during relatively lightly anesthetized and can generate a anesthesia and surgery do not end immediately negative inspiratory force of −30 cm H2 O or after completion of the procedure. Airway- better. The infant’s ability to raise his/her legs associated complications are frequent during the 17 Anesthesia Considerations for Facial Deformity Repair… 253

fi rst postoperative hour. Desaturation is most Postoperatively the practice is to maintain likely to occur. Few prospective studies exist and the children in lateral or swimmers position to a 5 % rate of immediate upper airway obstruction optimize air movement and to minimize the has been reported [12 ] and occurs in children chances of aspiration. The arm restraints, with associated syndromes because of critical which prevent elbow flexion, keep the child's decrease in size of a previous tenuous airway, hands away from the face to prevent rubbing excessive sedation, and laryngeal edema. at stitches, surgical site, and intravenous access Airway edema may arise since the head is site. placed in extreme extension during palate repairs along with Trendelenburg positioning. These factors combine to increase venous pool- Coagulopathy ing. With surgical manipulation of the airway, marked edema of the oropharynx may occur. In a survey of 223 cleft lip and cleft palate The loose alveolar tissue of the glottis is also cases (16 in India), anemia was seen in 83 % of prone to edema after minor trauma or overhy- cases with a majority being microcytic hypo- dration. If, after extubation, the child demon- chromic and eosinophilia in 25 % of cases. The strates signs of obstruction, namely retractions INR ratio was found to be elevated in 52 % of (suprasternal, subcostal, intercostal), nasal fl ar- cases. While a normal bleeding time was seen ing, inspiratory stridor, and decreased or absent in 70 %, 15.8 % had a prolonged prothrombin breath sounds, direct laryngoscopy should be time. These abnormalities suggest the need for performed. If the cause is not a retained throat backup supplies of vitamin K as well as tubing pack (vide supra), the airway should be exam- and stopcocks for whole blood person to per- ined for signs of edema and the trachea reintu- son transfusion if a bleeding diathesis is bated. Keeping the child in reverse Trendelenburg encountered. position and the administration of dexamethasone (0.5 mg/kg) will be of assistance in reducing the edema. Postoperative Analgesia According to Wood [13 ], children at ages between 44 weeks and 74 weeks after birth have Because opiates are often in short supply, gener- demonstrated greater vulnerability to oxygen ous amounts of local anesthetic are injected as desaturation in the postoperative period. As com- this may be the only postoperative analgesia pared to cleft lip surgery, palate is considered to available. Opiates should be locally sourced as be a high risk for postoperative hypoxemia. transporting narcotics across international bor- Quershi et al. [14 ] have reported hypothermia ders may be considered a severe criminal offense as an important complication found most com- regardless of whether the transporter is a physician monly in children with a bilateral cleft lip repair or that the drugs are destined for children submitted citing prolonged surgery as the cause. However, to surgery. others [12 ] report that hypothermia was not Morphine sulfate, given in 0.025 mg/kg incre- observed as adequate preventative measures can ments intravenously, should provide excellent be undertaken. Another important study [ 15 ] analgesia. Since airway obstruction is a concern, compared local anesthesia (LA) plus clonidine each administration needs to be carefully assessed and LA alone in infraorbital nerve block (IONB). and monitored. Standing orders for analgesia are The study concluded that addition of clonidine not an acceptable approach as the monitoring can as an adjunct to local anesthetic signifi cantly be very sparse on postoperative wards. Ketorolac decreased the requirements for other anesthetic tromethamine (1 mg/kg) i.m. also has been drugs and signifi cantly prolonged the duration used, but there is always concern about the risk of postoperative analgesia without any adverse of bleeding from the cyclooxygenase inhibition effects. effect. 254 C. Gevirtz

Cystic Hygroma is present at birth or appears in the fi rst weeks of life and grows most rapidly over the fi rst 6 months. Cystic hygroma, which originates from embry- Usually, growth is complete and involution has onic lymphoid tissue, is a benign tumor without commenced by 12 months. Half of all infantile potential for malignancy. It is commonly located hemangiomas have completely involuted by age 5, in the neck area. Anesthetic management of a 70 % by age 7, and most of the remainder by age large neck mass may be challenging due to diffi - 12. In more severe cases hemangiomas may leave culty in intubation and the severe hemodynamic residual tissue damage. If medical therapy of pro- effects of surgical removal of a giant tumor. pranolol, steroid injection, laser therapy, and direct Serious consequences such as sudden airway pressure application have failed, then surgical occlusion resulting in hypoventilation and hypox- intervention may be attempted. emia may arise. Patients with peri-orbital hemangiomas and Preoperative evaluation is similar to that of cleft lower lip hemangiomas should be transferred to lip and palate in that any co-existent abnormality facilities where there is an MRI available to assess needs to be detected prior to surgery. The hygroma the full scope of the lesion. These small abnormal- may extend into the mouth and atropine can be ities may be just the tip of the iceberg, i.e., a large used to dry secretions. If the hygroma obstructs the vascular mass may extend back into the depths of airway after induction, a “cannot ventilate, cannot the head and require extensive intervention that is intubate situation” can result, requiring an emer- not appropriate in the LDC setting. gency surgical airway if simple maneuvers like Forehead hemangiomas, especially when placement of an LMA or other supraglottic device located close to the hairline, tend to bleed pro- fail. While video laryngoscopy or fi beroptic fusely, spontaneously. The lesions can be excised scopes may be available on some missions, they through a direct incision. A bicoronal approach may not always be accessible and awakening the provides excellent exposure and allows for wide patient needs to remain an option throughout excision of the lesion with the scar hidden within induction. Partial aspiration of the cyst prior to the hairline. The anesthetic considerations induction may also help. include large bore venous access, the ability to If there is thoracic extension of the hygroma, turn the table 180° and the use of post-procedure then positive airway pressure (PEEP) may be restraints to keep the patient’s hands away from necessary to keep the airway open. However, the face post-procedure. positive pressure may alter the fl ow through Nasal bridge and nasal tip lesions can be the thoracic duct pushing more of the fl uid into excised directly and supplemented with an open the neck. rhinoplasty. If there was significant pre-tracheal involvement, there may be chondromalacia of the tracheal rings causing postoperative respi- Complications ratory obstruction. Extubation in the upright position when the patient is fully awake may Bleeding during the proliferative phase is of con- be beneficial. cern because there is high fl ow and erosions can occur with large amounts of sudden blood loss. Direct pressure can be a temporizing measure until Hemangiomas of the Face surgical intervention can be implemented. Thrombocytopenia can also occur in large heman- A hemangioma is a benign and usually self- giomas with a high fl ow (Kasabach–Merritt phe- involuting tumor of the endothelial cells of the nomenon). Signifi cant thrombocytopenia (less blood vessels and is characterized by increased than 100 K/cc) precludes surgical intervention in number of normal or abnormal vessels. It usually the LDC setting. 17 Anesthesia Considerations for Facial Deformity Repair… 255

6. Friesen RH, Honda AT, Thieme RE. Changes in ante- Conclusion rior fontanel pressure in preterm neonates during tracheal intubation. Anesth Analg. 1987;66:874–8. 7. Musgrave RH. Surgery of nasal deformities associ- The anesthesiologist plays a central role in the ated with cleft lip. Plast Reconstr Surg. repair of deformities of the face, allowing for 1961;28(3):261–75. plastic surgery interventions that could not oth- 8. Bell EF, Strauss RG, Widness JA, et al. Randomized trial of liberal versus restrictive guidelines for red erwise occur. However, a signifi cant portion of blood cell transfusion in preterm infants. Pediatrics. the preanesthetic assessment is determining 2005;115:1685–91. which patient is an acceptable risk and determin- 9. Kirpalani H, Whyte RK, Andersen C, et al. The pre- ing if the patient be managed without the backup mature infants in need of transfusion (PIUNT) study: a randomized, controlled trial of a restrictive (low) of a complete intensive care unit or blood bank. versus liberal (high) transfusion threshold for While this work is immensely satisfying, a key extremely low birth weight infants. J Pediatr. measure of success is the lack of serious compli- 2006;149:301–7. cations. It is that goal upon which we must focus 10. Lacriox J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. our efforts. N Engl J Med. 2007;356:1609–19. 11. Wilson W, Taubert KA, Gewitz M, et al. AHA guideline prevention of infective endocarditis guidelines from the American Heart Association: a guideline References from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease 1. Parker SE, Mai CT, Canfi eld MA, Rickard R, Wang Y, Committee, Council on Cardiovascular Disease in Meyer RE, et al. Updated national birth prevalence the Young, and the Council on Clinical Cardiology, estimates for selected birth defects in the United Council on Cardiovascular Surgery and Anesthesia, States, 2004–2006. Birth Defects Res A Clin Mol and the Quality of Care and Outcomes Research Teratol. 2010;88(12):1008–16. Interdisciplinary Working Group. Circulation. 2. Tanaka SA, Mahabir RC, Jupiter DC, Menezes JM. 2007;116:1736–54. Updating the epidemiology of cleft lip with or without 12. Jindal P, Khurana G, Gupta D, Sharma JP. A retro- cleft palate. Plast Reconstr Surg. 2012;129(3):511e–8. spective analysis of anesthetic experience in 2917 doi: 10.1097/PRS.0b013e3182402dd1 . patients posted for cleft lip and palate repair. Anesth 3. American Society of Anesthesiologists (ASA) Essays Res. 2013;7(3). Committee on Standards and Practice Parameters, 13. Wood FM. Hypoxia: another issue to consider when Jeffrey L. Apfelbaum, M.D. (Chair). Practice guide- timing cleft repair. Ann Plast Surg. 1994;32:15–8. lines for preoperative fasting and the use of pharma- 14. Qureshi FA, Kamran M, Ilyas M, Laiq N. Anesthetist cologic agents to reduce the risk of pulmonary experience for cleft lip and cleft palate repair: a review aspiration: application to healthy patients undergoing of 172 smile train sponsored patients at Hayat Abad elective procedures: an updated report by the medical complex, Peshawar. JPMI. 2011;23(1). American Society of Anesthesiologists Committee 15. Jindal P, Khurana G, Dvivedi S, Sharma JP. Intra and on Standards and Practice Parameters. postoperative outcome of adding clonidine to bupiva- Anesthesiology. 2011;114(3):495–511. doi: 10.1097/ caine in infraorbital nerve block for young children under- ALN.0b013e3181fcbfd9 . going cleft lip surgery. Saudi J Anaesth. 2011;5:289–94. 4. Smith I, Kranke P, Murat I, Smith A, O’Sullivan G, 16. Singhal S, Negi G, Chandra H, et al. Hematological Søreide E, Spies C. Perioperative fasting in adults and parameters in patients of cleft lip and cleft palate with children: guidelines from the European Society of special reference to eosinophil counts. J Craniofac Anaesthesiology. Eur J Anaesthesiol. Surg. 2014;25(1):103–5. doi: 10.1098/SCS.0b013e31 2011;28(8):556–69. 82a2eb3c . 5. van Veen MR, van Hasselt PM, de Sain-van der 17. Asegaonkar B, Kulkarni J, Totla R, et al. Perioperative Velden MG, Verhoeven N, Hofstede FC, de Koning Management of Cleft Palate Repair in a Patient with TJ, Visser G. Metabolic profi les in children during Williams Syndrome: A Case Report. Open J of Anaesth. fasting. Pediatrics. 2011;127(4):e1021–7. 2013;3:57–60 . A Regional Anesthesia Service in a Resource-Limited 18 International Setting: Rwanda

Alberto E. Ardon and Theogene Twagirumugabe

our preoperative interview was also the emergency Introduction room, with only one automated blood pressure cuff and pulse oximeter. Our anesthetic plan con- As a CA-3 resident I was able to participate in a sisted of using a brachial plexus block for surgical 1-month organized educational and clinical mis- anesthesia along with mild sedation. After learn- sion to Rwanda. Anticipating a fair amount of ing that neither the Rwandan anesthesia resident regional anesthesia, including peripheral nerve nor faculty was facile with a nerve- stimulator blockade, my supervising faculty and I had infraclavicular technique, we decided to forego secured the loan of an ultrasound directly from a the ultrasound and use this opportunity to teach manufacturer. After 2 weeks of working in the nerve-stimulator approach. One vial of 0.25 % Rwandan surgical suites, however, we had not bupivacaine was available. performed any peripheral nerve blocks and had We brought the patient into the operating used the ultrasound only once for central line room to perform the nerve block, as no exclusive placement. monitoring was available in the holding area. One day a 23-year-old man presented for open Additionally, even though the operating suite reduction and internal fi xation of a distal radius had been cleaned, the nursing staff still required fracture. The patient had been admitted to the hos- an estimated 30 min to prepare appropriate pital 2 days prior and had been awaiting availabil- instruments. After placement of ASA monitors, ity of the operating suite. He described eight out we successfully performed the brachial plexus of ten pain in the right upper extremity, which block and complete surgical anesthesia was improved with intravenous morphine. With the achieved. The patient received minimal addi- help of the Rwandan anesthesia resident, we tional sedation for the surgery and was thereafter confi rmed an unremarkable medical and surgical taken to the eight-bed post-anesthesia care unit history. The two-bay area where we conducted (PACU). He was comfortable and did not require analgesics or antiemetics. The single PACU nurse was appreciative of his unremarkable and abbreviated stay, as two of the beds were occu- A. E. Ardon , M.D., M.P.H. (*) pied by overfl ow patients from the intensive Department of Anesthesiology , University of Florida , care unit. 655 West Eighth Street , Jacksonville , FL 32209 , USA e-mail: [email protected]fl .edu From this experience we learned much of what is needed and what can work for anesthesia T. Twagirumugabe , M.D. National University of Rwanda , in orthopedic surgery in a limited resource 3 Butare , Rwanda , Africa center.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 257 DOI 10.1007/978-3-319-09423-6_18, © Springer International Publishing Switzerland 2015 258 A.E. Ardon and T. Twagirumugabe

consists of 2 public referral hospitals and 1 private The Path to Safe Orthopedic referral hospital, 34 district hospitals, and 402 Surgery in Rwanda health centers for the total population. Despite limited physical and human resources, In 2006, an American Society of Anesthesiologists/ Rwandan medical capacity has steadily increased Canadian Anesthesiologists Society International since the genocide of Tutsi and moderate Hutu in Educational Foundation (ASA-CASIEF) mission Rwanda by members of the Hutu majority and to Rwanda was established to create a sustainable the civil war of 1994. Over the past 10 years, per educational relationship between training pro- capita health care expenditure has risen from grams in the USA and Canada and the cities of $9.49 per Rwandan citizen to $55 per capita. Kigali and Butare in Rwanda. A continuum of US Health expenditure as percentage of GDP has and Canadian anesthesia teaching faculty from increased from 4 % in 2000 to 11 % in 2006 [ 4 ]. various institutions, including Dalhousie Many health indicators are better than those in University and the University of Virginia was pro- the neighboring countries of Democratic vided [1 ]. Another program, Human Resources Republic of Congo, and Burundi, as well as the for Health (HRH), is a multidisciplinary educa- African region overall (Table 18.1 ), yet they still tion initiative that provides faculty from nine US fall behind global indices [2 ]. teaching hospitals to train Rwandan residents and The capacity to perform safe surgery in mentor Rwandan faculty in anesthesia, surgery, Rwanda, while improving, is somewhat limited obstetrics and gynecology, pediatrics, internal secondary to and inadequate infrastructure, sur- medicine, and family medicine. ASA-CASIEF gical resources, and personnel. Up to 80 % of and HRH faculty work in synchrony to support hospitals in the southern province reported the development of Rwandan anesthesia training absent or insufﬁ cient pulse oximetry, and 35 % and clinical practice. reported no or inadequate oxygen supply [ 5 ]. The World Health Organization estimates that, Approximately 80 % of surgical procedures are as of 2012, Rwanda has a total population of performed at district level hospitals, which are almost 11.5 million people, with a median age of typically less likely to have adequate capability 18 years and an annual population growth rate of for blood banking, amputations, closed or open 3 % [ 2 ]. It is the most densely populated nation in fracture repairs, inhalational anesthetic adminis- Africa. Unfortunately, the number of hospital tration, and chest tube insertion [ 5]. Many of the beds is disproportionate, with an average of major surgical procedures are therefore per- 0.0017 beds per 100,000 people [3 ]. Likewise, the formed at the referral hospitals. There are two number of physicians is less than 0.5 per 10,000 public referral hospitals in Rwanda, the larger population. In contrast, the USA and Canada have of which is Centre Hospitalier Universitaire, 24.2 and 20.69 physicians per 10,000 population, Kigali (CHUK). The other is Centre Hospitalier respectively [ 3 ]. The Rwandan hospital system Universitaire, Butare (CHUB). These referral

Table 18.1 Mortality indicators in Rwanda [2 ] Democratic Rwanda Burundi Republic of Congo Tanzania Uganda Africa Global Under 5 mortality rate (per 1,000 55 104 146 54 69 95 48 population) Adult mortality (per 1,000 317 345 384 342 385 383 176 population) Maternal mortality ratio (per 100,000 340 800 540 460 310 480 210 live births) Adapted from www.WHO.int 2010 and 2012 data 18 A Regional Anesthesia Service in a Resource-Limited… 259

Table 18.2 Surgical caseload by public referral hospital of inadequate supplies and equipment, limited in Rwanda [ 5 ] monitoring, lack of appropriate training for anes- Major Major and thesia providers, and few qualifi ed anesthetists Operating surgeries minor surgeries [ 6 , 7 ]. In one 2006 survey among 97 non-private Hospital rooms performed performed hospital anesthesia providers in Uganda, only University 14 4,164 7,682 hospital— 23 % stated they had the minimum monitoring Kigali requirements to conduct a safe anesthetic in an (CHUK) 2010 adult patient. The most frequently unavailable data items included pulse oximetry and oxygen source; University 4 2,488 4,526 running water and electricity were also described hospital— Butare as not always available [7 ]. (CHUB) 2009 This shortage of physical and personnel data resources directly impacts the type of anesthesia and analgesia available for orthopedic surgery. As orthopedic procedures account for approxi- hospitals are equipped with eight and four gen- mately 40 % of the surgical caseload at CHUB, eral operating rooms, respectively. As shown in and orthopedic surgery is amenable to regional Table 18.2 , in 2009 approximately 4,164 and anesthetic techniques, this chapter focuses on 2,488 major surgeries were performed at CHUK regional anesthesia for orthopedic surgery. and CHUB, respectively [5 ]. Although referral Despite the decrease in postoperative opioid con- hospitals have better surgical capacity than their sumption and improvement in patient satisfaction district-level counterparts, they still have some that is associated with peripheral nerve block pragmatic limitations. On occasion, either of techniques [8 ], few orthopedic surgery patients in these large referral centers may have limited or Rwanda receive such blocks. Whereas 99 % of absent surgical or anesthetic supplies, such as lower extremity surgery at both CHUB and consistent capnography, local anesthetic agents, CHUK is performed under spinal anesthesia, or banked blood products. only 10–15 % of these patients receive supple- Limited personnel are also an issue. As of mental peripheral nerve blockade for postopera- 2013, Rwanda has only 10 licensed anesthesiolo- tive pain control. Although approximately 55 % gists; the national anesthesia residency program of orthopedic cases at CHUB involve upper currently has 16 trainees. In a continuing effort to extremity fractures, very few patients are offered build up Rwanda’s anesthesiology capability, brachial plexus blockade either for surgical anes- organizations such as ASA/CASIEF and HRH thesia or postoperative analgesia [9 ]. Frequently provide a signifi cant contribution to the anesthe- cited reasons by Rwandan anesthesiologists are sia workforce. These visiting anesthesiologists lack of needles or local anesthetic solution and not only participate in daily clinical care but also lack of skills regarding peripheral nerve block teach and mentor residents and Rwandan staff. techniques [1 ]. The low prevalence of brachial A recent surgical capacity national collaboration plexus blockade is particularly unfortunate given meeting emphasized the important role of inter- its benefi ts when compared to general anesthesia, national efforts in enhancing the education of including decreased postoperative pain, improved Rwandan health care providers and therefore readiness for discharge, and decreased nausea increasing Rwandan health care in a sustainable and vomiting [ 10]. In a setting such as Rwanda, manner [5 ]. where both material and personnel resources are Lack of medical supplies, electricity, or appro- signifi cantly limited, the impact of a consistent priately trained staff is of course a problem not regional anesthesia service may be substantial. exclusive to Rwanda. Infrastructure analyses Economical, clinical, and training spheres may across sub-Saharan Africa show common themes all be positively affected. 260 A.E. Ardon and T. Twagirumugabe

Rwandan hospital that, on average, provides 70 Economic Impact anesthetics a week, of which less than half would be considered potential candidates for peripheral Regional anesthesia has the potential to be cost- nerve blockade. In addition, ultrasound machines effective. For example, spinal anesthesia, which is require specialized maintenance and repair, already used in Rwanda for virtually all lower which often is not readily available in a develop- extremity and many intra-abdominal and pelvic ing country. procedures, can provide signifi cant cost savings Most studies regarding the cost-effectiveness when compared to general anesthesia. Spinal of peripheral nerve blockade seem to indicate, anesthesia has been shown to improve cost- however, that time involved with the block, as effectiveness in orthopedic as well as gynecologic well as overall anesthesia-care time is the largest surgery [11 , 12 ]. A study conducted in Sweden determinant of cost-effectiveness [13 – 15 ]. One from 2007 to 2009 compared the potential periop- retrospective study examining orthopedic and erative and recovery costs involved with each type trauma patients found that brachial plexus block- of anesthetic. As shown in Table 18.3 , a signifi cant ade was less cost-effective than either general cost-savings per patient can occur with an esti- anesthesia or spinal anesthesia, particularly dur- mated savings of approximately US$800 per ing short surgery [ 13]. A small prospective study patient when combined with a multimodal pain suggested that use of brachial plexus block for control regimen and minimization of opioids. outpatient hand surgery is associated with greater The use of peripheral nerve blockade, though, cost when compared to general anesthesia [14 ]. has been associated with considerable start-up In these studies, increased cost is secondary to: costs. Some of these costs can be prohibitive in a (a) the more extensive time required to perform limited-resource setting. While one study has the block, and (b) the nursing time needed for shown that an ultrasound-guided brachial plexus patient monitoring after the block is completed block can be a cost effective anesthetic for and prior to entry into the operating room. arthroscopic shoulder surgery, resulting in a Another prospective analysis from workers at savings of approximately $220 USD per case Duke University, however, indicates that a [11 ], the use of ultrasound-guided blocks in a regional anesthesia nursing team (block nurses) developing country hospital has its own chal- in fact increases operating room effi ciency [15 ]. lenges. Ultrasound machines are very expensive, Translating this data to the situation in Rwanda usually costing more than $10,000 USD. While requires special consideration of the work fl ow the initial cost of the machine may be recuperated and day-to-day resources available. In both refer- over several years in a high volume practice, ral hospitals in Rwanda, there is no designated such an economic plan might not be feasible in a preoperative regional anesthesia “block” area, nor is there suffi cient nursing staff to monitor a patient in such an area. However, average operat- Table 18.3 Economic impact of spinal versus general ing room turnover time at the Rwandan referral anesthesia in hysterectomy patients in Sweden (in US$) [12 ] hospitals is 1–1.5 h, which is signifi cantly greater Spinal- than turnover times at the Canadian, German, and General morphine Difference US hospitals where these studies were conducted. Costs anesthesia anesthesia in costs The patient could, therefore, be brought into the Time in operating 1,362 1,305 57 theater operating room while the surgical team is prepar- Anesthetic drugs 42 22 20 ing instruments for the case. The regional anes- Time in post- 263 218 45 thesia resident or faculty would be responsible anesthesia care unit for performing the nerve block and thereafter Sick leave 3,856 3,172 684 the patient could be monitored by the anesthesia Total cost 5,523 4,717 806 provider assigned to the case. This method could Adapted from Woodlin et al. minimize any potential delay in surgical start 18 A Regional Anesthesia Service in a Resource-Limited… 261

Table 18.4 Criteria for safe peripheral nerve blockade electricity, simple upper extremity surgery, which administration [31 ] does not require the use of a tourniquet, for exam- Battery-operated EKG, pulse oximetry, noninvasive blood ple, could be performed safely under a peripheral pressure monitoring prior to, during, and after nerve block nerve block with the support of E-cylinder oxygen Supplemental oxygen available tanks and battery-operated monitors. Regarding Resuscitation supplies—including 20 % fat emulsion (Intralipid)—available to treat local anesthetic toxicity capnography, half of the operating rooms in Butare Patient history, laboratory values (when available), and did not have capnography during our visit. The use surgical procedure compatible with peripheral nerve block of a brachial plexus block and maintenance of a Informed consent present natural airway during surgery, however, would Proper patient identifi cation prior to nerve block, with obviate the need for capnography. Safe periph- confi rmation of anesthesia and surgical laterality eral nerve block anesthesia under appropriate Hand washing by staff prior to performing block monitoring maximizes the available resources to Mask and hat worn by all staff involved meet the greater surgical need. Sterile technique using sterile antiseptic prep and gloves; drape when applicable Ability by staff to identify potential nerve injury or other complications Clinical Impact Ability to confi rm block effi cacy Adapted from Smith et al. Regional anesthesia is associated with decreased blood loss, lower risk of nausea and vomiting, less likely unanticipated hospital admission, better time. Additionally, the more frequent use of postoperative pain control, and less postoperative peripheral nerve blockade could have an effect on opioid consumption as compared to general anes- post-anesthesia care. Recovery room space is thesia [16 , 17 ]. The 20 % decrease in likelihood of restricted to eight PACU beds in Butare. transfusion associated with neuraxial anesthetics Unfortunately, these beds are also used for emer- is especially advantageous in a hospital such as gency room and ICU overfl ow, thus actual recov- CHUK, where only a dozen units of blood are ery space can be even more limited. Staffi ng for available for the entire patient population [16 ]. PACU consists only of one nurse and an anesthe- Regarding both neuraxial and peripheral nerve sia technician (who also provides sedation for anesthetics, a decrease in postoperative nausea minor procedures and responds to cardiopulmo- and vomiting and immediate postoperative opioid nary arrest events throughout the hospital), and consumption can decrease length of stay in the supervised by the ICU anesthesiology attending PACU and thus decrease cost for the anesthesia physician. A patient who received a peripheral department while improving patient satisfaction nerve block as the surgical anesthetic would have [ 10 ]. In a small study conducted in Butare hospi- an abbreviated PACU stay and lessen the burden tal in 2009, patients who underwent femur fracture on recovery room staff. repair and received a fascia iliaca block had less Another potential mechanism of cost-savings postoperative pain and opioid requirements in the and operating room effi ciency relates to oxygen, fi rst 12 h when compared to patients who received electricity, and capnography unavailability. In the a sham block [ 18 ]. While the use of perineural Rwandan referral hospitals, loss of electricity or catheters would be ideal for postoperative pain central oxygen supply occurs occasionally. Much control and minimization of opioid consumption, like in developed country surgical suites, induc- the cost and necessity for close follow-up would tion of general or spinal anesthesia is not carried be prohibitive in this setting. out under these circumstances. However, periph- Besides postoperative analgesia, peripheral eral nerve blockade could be performed and sur- nerve blockade can also provide improved pre- gery could proceed as long as certain safety operative analgesia to certain Rwandan surgical criteria could be satisfi ed, as shown in Table 18.4 . patients. In both Rwandan referral hospitals, Even with loss of a central source oxygen or orthopedic trauma patients may have to wait 262 A.E. Ardon and T. Twagirumugabe more than 48 h until their fractures can be surgically Rwandan residents graduate and practice regional addressed. Femoral nerve or fascia iliaca block- anesthesiology throughout the country. ade can be used to decrease pain and suffering Since visiting anesthesiologists and anesthesi- associated with hip fractures prior to surgical ology residents contribute a great deal to the intervention [19 , 20 ] without the need for a large development and implementation of the anesthe- amount of opioids. Additionally, blockade of the sia training curriculum, they are poised to not femoral nerve can facilitate proper positioning only empower local anesthesiologists with tech- for spinal anesthesia in the operating room. The niques that can enhance anesthesia delivery but relative ease of femoral nerve block and fascia also improve their own training. By applying iliaca block placement using a nerve stimulator clinical knowledge to situations that are not likely or loss-of-resistance technique also makes these to be encountered at their home institutions, visit- blocks useful. ing anesthesiologists and trainees can work with While some orthopedic surgeons are quite local staff to gain insights into clinical circum- concerned about the potential impact of continu- stances that may be unique to that specifi c country ous nerve blockade on the diagnosis of compart- or region. For the resident in particular, this experiment syndrome, current data and numerous case ence may prove invaluable. International encoun- reports suggest that peripheral nerve blockade, ters broaden differential diagnoses, improve even if given continuously, does not affect the physical exam skills, enhance cultural compe- timeliness or adequate diagnosis of this compli- tence, decrease the use of routine lab tests, and cation [21 – 23 ]. enrich an appreciation for health systems [26 , 27 ]. Specifi cally, the act of teaching may stimulate self improvement, improve clinical skills and Training Impact perceived professional competency, as well as expand the teacher’s knowledge base [ 28 ]. In the In addition to its economic and clinical benefi ts, Rwandan ASA/CASIEF and HRH missions, regional anesthesia can have a signifi cant impact there is a strong sense of cooperation among on a continually evolving anesthesia training pro- visiting and local anesthesiology staff, enhanced gram limited by low resources. Adequate training by the realization that both parties stand to bene- in regional anesthesia hinges on an adequate case fi t from the relationship. load to master technical skills as well as clinical application of anatomy, physiology, and pharmacology [24 ]. Evidence suggests that learning Limitations/Barriers nerve-stimulator-guided techniques may require more repetition that ultrasound-guided tech- One of the most frequently encountered limita- niques [25 ]. As nerve-stimulator peripheral nerve tions to consistent performance of neuraxial and block techniques are more practical in a limited peripheral nerve block techniques in a develop- resource setting, adequate patient volume ing country is lack of materials. While hyperbaric becomes a key issue to developing profi ciency. bupivacaine for use in spinal anesthesia is avail- In Rwandan referral hospitals, where anesthesia able in Rwandan referral hospitals, ropivacaine, residents train, approximately 30 patients a week mepivacaine, and bupivacaine for peripheral are anesthetized for orthopedic or extremity nerve blockade are quite often in extremely short trauma procedures. While certainly the evalua- supply. Likewise, nerve stimulator needles and tion of candidates for peripheral nerve blockade appropriately functioning nerve stimulators are needs to be done on a case-by-case basis, quite also not consistently available. Regarding safety, often many of these patients have the potential the ability to treat local anesthetic toxicity also to benefi t from peripheral block techniques. needs to be addressed, as currently there is no The ultimate impact of learning these techniques Intralipid in either referral hospital. The shortage during residency training would be evident as the of supplies for peripheral nerve blockade is 18 A Regional Anesthesia Service in a Resource-Limited… 263 multifactorial but mostly related to cost and thus We have learned valuable lessons from our largely depends on international donations. experiences: However, as health care expenditure grows and • Procuring regional anesthesia supplies includ- advocacy for regional anesthesia expands, anes- ing local anesthetic, nerve stimulators, and thesia in Rwanda will hopefully be less reliant on needles is a priority. external infl uence. • To initially increase local resource supply, vis- Another signifi cant limitation is a low level of iting anesthesiology faculty and residents may profi ciency in peripheral nerve block techniques need to provide local anesthetics, needles, etc. among Rwandan anesthesiologists. Currently until a more reliable local supply chain is there is a strong dependence on expatriate anes- secured. thesiologists to perform nerve stimulated or • Improved preoperative and postoperative (when available) ultrasound-guided blocks. analgesia, decreased infl ammatory and stress Herein lies the importance of teaching within the response, minimization of opioids, and framework of a nascent regional anesthesia ser- decreased nausea/vomiting are some of the vice. International academic partnerships benefi t benefi ts of regional anesthesia that would be from mutual learning, in which visiting faculty of value to this patient population. commit to teaching local faculty and residents, • The use of ultrasound-guided nerve blockade thus perpetuating local capacity [29 ]. Thus, a con- is potentially not ideal given current resources tinual stream of visiting faculty who are interested and infrastructure. both in teaching needle-handling techniques and • Working within the local framework is impor- functioning as clinical consultants is required tant for implementation of any new clinical over an extended period of time. While this endeavor. Utilizing available resources, while demand is graciously being met at the present introducing new modalities and means within time in Rwanda, the process is ongoing and reli- that framework, positions a visiting clinical ant on long-term commitment. mission for a better chance of success. As described by Schnittger with regards to the • The lasting impact of an international anesthe- example of Zambian hospitals, low availability of sia effort relies on the sustainability of the local anesthetics can create a low level of training effort, i.e. the impact must be present after the in regional techniques, which can thereafter lead visiting anesthesia faculty have returned home. to low prevalence of peripheral nerve block use. As equipment and supplies are procured and This low usage can in turn lead to less demand local staff become profi cient in regional anes- for regional anesthesia and thus eventually thetic techniques, the clinical environment inspire less demand for regional anesthetic sup- depends less on international educational aid. plies [30 ]. Based upon our Rwandan experience, • Continued international collaboration and we would emphasize that both material supplies research are needed to properly improve anes- and training are both initially essential for the thesia capacity in nations with limited establishment of a regional anesthesia service resources. and also for its sustainability. Concomitant adequate supplies and continual training are indispensible. References

1. Twagirumugabe T, Carli F. Rwandan anesthesia residency: a model of north-south educational part- Conclusion nership. Int Anesthesiol Clin. 2010;48:71–8. 2. World Health Organization Statistics Summary The establishment of a regional anesthesia service 2010–2012. www.who.int 3. Notrica M, Evans F, Knowlton L, McQueen K. in a limited resource setting such as Rwanda may Rwandan surgical and anesthesia infrastructure: a sur- positively impact local anesthesia capacity as vey of district hospitals. World J Surg. 2011;35: well as clinical, economical, and training aspects. 1770–80. 264 A.E. Ardon and T. Twagirumugabe

4. ABT Associates. Health Systems 20/20 Report: 17. Greenberg C. Practical, cost-effective regional anes- National Health Accounts: Rwanda 2006, 2008. thesia for ambulatory surgery. J Clin Anesth. 1995; 5. Petroze R, Nzayisenga A, Rusanganwa V, Ntakiyiruta 7:614–21. G, Calland J. Comprehensive national analysis of 18. Twagirumugabe T, Midonze D, Uwambazimana emergency and essential surgical capacity in Rwanda. M. Effi cacy of a single fascia iliaca block in postop- Br J Surg. 2012;99:436–43. erative pain management of femoral shaft or neck 6. Grady K. Building capacity for anaesthesia in low fracture repair. Poster Presented at All Africa resource settings. Br J Obstet Gynaecol. 2009;166: Anesthesia Congress; 2009; Nairobi, Kenya. 15–7. 19. Fletcher A, Rigby A, Heyes F. Three-in-one femoral 7. Hodges S, Mijumbi C, McCormick B, Wlaker I, nerve block as analgesia for fractured neck of femur in Wilson I. Anaesthesia services in developing coun- the emergency department: a randomized, controlled tries: defi ning the problems. Anaesthesia. 2007;62: trial. Ann Emerg Med. 2003;41:227–33. 4–11. 20. Rashiq S, Vandermeer B, Abou-Setta A, Beaupre L, 8. Kettner SC, Willschke H, Marhofer P. Does regional Jones A, Dryden D. Effi cacy of supplemental periph- anesthesia really improve outcome? Br J Anaesth. eral nerve blockade for hip fracture surgery: multiple 2011;107(S1):i90–5. treatment comparison. Can J Anaesth. 2013;60: 9. Personal communication with Twagirumugabe T, 230–43. program director University of Rwanda 21. Mar G, Barrington M, McGuirk B. Acute compart- Anesthesiology Residency; Kigale and Butare refer- ment syndrome of the lower limb and the effect of ral hospital data. postoperative analgesia on diagnosis. Br J Anaesth. 10. Hadzic A, Arliss J, Beklen K, Karaca PE, Yufa M, 2009;102:3–11. Claudio RE, Vloka JD, Rosenquist R, Santos AC, Thys 22. Cometa M, Esch A, Boezaart A. Did continuous fem- DM. A comparison of infraclavicular nerve block oral and sciatic nerve block obscure the diagnosis or versus general anesthesia for hand and wrist day-case delay the treatment of acute lower leg compartment surgeries. Anesthesiology. 2004;101:127–32. syndrome? A case report. Pain Med. 2011;12:823–8. 11. Gonano C, Kettner S, Ernstbrunner M, Schebesta K, 23. Mannion S, Capdevila X. Acute compartment syndrome Chiari A, Marhofer P. Comparison of economical and the role of regional anesthesia. Int Anesthesiol aspects of interscalene brachial plexus blockade and Clin. 2010;48:85–105. general anesthesia for arthroscopic shoulder surgery. 24. Neal J. Education in regional anesthesia: caseloads, Br J Anaesth. 2009;103:428–33. simulation, journals, and politics: 2011 Carl Koller 12. Wodlin N, Nilsson L, Carlsson P, Kjolhede P. Cost- lecture. Reg Anesth Pain Med. 2012;37:647–51. effectiveness of general anesthesia vs. spinal anesthe- 25. Luyet C, Schupfer G, Wipfl i M, Greif R, Luginbuhl M, sia in fast-track abdominal benign hysterectomy. Am Eichenberger U. Different learning curves for axillary J Obstet Gynecol. 2011;205:326. e1–7. brachial plexus block: ultrasound guidance versus nerve 13. Schuster M, Gottschalk A, Berger J, Standl T. A retro- stimulation. Anesthesiol Res Pract. 2010;2010:1–7. spective comparison of costs for regional and general 26. Grudzen C, Legome E. Loss of international medical anesthesia techniques. Anesth Analg. 2005;100: experiences: knowledge, attitudes and skills at risk. 786–94. BMC Med Educ. 2007;7. 14. Chan V, Peng P, Kaszas Z, Middleton W, Muni R, 27. Hau D, DiPace J, Peck Jr R, Johnson W. Global health Anastakis D, Graham B. A comparative study of gen- training during residency: the Weill Cornell Tanzania eral anesthesia, intravenous regional anesthesia, and experience. J Grad Med Educ. 2011;3:421–4. axillary block for outpatient hand surgery: clinical 28. Busari J, Scherpbier AJ. Why residents should teach: outcome and cost analysis. Anesth Analg. 2001;93: a literature review. J Postgrad Med. 2004;50:205–10. 1181–4. 29. Riviello R, Lipnick M, Ozgediz D. Medical missions, 15. Russell R, Burke K, Gattis K. Implementing a regional surgical education, and capacity building. J Am Coll anesthesia block nurse team in the perianesthesia care Surg. 2011;213:572. unit increases patient safety and perioperative effi - 30. Schnittger T. Regional anaesthesia in developing ciency. J Perianesth Nurs. 2013;28:3–10. countries. Anaesthesia. 2007;62:44–7. 16. Mauermann W, Shilling A, Zuo Z. A comparison of 31. Smith H, Kopp S, Jacob A, Torsher L, Hebl J. neuraxial block versus general anesthesia for elective Designing and implementing a comprehensive total hip replacement: a meta-analysis. Anesth Analg. learner-centered regional anesthesia curriculum. Reg 2006;103:1018–25. Anesth Pain Med. 2009;34:88–94. Management of Pain in Less Developed Countries 19

Clifford Gevirtz

Benin City, Nigeria, found that 85 % of women Introduction would request analgesia in labor if it were available. However, only 40 % of women received any Progress in acute pain management over the last 30 analgesic intervention. In a large number of rural years has demonstrated that effective pain relief can hospitals absolutely no analgesia is available to be achieved by the use of inexpensive drugs and women with either normal or complicated labors. therapies, yet the vast majority of patients in less The provision of analgesia is seen as a low pri- developed areas of the world have little or no access ority by many aid organizations in comparison to to even the most limited of therapies that could alle- the treatment of diseases such as malaria, tuber- viate the suffering from acute and chronic pain. culosis, and HIV/AIDS. Since basic resources The World Health Organization (WHO) [1 ] such as drinking water and electricity may not be estimates there are 5 billion people living in available, it is not surprising that the provision of countries with little or no access to pain medi- analgesic drugs is problematic and relegated to a cines, including 5.5 million terminal cancer lower priority. Although lack of fi nance is a sig- patients and millions of others suffering from nifi cant barrier to improving this situation, better acute illness and end-of-life suffering. Among management of health care resources and infra- patients with terminal cancer, 80 % are estimated structure are also required. to experience moderate to severe pain due to inadequate access to medicine. Obstetric services in the developing world are Cancer Related Pain lacking [2 ] with an estimated 99 % of all maternal deaths occur in the developing world and pro- A similar situation exists for the management of longed obstructed labor producing obstetric cancer related pain. An international survey [4 ] on fi stulae is a commonplace complication. The lack the availability of opioids for cancer pain manage- of obstetric services results in untold suffering of ment was conducted by the European Society for mothers, most of whom have no access to basic Medical Oncology (ESMO), the World Health gynecological and medical care, let alone analge- Organization (WHO), in collaboration with 17 lead- sia. A study [3 ] from the teaching hospital in ing cancer and palliative care organizations worldwide. The survey focused on the legal, regulatory, C. Gevirtz , M.D., M.P.H. (*) and social barriers that impact the availability and LSU Health Science Center , New Orleans , LA , USA access to seven essential opioids for cancer pain Somnia, Inc. , New Rochelle , NY , USA management in Africa, Asia, Latin America and the e-mail: [email protected] Caribbean, and the Middle East. The opioids selected

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 265 DOI 10.1007/978-3-319-09423-6_19, © Springer International Publishing Switzerland 2015 266 C. Gevirtz were all on the WHO Model Essential Medicines able to a large numbers of patients. While List and the International Association for Hospice comprehensive data about the incidence and and Palliative Care list of essential medicines for management of pain are lacking, it is clear that, palliative care. The seven essential opiates are: mor- even when patients do access health care facili- phine immediate release, morphine controlled ties, the degree of pain relief still seems to be release, morphine injectable, oxycodone oral tablets, inadequate. methadone oral liquid, and fentanyl transdermal Administration of available drugs may also patch. The survey was conducted between December not be managed appropriately. Doctors and 2010 and July 2012. Clinicians in 81 countries and nurses often receive little training in analgesic 25 Indian states completed an in-depth question- management. In rural hospitals in South America naires on formulary availability, cost and barriers to and Africa, it is not uncommon to have two accessing essential opioids, to measure current nurses looking after a ward of 50 patients; the national standards against the reality in the commu- overstretched nursing staff may be unavailable to nities. In LDCs, a majority of the seven essential administer analgesic drugs and, indeed, the safety opioids were on the national essential medicines of administering potent analgesics in this setting lists. Oxycodone, methadone, and fentanyl were less has to be questioned as there may be little moni- consistently included on the national formularies. toring and no reversal agents are available should However, analysis of the availability data revealed a problem arise. Lack of training manifests itself that in many of the surveyed countries and all of the as an unreasonable fear on the part of the medical Indian states surveyed, fewer than three of the seven and nursing staff of side-effects or addiction, medicines were routinely available for use in hospi- which may in turn propagate a culture of non- tal and pharmacies. In the Indian states, despite intervention. Doctors and nurses can become so codeine, three morphine formulations and transder- used to doing nothing for patients in pain that mal fentanyl being on state level essential medicine non-treatment becomes the standard approach. lists, only codeine was always or usually available. Further, patients begin to believe that nothing can The six other opiates considered essential for pain be done, or adopt a fatalistic attitude and suffer in management were either only occasionally or never silence, with little more than family members to available. All regions of the world show inconsisten- offer comfort. cies between the adoption of the essential medicine list at the national policy level and the actual range and availability of essential opioids to patients. Therapeutic Agents There is also a major gap in clinician attitudes and education. Although not a focus of the ESMO Opioids survey, there is a broad consensus among the international medical community and the WHO Opioid analgesics are the gold standard for treat- that inadequate education of health care providing moderate to severe pain, drugs such as mor- ers is one of the most pervasive and urgent obsta- phine being low cost and highly effective. cles to address. A recent Human Rights Watch However, the availability and use of opioids is survey [5 ] on palliative care barriers in 40 coun- not uniform across the globe. tries found that most countries had inadequate Cleary et al. [6 ] studied the mal distribution medical education in palliative care and pain of opiates and found in 2013, that 90 % of the management and four of the countries surveyed world’s morphine was consumed by ten major had no relevant curriculum in these areas at all. industrial countries: Australia, Canada, Denmark, France, Germany, Japan, Spain, Sweden, the UK, and the USA; 85 % of the On the Ground Reality world’s population shared the remaining 10 % of the world’s morphine. It appears that analgesia has a lower priority than In 1996, in a seminal publication [7 ], entitled many other aspects of health care in developing “Cancer Pain Relief: A Guide to Opioid countries so that effective pain relief is unavail- Availability,” the WHO contributed a framework 19 Management of Pain in Less Developed Countries 267 for developing or improving palliative care and Veterans Health Administration was the first pain relief within a country that comprised three to popularize the concept of pain scales as the key components: fifth vital sign. Simple pain assessment tools 1. Government policies that ensure the integra- such as the visual analog scale as well as the tion of palliative care services into the struc- memorial pain card have been translated into ture and fi nancing of the national health care nearly every language on the planet demon- system. strating that pain measurements can be 2. Educational programs that provide support for adapted to local circumstances in LDCs. the training of health care professionals, volunteers, and the public. 3. Drug availability supported by appropriate Therapeutic Interventions drug control policies and their administration to ensure the availability of essential medi- Psychological Interventions cines for the management of pain and other symptoms, in particular, opioid analgesics for Training programs in LDCs should encourage the pain relief. discussion of pain management as part of the rou- Now almost 20 years later, many barriers tine medical and surgical care of the patient. A remain to correct opioid use in the developing simple explanation of the cause and likely dura- world. There may be concerns at government tion of pain can noticeably improve a patient’s level over risks of addiction and abuse. Import ability to cope, even when other material inter- restrictions may be overly stringent and the laws ventions may be diffi cult to provide. Patients may regarding prescribing and dispensing opioids can have a limited understanding of their condition make it virtually impossible to get opioids to and assume that pain may be inevitable or not patients. Of the governments that responded to treatable in any measure. At this point, the pallia- the International Narcotics Control Board survey, tive care training programs in the LDCs do not 43 % said that they require physicians to report to address chronic non-malignant pain. the government those patients who are prescribed opioid analgesics; this acts as a powerful disin- centive to prescribe opioids. Drug Treatment Currently, the cost of importing morphine to developing countries is disproportionately high. The benefi ts of techniques such as patient- A survey of opioid costs [8 ] in 2003 showed that controlled analgesia have been clearly demon- opioid drugs were up to ten times more expensive strated in the developed world, but the lack of in the developing world than in the developed equipment and the lack of careful monitoring of world, after adjustment for differences in gross these devices mean that in developing countries domestic product. their use is impracticable and unsafe. However, National legislation in individual countries [ 9 ] administration of effective analgesia does not can have a massive effect on opioid consumption. need to depend on sophisticated technology. In India, the introduction of a piece of legislation The original WHO analgesic ladder outlines that resulted in a signifi cant increase in the simple techniques using minimal resources to bureaucracy associated with purchasing opioids combat cancer pain. This model has been applied led to a 97 % fall in consumption of morphine to acute pain by the World Federation of Societies from 716 kg in 1985 to 18 kg in 1997. The WHO of Anesthesiologists (WFSA), which has pro- estimates that if barriers to accessing morphine in duced a modifi ed ladder for acute pain [10 ] (see the developing world could be removed, then a Fig. 19.1 ). reasonable estimate of the cost of morphine Starting with strong parenteral opioids, ket- would be just one US cent per milligram. amine, and/or local anesthetic, there is then a step In an ideal world, assessment of pain down to oral opioids and fi nally to nonsteroidal should become as basic an observation as anti-infl ammatory drugs and acetaminophen on measuring pulse and blood pressure. The US its own. All of these drugs appear on the WHO 268 C. Gevirtz

public enlightenment, and education (including undergraduate, postgraduate, and other health professionals) there has been a dramatic improvement in pain management achieved by the safe use of opioid analgesics.

Local Anesthetics

Local anesthetic techniques can provide excel- Fig. 19.1 WFSA Analgesic Ladder lent postoperative pain relief and their use should be encouraged whenever possible, by whichever route possible, even if only by local infi ltration. list of essential drugs. This ladder should be Limited postoperative facilities and equipment coupled with multimodal analgesia techniques shortages limit some of the more advanced including local anesthesia blocks with longer options (epidurals and continuous plexus block- duration agents, and prescribing regular analge- ade), but simple techniques remain underutilized sics with provisions for breakthrough pain. and have a low incidence of adverse effects. Ideally, the oral route should be used for postop- Single shot techniques including spinal anes- erative analgesia, including the use of oral mor- thesia, plexus blockade, caudal anesthesia in phine when available and feasible. children, and infi ltration of local anesthetic into Simple analgesics such as acetaminophen, wounds can be accomplished with minimal ibuprofen, and diclofenac are cheap and readily resources but great effectiveness. These tech- available in most countries of the world. However, niques work most effectively using bupivacaine access to drug supplies may be limited within the if it is available, but the use of shorter acting hospital; a common solution is to pre-prescribe drugs such as lidocaine with epinephrine is also analgesics to be purchased by patients or rela- effective. The use of additives such as ketamine tives from local pharmacies prior to elective sur- and clonidine should be encouraged, if available, gery. Unfortunately, patient may be unable to but it is important to avoid additives with preser- afford even the cheapest of analgesics. vatives. Both surgeons and anesthesiologists Ketamine is the mainstay of anesthesia in need training to develop the use of these straight- many parts of the developing world, particularly forward techniques. Liposomal bupivacaine for children. It is also an effective analgesic when offers the opportunity to provide more than 24 h administered in sub-anesthetic dosages (e.g., of analgesia. 10 mg i.m.) and can be used to provide immedi- Many anesthesiologists in LDCs do not own ate postoperative analgesia. It is particularly an anesthesia textbook. Publications such as potent in combination with parenteral opioids, Update in Anaesthesia and the Tutorial of the where it has a signifi cant opioid-sparing effect. Week published by the World Anaesthesia Society Opioid use should be encouraged where pos- show how simple, cost-effective, practical infor- sible, but this must include introduction of mation can be made available to isolated anesthe- effective systems for opioid administration— siologists in LDCs, both in hard copy and via the reliable systems for purchase, safe storage, Internet. Open access journals are a newer recording of use and training regarding effects approach to presenting information in the LDCs. and side effects. An example of success [11 ] in Encouraging links between developed and devel- this area is in Nigeria where through several oping countries (e.g., by linking academic anes- years of advocacy for availability of opioid thetic departments) can lead to the sharing of analgesics at central government supply level, ideas and problems, and exchange visits of 19 Management of Pain in Less Developed Countries 269 personnel, and may even help with the supply of available and used for cancer patients. Both phys- essential equipment and drugs. ical and psychological therapies are offered by Refresher courses provide invaluable opportu- the multidisciplinary team. nities to share ideas about analgesia (Please also A major challenge of that clinic is that patients see details of the NYSSA Visiting Scholar pro- expect to be cured and dropped out from the gram in the vignettes section) and can reach a clinic after a few visits because of a lack of large number of staff. Materials can be modifi ed understanding that chronic pain may persist for for the level of resources found in the country, years. The lack of pain specialists and specialized local protocols developed, and expertise can be pain clinics along with the lack of training among brought to bear on particular local problems. health professionals constitute the major impedi- On a cautionary note, care should be taken to ment to chronic pain services in the LDCs. ensure that training programs are relevant to the problems that are encountered in everyday practice. For instance, it is important to include con- Unaddressed Pain Challenges sideration of the side-effects of different drugs, especially in hypotensive patients. Intramuscular Dengue Fever (Break Bone Fever) opioids should be used carefully in such patients (i.e., it is preferable to titrate intravenous opioids) Dengue is an infectious disease caused by dengue and trainers should be aware of the limitations or viruses, which are transmitted to humans by mos- lack of monitoring in ward areas. quitoes. The rising number of dengue infections and Although classroom teaching can improve the expanding range has become a serious interna- knowledge, the best way of improving practice is tional concern. Each year, the WHO reports that to be taught in the operating room or recovery approximately 50 million people are infected with area by an anesthesiologist. As well as providing dengue. Typically, dengue causes a severe fl u-like personal attention and mentorship, it allows anes- illness with high fever, headache, and severe body thesiologists to act as role models and to stress and joint pains (hence the name break bone fever). the effectiveness of basic techniques and the A more dangerous form of dengue infec- importance of patient safety. In addition, it may tion, however, called severe dengue, hospital- help to recruit young doctors in training into a izes an estimated 500,000 people—most of career in anesthesia. Training the local trainers them children—every year. In some regions of and adding to the anesthesia workforce are the world, severe dengue is fatal in more than important steps on the route to sustainability in 5 % of patients. An estimated 2.5 billion to 3 developing countries. billion people around the world are currently at Chronic pain management requires pharmaco- risk of dengue infections, and most of these logical and non-pharmacological therapies with people live in tropical, urban regions of attention to other needs of the patient (psychoso- Southeast Asia, the Americas, Africa, and the cial and spiritual). In Nigeria, a pain clinic [11 ] Pacifi c. The risk of dengue is higher in urban was fi rst established at the University College regions than in rural areas. hospital, Ibadan, by the Department of Anesthesia Babies and young children infected with the in 1979 but the clinic failed to survive the period dengue virus typically have mild symptoms such of specialist medical manpower exodus from the as a fever and a rash over their entire bodies, but country in the late 1980s. The clinic was reestab- no other symptoms of dengue. Older children and lished by a multidisciplinary group as a Pain and adults may also have these mild symptoms, or Palliative Care Clinic in 2005 to treat cancer and they may have classic symptoms of dengue, non-cancer pain. The analgesics available were including a high fever that lasts for 2–7 days, mainly non-opioids until recently, when opioids severe pain in the muscles, bones, and joints, pain including oral morphine solution have become behind the eyes, severe headaches, nausea and 270 C. Gevirtz vomiting, and a rash [12 ]. Dengue fever is char- with gabapentin or tricyclic antidepressants acterized by a fever response with two peaks. would be fi rst line therapy. Near the beginning of the infection, the patient experiences a very high body temperature, which then starts to drop and then suddenly climbs Pain in Victims of Torture again for a second time. Other symptoms of dengue fever include a decrease in the number of According to Amnesty International, government- white blood cells and thrombocytopenia. Patients sanctioned torture is verifi ed in one-third of the with dengue fever may have frank purpura. countries in the world. The physical and psycho- Dengue fever can also cause bleeding from the logical sequelae are numerous. Thomsen et al. skin, nose, and gums. Recovery from dengue [14 ] studied the pain diagnosis, characterizing fever is often lengthy, lasting several weeks, and pain types as nociceptive, visceral, or neuropathic. patients can experience lingering pain, fatigue Torture victims from the Middle East, treated at and depression. The pain symptoms associated the Rehabilitation and Research Centre for Torture with dengue can be managed with pain relievers Victims (RCT) in Copenhagen, participated in the that do not increase the risk of bleeding (acet- study. The patients were referred to a pain special- aminophen, opiates). There is currently no vac- ist for evaluation of unsolved pain problems. cine and treatment is mainly supportive. Eighteen male torture victims were examined. Twelve patients experienced pain at more than three locations. Nociceptive and neuropathic pain Pain in Leprosy (Hansen Disease) were demonstrated in all patients. Specifi c neuropathic pain conditions were related to the follow- Stump et al. [ 13 ] reviewed the prevalence of ing four types of physical torture: Palestinian neuropathic pain in leprosy patients. While the hanging, falanga, beating and kicking of the head, introduction of multidrug therapy by the WHO and positional torture. When treating torture vic- has dramatically reduced the world prevalence tims, it is important to know about torture meth- of leprosy the disease is still a public health ods, to think differently than normal on etiological problem in many countries, with a world preva- and pathogenetic factors and always consider the lence of almost 600,000 cases in 2001. Damage presence of neuropathic pain. to peripheral nerves is a key component of leprosy and the sensory and motor loss that follows is the basis for many of the classical features of Ongoing Efforts this disease, such as skin wounds, cracks, plan- tar ulcers, clawed hands, drop foot, and incom- The IASP offers visiting lectureships and consul- plete closure of the eyelids. One of the most tations to assist nascent pain programs in the remarkable aspects of leprosy to lay persons LDCs. It also has a “adopt a member” program, and health care workers alike is that patients are to pair members in the developed world with reputed to feel no pain. However, neuropathic those in the LDCs to encourage ongoing educa- pain is arising as a major problem among lep- tional and experiential exchange. The IASP also rosy patients. It can be nociceptive due to tis- offers translation and publication of monographs sue infl ammation, which mostly occurs during into various languages as well as travel grants to episodes of immune activation or neuropathic attend its world congress. due to damage or dysfunction of the nervous The World Institute of Pain (WIP) (founded system. In Stump’s study [13 ] of 358 leprosy 1993) has helped train and provide a global forum patients, there was a considerable prevalence of for pain physicians from around the world. In neuropathic pain, which suggests that this com- 2010, the WIP Foundation was established and mon problem should be a high priority of those provides fellowships for physicians from LDCs in charge of leprosy control programs. Therapy to attend programs conducted by the WIP. 19 Management of Pain in Less Developed Countries 271

5. Human Rights Watch. Global State of Pain Treatment: Conclusion Access Palliative Care as a Human Right. May 2011. Available from: http://www.hrw.org/sites/default/ fi les/reports/hhr0511W.pdf It is indeed frustrating that 20 years on from the 6. Cleary J, for the Pain and Policy Study Group. fi rst recognition of the paucity of pain manage- Improving opioid availability for pain and palliative ment in the LDCs, only modest improvements care: a guide to a pilot evaluation of national policy. Madison, WI: University of Wisconsin Carbone have been made. Anesthesiologists must take the Cancer Center; 2013. opportunity to teach pain medicine in LDCs along 7. World Health Organization. Cancer pain relief with a with supporting efforts to establish pain clinics. guide to opioid availability. Geneva: World Health Organization; 1996. p. 43. 8. De Lima L, Sweeney C, Palmer JL, Bruera E. Potent analgesics are more expensive for patients in develop- References ing countries: a comparative study. J Pain Palliat Care Pharmacother. 2004;18:59–70. 1. World Health Organization Briefi ng Note. Access to 9. Rajagopal MR, Joranson DE, Gilson AM. Medical controlled medications programme. Developing WHO use, misuse, and diversion of opioids in India. Lancet. clinical guidelines on pain treatment. Feb 2009. 2001;358:139–43. Medicines Access and Rational Use, Department of 10. Charlton E. The management of post operative pain. Essential Medicines and Pharmaceutical Policies Health Update Anaesth. 1997;7:1–7. Systems and Services, World Health Organization. 11. Akinyemi OO, Famewo CE. Pioneering a Pain clinic 2. Graham WJ, Cairns J, Bhattacharya S, et al. Maternal in a developing country. The fi rst two years. J Pain and perinatal conditions. In: Jamison DT, Breman JG, Suppl. 1981;1:299. Measham AR, et al., editors. Disease control priorities 12. Dengue Fever. Centers for Disease Control and in developing countries. 2nd ed. New York: The World Prevention. National Center for Emerging and Bank and Oxford University Press; 2006. p. 499–529. Zoonotic Infectious Diseases. Atlanta, GA. http:// 3. Imarengiaye CO, Ande AB. Demand and utilisation www.cdc.gov/dengue/ . Accessed 28 May 2014. of labour analgesia service by Nigerian women. J 13. Stump PR, Baccarelli R, Marciano LH, Lauris JR, Obstet Gynaecol. 2006;26:130–2. Teixeira MJ, Ura S, Virmond MC. Neuropathic pain 4. The First International Survey on Availability of Opioids in leprosy patients. Int J Lepr Other Mycobact Dis. for Cancer Pain Management: Data Results for Africa, 2004;72(2):134–8. Asia, Latin America & the Caribbean and the Middle 14. Thomsen AB, Eriksen J, Smidt-Nielsen K. Chronic East. Data available by region from: http://www.esmo. pain in torture survivors. Forensic Sci Int. org/Policy/International -Access-to-Opioids-Survey 2000;108(3):155–63. Living the Mission in Serbia and Other Less Affl uent Worlds 20

Miodrag Milenovic

charitable associations, nongovernmental and Introduction governmental organizations, philanthropic efforts, together with industrial and pharmaceutical devel- Teaching, learning, and anesthesia practice has opment facilitated changes the basic needs of the changed globally, together with medical science vast majority of the global population, as well as during the last few decades. An important devel- in less-affl uent parts of the world [2 ]. A lot of opment has happened, especially in economically educational possibilities, ethical dilemmas and prosperous regions. Recent years have been more safety issues came along with undoubted good dynamic and have produced more professionally intentions. Outreach medical missions are a sig- challenges for anesthesia societies in less affl uent nifi cant part of these efforts. A number of various countries, than occurred in the previous half cen- models of medical outreach have shown the abil- tury. Globalization of knowledge, dynamic com- ity to create sustainable change through educa- munication, and transfer of technology saved tion, which is much more needed than episodic some time, efforts, planning, and resources but impact [3 ]. still takes signifi cant effort to ensure that anesthesia in low-income countries can reach internationally accepted standards. It is diffi cult to standardize History access to medical service, quality, and safety in highly populated areas without an organized mod- Some fi elds of Anesthesia, Intensive Therapy ern health system [1 ]. and Pain in Serbia and the region were organized Evolution and undoubted improvement in in the early 1950s of the last century. Good struc- everyday clinical practice was scientifi cally, but tured and suffi ciently founded anesthesia, syn- also strategically guided by international profes- chronised with the latest modern standards at that sional organizations. National anesthesia societ- time was achieved in the late 1970s and 1980s [4 ]. ies, universities, and anesthesia departments Theoretical background was obtained by the pio- mostly were helpful, but crucial was the per- neers and teachers of Anesthesia trained abroad, sonal initiative of proactive individuals with a at the best modern medical systems at that time. strong vision. International professional societies, Later on, during the 1990s together with political instabilities, isolation, wars, and economic crisis M. Milenovic , M.D. (*) in the region, all the deterioration and devastation Department Anesthesiology and Intensive Care happened [5 ]. Nearly a million refugees and inter- Medicine, Emergency Center , Clinical Center of Serbia, Pasterova 2 , Belgrade 11000 , Serbia nally displaced persons became a hard burden for e-mail: [email protected] the public health system.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 273 DOI 10.1007/978-3-319-09423-6_20, © Springer International Publishing Switzerland 2015 274 M. Milenovic

for the anesthesia professionals practicing in Education well- equipped and well-provided, resourceful environment. The visiting mission teams have an Investments in education are strongly related to opportunity to learn as much as the people they the economic system of one country and Gross are helping and teaching, because this is a two- Domestic Product (GDP), so less affl uent parts of way process [3 ] (Fig. 20.2 ). The importance is in the world suffer a lot and sustain serious human the opportunity to practice anesthesia with a less resource problems in education. Life expectancy, developed technology and older generation of mother and infant mortality rate, recognition and anesthesia drugs, which are mostly abandoned treatment of curable illnesses on time, pain treat- because of safety issues, new and improved prod- ment, and other variables are measurable in the ucts, or simply because they are much cheaper process of quality evaluation of the education and than recently developed [7 ]. The level of infra- medical care. There is no doubt that strong infl u- structure development on the European ground, ence in education is possible during short-term especially in the non-European Union nations are medical missions. In an increasingly globalized so divergent, that some of the anesthesia tech- world, it is not likely that medical missions will niques considered as a part of anesthesia history be less needed in the near future. What should be are still in use (e.g., “blind” landmark-based changed in strategy if possible is that health care regional anesthetic techniques; eliciting paresthe- professionals instead of tending to treat patients sia regional anesthesia techniques; or “blind” with illnesses do more in education, prevention central venous catheter insertion techniques etc.) and earlier detection [6 ] (Fig. 20.1 ). [ 8 , 9 ]. Some other areas of the less affl uent world are still struggling with the lack of basic needs like Outreach Anesthesia Team Benefi t running water, electric supply, oxygen, and anesthetic gas supply, as well as no physician anesthe- Surgical and anesthesiology education as a part siologists, so training and teaching experience for of the international mission’s curriculum with the anesthesia professionals in that circumstances the basic aim to provide help to those who are priceless because of the constant safety chal- work in resource-poor areas of the world and lenges of the modern world (major climate care for underserved populations may be signifi cant changes, tectonic disorders, terrorism, etc.) [10 ].

Fig. 20.1 AAF Salzburg medical seminar “Severe Bleeding Management” and point-of-care testing workshop, Salzburg, Austria, July 2012 20 Living the Mission in Serbia and Other Less Afﬂ uent Worlds 275

Fig. 20.2 International School of Obstetric Anesthesia, supported by WFSA, ultrasound guided regional anesthesia techniques workshop, Novi Sad, Serbia, September 2013

In the moderately developed, but still less- resourceful societies, there is signifi cant experi- Local Priority Change ence with donation of necessary equipment and simultaneously organized training with the prior- Health authorities detected the local need for priority of teaching skills (operative or anesthesia ity change and some efforts and necessary changes technique), as opposed to just performing opera- have been made recently, but not enough. Private tions by the mission team, it is possible to achieve initiative in the teaching and education of healthcare sustainable surgical care after missions are offi - providers is insuffi cient and not nationally standard- cially concluded [11 ]. ized yet. This will be hard to achieve under the pres- The problems are ubiquitous. State-owned ent human recourse policy. Negative and and public universities in less-affl uent and intransparent human resource selection dominates post-“Iron-Curtain” societies, dominantly affi li- in anesthesia university departments, so now they ated with public hospitals, have the tradition and have manpower problems relating to useful applied exclusive rights in teaching and education of knowledge. Real change would be electing hard healthcare providers and future professional working professionals and devoted teachers with leaders. Archaic inherited rigid rules in education the knowledge and vision to emphasize quality, in former East European and Ex-Yugoslavia safety and professionalism, together with introduc- countries, as well as negative selection in teaching region-specifi c teaching methods and problem- ers and leaders in anesthesia through generations, based learning techniques [12 ]. Hospitals have a infl uenced the basic structure and moral views. dramatic problem keeping a suffi cient number of Open-minded, intellectually independent indi- trained anesthesiologists. Public sector without sta- viduals, exhausted by a long post-confl ict period ble funding suffers signifi cant governmental and and economic transition, migrated and became international creditors infl uence on reduction of part of the post-“Iron-Curtain” intellectual exodus personal incomes and on numbers employed. named “Brain Drain.” A small minority made a Added are all previous challenges that opened the diffi cult and insecure choice, to stay and try to space for unethical and unmoral corrupting ele- infl uence the system. All the others simply “fl oated ments. The most vulnerable part of society and the with the mainstream” to become a silent part of ultimate victims are the youngest, the oldest, and the structure. the critically ill part of the population [13 ]. 276 M. Milenovic

Migration of Professionals Teach the Teachers in Anesthesiology The most important and hardest part was to detect the local needs and the people willing to facilitate The area with obvious diffi culties and a huge the transition of knowledge and practice. The quality and safety gap that was detected between demands differed in various parts of the world West and the former East European nations was and depended on the stage of development and anesthesiology. Some original ideas of visionary the number of educated individuals [ 14 ]. people with huge experience in education and Language barriers, not enough IT trained people strategically guided system development, sup- and prolong periods of segregation are constant ported and funded by WFSA Education problems. Even so, a number of anesthesiologists Committee and ESA later on, offered original from less affl uent countries participated in inter- solutions. Systematically chosen young people national trainee exchange programs, and visited a from former East European nations and less- number of university hospitals with highly devel- affl uent parts of Europe, with teaching and lead- oped and structured educational system [10 ]. ing capabilities were delegated from their national They acquired personal knowledge and skills and anesthesia societies (Fig. 20.3 ). They were then decided to stay permanently, instead of exposed to practice of the modern theory of teach- returning to the home country. They utilized the ing and adult learning in the form of originally opportunity to change a personal lifestyle and created “Teach the Teachers” (TTT) courses and offered to their families a better and certainly techniques, to upgrade already acquired knowl- more predictable future. The personal free choice edge and to adopt new and modern ways of plan- cannot be questioned, but investment in that ning, preparation, presentation, research planning, “one-way” migration has to be considered as sub- dealing with the diffi culties they can meet on the stantial loss of human resources [15 ]. The legal way and much more [17 ]. background of those actions came along with the After the pilot project with participants from opening of the European borders and the estab- fi ve national societies were concluded, more lishment of a European job market for the health than 20 national societies delegated participants care professionals [16 ]. and they successfully completed the program.

Fig. 20.3 Visual aids in teaching and simulation with low resources. “Double lumen tube and one lung ventilation simulation”, by participants from Romania and Macedonia, ESA TTT course, Brussels, Belgium, April 2014 20 Living the Mission in Serbia and Other Less Afﬂ uent Worlds 277

Fig. 20.4 European ISIA 3 (TTT) Course, cofounded by WFSA and ESA, Crete, Greece 2012. Participants from Latvia, Lithuania, Georgia, Croatia, Greece, Turkey, and Malta

The graduates took the obligation to detect local professional societies and contributed to raising the anesthesia needs and to start similar TTT or the level of quality care and patient safety. The next original educational programs at the national step is to start calling for reform of postgraduate level (Fig. 20.4 ). This strategy gave unexpectedly medical training structures, to defi ne excellence quick excellent results and exceeded previous in anesthesia and to redefi ne the role of personal format. Because of the high accomplished stan- merits and responsibilities [18 ]. dards and excellent feedback from previous participants, a great number of other European nations asked to participate. Not all of the national International Cooperation teams gave the same results, but all have produced a substantial quality change in teaching Several international professional organizations, and started the mission in their home countries. some friendly foreign humanitarian organiza- The graduates remain connected in between and tions as well as a number of nonprofi t and non- have created a network of people with the same governmental organizations, offered their help. goal, to raise the level of education and anesthe- The Serbian Association of Anesthesiologists sia practice. They organized international events and Intensivists (SAAI) regained its position in with the participants from the region, and hosted international professional organizations. World a number of quality CME programs: seminars, Federation Of Societies of Anaesthesiologists workshops, national congresses which created a (WFSA), European Society of Anaesthesiology “snowball effect.” (ESA), the New York State Society of Alumni of the TTT course named International Anesthesiologists (NYSSA), as well as university School for Instructors in Anesthesiology (ISIA) exchange programs of the European Commission have become devoted teachers and took leading as a promotion of harmonization of education roles in their environment: hospitals, universities, in Europe and a great number of international 278 M. Milenovic

Fig. 20.5 Prof. Elizabeth Frost, chairperson of the PGA International scholar committee, with the scholars from Serbia, New York, December 2006. From the left : Miodrag Milenovic, Elizabeth Frost, Marina Lukic

organizations and foundations offered indepen- globally to improve patient safety, with partial dent international scholarships and awards success. It is time for the health authorities of (Fig. 20.5 ) [19 ]. nations with developing or transitional econo- With intention to help in bridging the gap in mies to treat the patient safety issue with the medical knowledge and practice between the greatest concern [21 ]. affl uent and less-affl uent worlds, signifi cant help A number of former East and South European came from the American Austrian Foundation. nations made great efforts to achieve a suffi cient Thousands of medical doctors from all over the level of trained anesthesia professionals, equip- world and hundreds from Serbia used that oppor- ment, and safety regulations, but long period of tunity and spent some time for education in the political instability and economic crisis slowing highly ranked Austrian university hospitals. That down the process. Pioneer efforts have been made gave an opportunity to gain priceless knowledge to unite the political and professional infl uence, and experience and establish good interpersonal knowledge, and experience and to launch the fi rst relations with the experts from abroad [20 ]. Our international declaration on patient safety—The national organizations and universities hosted, Helsinki Declaration on Patient Safety in co-organized, and endorsed a number of interna- Anaesthesiology. The main initiative came from tional scientifi c meetings and hands-on training the two prominent European Anesthesia bodies: workshops in Anesthesia subspecialty fi elds European Board of Anaesthesiology (EBA) and (pediatric, obstetric, pain, etc.), with the the European Society of Anaesthesiology (ESA). signifi cant regional infl uence and international The endorsement of this important initiative came professional recognition. from the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients’ Federation Safety Issues (EPF). The Declaration gave strategic foundation and short term plan for improvement to all parties Epidemiology and safety issues of anesthesia in the safety process: anesthesiology profession- related complications, for long were not in the als, industry, and patients [22 , 23 ]. focus of health authorities in less affl uent societies. A number of perioperative and postprocedural crisis in anesthesia, intensive care Cultural and Ethical issues medicine and pain therapy that might have been expected were not avoided, majorly because of Cultural and religious background of the targeted inconsistency of a education and medical system population and ethical challenges should be and insuffi ciency of health authority. Numerous considered when planning outreach missions in of unsynchronized attempts have been made less affl uent parts of the world. Careful planning 20 Living the Mission in Serbia and Other Less Affl uent Worlds 279 may help in avoiding confl ict with local tradi- of operative skill transfer and sustainable care in tions and religious beliefs. Sometime local regu- Lima, Peru. Childs Nerv Syst. 2012;28(8):1227–31. 12. Dubowitz G, Evans FM. Developing a curriculum lations or habits are not compliant with modern for anaesthesia training in low- and middle-income western medical approach and often neglected countries. Best Pract Res Clin Anaesthesiol. 2012; during planning. It does not mean that certain 26(1):17–21. changes for the better are not wanted or possible. 13. Paredes-Solís S, Andersson N, Ledogar RJ, Cockcroft A. Use of social audits to examine unoffi cial pay- Some level of reserve can be expected in the very ments in government health services: experience in conservative or religiously infl uenced societies South Asia, Africa, and Europe. BMC Health Serv (e.g., reproductive health and sexual behavior). Res. 2011;11 Suppl 2:S12. 14. Lipnick M, Mijumbi C, Dubowitz G, Kaggwa S, Goetz L, Mabweijano J, Jayaraman S, Kwizera A, Tindimwebwa J, Ozgediz D. Surgery and anesthesia capacity-building in resource-poor settings: descrip- References tion of an ongoing academic partnership in Uganda. World J Surg. 2013;37(3):488–97. 1. Enright A. Review article: safety aspects of anesthesia 15. Blacklock C, Ward AM, Heneghan C, Thompson M. in under-resourced locations. Can J Anaesth. 2013; Exploring the migration decisions of health workers 60(2):152–8. and trainees from Africa: a meta-ethnographic synthesis. 2. Eichhorn JH. Review article: practical current issues Soc Sci Med. 2014;100:99–106. in perioperative patient safety. Can J Anaesth. 2013; 16. Costigliola V. Mobility of medical doctors in cross- 60(2):111–8. border healthcare. EPMA J. 2011;2(4):333–9. 3. Hughes SA, Jandial R. Ethical considerations in tar- 17. Bould MD, Naik VN, Hamstra SJ. Review article: geted paediatric neurosurgery missions. J Med Ethics. new directions in medical education related to anes- 2013;39(1):51–4. thesiology and perioperative medicine. Can J Anaesth. 4. Simić D, Dragović S, Budić I. History of pediatric 2012;59(2):136–50. anesthesiology. Srp Arh Celok Lek. 2007;135(1–2): 18. Smith AF, Glavin R, Greaves JD. Defi ning excellence 111–7. in anaesthesia: the role of personal qualities and prac- 5. Vucovic D. The development of anaesthesia in tice environment. Br J Anaesth. 2011;106(1):38–43. Serbia. The newsletter of the association of anaesthe- 19. Pallikarakis N, Bliznakov Z, Miklavcic D, Jarm T, tists of Great Britain and Ireland. ISSN 0959-2962. Magjarevic R, Lackovic I, Pecchia L, Stagni R, The history page – Anaesthesia News June 2008 Jobaggy A, Barbenel J. Promoting harmonization of Issue 251, 17–18. http://www.aagbi.org/sites/default/ BME education in Europe: the CRH-BME Tempus fi les/june08.pdf. Accessed 18 Apr 2014. project. Conf Proc IEEE Eng Med Biol Soc. 2011; 6. Martiniuk AL, Manouchehrian M, Negin JA, Zwi AB. 2011:6522–5. Brain gains: a literature review of medical missions to 20. AAF, Newsletter of the American Austrian low and middle-income countries. BMC Health Serv Foundation. Healing, Harmony, Honesty…and Hope. Res. 2012;12:134. http://www.aaf-online.org/tl_files/externals/down- 7. Adudu OP, Isa I, Longway FO. Trends in intraopera- loads/publications/docs/AAF_image_folder_2007. tive pain relief in anesthesized Nigerian pediatric pdf . Accessed 18 Apr 2014. patients: implications for a developing economy. Ann 21. Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent Afr Med. 2011;10(3):233–7. C, El-Assady R, Rasslan O, Qsous S, Macharia WM, 8. Howe KL, Malomo AO, Bernstein MA. Ethical chal- Sahel A, Whittaker S, Abdo-Ali M, Letaief M, Ahmed lenges in international surgical education, for visitors NA, Abdellatif A, Larizgoitia I, WHO Patient Safety and hosts. World Neurosurg. 2013;80(6):751–8. EMRO/AFRO Working Group. Patient safety in 9. McDermott G, Korba E, Mata U, Jaigirdar M, developing countries: retrospective estimation of Narayanan N, Boylan J, Conlon N. Should we stop scale and nature of harm to patients in hospital. BMJ. doing blind transversus abdominis plane blocks? Br J 2012;344:e832. Anaesth. 2012;108(3):499–502. 22. Mellin-Olsen J, Staender S, Whitaker DK, Smith 10. LeBrun DG, Chackungal S, Chao TE, Knowlton LM, AF. The Helsinki Declaration on patient safety in Linden AF, Notrica MR, Solis CV, McQueen anaesthesiology. Eur J Anaesthesiol. 2010;27(7): KA. Prioritizing essential surgery and safe anesthesia 592–7. for the post-2015 development agenda: operative 23. Staender S, Smith A, Brattebø G, Whitaker D. Three capacities of 78 district hospitals in 7 low- and middle- years after the launch of the Helsinki Declaration on income countries. Surgery. 2014;155(3):365–73. patient safety in anaesthesiology: the history, the 11. Duenas VJ, Hahn EJ, Aryan HE, Levy MV, Jandial progress and quite a few challenges for the future. R. Targeted neurosurgical outreach: 5-year follow-up Eur J Anaesthesiol. 2013;30(11):651–4. Anesthetic Management During the Lebanese Civil War 21

Anis Baraka

were an estimated 120,000 killed and an unknown Introduction number injured with enormous property damage (Fig. 21.1a–c ). The American University of Beirut (AUB) and the Faculty of Medicine and its Medical Center have been the major lifeline for the local popula- Statistics tion and foreign communities during two world wars and several local and regional crises [1 ]. Between April 1975 and November 1976, 8,324 The 15-year civil war in Lebanon caught us casualties came though the Emergency Room of unprepared and stretched our resources beyond AUB (Table 21.1 ). The age range was newborn belief [ 2 , 3 ]. Confl ict had started after the balance to 76 years but most were adult males 14–30 of power in Lebanon became uneven. Before years; only 20 % were >30 years and 10 % <14 1975, the Sunni dominated the coastal regions; years. Gender differences were males 87 %, and the Shias were more in the South and the Druze females 13 %. Shrapnel was the cause of injury in the Central Chouf. The government was in the in 66 %, bullet wounds in 29 %, and blast inju- hands of Maronite Christians and had been pro- ries and extensive burns in 5 % [ 2 ]. Abdominal Western since the end of the French occupation. injuries were most common at 35 %, followed by With a large infl ux of Palestinians, Muslim num- chest 21 %, extremities 20 %, head 13 %, spine bers increased and opposition to the government 2 %, mandible 1 %, and multiple injuries 8 % grew. The war may have started after the fi sher- (Table 21.2). men in Sidon went on strike and the government moved to take over the port. Matters quickly escalated and foreign countries like Israel, Dead on Arrival Syria, Jordan, and Germany became involved. Several communist groups formed along with Patients dead on arrival at the Emergency Room other more militant organizations. Alliances had usually succumbed immediately from over- were made and almost as quickly broken. Chaos whelming injury or from exsanguination soon reigned. During the war that followed there (Fig. 21.2a–c ) Death from trauma occurs in a trimodal fashion. Fifty percent of deaths in the theater of war are immediate and result from * A. Baraka , M.D., F.R.C.A. (Hon.) ( ) massive injury to a major vessel, the heart, the Department of Anesthesiology , American University of Beirut-Lebanon, Bless Street , Beirut , Lebanon brain, or the spinal cord. After a hiatus period, e-mail: [email protected] sometimes called the “golden hour,” 30 % of

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 281 DOI 10.1007/978-3-319-09423-6_21, © Springer International Publishing Switzerland 2015 282 A. Baraka

Fig. 21.1 (a , b ) The AUB clock Tower before and after destruction. (c ) Center of Beirut destroyed

deaths occur as a result of potentially treatable minor problems. Patients were then discharged conditions such as hypoventilation, hemorrhage, home. hemopneumothorax, cardiac tamponade, or an 3. Patients who were dead on arrival were trans- expanding intracranial mass. Days to weeks later, ferred to the morgue. 20 % of patients die from sepsis or multiple- organ failure, or both. Challenges of Anesthesia

Triage Table 21.3 illustrates some of our challenges. Unprepared for such a massive onslaught personnel Triage in the emergency room (Fig. 21.3 ) con- were afraid. Also, given the large exodus of many sisted of assigning patients to one of the three who were able to leave Lebanon, we were short not categories: just of supplies but also of skilled people. 1. Seriously injured patients were stabilized Oxygen and nitrous oxide were in shortest sup- using measures such as ﬂ uid resuscitation, ply. We economized gas by using low ﬂ ows via a endotracheal intubation, and ventilation. carbon dioxide absorption circuit. All respirators They were then transferred for further inves- driven by oxygen (Ohio, Bird, etc.) were retired. tigation or surgery, or sent to the recovery Finally we used compressors to feed room air into room. anesthesia machines. The noise of these machines 2. Patients with lesser injuries were taken to compelled us to turn to simple draw over equip- the outpatient department reception area, ment such as the Epstein, Mackintosh, and Oxford where interns and medical students managed (EMO) inhaler (Fig. 21.4a, b). 21 Anesthetic Management During the Lebanese Civil War 283

Table 21.1 Casualties received at the American Table 21.2 Statistical analysis of operated casualties University of Beirut Medical Center from April 1975 to according to their sex, age, cause, and site of injury November 1976 Sex Male 87 % Female 13 % Casualties Admitted to Age 70 % 14–30 years treated in Total AUBMC Deaths 20 % more than 30 E.R. deaths from ER Month in OR years 1975 10 % less than 14 April 60 1 24 0 years May 38 7 9 1 Cause of injury Shrapnels 66 % June 28 0 12 0 Bullets 66 % July 41 1 24 0 Blast 5 % Aug. 10 1 0 1 Site of injuries Abdominal injuries 35 % Sept 86 0 31 0 Chest 21 % Oct. 110 1 58 1 Extremities 20 % Nov. 73 4 32 2 Head 13 % Dec. 235 5 58 1 Spine 2 % 1976 Mandibular 1 % Jan. 375 10 149 3 Multiple 8 % Feb. 92 4 25 2 Anesthesia Ketamine induction 55 % Mar. 788 39 207 3 Thiopentone 40 % Apr. 609 22 135 9 induction May 1,114 76 243 12 Regional anesthesia 3 % June 1,131 49 245 7 No anesthesia 2 % July 793 52 132 1 Blood transfusion 50 % received blood Aug. 1,008 53 143 3 transfusion Sept. 631 33 92 2 Intraoperative death 2.9 Oct. 750 54 126 6 Reprinted from MEJA 7(1–2) 1983 by kind permission of Nov. 352 17 57 0 Prof M.K. 8,324 429 1,802 54 5.15 % 2.99 % fresh blood donated by relatives and militia comrades. Simple clinical criteria such as adequate urine output, blood pressure, and pulse rate Preoperative Assessment assessed replacement therapy. Arterial blood gas analyses were available as were As many as 150 casualties might come in simul- blood warmers. Metabolic acidemia was corrected taneously and we had to transfer more severely by sodium bicarbonate according to the equation injured cases to the recovery room where they Body weight() kg were assessed, resuscitated and triaged further Base deficit : (Fig. 21.5 ). Cardiac tamponade and major ves- 5 ´Base deficit mEq/. kg sel injuries were given ﬁ rst priority. Life- () threatening trauma cases were transferred directly to the operating room which was in Severely shocked patients were given 1 mEq/kg close proximity to the recovery room. Table 21.4 of sodium bicarbonate on arrival but routine lists our assessment. bicarbonate administration according to the Rapid infusion of lactated Ringer’s solution amount of transfused blood was not done via intravenous cannulae was initiated to correct because of the extreme variability in acid–base hypovolemia and we proceeded with emergency response to multiple blood transfusions. Rapid surgery without waiting for blood. Blood transfu- correction of acidemia was followed by cardiac sion was given in 50 % of cases usually with arrest in two patients. 284 A. Baraka

Fig. 21.2 (a , b ) Death on arrival. (c ) Death in the operating room

Fig. 21.3 Emergency room during an attack

Many patients with head injuries required surgeons preferred nasotracheal intubation, perhaps ventilator support and were intubated and ill-advised in the presence of maxillary and basal hyperventilated before surgery in the hope of skull fractures. Figure 21.6 shows the most severe stabilizing intracranial pressure. Intubating facial injury we treated. Tracheotomy under local patient with facial injuries was challenging, most anesthesia was done before general anesthesia 21 Anesthetic Management During the Lebanese Civil War 285 could be administered. Neck injuries often involved the spine, trachea, esophagus, and/or the Anesthetic Management of Head, great vessels. Neck, and Faciomaxillary Injuries Chest injuries included ﬂ ail chest, hemothorax, and pneumothorax which necessitated tracheal Head and neck injuries secondary to bullets, intubation and underwater seal drainage. Cardiac shrapnel, and/or glass were frequent. These injuries and cardiac tamponade were explored injuries involved the faciomaxillary structures, the immediately [4 ]. Abdominal injury especially liver upper airways and the carotid arteries, as well as and splenic injuries required prompt attention to the head and the cervical spine. Management of control internal bleeding. these patients followed a comprehensive approach that included safe transfer of the patient, airway management, and hemodynamic resuscitation.

Table 21.3 Statistical analysis of operated casualties according to their sex, age, cause, and site of injury Faciomaxillary Injury 1. Problems related to the civil war itself 2. Personnel defi ciency (death, exodus, isolation, and nervous exhaustion) At least one-third of the casualties suffered from 3. Defi ciency of supplies particularly oxygen and nitrous faciomaxillary injury. The maxilla was the most oxide commonly involved facial structure (24 %), 4. Work load followed by the mandible (18 %). Most maxillary 5. Problems of anaesthesia of the seriously traumatized fractures were of the compound comminuted patients such as type. Le Fort I (the transverse fracture), Le Fort (a) respiratory failure (b) shock, cardiac tamponade, fl ail chest… II (the pyramidal fracture), and Le fort III (c) full stomach (craniofacial disjunction) followed in order of 6. Special problems decreasing frequency, but were rarely in the sim- (a) postoperative respiratory failure ple or classical forms. Also, most mandibular (b) tetanus (c) gas gangrene fractures were of the compound comminuted (d) decompression sickness type. Mandibular fractures involved the body, the Reprinted from MEJA 7(1–2) 1983 by kind permission of parasymphyseal area, the condyle, the alveolar Prof M. Khatib margin, the angle, and ascending ramus and the

Fig. 21.4 ( a , b ) Patient anesthetized with ether using the EMO inhaler. The EMO inhaler connected to the Radcliffe respirator 286 A. Baraka

Fig. 21.5 The recovery room open 24 h, and accommodating up to 50 patients. Its function was often modiﬁ ed to serve as a preoperative and postoperative surgical intensive care

Table 21.4 Assessment of Injury 1. Adequate respiration and patent airway 2. Blood loss 3. Tissue damage 4. Possible fractures 5. C.N.S. or spinal cord injuries 6. Effect of injury on pulmonary, cardiovascular, renal, cerebral, and hepatic organs 7. Evidence of recent use of alcohol as drug abuse coronoid process in decreasing frequency. Since the mandible is a tubular bone, it is most vulnerable to fracture where the cortex is thin and, hence, most fractures occur in the ramus, while the second most common point of fracture is at the ﬁ rst or second molar.

Management of the Traumatized Airway

Adequate management starts with recognition of Fig. 21.6 Faciomaxillary trauma necessitating tracheostomy the traumatized airway and knowing the common patterns of disruption, as well as the differ- airway injury as potentially hypoxic, with a ent techniques of securing the airway. It must be compromised airway and as having recently emphasized that airway injuries are dynamic eaten. Essential monitoring includes continuous rather than static, and hence close observation is ECG and pulse oximetry. Awake examination of essential. Most catastrophes occur when possi- the airway and preoxygenation must be carried ble difﬁ culty with the airway is not recognized. out before any attempt is made to commence It may be safer to consider all patients with upper anesthesia or intubate the trachea. 21 Anesthetic Management During the Lebanese Civil War 287

Fig 21.8 Extensive burn necessitating tracheostomy

tubation if indicated, and to maintain postoperative oxygenation.

Neck Injury

Fig. 21.7 A patient with faciomaxillary trauma. Following surgery, the TEC was reintroduced via the tra- Injuries of the soft tissues were the commonest, cheal tube into the trachea . The trachea was extubated followed by trauma to the laryngotracheal com- over the TEC which was left in situ plex and the pharynx. The larynx is relatively superfi cial, and unprotected, and is thus vulnerable to injury, while the trachea is well protected by In patients with faciomaxillary injury, there the thoracic cage and pulmonary tissue which will may be airway obstruction from blood, teeth, serve to cushion the effect of blunt trauma and soft tissue, vomitus, or edema. Incomplete clo- even missile injury. Severe injury of the laryngo- sure of the airway will result in noisy, stertorous tracheal complex mandated tracheostomy. breathing; the patient is usually anxious, and Cervical spine fracture was always considered in may sit up and lean forward in order to allow patients with head and neck injury. As well, 10 % gravity to assist in preventing a disrupted tongue of neck injuries were complicated by carotid and/or mandible from falling backward and artery injuries. Most of the surviving patients had impacting the upper airway. Placing the patient only carotid lacerations, but few patients reaching in the lateral or semi-prone position may also the hospital alive had total disruption. The patients help to clear the airway. With severe disruption presented either with severe hemorrhage from a of the airway, emergency tracheostomy may be neck vessel, or with a rapidly expanding neck the safest method of securing the airway hematoma compromising the airway. Neurologic (Fig. 21.7 ). defi cits were present in about one-third of those In some patients with severe faciomaxillary cases. Most of the vascular injuries were repaired trauma, the Cook tube exchange catheter by end-to-end anastomosis, with or without a (TEC) was inserted, following induction of venous graft. A shunt was not used in the assump- anesthesia and direct laryngoscopy, into the tion that most victims were young healthy patients trachea to facilitate tracheal intubation( who had an adequate collateral circulation. Fig. 21.8). At the end of surgery, the TEC was Neurological defi cit sequelae occurred in patients reintroduced via the tracheal tube lumen before who were severely shocked, or who had a delayed extubation, in order to facilitate tracheal rein- transfer to the hospital. 288 A. Baraka

Head Injuries About 85 % of patients with transection above T6 exhibit the refl ex. About 10 % of all casualties seen during the study Moreover plasma catecholamines (epinephrine period had an injury to the skull and a little more and norepinephrine) are subnormal in patients than half of them suffered a penetrating brain with cord transection. During autonomic hyper- injury. There were three types of injury; high refl exia, the level of norepinephrine increases velocity, low velocity and tangential. Craniotomy but still does not exceed the resting level of con- whenever feasible was found to be superior to the trol normal patients. Thus, patients with chronic accepted technique of craniectomy. It affords a spinal cord transection have a subnormal sympa- wider fi eld, better exploration, and greater decom- thetic tone, even during an attack of autonomic pression and does not have the disadvantage of hyperrefl exia. The results suggest that the exces- requiring a second operation for cranioplasty. sive refl ex elevation of blood pressure in patients Mortality and morbidity rates were no higher than with spinal cord transection is not secondary to for craniectomy. Retained fragments of bone are autonomic hyperrefl exia, but is rather due to a not as dangerous as is widely believed. If a thor- denervation supersensitivity response to the ough debridement of the brain is carried out with released norepinephrine. perfect hemostasis, one or two deeply placed bone Although many patients with spinal cord inju- fragments have no deleterious effect, at least for ries were not candidates for immediate surgery, the period of our follow-up ranging from 3 to 15 they often developed later complications that months. However, patients with retained bone required intervention, especially adequate anes- fragments should be closely observed for at least thetic management [6 ]. 6 weeks. Traumatic aneurysms are not as rare as the literature indicated. Routine postoperative arteriography was carried out [ 5 ]. Limb Injuries

No matter how effi cient the eventual manage- Spinal Cord Transection-Autonomic ment of war injuries may be, good results depend Hyperrefl exia on early proper treatment. Essential fi rst-aid, energetic resuscitation, wound excision plus Spinal cord injuries carried with them the risk of delayed primary closure and coverage of the later development of autonomic hyperrefl exia. wound with split thickness graft at the proper Traditionally, autonomic hyperrefl exia has time, and immobilization are the essential prin- been attributed to massive unchecked refl ex ciples that have been learnt from war surgery [7 ]. sympathetic discharge that occurs below the They must be applied to missile wounds in par- level of spinal cord transection in patients with ticular those resulting from high velocity bullets, chronic spinal cord injury. In neurologically and high velocity fragments from explosive blasts intact individuals, spinal sympathetic outfl ow is (Fig. 21.9). These principles must be understood modulated by inhibitory impulses from higher by all who are concerned with the treatment of centers in the central nervous system. In patients wounded patients. They have stood the test of with spinal cord transection, the spinal sympa- time and sadly they have to be relearned the hard thetic outfl ow is isolated from restraining supra- way in every war [7 ]. spinal infl uence, and hence stimulation below the level of cord transection initiates an exagger- ated autonomic refl ex, resulting in excessive Techniques of Anesthesia vasoconstriction below the level of cord injury with marked elevation of the blood pressure. General anesthesia was used in 95 % of the cases, Elevation of the blood pressure will be sensed by while regional analgesia was only used in 3 % and the baroreceptors resulting in refl ex bradycardia no anesthesia in 2 %. Regional analgesia was and vasodilation above the level of transection. limited in the emergency situation because of the 21 Anesthetic Management During the Lebanese Civil War 289 severity and multiplicity of trauma and because of for 3–5 min has been commonly practiced as the the associated shock and/or respiratory failure. standard technique for preoxygenation. However, All patients were considered as full stomachs eight deep breaths within 60 s can produce maxi- and rapid sequence induction anesthesia was mal preoxygenation, and is followed with slower used in most with application of the Sellick desaturation than that following the traditional maneuver [ 8 ]. tidal volume preoxygenation [9 , 10 ].

Preoxygenation C o n ﬁ rmation of Tracheal Intubation

Preoxygenation is widely accepted to increase Auscultation of breath sounds is the traditional oxygen reserves and delay the onset of arterial technique for confi rming tracheal intubation and oxygen desaturation during subsequent periods end-tidal capnography has been used since the of apnea. For many years, tidal volume breathing mid-1980s. Capnography was not available to us, and we relied on the self-infl ating bulb of the esophageal detector devices to confi rm tracheal intubation (Fig. 21.10a–c ). The underlying principle is that the esophagus collapses when a negative pressure is applied to its lumen, while the trachea does not. Nunn utilized a self-infl ating bulb (SIB) of 75–90 ml capacity. After tracheal intubation, the device is connected to the tracheal tube, and the bulb is compressed. Compression is silent and refi ll is instantaneous if the tube is in the trachea. In contrast, if the tube is in the esophagus, compression of the SIB is accompanied by a characteristic fl atus-like noise, and the SIB Fig. 21.9 Limb injury remains collapsed on release [11 ]. The technique

Fig. 21.10 The self-infl ating bulb (SIB) for confi rmation tracheal versus esophageal intubation. (a ) SIB. ( b ) The bulb remained collapsed denoting esophageal intubation. (c ) The bulb refi lled denoting tracheal intubation 290 A. Baraka was modifi ed by compressing the SIB before connected to the air inlet of a Radcliffe respirator rather than after, connection to the tracheal tube (Fig. 21.11a, b). Both ether and ketamine anes- connector [12 ]. thesia maintained stable circulation, provided the blood volume was maintained. Such simple techniques of anesthesia proved Anesthesia their safety. In rush hours, one anesthesiologist might cover up to fi ve operating rooms at the same Anesthesia was induced in 55 % of patients with time. The patient was anesthetized, monitored by ketamine 2 mg/kg intravenously for induction and EKG, attached to the respirator, and was left followed by 1 mg/kg every half an hour for main- attended by a student, a nurse, or a technician and tenance. Tracheal intubation was facilitated by occasionally unattended except by the surgeon. succinylcholine 100 mg. while pancuronium was used to maintain muscular relaxation. Controlled Table 21.5 Arterial blood gas analysis (PO2, PCO2, and ventilation was achieved either manually by the pH) in traumatized and anesthetized patients ventilated Ambu bag, or by connecting the tracheal tube to an PO2 (mm Hg) PCO2 (mm Hg) pH electrically driven respirator such as the Radcliffe 90 16 7.63 or Emerson. No signifi cant operative awareness 65 37 7.45 or post-operative hallucinations were observed 90 23 7.58 following pure ketamine anesthesia in shocked 92 21 7.6 patients, despite the limitation of premedication 50 30 7.56 to atropine. PaO2 and PaCO2 were adequately 100 19 7.7 maintained, as spot checked by arterial blood gas 85 40 7.37 analysis (Table 21.5 ). 90 41 7.4 The E.M.O. (Epstein, Macintosh, Oxford) 90 25 7.66 draw-over ether inhaler proved itself during this 110 30 7.49 crisis. Following intubation and connection to the 120 25 7.51 E.M.O. inhaled anesthesia was maintained with 118 17 7.6 3 % ether and pancuronium, while controlling 110 22 7.54 respiration manually. The E.M.O. could be also Mean 93.0 26.6 7.54

Fig. 21.11 ( a ) Ventilating with an EMO draw-over inhaler and (b ) a Radcliffe respirator 21 Anesthetic Management During the Lebanese Civil War 291

None of the mild cases of tetanus died, Specifi c Problems Specifi c Problems while three of the moderate and severe cases died from secondary to sepsis, pulmonary 1 . Respiratory failure embolism, and respiratory failure. Another Patients with multiple injuries and head case of severe tetanus developed a compres- injuries were artifi cially ventilated. Spinal sion fracture of the dorsal spine during cord injuries associated with quadriplegia, convulsions. chest injuries, particularly those associated 3 . Gas gangrene (Fig. 21.14 ) with fl ail chest and/or severe lung lacerations, Several patients developed gas gangrene. and massive abdominal injuries also necessi- Anaerobic infections, particularly those due to tated respiratory support. The “shock lung clostridial organisms, respond dramatically to syndrome” resulting from multiple factors hyperbaric oxygenation. We did not have enough such as: aspiration, fat emboli, pulmonary oxygen and could only manage ten patients edema, massive blood transfusion and/or using 7–9 sessions each limited to 2 h reaching shock all necessitated prolonged I.P.P.V. using PEEP and high FIO2. Weaning was sometimes Table 21.6 Cases of tetanus classifi ed according to incu- delayed and problematic (Fig. 21.12 ). bation period 2 . Tetanus Incubation period (injury-trismus) We treated 11 patients with tetanus follow- Severity No. 14 days 10–14 days 10 days ing trauma. The cases were classifi ed into mild, Mild 3 2 1 0 moderate, or severe according to the clinical Moderate 2 2 0 0 picture, incubation period (injury-trismus), and Sever 6 2 2 3 onset period (trismus-convulsions) (Tables 21.6 and 21.7, Fig. 21.13). The severity of tetanus correlated better with the onset period rather Table 21.7 Cases of tetanus classifi ed according to onset period than the incubation period. All cases of severe tetanus required intubation to be followed by Severity No. Incubation period (injury-trismus) tracheostomy, curarization, and intermittent 7 days 3–7 days 3 days positive pressure ventilation. The period on Mild 3 3 – – respiratory control varied between 5 and 55 Moderate 2 – 1 1 days (average 4 weeks). Sever 6 – – 6

Fig. 21.12 Patient with multiple injuries necessitating respiratory support 292 A. Baraka

Brain Death

Because of the increasing number of casualties in face of the shortage of personnel, supplies, and space, some guidelines depending on brain function were established to be applied according to the injuries and circumstances: 1. Total support: normal brain function or brain failure with potential reversibility. 2. All but CPR (cardiopulmonary resuscitation): normal brain function or brain failure with Fig. 21.13 Child suffering from tetanus potential reversibility + irreversible vital organ failure. 3. No extraordinary measures: severe irreversible brain failure with only minimal neurological activity + irreversible other vital organ failure. 4. Brain death. Unfortunately, we could not manage all patients even those in the ﬁ rst two categories. Death was surrounding us, and often we could not prevent it.

Acknowledgement I am extremely grateful to Dr. Mohamad Khatib, Managing Editor of the Middle East Journal of Anesthesiology and Director of the Respiratory Therapy Department, for reviewing my report and granting permission to reprint several ﬁ gures that are published in the Middle East Journal of Anesthesiology 7(1–2), pp 41–53, 1983.

References

1. Khuri RN. The summer of 1982. M E J Anaesth. 1983;7(1–2):107. 2. Baraka A. Anaesthetic problems during the tragic civil war in Lebanon. M E J Anesth. 1983;7(1–2): 41–53. 3. Shehadi SI. Anatomy of a hospital in distress. M E J Fig. 21.14 A patient with gas gangrene inside the com- Anaesth. 1983;7(1–2):21–7. pression chamber to undergo hyperbaric oxygen therapy 4. Slim M, Yacoubian HD, Dagher I. Penetrating injuries of the heart and great vessels. M E J Anaesth. 1983;7(1–2):94–104. three absolute atmospheres (3 AT.A.). Some 5. Haddad FS. (Wilder Penfi eld Lecture) Nature and surgeons amputated the affected areas fi rst and management of penetrating head injuries during the civil war in Lebanon. M E J Anesth. 1983; then put the patient in the compression chamber, 7(1–2):73–5. while others believed that the patient should be 6. Baraka A. Is it autonomic hyperrefl exia or denervation put fi rst in the compression chamber. supersensitivity. M E J Anaesth. 1989;10(2):95–7. Our compression chamber was small and 7. Nsouli A. War injuries of limbs. Basic principles of management. M E J Anaesth. 1983;7(1–2):137–40. portable and could only accommodate the 8. Baraka A. “Crash induction” in patients with full patient (Fig. 21.14 ) . stomach. M E J Anaesth. 1979;5(4):283. 21 Anesthetic Management During the Lebanese Civil War 293

9. Baraka AS, Taha SK, Aouad MT, et al. Preoxygenation: 11. Nunn JF. The oesophageal detector device. comparison of maximal breathing and tidal volume Anaesthesia. 1988;43:804. breathing techniques. Anesthesiology. 1999;91:612–5. 12. Baraka A. The oesophageal detector device. 10. Benumof JL. Preoxygenation. Best method for both Anaesthesia. 1971;45:697. efﬁ ciency and efﬁ cacy (editorial). Anesthesiology. 1999;91:603–5. Trauma, War, and Managing Vascular and Orthopedic Injuries 22

John Benjamin and John Rotruck

Introduction Injury Patterns

There are marked differences in trauma anes- There is considerable data on injury cause and thesia between the dedicated trauma center in location for US military forces in confl icts from the developed world and the care that is ren- World War I all the way to the most recent decade dered under less than ideal conditions in the of war in Iraq and Afghanistan [ 1 ]. It can be rea- wartime environment. These differences sonably extrapolated that the armed forces of include the variety of injuries that can be antic- other fi rst-world nations experienced similar ipated. While the clinical guidelines of US and injuries over the same time period, both in the NATO military medicine units are referenced cause and affected parts of the body. Far less data here, similar protocols may be encountered exists on the injury patterns experienced by the among other military units. Preoperative evalu- civilian populations in these same confl icts, or ation and resuscitation of war-injured patients, for the combatants representing guerilla armies their intraoperative care, and the postoperative or insurgent forces not tied to a specifi c nation. environment along with considerations for Nevertheless, some general observations can be transfer to other facilities are presented. made on the evolution of wartime injuries for Finally, the use of regional anesthesia tech- these various groups. For all of these groups, it is niques for wartime casualties with possible important to consider the rise in use of the impro- benefi ts extending beyond the operating room vised explosive device (IED) as a cause of injury is considered. in the modern era to be of equal or greater or importance than traditional weapons of war. Nowhere is the shift to IED-related injuries more apparent than for the armies of developed nations. During World War II, a third of injuries were due to gunfi re, with the remaining majority The views expressed in this chapter are those of the coming from mortar rounds, artillery, and gre- authors, and do not necessarily refl ect the offi cial policy or position of the Department of the Navy, Department of nades. In more recent confl icts in Iraq and Defense, or the US Government. Afghanistan, gunfi re still accounts for a quarter J. Benjamin , M.D. (*) • J. Rotruck , M.D. of injuries, but two-thirds of injuries are now due Department of Anesthesia , Walter Reed National to IEDs. The injury location and severity have Military Medical Center , 8901 Wisconsin Avenue , also evolved. Although extremity injuries have Bethesda , MD 20889 , USA always been prevalent, they are now much more e-mail: [email protected]; [email protected] likely to be traumatic amputations due to IED

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 295 DOI 10.1007/978-3-319-09423-6_22, © Springer International Publishing Switzerland 2015 296 J. Benjamin and J. Rotruck blasts rather than simple gunshot or fragment greatly by the skill levels of the individuals in the wounds. Signifi cant penetrating injuries to the fi eld, combined with their available supplies, and thorax and abdomen are less common, which is the extent of ongoing hostilities. In the event of easily explained by the widespread use of high- active fi ghting, the priority will be on protecting quality body armor in these areas. Many poten- the fi ghting forces and enabling medical evacua- tially catastrophic exposures to IED blasts result tion instead of rendering care. Likely pre-hospital in no fatalities due to the use of heavily armored interventions include obtaining intravenous vehicles, although traumatic brain injury of vary- access and administering crystalloids, or some- ing degrees is quite common for the occupants of times packed red blood cells. Occasionally, these vehicles, as the blast can still easily over- advanced airways will also be placed in the fi eld, turn the vehicle. whether intubation with an endotracheal tube In contrast, the civilian population and guerilla (ETT) or percutaneously with cricothyroidotomy. or insurgent forces can be considered together, as For any in-situ advanced airway encountered, it is they often uniformly lack any sort of body armor, important to confi rm that it is in the trachea. As helmets, or armored vehicles. For these groups, would be expected, airway devices placed in fi eld wartime injuries can and do cross the entire spec- conditions have a higher failure rate than those trum. In the absence of any protective equipment, placed in a medical facility. Confi rmation should exposure to an IED blast results in more battle- include the presence of end-tidal CO2 and bilat- fi eld fatalities before these individuals can be eral breath sounds, with the understanding that a brought to any level of medical care. pneumothorax or hemothorax might obfuscate the latter fi nding. For patients with facial or head injuries, sometimes advanced airways are placed Preoperative Assessment in the fi eld preemptively, despite the patient having a normal level of consciousness and adequate Preoperative evaluation of wartime casualties minute ventilation without signs of respiratory begins with ensuring that they can be safely distress. In these instances, if the advanced airway treated by the surgical team. For friendly forces, from the fi eld is not found to not be in the trachea, this includes having a security team remove any consideration should be given as to whether it weapons, ammunition, and other potentially dan- needs to be urgently replaced. gerous items, preferably at a point prior to enter- Unless the patient is in respiratory or cardiac ing the medical facility. This security search arrest on presentation, securing the airway with- should also look for unexploded ordinance (i.e., out patient resistance is usually contingent on an unexploded grenade), which the casualty may fi rst obtaining intravenous (IV) access and not even be aware of depending on the extent of administering the appropriate anesthetic and their injury. This search and clearing phase is muscle relaxant agents. As with other trauma even more critically important in the case of scenarios, one or more short, large-bore periph- civilians and insurgent fi ghters, who are essen- eral IV catheters are the most desirable form of tially indistinguishable from each other. It would initial access. However, in the patient with exten- be a simple matter for an insurgent to present a sive injuries including multiple traumatic ampu- real or simulated injury in order to gain access to tations as may be seen with IED blast exposure, the medical facility, and then detonate concealed peripheral IV access may not be available. These explosives or attack the health care team with patients are often the ones most in need of early hidden weapons. aggressive resuscitation with blood products, so Patients may arrive via ground vehicle or on IV access is a high priority. If central venous aircraft, although those being transported by air access is required, an introducer of at least 8.5 are often met by a ground vehicle at the runway or French diameter with one or more side arms helipad for fi nal transport to the medical facility. should be used instead of long, multi-lumen cath- The extent of post-injury pre-hospital care varies eters of smaller diameters. For central venous 22 Trauma, War, and Managing Vascular and Orthopedic Injuries 297 cannulation, any site where access may be of whether they arrive to the medical facility with obtained quickly is suitable, although there are a cervical collar and other spinal precautions in advantages and disadvantages to each. The inter- place. Well-functioning suction and tools for nal jugular vein is the easiest for the anesthesia managing diffi cult airways should be readily provider to access, but it may be unavailable due available at this time, to include the Eschmann to the presence of a cervical collar. The subcla- tracheal tube introducer (aka bougie) and other vian vein is also an option, although the haste adjuncts such as a video laryngoscope and/or a with which these lines are placed in a trauma set- lighted intubating stylet. Once the patient is intu- ting may increase the risk of known complica- bated, or for patients who arrive with an advanced tions such as non-compressible vessel injury and airway in place, it is recommended to place them pneumothorax. The femoral vein does offer some on mechanical ventilation in the preoperative advantages in the trauma setting: phase in order to maximize the ability of the team • Generally offers easy access for the surgeon to to focus on other aspects of the patient’s care. place the catheter. Most patients arrive tachypneic as an adaptive • Although the femoral vein is considered a response to the trauma and shock. Respiratory “dirty” site, central venous catheters placed in rates should be maintained (at least 20 breaths an emergent trauma setting are rarely inserted per minute) on the ventilator and then adjusted as

with ideal sterile technique and full body blood gas or end-tidal CO2 readings become draping. Using the femoral site initially pre- available. serves the internal jugular and subclavian Drugs to facilitate intubation for wartime casu- veins for later access in a controlled environ- alties are similar to other trauma situations. ment with the use of true sterile technique if Although any induction agent can be utilized, central venous access is still required. those with minimal hemodynamic effects are bet- • In the event the femoral artery is inadvertently ter suited for the trauma patient. In the absence of accessed, consideration should be given to signifi cant myocardial injury, Etomidate is hemo- advancing a guidewire, and then continuing dynamically comparatively stable as opposed to on with accessing the femoral vein. Once the Propofol and the barbiturates. Ketamine is also an femoral vein has been successfully cannu- option, although the expected small increase in lated, a catheter can be advanced over the wire sympathetic tone to help support the blood pres- in the femoral artery to use for arterial pressure is usually not seen in signifi cant trauma, as sure monitoring, as more peripheral arteries these patients already have high sympathetic out- such as the radial can be diffi cult to success- put. For the severely injured patient, the expecta- fully access in the setting of trauma and sig- tion would be a single endotracheal intubation at nifi cant hypotension. the fi rst medical facility providing surgical care, Once IV access is established, or immediately with the ETT remaining in place through most of in the case of cardiac or respiratory arrest, the the critical care phase of the patient’s recovery, to anesthesia provider’s attention can turn to secur- include early follow-up surgeries. Therefore, rela- ing the airway. Indications for endotracheal intu- tive contraindications to succinylcholine such as bation remain the same as other non-wartime use more than 24 h after a signifi cant burn or spi- trauma patients. All of these patients should be nal cord injury generally will not apply to this considered to be at increased risk for aspiration population. If succinylcholine is used to facilitate regardless of the timing of their last oral intake, the intubation, it will likely be of benefi t to admin- so some version of a rapid-sequence intubation is ister a longer-acting nondepolarizing neuromuscu- recommended. It should be expected that any lar blocking agent once the airway is secured. casualty exposed to an IED blast is at risk for cer- Concurrent with appropriate airway manage- vical spine injury, so those patients should have ment and following establishment of IV access, airway management conducted with manual volume resuscitation must begin for severely in- line cervical spine immobilization, regardless hypovolemic patients with signifi cant blood loss. 298 J. Benjamin and J. Rotruck

The later section on transfusion medicine will with a Glasgow Coma Scale (GCS) score of less address issues such as the ratios of blood compo- than 9 with one for both pupils fi xed and dilated nent therapy and the use of fresh whole blood. and asymmetric motor posturing are at the high- However, the preoperative phase is where aggres- est risk. In addition to standard efforts to avoid sive resuscitation with blood products must begin hypoxemia and hypotension, normocarbia should for these severely injured patients, with the goal be maintained with a goal PaCO2 of 35–40, of minimizing the total amount of crystalloid unless there is a need to transiently hyperventi- infused. For patients deemed to be appropriate late the patient to acutely decrease the ICP in candidates for antifi brinolytic therapy, this is also response to rapid clinical deterioration. In the the time to begin the initial bolus of tranexamic absence of readily available POCT for arterial acid (TXA). If rapid transfusion devices are blood gases, an end-tidal CO2 goal of 30–35 can available, they should initially be used in the pre- be used for most patients. In addition, a bolus and operative environment, and then follow the infusion of 3 % saline can be administered, even to patient into the operating room to continue the patients who are hypotensive, whereas the second- resuscitation. It is critically important to adminis- line agent Mannitol should not be used in the ter supplemental IV calcium as needed to offset setting of ongoing hypotension and hypovolemia. the chelating effect of the additives to various If serum chemistries are available, the target serum blood products. If time allows, point-of-care test- sodium level is 155–160 mEq/L. Despite a long ing can be utilized to monitor and maintain the history of controversy in the literature, steroids are ionized calcium level in the normal range. not currently indicated in the management of head However, in the midst of a massive transfusion, it injury [2 ]. Although aggressive measures are gen- may be necessary to simply administer IV cal- erally employed to prevent heat loss in trauma cium empirically, particularly in the setting of patients to prevent hypothermic coagulopathy, new or worsening hypotension without other head injury patients are one subgroup who should obvious causes. not be allowed to become hyperthermic as a result For patients with traumatic amputations, the of warming efforts. surgeons may desire to release the tourniquets in Early on in the preoperative phase, it is impor- the preoperative period for a number of reasons. tant to make an overall assessment of the surviv- First, they may want to better assess the extent of ability of the casualty’s injuries. This assessment vascular injury and whether there is ongoing is not based solely on the ability of the initial blood loss. In addition, from an orthopedic stand- surgical team to keep the patient alive through point, minimizing tourniquet time also decreases transport to the next facility. It must take into the risk of nerve injury. Since the anesthesia pro- account what follow-on surgical and intensive vider is usually ultimately responsible for main- care is available for the particular patient. This taining the patient’s hemodynamics, it is critically level of care available may be dictated by the important for the surgeons to communicate their patient’s status as a member of the armed forces intent to release a tourniquet. Likewise, the anes- of the host nation or a foreign government, or if thesia provider should not consent to the release the patient is a civilian or insurgent fi ghter who of a tourniquet unless the patient has adequate IV will be classifi ed as a prisoner of war. Severe access to permit a massive transfusion, and the injuries that might be survivable with multiple immediate availability of blood products to sup- surgeries and an extended ICU stay in the devel- port that transfusion if needed. oped world may not be so in other parts of the Particularly with exposure to IED blasts, it is world. If the injury is deemed non-survivable common for wartime patients to present with based on the access to follow-on surgical and closed head injury and the risk of increased critical care, the surgical team may need to make a intracranial pressure (ICP). Closed head injury diffi cult decision about how best to utilize limited can be diffi cult to assess in the setting of other resources in caring for these patients. For example, concomitant signifi cant injuries. Blast victims the team may elect to evaluate the likelihood of 22 Trauma, War, and Managing Vascular and Orthopedic Injuries 299 long-term survival after administering 10 units For maintenance of anesthesia during the of blood products before deciding to continue surgical procedure, there are several options avail- with resuscitative efforts. This is a diffi cult deci- able. If calibrated vaporizers for volatile anesthet- sion that is very much dependent on the circum- ics and a delivery system are available, anesthesia stances of both the individual patient and the can be maintained as for any routine case in the health care system. developed world. One challenge with this in austere environments is the ability to provide waste anesthetic gas disposal. As an alternative to vola- Intraoperative tile anesthetics, a balanced total IV anesthetic (TIVA) can be employed. In regular hospitals it For the anesthesia provider, the intraoperative might be common to do TIVA using a separate management of the wartime casualty is mainly a pump and tubing for each IV agent. In a wartime continuation of what has been done in the preop- scenario, it may be simpler to mix varying ratios of erative period. If the airway was not secured before Propofol, Ketamine, a benzodiazepine such as coming to the OR, that is usually the fi rst step after Midazolam, and an opioid such as Fentanyl into a applying the appropriate monitors. Resuscitation 100 or 250 mL IV bag and use a micro-dripper in with blood products and fl uids must continue, with order to titrate the TIVA to effect. This technique the agreed upon ratios of packed red cells to fresh requires no IV pump or electrical power, and any frozen plasma and platelets, or alternatively with combination of the aforementioned drugs can be the use of fresh whole blood. used at the practitioner’s discretion. The intraoperative phase is also the time to If the patient will require longer-term central introduce the concept of damage control surgery venous access for their postoperative care, the (DCS). DCS has been growing in acceptance intraoperative setting is a good time to perform amongst both military and civilian surgeons. The that cannulation under sterile conditions. fundamental principle behind DCS is attempting Likewise, if regional anesthesia is being consid- to minimize the time initially spent in the OR ered for post-operative pain management, this after injury, limiting interventions to attaining may be a good opportunity to employ that tech- hemostasis and stopping further contamination. nique under controlled circumstances while the The focus is on getting the patient to an intensive patient is still under general anesthesia. care setting in order to restore coagulation, reverse acidosis, and regain normothermia, prior to returning to the OR for more defi nitive surger- Postoperative ies [3 ]. The corollary to DCS is damage control resuscitation (DCR), which further attempts to Modern deployed trauma facilities are not limit or prevent coagulopathy by using a combi- designed to hold patients and need to be part of nation of blood components, antifi brinolytics, an extensive evacuation system. In Afghanistan and recombinant factor VIIa, while simultane- and Iraq, seriously wounded US and allied casu- ously avoiding dilution of these factors by alties were evacuated the night of injury to either excessive use of crystalloid. Each of these ele- a larger facility in theater or to Landstuhl ments of component therapy is considered in Regional Medical Center in Germany. From more depth in the later section on Transfusion Germany, US patients proceeded either to the Medicine. A further principle of DCR is the Walter Reed National Military Medical Center in notion of permissive hypotension until surgical Maryland or, particularly if signifi cant burn inju- control of bleeding is attained, with the exception ries were present, to the Brooke Army Medical of head injury patients [4 ]. While DCS begins in Center in Texas. Most combat hospitals are not the OR, the principles of DCR begin as soon as designed to hold patients for any length of time. IV access is obtained preoperatively in severely In many facilities, the anesthesiologist functions injured patients. as the intensivist and trauma and perioperative 300 J. Benjamin and J. Rotruck nurses staff the ICU. It is critical that continual case. Ethical issues such as code status and end of communication be maintained between the life issues on critically injured local patients can combat hospital and the evacuation and air asset quickly overwhelm a small combat hospital. command. If just a few critically injured patients Family members are often diffi cult to locate to require an extended stay in a small combat hospi- guide decision making. Knowledge of local cus- tal, the ability of that facility to receive new casu- toms and practices is necessary to avoid offend- alties may be signifi cantly degraded. ing citizens of the host country. In addition, Both patient and aircrew safety are major fac- employing translators who have medical knowl- tors in determining when a patient can be evacu- edge is often impossible. Using a translator who ated. Weather and enemy activity often prevent cannot comprehend the information that he is fl ight operations. Dust storms are often encoun- then conveying to a patient’s family is fraught tered in the Middle East and often ground fl ight with complications and potential immeasurable operations. The asymmetric nature of modern misunderstandings. warfare has blurred the concept of “front lines” and combat hospitals frequently come under attack by snipers and indirect fi re (rockets and Transfusion Medicine mortars). It is usually safest to operate medevac aircraft at night to lessen the risk of hostile fi re. Transfusion and resuscitation strategies are a Given all of these variables, there is usually a combination of factors based on trauma litera- limited period of time for aircraft to operate ture, logistics, facility capability, and patient vol- safely and patient transport may be delayed. As ume. Current practices advocate a “whole blood” discussed above, trauma patients often undergo and low crystalloid approach. Studies, mostly damage control procedures and can require return observational, call for a unit of plasma to be trips to the operative theater within several hours. transfused with every unit of packed red blood Frequently those patients are manifested for cells (PRBC) and an apheresis unit of platelets evacuation the following day. The ability to mon- (or “six pack” depending on transfusion medi- itor and intervene on an unstable patient is lim- cine services) administered after every six units ited in an aircraft, particularly a helicopter; of PRBCs. This research largely came from data therefore, questionable patients often remain in a from the most recent confl ict in Iraq [5 ]. Civilian facility until they are deemed stable enough to data investigating similar practices are more survive a several hour fl ight. equivocal [6 , 7 ]. Most retrospective studies con- Coordination with local host nation medical tain survivor bias, meaning that a patient enrolled assets and capabilities is essential and must be in the high PRBC to plasma ratio group must constantly assessed and updated. A critically survive long enough to receive thawed plasma. injured local patient may be stable enough for A recent randomized prospective trial in civilian transport but the receiving facility may have trauma centers demonstrated a survival benefi t at inadequate equipment, such as ventilators, 6 h in patients receiving increased plasma and staffi ng (physicians able to perform vascular pro- platelet to PRBC ratios but no benefi t after 24 h cedures) or technical knowledge (can they place and no survivor benefi t in patients who were alive an intramedullary nail or just apply an external after the fi rst day [8 ]. fi xator?). It is recommended that, if feasible and In a well-supplied, busy trauma hospital, safe, site visits to local receiving hospitals be thawed plasma can be stored in close proximity made frequently and, if a facility will be used to the trauma bay and transfused in conjunction often, a permanent liaison team set up. What may with PRBCs. Due to the short shelf life of thawed seem to be a universal standard of care—such as plasma, another option in lyophilized plasma. sending more than just a driver in an ambulance This is a freeze-dried formulation of human to retrieve a ventilated patient—is often not the plasma that can be stored up to 1 month at room 22 Trauma, War, and Managing Vascular and Orthopedic Injuries 301 temperature and reconstituted when required. blood bank are infection, ABO compatibility, and There appears to be only a slight decrease in administrative implementation. Rapid HIV, HBV, clotting activity in lyophilized plasma when and HCV tests exist and should be performed on compared to thawed plasma [9 ]. every unit of whole blood prior to administration. Cryoprecipitate contains ten times the con- While the sensitivity of these tests is high, other centration of fi ve clotting factors compared to a infectious agents may be transferred to the recipi- unit of plasma, several which are rapidly con- ent, including bacterial contamination. With the sumed in an exsanguinating, critically injured chaos that normally surrounds a high volume of trauma patient. If available, cryoprecipitate trauma admissions and the inherent hygiene should be administered: issues that are present in a deployed environment, – With every 6–8 units of PRBCs. maintaining both aseptic technique and using – If labs are available and fi brinogen levels fall sterile equipment does not always take place. below 100 mg/dL. Unlike transfusing Type O PRBCs, there is no – If guided by point of care testing (see below). universal donor with whole blood. Not only does Caution should be exercised when using rapid donor blood need ABO/Rh typing performed, transfusion technology such as the Belmont Rapid but the recipient’s blood type must be confi rmed. Infuser® . The extremely high fl ow rates (in excess Patient recall and identifi cation systems (i.e., of 400 mL/min) may provide life-saving blood “dog tags”) are notoriously unreliable. The products to a trauma patient with uncontrolled administrative burden in implementing, main- hemorrhage. However, at this fl ow rate, blood taining, and utilizing a walking blood bank is products are being infused almost as quickly as signifi cant. Ideally, donors are pre-screened new bags are hung. Any delays in a continual sup- every 90 days for infectious diseases and their ply of new bags will often cause the operator to blood type is maintained on a roster. The frequent run saline while additional products are made rotation of donors in a forward deployed camp ready because interruptions in fl ow cause the mandates continued screening and updates to the machine to alarm and require repriming the roster. A reliable and prompt notifi cation and tubing. If the operator doesn’t decrease the fl ow response system must be in place for when blood rate, several liters of crystalloid can be infused, in is needed. If the walking blood bank is the pri- direct confl ict with the goal of low crystalloid/ mary source of blood products for a combat hos- high blood product resuscitation. pital, the call for donors must take place before arrival of casualties if at all possible due to the delay from notifi cation to units ready to trans- Walking Blood Bank fuse. This delay can be deadly to a bleeding patient. The nature of a combat trauma hospital Even in a well-established trauma network with a means patients often arrive unannounced. In the robust supply system, platelets are routinely not excitement surrounding initial casualty assess- available or must be obtained from donors at ment and treatment, clerical tasks such as ensur- individual treatment facilities. In response to the ing donor blood is properly labeled and then numerous supply, storage, and limited shelf-life subsequently verifi ed prior to transfusion may be issues of component therapy, the US military hastily done and thus prone to error. instituted a walking blood bank policy. Signifi cant observational data supports the use of fresh whole blood in bleeding trauma patients; however, this Point-of-Care Testing practice is not FDA approved and is used primarily when component therapy is limited or patient Portable blood analyzers such as the iStat® needs surpass blood bank capabilities. The pri- analyzer may help guide transfusion therapy in mary concerns with implementing a walking combat trauma victims. Rapid assessment of 302 J. Benjamin and J. Rotruck blood gas, hemoglobin concentrations and INR Recombinant Factor VIIa are available for interpretation. The US military also utilizes rotational thromboelastogra- The use of recombinant factor VIIa (rFVIIa) phy (ROTEM® ) in some of the larger deployed during a massive transfusion is both off label and combat hospitals. While a review and interpretation controversial given recent literature elaborating on ROTEM® is beyond the scope of this chapter, on the relatively high incidence of thrombosis ROTEM® can provide valuable data for the man- [11 , 12 ]. Administration during the resuscitation agement of a coagulopathic trauma victim and of a trauma patient should be on a case-by-case guide transfusion of component therapy. basis and not used as a routine. If bleeding is from an isolated source (i.e., inferior vena cava, femoral artery), the use of rFVIIa has little utility Tranexamic acid and surgical control is essential. However, blast injury patients often have dozens of penetrating Tranexamic acid (TXA) is an antifi brinolytic wounds not amenable to rapid surgical interven- shown to decrease mortality in civilian trauma tion. The authors recommend use of rFVIIa in an patients and is used in deployed US military exsanguinating patient with multiple injuries trauma hospitals [10 ]. TXA’s effects are believed where rapid surgical control of bleeding cannot to blunt the hyperfi brinolysis associated with the be obtained. coagulopathy seen in trauma patients. Survivor benefi ts are most signifi cant if administered within an hour of injury and there appears to be no benefi t Regional Anesthesia beyond 3 h post-injury. In a combat environment where evacuation is often delayed due to ongoing Regional anesthesia was once considered an enemy activity in the landing zone or evacuation intervention best utilized after patients were point, the 3-h window for TXA administration is evacuated out of the combat zone and stabilized not always possible. Current US military guide- in a tertiary care center. Thanks to the works of lines advocate administering TXA in concordance Buckenmaier et al. and other military acute pain with the CRASH-2 trial recommendations. One specialists, regional techniques are utilized gram of TXA is given intravenously over 10 min early in combat trauma patients [ 13 ]. Although and a second gram is infused over 8 h. TXA no formal studies have investigated the infection should not be administered through the same line rate associated with regional techniques per- in which blood products are infusing. In addition, formed in combat hospitals, there appears to be plasma volume extenders derived from starch, no increased infection rate. There is data to sup- such as Hextend® or Hespan ® , should not be used port early intervention in the pain process to as a carrier fl uid or infused through the same line prevent both chronic and phantom limb pain as TXA. Some experts believe that hetastarch [14 ]. While preemptive analgesia cannot be products may attenuate the antifi brinolytic activity obtained in trauma patients, an effective nerve of TXA. block that persists until central sensitization The use of TXA with either recombinant subsides may help prevent chronic pain. Patients factor VIIa (rFVIIa) or activated prothrombin with traumatic amputations require multiple complex concentrate (APCC) must be carefully wound wash outs before fi nal closure. These considered given the theoretical risk of forming repeated reinitiating events are best prevented, thrombotic complexes. In the CRASH-2 trial, a if possible, by a continuous nerve catheter rather small number of patients in the TXA treatment than multiple single shot injections. In addition, group also received rFVIIa with no recorded there may also be mental health benefi ts as well. thrombotic complications. However, it is diffi cult In Afghanistan, we were able to extubate many to draw any signifi cant conclusions given the patients after the OR that traditionally would small sample size in a subgroup analysis. have remained intubated for their evacuation 22 Trauma, War, and Managing Vascular and Orthopedic Injuries 303

fl ight. Instead of squad members visiting an chronic pain maybe decreased. Similarly, further intubated and sedated patient, we often wit- research by Gironda et al. [ 17] suggested that in nessed joyous reunions and conversations. It is order to decrease the total pain experienced along our belief that this early “telling your story” with effectively treating associated comorbid may have later benefi ts and help prevent or conditions such as post-traumatic stress disorder lessen posttraumatic stress disorder. and postconcussive syndrome will require the In deciding between single shot peripheral development of integrated approaches to clinical nerve blocks and continuous techniques, whether care which bridge traditional subspecialty divi- peripheral or neuraxial, a safe delivery system for sions. Several of these multi-specialty teams are local anesthetic must be considered. The US mil- in operation and their long term effectiveness will itary used pumps cleared for fl ight operations. be evaluated. Given the logistics of air evacuation and variables such as cabin pressure, pumps must undergo certifi cation before use to prevent such disasters as Summary runaway infusion. If a single shot technique is utilized, the timing of the block must coincide The modern combat hospital spans a few tents with evacuation to avoid loss of analgesia while with a makeshift operating room and basic sup- airborne. plies to stabilize a patient all the way to hardened Controversy exists regarding regional anes- structures with modern facilities and capabilities thesia and masking compartment syndrome in such as interventional radiology and MRI scan- extremity injuries. The literature does not support ners. Ideally, each hospital should be part of an this belief [15 ]. The use of local anesthetic tech- established evacuation system to both receive and niques to achieve a surgical block should not be discharge casualties. Capabilities are often lim- continued into the postoperative period. Low- ited by logistics and therefore goals, such as concentration infusions (i.e., bupivacaine 0.125 blood product administration, must be estab- or 0.25 %) should provide analgesia while main- lished so a single patient doesn’t exhaust the taining an examinable extremity. What is even resources available. Combat hospitals see pri- more important is an educated surgical staff and marily penetrating injury trauma as opposed to an involved acute pain team. Whether a patient at civilian centers where motor vehicle and other risk for compartment syndrome is using opioids blunt force trauma victims make up a majority of or a peripheral nerve catheter for post surgical patients. In recent years, blast injuries have analgesia, missing a change in the exam will become the primary injury mechanism. In a mod- delay the diagnosis of compartment syndrome. ern combat force wearing body armor, extremity Vigilance on patients requiring more frequent injuries are most common and the use of tourni- pushes on a PCA or nursing intervention cannot quets has dramatically improved survival. Prompt be overlooked and a mechanism for identifying evaluation, recognition, and treatment of injury these patients and contacting a surgeon are are no different than in civilian trauma centers. paramount. What is more unique to combat hospitals is the frequent delay in treating casualties due to hostilities and the chance that the hospital itself may The Need for Future Research come under fi re. The energy from a blast and the ensuing deep seated soil contamination often The future of chronic pain prevention may lie in leads to wound infections that delay defi nitive the aggressive management of acute pain. Clark treatment of fractures. The deployed military et al. [16 ] found that using regional anesthesia environment is uniquely well suited for the imple- and opiates lowered pain scales over the entire mentation of a walking blood bank. Early use of hospital course of veterans suffering from poly- regional anesthesia may reduce the incidence of trauma and suggested that the incidence of chronic pain and PTSD. 304 J. Benjamin and J. Rotruck

9. Shuja F, Shults C, Duggan M, Tabbara M, et al. References Development and testing of freeze-dried plasma for the treatment of trauma-associated coagulopathy. J Trauma. 1. Borden Institute. Weapons effects and war wounds. In: 2008;65:975–85. Cubano MA, Lenhart MK, et al., editors. Emergency 10. CRASH-2 Trial Collaborators. Effects of tranexamic war surgery. Fort Sam Houston, TX: Borden Institute; acid on death, vascular occlusive events, and blood 2013. p. 1–16. transfusion in trauma patients with signiﬁ cant haem- 2. Management of patients with severe head trauma. In: orrhage (CRASH-2): a randomized, placebo- US Army Institute of Surgical Research joint theater controlled trial. Lancet. 2010; published online June trauma system clinical practice guidelines. 2012. 15. doi: 10.1016/S0140-6736(10)60835-5 . http://www.usaisr.amedd.army.mil/clinical_practice_ 11. Levi M, Levy JH, Andersen HF, Truloff D. Safety of guidelines.html . Accessed 15 May 2014. recombinant activated factor VII in randomized clini- 3. Duchesne JC, Barbeau JM, Islam TM, Wahl G, cal trials. N Engl J Med. 2010;363:1791–800. Greiffenstein P, McSwain NE. Damage control resus- 12. Simpson E, Lin Y, Stanworth S, et al. Recombinant citation: from emergency department to the operating factor VIIa for the prevention and treatment of bleed- room. Am Surg. 2011;77:201–6. ing patients without haemophilia. Cochrane Database 4. Damage control resuscitation. In: US Army Institute Syst Rev. 2012;3, CD005011. of Surgical Research joint theater trauma system clin- 13. Buckenmaier III CC, McKnight GM, Winkley JV, ical practice guidelines. 2013. http://www.usaisr. et al. Continuous peripheral nerve block for battleﬁ eld amedd.army.mil/clinical_practice_guidelines.html . anesthesia and evacuation. Reg Anesth Pain Med. Accessed 16 May 2014. 2005;30:202–5. 5. Holcomb JB, Jenkins D, Rhee P, et al. Damage control 14. Kissin I. Preemptive analgesia. Anesthesiology. resuscitation: directly addressing the early coagulopa- 2000;93:1138–43. thy of trauma. J Trauma. 2007;62:307–10. 15. Mar GJ, Barrington MJ, Mcguirk BR. Acute compart- 6. Holcomb JB, Wade CE, Michalek JE, et al. Increased ment syndrome of the lower limb and the effect of plasma and platelet to red blood cell ratios improves postoperative analgesia on diagnosis. Br J Anaesth. outcome in 466 massively transfused civilian trauma 2009;102:3–11. patients. Ann Surg. 2008;248:447–58. 16. Clark ME, Bair MJ, Buckenmaier CC, Gironda RJ, 7. Scalea TM, Bochicchio KM, Lumpkins K, et al. Early Walker RL. Pain and combat injuries in soldiers return- aggressive use of fresh frozen plasma does not ing from operations enduring freedom and Iraqi free- improve outcome in critically injured trauma patients. dom: implications for research and practice. J Rehabil Ann Surg. 2008;248:578–84. Res Dev. 2007;44:179–94. 8. Holcomb JB, del Junco DJ, Fox EE, Wade CE, et al. 17. Gironda RJ, Clark ME, Ruff RL, Chait S, Craine M, The prospective, observational, multicenter, major Walker R, Scholten J. Traumatic brain injury, polytrauma transfusion (PROMMTT) study: comparative trauma, and pain: challenges and treatment strategies effectiveness of a time-varying treatment with competing for the polytrauma rehabilitation. Rehabil Psychol. risks. JAMA Surg. 2013;148:127–36. 2009;54:247–57. Anesthesiologists’ Role in Disaster Management 23

Debbie Chandler , Yenabi Keﬂ emariam , Charles James Fox , and Alan David Kaye

essence contained with the defi nition of a disaster Introduction are the circumstances which prove that these instances are usually unforeseen and similarly The fi eld of anesthesiology provides life- exert catastrophic damage as a result from inap- supporting care regardless of the etiology or cir- propriate preventative or preparative measures. cumstances. The anesthesia provider occupies a In the face of disaster, the implementation of the crucial and essential role in initiating effective aforementioned responsibilities of the anesthesi- and effi cient health care, serving as a link between ologist ultimately will attempt to save lives by surgical services and the Intensive Care Units blunting the associated morbidity and mortality (ICUs) in the provision of medical care and the common during disaster circumstances. coordination and/or implementation of a disaster As history has proven, there are many etiolo- response strategy. Given the anesthesiologist’s gies that fall under the umbrella term disaster . familiarity with the two specialties, it is of little More formally, these are categorized as natural doubt that the specialty of Anesthesiology should disasters to include hurricanes, earthquakes, tsuna- embrace a key primary role in the event of a mis, forest fi res, and epidemic diseases, and unnat- disaster. The responsibilities of the anesthesiolo- ural events including plane crashes, explosions, gist would include, but not be limited to, fre- and train and car accidents. With increasing occur- quently coordinating the care of patients in nearly rence rates, a new category has grown in signifi - all fathomable settings/scenarios, analyzing and cance. These types of disasters of malicious and/or problem solving, performing a systematic triag- ill intent have included airline hi- jackings and ing of patients, providing or supervising optimal serial killings, especially seen in educational insti- anesthesia for best patient outcomes, and helping tutions, to the use of weapons of mass destruction. to improve upon previous areas of defi ciency as a Some notable natural disasters of the last two region begins the process of rebuilding. The sheer decades include Hurricane Katrina (2005), the Haiti earthquake (2010), the Tohoku earthquake and tsunami (2011), and the forest fi res of Southern D. Chandler , M.D. • Y. Kefl emariam , M.D. C. J. Fox , M.D. California (2003). Of the un-natural disasters, Department of Anesthesiology , LSU School most vividly remember, the tragedy of September of Medicine Shreveport , Shreveport , LA , USA 11th, 2001, which killed nearly 3,000 people and A. D. Kaye , M.D., Ph.D. (*) sent 10,000 people for medical treatment of inju- Department of Anesthesiology , LSU School ries related to the event(s) [1 ] and the bombing of of Medicine, Room 656, 1542 Tulane Avenue , the Alfred P. Murrah Federal Building in down- New Orleans , LA 70112 , USA e-mail: [email protected] town Oklahoma City, Oklahoma, in 1995.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 305 DOI 10.1007/978-3-319-09423-6_23, © Springer International Publishing Switzerland 2015 306 D. Chandler et al.

Regardless of the underlying cause or mechanism were the cause of roughly 140 deaths and property of disaster, the ultimate goals of the damages estimated at 6$ billion US dollars every Anesthesiologists or anesthesia providers are to year over a 25-year period [3 ]. In the USA, fl ash maximize the number of lives saved while limit- fl ooding is the leading cause of weather-related ing the injury and impact upon the population at mortality [3 ]. The overall impact of fl ooding is risk. Such outcomes require a systematic and multi-faceted including the loss of safe water, crop coordinated interplay of all medical professionals losses, disruption of food, distribution, adequate involved with anesthesiology and surgical spe- sanitation, loss of shelter, and disruption of health- cialties at the reins. Specifi c plans of action with care services [3 ]. Hurricane Katrina was the most emphasis on pre-, intra-, and post-disaster man- devastating hurricane of the 2005 hurricane season agement are crucial to the effectiveness of the and the most costly natural disaster in the US his- distribution of medical expertise, manpower, and tory [ 3 ]. Hurricane Katrina made initial landfall in resources. In this chapter, we review the types of Florida before entering the Gulf of Mexico and disasters and identify the important underlying gaining enough strength to become a Category 5 principles and/or strategies for each circumstance storm. Just prior to making its second landfall on from an anesthesiology perspective. August 29th, 2005, at the Southeastern portion of the state of Louisiana, the storm weakened and came ashore as a Category 3 storm. The subse- Classifi cation of Disasters quent storm surge caused massive widespread fl ooding which resulted in property damages esti- A disaster is defi ned as “a sudden calamitous mated at $81 billion US dollars and took the lives event which results in great damage, loss, or of roughly 1,836 people with 135 people reported destruction” [2 ]. When applied to modern societ- missing [4 ]. The majority of the deaths attributed ies, it is understood that this defi nition is often to Hurricane Katrina were a direct result of fl ash associated with widespread destruction of the fl ooding caused by catastrophic failure of multiple environment and the loss of human life. The cat- levees which made 2005 the third deadliest fl ood egorizations of disasters, for the purpose of this year in the US history [3 ]. See Fig. 23.1 . chapter, are determined by the inciting event and Worldwide demographic analysis has proven have been described as natural or unnatural to that many heavily concentrated populations are include those disasters of malicious intent. located along major fault lines [3 ]. Such population trends predispose large numbers of people to the risks and complications associated with earth- Natural Disasters quakes. The most common causes of injury and/ or death are crush injuries and the development of Natural disasters are any events or forces of compartment syndrome. It has been shown that nature that have catastrophic consequences such patient survival is inversely related to the amount as avalanches, earthquakes, fl oods, forest fi res, of time necessary for extrication from collapsed hurricanes, tornados, tsunamis, and volcanic buildings and structures damaged by the seismic eruptions. Examples of such natural disasters that activity [ 3 ]. The Haiti Earthquake occurred on have signifi cantly impacted densely populated January 12, 2010, and registered as a catastrophic regions of the world include: Hurricane Katrina magnitude 7.0 Mw . Occurring roughly 16 miles (2005), the Haiti earthquake (2010), the Tohoku from the capital city of Port-au- Prince, the earth- earthquake and tsunami (2011), the forest fi res of quake was, paradoxically, not proven to involve Southern California (2003), and the devastating slipping of faults, the major cause of prior signifi - fl oods that occur in Bangladesh annually. cant earthquakes. This earthquake’s effects were Floods remain the number one nonterrorist- felt by over 3.5 million people. The earthquake’s related disaster in the USA in regard to mortality intensity was severe enough to cause moderate- and property damages [3 ]. Prior to 2005, fl oods to-heavy damage to structures deemed earthquake 23 Anesthesiologists’ Role in Disaster Management 307

Fig. 23.1 Hurricane Katrina http://densitykatrina.wordpress.com resistant. The shallow depth of the earthquake coast of the Oshika Peninsula of Tohoku. The sub- zone was postulated as the reason for its intensity sequent tsunami created waves as high as 133 feet [4 ]. It has been postulated that roughly 222,570 which traveled nearly 6 miles inland. It is of little people lost their lives in this earthquake, while surprise that the devastation of such a massive some 300,572 were injured. The estimated fi nan- earthquake and tsunami would top those created cial damage caused by this devastation tallied by the Haiti Earthquake of 2010. One year after nearly $7.8 billion US dollars ($4.3 billion in the traumatic occurrence, reports had documented physical damages and roughly $3.5 billion dollars 16,273 fatalities, 3,061 missing, and 27,074 peo- in economic losses) [5 ]. Other notable causes of ple injured with these numbers continually grow- morbidity surrounding the initial devastation ing [6 ]. Unique to this particular disaster is the fact caused by an earthquake include secondary events that there were two separate natural disasters such as fi res, landslides, tsunamis, and exposure which synergistically caused unimaginable to toxic chemicals secondary to the destruction of destruction and changed the eastern coast of Japan chemical stores/plants [3 ]. See Fig. 23.2 forever. At the 1-year mark, damages were esti- March 11, 2011, was a day that changed the mated roughly at $275 billion US dollars. It is now lives of many, if not most, on the eastern coast of believed that the earthquake alone would have Japan. The Tohoku earthquake, which registered at caused 40–45 % of the total damage surrounding a magnitude of 9.0 Mw, compared to the Haiti this catastrophe [7 ]. See Fig. 23.3 . earthquake which was recorded at a magnitude of There have been many forest fi res in the US, 7.0 Mw, occurred nearly 43 miles off of the eastern but the densest concentrations of these disasters 308 D. Chandler et al.

noted to cause 24 deaths while destroying nearly 800,000 acres including 3,640 homes throughout the San Diego, Ventura, Riverside, and San Bernadino counties [8 ]. Although not as costly as the previously discussed natural disasters, there was widespread criticism by review committees as to the preparation and response to the disaster. As a consequence of geographical location on the Ganges Delta, a tributary system which feeds into the Bay of Bengal, and the Himalayas, the country of Bangladesh is continually at risk for widespread destruction secondary to torrential fl oods during the monsoon season (June through September). 75 % of the landscape of Bangladesh is within 10 m of sea level with 80 % of this land being comprised of fl ood plains. With the rains provided by the monsoon season coupled with the rain and melting water runoff of the Himalayas, nearly two-thirds of the country are fl ooded annually despite ongoing attempts to improve the infrastructural stability designs specifi cally created to combat the well-known, recurring devastation. The most destructive fl ood Fig. 23.2 Haiti earthquake destruction. http://www.scholas- witnessed by the country occurred in 1998 leav- tic.com/content/images/articles/sn_ts/sn_ts_011510_hdr.jpg ing 75 % of the country’s land was left under water due to the rains occurring between August and September of that year. The heavier than normal rains led to the three-river system within Bangladesh reaching peak fl ow levels. The additional factors of global warming and above average melting of snowmelt on the Himalayas further exacerbated the annually anticipated fl ooding of the region causing over 1,000 deaths and forcing 30,000+ people to become homeless. Undercut by fl ooding and overcrowding, many victims perished as a consequence of everyday injuries and otherwise treatable medical conditions. Contamination led to both cholera and typhoid outbreaks. Crop and economic produc- Fig. 23.3 Tohoku earthquake and Tsunami. http://www. tion and communication were crippled. elist10.com/wp-content/uploads/2013/03/T%C5%8 Dhoku-Japan-earthquake- 2011.jpg Unnatural Disasters and Malicious have occurred on the Pacifi c coast. California has Disasters witnessed multiple incidents with the most devastating occurring between October 25th and Unnatural disasters and malicious/ill-intent October 29th of 2003. A series of 15 wildfi res disasters occur far more frequently than natural cumulatively coined the “2003 Firestorm” was disasters but are generally not as catastrophic. 23 Anesthesiologists’ Role in Disaster Management 309

Fig. 23.4 Oklahoma City bombing. “Oklahoma City Bombing.” Wikipedia, The Free Encyclopedia, 2014 . Web. April 19 2014 http://en.wikipedia.org/wiki/2010_Haiti_earthquake

Examples of such include plane crashes, train Timothy McVeigh, and his co-conspirator Terry and automobile accidents, explosions, and chem- Nichols, were soon detained and charged with ical spills. The most notable of these was the the crime. Upon interviewing McVeigh in September 11th attacks of 2001 which occurred search of a possible motive, he explained that in New York, Virginia, and Pennsylvania which the attack was greatly fueled by his hatred of proved to be the most deadly terrorist-driven the Federal Bureau of Investigation (FBI) as a attack on United States soil. Four passenger air- result of what he believed to be mishandling of liners were hijacked and used as weapons to the Waco Siege which occurred 2 years prior in attack both the North and South towers of the 1993 as well as the Ruby Ridge incident in World Trade Center, the Pentagon, and 1992 [10 ]. The premeditated plan was to attack Washington D.C. The attacks on the World Trade as many federal law-enforcement agencies as Center involved two airliners making direct possible simultaneously making the Alfred impact with the two towers eventually causing P. Murrah Federal Building a leading target as it their collapse. The destruction of these two tow- housed not only the FBI but also the Drug ers took the lives of 2,606 people, including 343 Enforcement Agency (DEA) and the Bureau of fi refi ghters. The attack on the pentagon killed Alcohol, Tobacco, and Firearms (ATF). The 125 people and there were a total of 246 people man-made bomb harnessed the blast equivalent who lost their lives on the four passenger airlin- of 5,000 pounds of TNT and could be heard as ers. Estimates point to a total of roughly $2 tril- well as felt more than 50 miles away upon deto- lion US dollars when including all economic nation. See Fig. 23.4 . losses from physical damages and the impact on As the Iran-Iraq War came to a close in March the stock market [9 ]. of 1988, one of the world’s worst genocidal mas- On April 19th, 1995, the Alfred P. Murrah sacres took place at the hands of the Iraqi regime Federal Building in downtown Oklahoma City, under Saddam Hussein. The attack involved a Oklahoma fell victim to a domestic terrorist series of more than 14 chemical bombings coor- bombing which claimed the lives of 168 people, dinated by helicopters of residential areas in the injured nearly 700 people, and caused roughly city of Halabja in Southern Kurdistan. The bombs $650 million US dollars in damage [10 ]. were noted to contain combinations of sulfur 310 D. Chandler et al. mustard (also known as “mustard gas”), hydrogen emergency medicine, and internal medicine is cyanide, and other nerve agents. The effects of essential. This committee will be the central unit the nerve gas exposure led to the death of roughly in creating disaster management strategies to 5,000 people and injured between 7,000 and include pre-disaster awareness, disaster manage- 10,000 other civilians [11 ]. The devastation car- ment planning, identifying resources and surplus ried on for years after the initial attack as many availability, and creating mock-disaster trials. more people perished from complications includ- Given that the remainder of disaster strategy pre- ing diseases and birth defects. This attack, more paredness revolves around this central organiza- commonly referred to as the Halabja Massacre or tion, there should also be elected/selected Bloody Friday, was the largest chemical weapon delegates of this group who hold ranking posi- attack in history against a civilian populated tions to ensure a tier-structure of command to region [11 ]. facilitate instruction and direction in the event of impending catastrophe. The contact information of all ranking and registered providers should be Pre-disaster Strategies available via various means in the case that activation of the group be needed and established lines Some of the founding principles of the anesthesiol- of communication are jeopardized or destroyed ogy specialty include anticipation, thorough pre- entirely. Accordingly, all medical professional paredness, hypervigilence, apt problem- solving subspecialties should create similar registries skills, and sound decision making in critical situa- with appointed ranking leaders and individual tions. Anesthetic care providers must have a sense contact information should there be a breakdown of discipline, dedication, empathy, and determina- in the ability for there to be a central organization tion to respond to emergencies in an attempt to save coordinated disaster plan. Within each committee, the lives of victims and treat those injured in the rank should be appointed based on knowledge face of catastrophic events. In order to maximize and experience within the particular specialty and this initiative, there must be great emphasis and subsequent positions should be appointed accord- effort directed at being prepared. Such preparedness ingly. It should be left to the discretion of commit- comes by way of identifying and organizing com- tee leaders to determine the roles and responsibility mittees, resources, facilities, and personnel that can given to each member. Creating individual com- all be mobilized swiftly and effi ciently. mittees, with their respective leaders, will ensure that once disaster is suspected or anticipated, all personnel, through a previously designed, or Committees, Roles, and Communication alternative, communication system will be informed and on high-alert that their individual Organization is imperative to the success of disas- skill sets may be called upon. The delegates of ter response. Because anesthesiology provides a these groups should ensure that their registries are key linkage between multiple specialties and also updated at least bi-annually and remain current to holds a central position in most medical care set- the best of their abilities. These appointed leaders tings, providing the most effi cient medical care to would themselves join together to form a Disaster those in need should include the direction and Management Board (DMB) which should simi- coordination of an anesthesiologist. In ideal situa- larly include senior ranking members/directors tions, there should exist a network of local and and administrators of all major hospital or health regional anesthesiology providers who are willing care facilities, local police and fi re departments, and able to provide their skill sets if called upon in and the local department of transportation. The the face of disaster. The creation of a core com- DMB collectively formulates disaster plans and mittee which includes these anesthesiologists as strategies built upon previous catastrophic experi- well as other subspecialties including, but not lim- ences of all etiologies. Regularly scheduled meetings ited to, surgical subspecialties, critical care, nursing, should be held in an attempt to review and update 23 Anesthesiologists’ Role in Disaster Management 311 strategies and allocation of resources amongst two-way radio communications as the pilots were many other facets of disaster management. These able to make contact with the Shanwick Oceanic meetings may also be used to simulate potential Area Control just seconds before the plane was disaster situations and test the abilities and limita- subsequently destroyed by a terrorist bomb tions of the current policies and strategies. believed to be orchestrated by the regime under McIsaac et al. noted that the Joint Commission on Libyan leader Muammar Gaddafi [ 13 ]. Ideally in Accreditation of Healthcare Organizations disaster scenarios, the use of two-way radio com- (JCAHO) requires all hospital to have biannual munication would be able to provide key linkage disaster exercises to help ensure proper coordina- between fi rst responders and appropriate facili- tion of operating room (OR) personnel and the ties or personnel in the event that other electricity- department of anesthesiology [12 ]. driven forms of media/communication were It is also important to establish an organized destroyed or rendered inoperable. The implemen- group to be deemed “First Responders.” Ideally tation of such alternative forms of communica- this group would comprised a select group of tions would thus prove to be essential for anesthesiology providers as well as surgical spe- execution of disaster strategies and providing cialists of each region. The primary goal of these up-to- date information regarding different health care providers is to make initial assess- aspects of disaster response(s). ments based on: 1. The type of disaster and the most common types of injuries (crush, burn, chemical, etc.). Identifying Resources and Materials 2. The need for particular types of medical specialists to be dispatched to the scene as well as Each DMB needs to identify potential resources suffi cient numbers of such specialists. and materials that can be mobilized in the event 3. Activation of all participating committees and of a disaster which will require the input of hos- hospital facilities needed based on the type of pitals and other medical facilities. Information care required. that is usually needed includes, but is not be lim- Once the initial assessments have been made ited to, the numbers of hospital beds, including and the disaster has been categorized, the DMB emergency room capacities, ICU and inpatient should activate predesigned protocols needed for beds, functioning operating rooms (ORs), func- the peri-disaster phase of management. tioning mechanical ventilators, and emergency Communication amongst these committees is transportation vehicles (ambulances, fi re trucks, essential for initiation of proper disaster response. other emergency vehicles). Particular attention should be given to the wide- It would be of great value to create a registry spread distribution of a central set of contacts and of approximate volumes of necessary resources contact numbers that others (professionals, particularly those that are more likely to be administrators, media, etc.) may use for inter- exhausted during a disaster situation. Of particu- group communication, reports, and updates. lar importance are the emergency medications There should also be particular attention paid to that are specifi c to the treatment protocols of cer- the types of communications that may be lost tain chemicals and nerve gases in the event of given the type of disasters that are most likely to bio- or chemical disaster as well as those neces- occur. In the event of widespread loss of electric- sary to perform a wide array of anesthetics ity or cellular technologies, an alternative means depending on the clinical scenario. The anesthe- for effective communication to facilitate and siologist must have the ability to treat patients coordinate the disaster response is warranted. both in and out of the hospital setting as it has History has shown that the use of two-way radios been shown that the degree and types of injuries provides a rather inexpensive means of commu- vary widely depending on the etiology of the nication in distances up to 12 miles. The Pan Am disaster. The ability of the anesthesia provider to 103 fl ight bombing was an example of abilities of administer adequate clinical care for patients is 312 D. Chandler et al.

Fig. 23.5 Haiti earthquake http://www.cnn.com/video/world/2010/01/14/watson.haiti.trapped.girl.update.cnn.640x480.jpg heavily dependent on his/her ability to construct Health (NIOSH) was designed to maximize work- anesthetic regimens based on individual clinical place safety via a series of guidelines which defi ne conditions. The anesthetic regiment may consist particular forms of protective equipment protocols of particular drugs which provide better hemody- based upon the type of chemical and/or biological namic control in the face of severe traumatic inju- disaster [3 ]. In the event that the initial supply of ries. Of particular note, patients who have medications and/or personal protective equipment succumbed to collapsing infrastructures and is exhausted with the fi rst waves of treatment, sec- whose survival is dependent on emergency sur- ondary resources or supplies may need to be mobi- geries involving amputation of a limb pose a dif- lized to supplement the defi cits. For this reason, of fi cult, yet manageable, anesthetic scenario for the the most plausible types of bio- or chemical expo- anesthesia provider as securing of a patient’s air- sure, it would be advantageous to identify depots way may be impossible. In these dire circum- or secondary outlets that would be able to provide stances, the anesthesia provider would be best any necessary medications or supplies based on served in utilizing medications whose side effect the specifi c type of disaster. See Fig. 23.6 . profi le minimizes the possibility of respiratory Blood and blood products are often needed in depression (i.e. ketamine, non-steroidal anti- the initial resuscitation of critically injured infl ammatory drugs (NSAIDs)) but are capable patients. For this reason, there should be a regis- of providing analgesia. See Fig. 23.5 . try designed to monitor supply levels of such In the face of toxin or chemical exposure, the products. Most hospitals are associated with a anesthesia provider will need to have suffi cient coordinated blood bank system which monitors quantities of disease-specifi c medications to regional availability of blood and blood prod- appropriately treat exposed patients. There will ucts. Given that patients will not be able to also have to be suffi cient protective apparel to be receive appropriate blood group matching strate- adorned by those providing medical care to pre- gies in such emergent/urgent scenarios, Type vent primary exposure and ultimately to maximize O-blood will be most commonly administered to the effi ciency of the disaster response [3 ]. The decrease chances of ABO incompatibility. It is National Institute of Occupational Safety and well-known that the transfusion of blood and 23 Anesthesiologists’ Role in Disaster Management 313

Fig. 23.6 Tohoku earthquake. http://jto.s3.amazonaws.com/wp-content/uploads/2014/03/p1-cleanup-a-20140309.jpg blood products carries with it the risk of trans- that there is an exhaustive demand through mission of human immunodeﬁ ciency virus voluntary blood drives. The DMB should be in (HIV), hepatitis B virus (HBV), hepatitis C virus constant communication with available local (HCV), Chagas disease, malaria, and other types blood banks to help create community outreach of diseases [ 14 ]. In the event that an emergency initiatives to maximize public awareness. transfusion is deemed necessary to provide oxygen-carrying capacity to patient’s hemorrhaging or facing severe anemia, one must be mindful of When Disaster Strikes the potential for complications associated with hypothermic transfusions including coagulopa- There is a direct relationship between the overall thy and hemolysis. For these aforementioned dampening of the devastation caused by a disas- reasons, it is much safer to use non-blood substi- ter and the appropriate pre-planning and execu- tutes (crystalloids, synthetic colloids, etc.) and, tion of disaster management strategies. If a in some circumstances, more cost effective [14 ]. disaster is imminent, it is imperative that the Anesthesiologists are aware of such risks DMB coordinate meetings to review all avenues involved but it is without question that the ability to protect and provide relief for people in harm’s to provide oxygen to at-risk tissues is best served way. Medical personnel should be on high alert by increasing the availability of circulating as well as all operational medical facilities that hemoglobin via red blood cell transfusions. In are capable of assisting (hospitals, surgical cen- knowing this simple fact, blood bank registries ters, outpatient clinics, etc.) The anesthesiology should make great efforts to maximize the acqui- DMB members will assume the leading role in sition and appropriate storage of these blood ensuring that all essential personnel are ready to products to increase the availability in the event act if and/or when swift action is needed. 314 D. Chandler et al.

Implementing an Initial Table 23.1 START triage [3 ] Response Plan Red Any of the following Immediate Respirations >30 breaths/min If a disaster occurs, the anesthesiology DMB mem- Priority 1 Capillary refi ll <2 s or no palpable radial pulse bers should activate the response team(s). The noti- Not able to follow commands fi cations should be delivered through all forms of Yellow Non-ambulatory patients who do not meet media (television, telephone, e-mail, and radio) and black or red criteria the emergency contact numbers should be used to Delayed Priority II alert all essential personnel. These persons should Green Able to walk to a designated safe area for be delegated their roles and eventual destinations further assessment by the Anesthesiologist DMB members in direct Minor coordination with the First Responders. The pri- Priority III mary goal of the fi rst responders is to identify the Black Not breathing despite one attempt to open type and severity of the event, the most common the airway anticipated types of injuries, and to determine Deceased whether there is a greater need for on-site medical Priority IV treatment and facility establishment versus evacu- ating and transporting patients to more appropriate and capable medical facilities. If transportation is to allow the healthcare provider to perform a deemed impossible, the appropriate course of patient assessment within 60 s and to identify action must be taken to bring medical profession- those victims in need of immediate medical als, supplies, and resources to the scene under the attention/intervention. Patients are assigned a guidance of the local department of transportation colored ribbon dependent upon the severity of and police authorities. their injuries. The categorization of these patients is based upon respirations, perfusion/pulses, and mental status. Patients who remain apneic after Triage Strategies initial airway repositioning are tagged as “deceased” and subsequently have a black label Upon establishing a plan, the anesthesiologist(s) placed upon their body. Those patients who have within the fi rst responder group should begin a a respiratory rate greater than 30 breaths per min- survey of those most severely injured and imme- ute, have a capillary refi ll greater than 2 s, or are diately begin to triage these victims based on unable to follow simple commands are deemed their individual injuries and clinical condition. “immediate” and are assigned a red label. The From a broad approach, these individuals should remaining patients are deemed “delayed” and are be categorized as: given a yellow label. Many other triage systems 1 . Critical—Prognosis is very poor and are have been created and implemented based on the beyond medical treatment. determination of each regional disaster manage- 2 . Severe—Those in need of immediate medical ment board. See Table 23.1 . attention and treatment on-site. Patients should be registered upon arrival in 3 . Moderate —Those who are clinically stable any type of medical care facility as they would be and not requiring emergency medical atten- in the event of any naturally occurring hospital- tion/treatment. ization or clinic visit. In the event of a cata- The Simple Triage and Rapid Treatment strophic event/emergency, some patients may not (START) system has been used in the USA since be competent clinically to provide such informa- its creation in the 1980s. Its principles have been tion. These patients should be assigned tempo- adopted by many other countries including rary medical record numbers (MRNs) that will be Canada, Saudi Arabia, Israel, and parts of used to identify them as they receive different Australia [3 ]. The START system was designed phases of medical care. The MRN numbers of 23 Anesthesiologists’ Role in Disaster Management 315 current patients should be given to the hospital its lack of cardiovascular depression, the ability coordinator to help maintain an up-to-date census to maintain spontaneous respiration, amnesia, of those victims receiving care at their institution. and analgesic potential in sub-therapeutic dos- These MRNs will also help ensure that the each ages. It is also able to be administered via an IM patient receives his/her appropriate medication route which greatly facilitates its use. An assis- optimizing continuity of care. The effectiveness tant will be needed specifi cally for the anesthesi- of this care is often derived from attentive and ologist especially in the event that signifi cant coordinated supervision provided by anesthesi- amounts of intravenous fl uids (blood and blood ologists whether on-site or in ICU and/or hospital products, crystalloids, colloids) are needed for settings. Anesthesiologists must be able to dili- resuscitation of these patients granted there is gently and effi ciently provide goal-directed intravenous (IV) or intraosseous (IO) access. medical care whether it is via direct patient care Urgent plans should be made with ICU capable or through a guided supervisory position. medical facilities for the transportation of these patients immediately after surgical intervention. The on-site anesthesiologist should communicate Initial Treatment Considerations appropriate hand-off ideally directly to the anesthesiologist at the receiving hospital or facility. Once the triage assessments have begun, coordi- Of importance is the type of procedure, resuscita- nated groups should begin prioritizing treating tion requirements, and anesthetic management patients according to their categorization and/or provided. severity. Ideally, these cohort groups should con- In the event of chemical or toxin exposure, the sist of an anesthesia provider, a surgical special- anesthesiologist must ensure protection to all ist, and at least three assistants if available: one medical personnel primarily to allow for medical dedicated to each specialist and one to serve as care to be provided to victims, including avail- needed. If the clinical situation requires emer- ability and distribution of biohazard suits and gency surgery, these assistants will help the spe- masks. The fi rst responder group should also cialists however possible with particular emphasis include infectious disease specialists and/or spe- on the provision of supplies/equipment. The cialists knowledgeable in the chemistry and anesthesiologist will briefl y assess the patient’s chemical warfare. Treatment requirements should current clinical condition as it may be impossible be assessed based on estimates of the number of to implement the standard American Society of victims involved. These resources should be Anesthesiologist standards for monitoring in mobilized to the scene as well as to designated these disaster situations and will develop an anes- facilities. Of the anesthetic medications, the thetic plan. Of primary importance to the Oximes (Pralidoxime chloride, Obidoxime) as Anesthesiologist is to be able to control and/or well as Pyridostigmine should be readily avail- assist the patient’s airway, breathing, and circula- able in mass quantities in the event of toxic nerve tion (ABCs). If unable to properly secure the air- gas exposure. way, the anesthesia provider will be wary of Patients who are deemed “delayed” by initial using drugs that may potentially cause respira- triage should be evacuated and assisted to pre- tory depression or apnea while still being able to designated centers for secondary assessment and provide analgesia to the patient. Securing intra- subsequent transfer to medical facilities. The venous access may also be very diffi cult in these continual reporting and updating of disaster cov- situations hence the use of intramuscular (IM) erage, the ongoing need for anesthesiologist(s) as drugs that will greatly facilitate the ability to pro- well as other specialists, capacities of medical vide anesthesia. Ketamine , an N -methyl- d - facilities, and inventories of supplies are essential aspartate (NMDA) receptor antagonist, has functions to stay ahead of the curve in continu- been the drug of choice in these dire circum- ally providing appropriate care and maximizing stances given its clinical profi le which includes patient outcomes. There should be a designated 316 D. Chandler et al. offi cial within each hospital facility whose new developments and changes in climate primary objective is to continually review the patterns were not enough to prompt review of availability of operating rooms, ICU rooms, and the infrastructure of New Orleans’ levee system hospital beds. Transfer of critical patients to and this lack of attention proved to be cata- capable medical facilities without delay or the strophic when challenged by Hurricane Katrina potential for the lack of essential resources to fl ooding. Ideally, there should be a regulatory provide necessary care will greatly improve body of offi cials who are responsible for the patient outcomes. The designated coordinators at maintenance of such structures which tests the each facility should continually update the status integrity of such protective structures to ensure of their capacity to the central DMB so as to their quality and effectiveness. As in the case of avoid overcrowding or defi ciencies in provision the torrential annual fl ooding in Bangladesh of appropriate medical care to victims. which is necessary for the revitalization of fer- There is much to be learned from previous tile lands for crop productions, efforts should be disasters to improve outcomes in the event that placed on minimizing the damage of such fl oods another disaster is to occur in particular regions. while ensuring that the damages incurred by For example, there have been multiple reviews such are limited as much as feasibly possible. of the intricacies of Hurricane Katrina and its overall impact on New Orleans, Louisiana as well as the Gulf Coast. Great emphasis has been Post-disaster Management placed on certain essential points that correlate with those discussed in this chapter. In areas Without a doubt, victims of a wide range of disas- which are more likely to experience severe ters will often need medical and psychological fl ooding secondary to geographical location, care provided from initial triage to eventual there should be meticulous review of previous return back to an approximation of life pre- data that serve to identify those areas most prone disaster. There are many facets of recovery that to being heavily impacted. Once these highly should be addressed beyond the initial triage and susceptible regions have been identifi ed, the medical attention. Long term issues that are management of these lands should be monitored equally important in addressing in order to allow very closely. Prohibiting new development and a disaster-stricken region a more global recovery fl ood-proofi ng existing structures will signifi - include infection rates/epidemics, psychological cantly decrease the amount of damage in the issues (i.e., post-traumatic stress disorder event of a fl ood as seen by the Gulf Coast during (PTSD)), as well as a retrospective review of the Hurricane Katrina [15 ]. If certain preventative chronology of the actual disaster(s) and the sub- and/or protective measures have previously sequent disaster response. been constructed (dams, levees, storm channels, etc.), it is of great importance to ensure these structures are of the highest standards of mod- Infectious Disease Transmission ern construction [ 15]. This point is emphasized and Outbreaks by the catastrophic failures of the levees in New Orleans which were overpowered by the fl ood The majority of mortalities post-disaster are waters caused by Hurricane Katrina. A review most often directly related to the initial disaster of construction efforts centered around these impact. As previously mentioned, crush inju- levees revealed a chilling fact that these levees ries, blunt trauma, and burn injuries are those had not been assessed formally since 1985 when identifi ed to place victims at higher mortality the Lake Pontchartrain and Vicinity Hurricane risk. Beyond the initial catastrophe, the pro- Protection Project (LP & VHPP) was re-evalu- longed detrimental impact on health has been ated and the decision was made to replace the proven to be multifactorial. The associated existing surge barriers with a taller levee system destruction or interruption in healthcare facili- [16 ]. Over 20 years after initial construction, ties and systems, the limitations to securing 23 Anesthesiologists’ Role in Disaster Management 317 stable food sources secondary to disruptions in impact of such traumatic experiences, we look farming, livestock, or the usual importation of towards the experiences of victims of Hurricane foods into the region, or the scarcity of medica- Katrina and the Haiti Earthquake. tions or interruptions of ongoing treatments. Identifi ed risk factors for infectious disease transmission or outbreaks include overcrowding Post-Katrina-Health Issues and unplanned shelters, poor water conditions or sanitation, poor nutritional status, and inade- New Orleans and surrounding cities experienced quate provisions to maintain an appropriate massive fl ooding due to multiple levee breaks. level of hygiene (Fig. 23.7 ). Because of this, more than 100,000 homes were The infectious disease outbreaks witnessed in inundated with 4 or more feet of water. Many previous disaster situations have allowed Mississippi or Louisiana coastal areas (within researchers to categorize the associated events one mile of the Gulf of Mexico) lost all struc- into phases. Given that disease transmission can tures. Additionally, this natural disaster resulted occur hours, days, or even months after the initial in over 1,800 deaths. This combination of events disaster, three clinical phases have been described created unimaginable stress for inhabitants left to to chronologically categorize the health effects of deal with the aftermath [18 ]. survivors and those injured. Over 500,000 people were in possible need of mental health treatment after Hurricane Katrina Phase 1 or Impact Phase : 4-day period when according to The Substance Abuse and Mental most victims are extricated and initial treatment Health Service Administration (SAMHSA). It strategies are implemented. was determined later that only 1.6 % of those in need received mental health treatment. First Phase 2 or Post-impact Phase: Period extending responders were surveyed 2–3months after the from day 4 up to 4 weeks when most infectious event; 19 % of police offi cers reported symptoms diseases (airborne, waterborne, and food-borne of posttraumatic stress disorder (PTSD) and 26 % etiologies) would surface. reported symptoms of major depression, while amongst fi refi ghters surveyed 22 % reported Phase 3 or Recovery Phase: Period starting at 4 symptoms consistent with PTSD and 27 % weeks post-disaster when symptoms of latent- reported major depressive symptoms [18 –20 ]. type of infections become clinically apparent. Most associate PTSD when thinking of major This period is noted to be when infectious dis- mental health issues experienced by a commu- eases begin to grow into epidemics. nity rebounding from a natural disaster; however, It is extremely important to realize that it is common anxiety and depressive disorders are not the initial disaster that causes the infectious more prevalent while long-term chronic stress disease transmission and/or outbreaks but rather may result in cognitive impairment. The term the exacerbation of the risk factors that exist in “ Katrina Brain” was coined to describe the com- the disaster region(s). It has been postulated that mon impairments in concentration and memory there should be a rapid disease risk assessment experienced by many left to rebuild their lives performed within the fi rst week post-disaster under long-term chronic stress [22 ]. impact to identify risk factors and health needs. Ken Sakauye, MD, professor of Psychiatry at Utilizing case management and systems of sur- Louisiana State University Health Science Center veillance can signifi cantly limit infectious disease in New Orleans, before and after Hurricane burdens associated with catastrophes. Katrina, described the effects created by long term The psychological impact of disaster is a topic stress. Diurnal regulation of cortisol is lost in these of much interest as it can prove to be a signifi cant individuals and persistently high cortisol levels burden to the mental health of disaster victims eventually lead to hippocampal atrophy, short term and witnesses alike. In reviewing the potential memory impairment and may contribute to the 318 D. Chandler et al.

Fig. 23.7 Risk factors and onset of communicable diseases following natural disasters [17 ]

high health morbidity and death rates experienced loss of the support network (family and friends by communities after a natural disaster occurs scattered), healthcare network and feeling of gov- [22 ]. Additionally, Dr. Sakauye theorized that the ernmental abandonment compounded daily stress. 23 Anesthesiologists’ Role in Disaster Management 319

Months after Hurricane Katrina, with 50 % of HIV disease progression has been measured the population gone, crisis helpline calls for psy- post Katrina. A year after Hurricane Katrina, 145 chiatric issues increased by 61 %. Dramatic HIV-infected patients returned for care at the changes in death, murder and suicide rates HIV Outpatient Program clinic in New Orleans. occurred in Orleans parish. From the previous They were interviewed and blood was drawn. year, death rates increased by 25 %, murder rates Clinical factors pre and one and two year’s post- doubled for Orleans parish, while suicide rates Katrina were obtained. Of the 145 patients, tripled. Additionally, new mental health prob- 37.2 % had PTSD. Those HIV patients with lems for children increased signifi cantly [23 ]. PTSD were more likely to have CD 4 cell counts The majority of initial reports and studies <200/mm [3 ] 2 years post disaster and have involved those individuals and families who detectable viral loads at both follow-up sample returned to the New Orleans area to rebuild times post-disaster [29 ]. after Hurricane Katrina. It is now recognized that those displaced experienced even higher rates of mental health and substance abuse Outside Aid issues after Hurricane Katrina. The Center for Disease Control and Prevention surveyed indi- Medical capabilities of local or regional hospitals viduals living in the New Orleans area in are sometimes overwhelmed when disasters October 2005 and those living in trailers or occur. Because of this, medical aid from sur- hotels in 2006 and found that adults displaced rounding states or countries is needed to meet from their dwelling for greater than two weeks demands. Many hospitals have provided medical post Katrina had higher drug use, cigarette use, supplies or medical talent to aid those facing serious psychological distress, major depres- obstacles post-disaster. Some hospitals and uni- sive episode and unmet need for mental health versities medical centers have developed mission treatment or counseling than those not dis- programs to help those in need. Those creating a placed. A recent study concluded that of the pre-disaster plan should create a list of these pro- 20,000 children displaced by Hurricane Katrina, grams, so that all contingencies are addressed. 60 % have serious emotional disorders, behavior issues or housing instability [ 23 , 24 ]. Much is known about the psychological con- Protocol Improvements sequences of Hurricane Katrina; however, the effects on one’s physical health are now emerg- As the region affected by disaster begins the pro- ing [25 –27 ]. A retrospective study was conducted cess of recovery and rebuilding, it is imperative at Tulane Medical Center involving patients that the details of the catastrophe be reviewed admitted with acute myocardial infarction (AMI) meticulously. It is of utmost importance for cer- 2 years before Hurricane Katrina and in the 5 tain details to be addressed so as to improve upon years afterward. The two groups were compared current protocols and/or treatment strategies for and the post-Katrina group had a higher preva- future unforeseen disasters. The type of disaster(s) lence of known coronary artery disease, prior should be identifi ed and individualized (in the coronary artery bypass grafts, hyperlipidemia, event that multiple events occurred concurrently psychiatric comorbidities, smoking, and sub- or sequentially) as well as the initial responses to stance abuse. Also, the post-Katrina group was each. Both tasks that were effi ciently executed as more likely unemployed and uninsured. Overall, well as those which lacked in strength should be they found a threefold increase in the incidence identifi ed and reconstructed if needed. Different of AMI and believe the prevalence of these clini- strategies should be proposed and tested for their cal and psychological factors have and will con- integrity when hypothetically applied to the tinue to have a profound impact on the previous events. The DMB, and more impor- community’s cardiovascular health [28 ]. tantly the anesthesiologists, should identify the 320 D. Chandler et al. strengths and weaknesses of their primary role 2014. http://earthquake-report.com/2012/03/10/ and identify areas that need improvement to japan-366-days-after-the- quake-19000-lives-lost-1-2- million-buildings-damaged-574-billion/ . ensure better outcomes in future scenarios. 8. Worst U.S. Forest Fires. Infoplease, 2014. Web. 7 It would be of great benefi t for committees to April 2014. http://www.infoplease.com/ipa/ review the statistics and data directly related to A0778688.html#ixzz2wo84ODyP . the disaster. Statisticians should calculate all 9. The cost of September 11. Institute for the Analysis of Global Security, 2004. Web. 7 April 2014. http:// important data in order to quantify the toll that www.iags.org/costof911.html . was infl icted upon that particular region by the 10. Oklahoma City bombing. Wikipedia, the free ency- events. Data should be compiled to review many clopedia, 2014. Web. 19 April 2014. http://en.wikipe- different facets of the disaster including the num- dia.org/wiki/2010_Haiti_earthquake . 11. Halabja chemical attack. Wikipedia, the free encyclo- ber injured, most common types of injuries, num- pedia , 2014. Web. 19 April 2014. http://en.wikipedia. ber/type of emergency surgeries needed, length org/wiki/2010_Haiti_earthquake . of hospital stays, number of medical providers, 12. Joseph M. Chapter on emergency preparedness – types of medications used, overall cost burdens, manual for anesthesia department organization and management. ASA Committee on Trauma and and the types of resources required and used in Emergency Preparedness, American Society of the care of all victims regardless of clinical sever- Anesthesiologists, 2010. Web. 7 April 2014. http:// ity. These reviews will help to identify strengths www.asahq.org/For-Members/About-ASA/ASA- Committees/~/media/For%20Members/COTEP/ and weaknesses in previous disaster strategies MADOM-Edited-by-McIsaac-6.ashx . and plans. Once identifi ed, these protocols can be 13. Pan Am Flight 103. Wikipedia, the free encyclopedia, strengthened or changed altogether so that in the 2014. Web. 19 April 2014. http://en.wikipedia.org/ unfortunate event of future catastrophes, a region wiki/2010_Haiti_earthquake . 14. Iserson, Kenneth V. Improvised medicine. will be optimally prepared and better equipped to 15. http://www.un.org/esa/sustdev/publications/flood_ address the immense burden of providing medi- guidelines_sec02.pdf . cal care in an unforeseen, uncontrolled environ- 16. http://www.journalofamericanhistory.org/projects/ ment. All of this information can be reused in katrina/resources/levee.html . 17. http://unu.edu/publications/articles/preventing-and- formulating improvements upon the former controlling-infectious-diseases-after-natural- disaster management strategies. disasters.html#info . 18. Weisler RH, Barbee IV JG, Townsend MH. Mental health and recovery in the Gulf Coast after Hurricanes Katrina and Rita. JAMA. 2006;296:585–8. References 19. Agency for Toxic Substances and Disease Registry, 2005. Helping families deal with the stress of relocation 1. Casualties of the September 11 attacks. Wikipedia, the free after a disaster. http://www.atsdr.cdc.gov/publications/ encyclopedia, 2014. Web. 7 April 2014. http://en.wikipedia. 100233-RelocationStress.pdf . Accessed 22 Dec 2006. org/wiki/ Casualties_of_the_September_11_attacks . 20. Centers for Disease Control and Prevention. 2. Disaster – defi nition and more from the free Merriam- Assessment of Health Related Needs after Hurricanes Webster dictionary. Merriam-Webster, 2014. Web. 7 Katrina and Rita: Orleans and Jefferson Parishes, April 2014. http://www.merriam-webster.com/dic- New Orleans area, Louisiana, October 17–22. Morb tionary/disaster . Mortal Wkly Rep. 2006a;55:38–41. http://www.cdc. 3. Koenig and Schultz. Disaster medicine. gov/mmwr/preview/mmwrhtml/mm5502a5.htm . 4. Hurricane Katrina. Wikipedia, the free encyclopedia, Accessed 22 Dec 2006. 2014. Web. 7 April 2014. http://en.wikipedia.org/ 21. Centers for Disease Control and Prevention. Health wiki/Hurricane_Katrina . hazard evaluation of police offi cers and fi refi ghters 5. 2010 Haiti Earthquake. Wikipedia, the free encyclo- after Hurricanes Katrina—New Orleans, Louisiana, pedia , 2014. Web. 7 April 2014. http://en.wikipedia. October 17–28 and November 30–December 5, 2005. org/wiki/2010_Haiti_earthquake . Morb Mortal Wkly Rep. 2006b;55:456–8. 6. Key statistics. U.N. Offi ce of the Secretary-General’s 22. Sakauye K. “Katrina Brain:” acute cognitive impair- Special Adviser on Community-Based Medicine & ment. Program and abstracts of the 19th US Lessons From Haiti, 2012. Web. 7 April 2014. http://www. Psychiatric & Mental Health Congress; 2006 Nov lessonsfromhaiti.org/relief-and-recovery/key-statistics/ . 15–19, New Orleans, Louisiana. Session 23–3. 7. Armand V, James D. Japan – 366 days after the Quake… 23. Centers for Disease Control and Prevention. 19000 lives lost, 1.2 million buildings damaged, $574 Assessment of health-related needs after Hurricanes billion. Earthquake-Report.com, 2012. Web. 7 April Katrina and Rita—Orleans and Jefferson Parishes, 23 Anesthesiologists’ Role in Disaster Management 321

New Orleans area, Louisiana, October 17–22, 2005. 26. Osofsky HJ, Osofsky JD, Kronenberg M, Brennan A, Morb Mortal Wkly Rep. 2006c;55(2):38–41. http:// Hansel TC. Posttraumatic stress symptoms in children www.cdc.gov/mmwr/preview/mmwr/mm5502a5.htm . after Hurricane Katrina: predicting the need for 24. Abramson D, Redlener I, Stehling-Ariza T, Fuller E. mental health services. Am J Orthopsychiatry. The legacy of Katrina’s children: estimating the num- 2009;79:212–20. bers of hurricane-related at-risk children in the Gulf 27. Children’s Health Fund. Reforming disaster case man- Coast States of Louisiana and Mississippi. NCDP agement: national lessons learned from Louisiana. New Research Brief 2007_12. National Center for Disaster York, NY: Children’s Health Fund; December 2009. Preparedness, Columbia University Mailman School of 28. Moscona J, Tiwari T, Munshi K, Srivastav S, Public Health, December 2007. http://www.ncdp.mail- Delafontaine P, Irimpen A. The effects of Hurricane man.columbia.edu/fi les/legacy_katrina_children.pdf. Katrina on acute myocardial infarction fi ve years after 25. Madrid P, Grant R, Rosen R. Creating disability the storm. J Am Coll Cardiol. 2012;59(13s1):E354. through inadequate disaster response: Hurricane 29. Reilly K, Clark R, Schmidt N, et al. The effect of post- Katrina and its aftermath. In: Disability: insights from traumatic stress disorder on HIV disease progression across fi elds and around the world. Volume 2. following hurricane Katrina. AIDS Care. 2009;21(10): Portsmouth NH: Praeger Press; 2009. p. 1–16. 1298–305. Part III Education at Home and Abroad Surgical Mission Trips as a Component of Medical 24 Education and Residency Training

Peter J. Taub and Lester Silver

abroad. When machines break, there might not be Benefi ts a technician on call to repair them or a backup machine ready to substitute. In such circum- The benefi ts of global missions are numerous and stances, ingenuity and decision making become students and residents can provide valuable assis- valuable traits. Is the problem something that can tance on such trips. Certainly, those who speak be overcome with the available resources or do the language of the host country are at an obvious hard decisions have to be made about making advantage and often serve as translators for those alternate plans? These experiences have been who do not. The education students and residents shown to improve skills and confi dence among receive is immeasurable. They learn alternative students and residents, as well as increase their models of health care delivery, how to manage sensitivity to health care costs, awareness of reli- health care with fewer resources, the effects of ability on technology, and need to improve com- local culture on health care, and the management munication across different cultures [1 ]. of disease entities they might not see back home, There are also benefi ts to the Departments that among other advantages. In the absence of support and offer an international experience. sophisticated primary care and routine imaging Many students and residents have an interest in studies, students and residents must rely more on such programs and electively seek out and rank their ability to perform thorough patient histories higher those programs that offer rotations or trips and complete physical examinations than they to foreign countries. The Department also creates might at home where patients may have extensive a wider exposure for itself if their attendings, resi- medical charts documenting their entire medical dents, and students carry with them the name of history, including monthly clinic visits and their institution as they travel abroad. Relationships numerous diagnostic studies. with colleagues in foreign countries and at foreign Mission trips also foster problem solving medical schools are established and reinforced by (the “MacGyver effect”). Where resources might future trips. be abundant back home, they are often scarce There are numerous examples where ongoing relationships outside of the single mission trip have developed between mentor programs in P. J. Taub , MD, FACS, FAAP • L. Silver , MD (*) North America and a local university or hospital. Division of Plastic and Reconstructive Surgery , As an example in Rwanda, a mutually benefi cial Icahn School of Medicine at Mount Sinai , relationship has been established between the 5 East 98th Street , Box 1259 , New York , NY 10029 , USA e-mail: [email protected]; Canadian Anesthesiologists International [email protected] Education Foundation, the American Society of

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 325 DOI 10.1007/978-3-319-09423-6_24, © Springer International Publishing Switzerland 2015 326 P.J. Taub and L. Silver

Anesthesiologists, and the National University of to safely care for the patients or make do with Rwanda. Volunteer faculty, often with residents what the host institutions provide. Thus scouting from Canadian programs, travel to Rwanda to a location for a trip is critical and team members lecture and demonstrate in the local residency- have to be fl exible and resourceful in their training program. Similarly, Rwandan residents decisions. travel to Universities in Canada to enhance their Some students may also be concerned with their training [2 ]. own personal welfare, such as the safety of the From these relationships, joint research projects housing and the cleanliness of the food and water and publications should be fostered. In many supply. Again, housing arrangements should be instances, academic endeavors by foreign clini- scouted well in advance of the trip with a backup cians are rare on account of limited resources but plan in hand. Smart food decisions should be made are certainly desired. Efforts should be made to while abroad, including avoiding ice and freshly include foreign colleagues on papers and presen- washed vegetables and drinking only bottled water tations that relate to those conditions addressed on in areas where gastrointestinal distress is common the trip. in those not used to the drinking water. Students and residents may also have concerns about the costs involved in a mission trip. They Challenges should be aware of what is required of them up front so that there are no surprises during or after There are numerous challenges to developing a the trip. Some schools and organizations cover global health initiative and the amount borne by student and resident expenses, which alleviates students and residents will relate to their level of this burden; others cover some or none of the involvement. Some students may not have ven- costs. Funds may be available for travel alone tured far from home for either college or medical while the students or residents cover housing and school and may fi nd it diffi cult to adjust to a dif- meals. However, meals and incidentals over the ferent culture, as they will interact with people of duration of a trip may prove costly. different opinions, who speak different languages, and eat foods with different ingredients and fl avors. Planning For some, the sheer numbers of patients that require care may be daunting. Students and resi- The ultimate success of any medical mission lies dents who see a small handful of patients in clin- in the completeness of the plan. Preparation ics at home may be surprised to fi nd large numbers should probably begin one or more years in of patients of all ages needing care. Such experi- advance of the actual mission. Medical students ences may elicit feelings that the care provided on and/or residents with proper guidance and direc- any one short trip is insignifi cant to the population tion from more senior physicians should actually on a global scale. Similarly, any one mission is participate in the planning. Such actions serve as limited by time and hard decisions often have to a valuable learning experience for international be made about which patients receive care and health care delivery. The plan should include the which do not. These decisions should probably local problems to be addressed, the country and not fall on students and residents who are the city, the medical facility, the length of the trip, more junior members of a team, but are better left team members, housing, transportation, and other to attendings and local clinicians. critical information discussed herein. At home, team members have the luxury of any The index population should have one or more and all supplies they require and the opportunity medical conditions in which the team has an to try out and use the latest equipment. Abroad, a interest and familiarity regarding pathology and lack of basic tools is usually the norm and team treatment. The condition(s) addressed abroad members have to bring what they feel they need should be fairly straightforward, not requiring 24 Students and Residents 327 complicated preoperative studies, extensive equip- distance from the medical facility, transportation ment, or intensive postoperative care or rehabilita- should be planned, either public transportation tion. That being said, there are certainly successful and/or a rental vehicle. Buses and taxis should be mission trips that address the above, such as cranio- used with care and never alone. At least one team facial malformations that require preoperative member should be comfortable driving in a for- computed tomography, intraoperative drills and eign country, possibly in a vehicle with manual saws, and postoperative intensive unit care [3 ]. transmission. All local rules for driving should be While medical students and residents may not known and followed as they are at home. have much familiarity with the medical condi- Currently, most institutions seek to approve tions to be addressed, the attending physicians mission trips in which their attendings, residents, (surgeons, anesthesiologists, and others) should or students are participating prior to embarking. only treat those conditions that they manage at The location, schedule, and overall plan will be their home institution. International patients reviewed by a global health committee and either should be offered the same respect and high-level approved or denied based on the merits of the care that is offered at home. Medical missions proposed mission. Some institutions insist on a should not serve as a venue to “practice” proce- review of the travel advisories from the State dures that one does not do at home. The students Department to ensure that the region is safe. and residents however may benefi t from working Most require proof of immunization for team with attendings from different subspecialties with members traveling abroad. Often, approval by whom they may not get to work at home until they the host institution is necessary for the institu- are more senior. tion to provide insurance for resident and student The destination country should be decided team members. Documentation should cover upon based on several important factors. It should medical care for illnesses to team members have a relatively stable governmental structure while they are abroad, as well as emergency that does not place the team in signifi cant danger evacuation. from either the political climate or environmental Financing an international mission often falls concerns. The planners should be aware of any on the sponsoring organization or the team mem- local customs/religions so as not to offend the bers. The budget generally includes costs for host team members and patients upon arrival. travel, housing, local transportation, food, and The destination city should have a medical facil- medical supplies. Students and residents can be ity that has the resources needed for the safe asked to pay their own travel expenses and treatment of patients, including a functioning accommodations or the organization or school blood bank and an intensive care unit. Also criti- with which they are participating may cover cal to international missions are “ground forces” them. Larger organizations often have the fi nan- (i.e., host team members) that can identify cial structure and clout to subsidize the travel and patients needing care and caring for these patients housing of all team members. Smaller organiza- after the team returns home. The attendings from tions can benefi t from fund raising efforts, which home should have an amicable, open relationship may be organized and run by students and with the local host physicians since the latter are residents. critical to the success of the mission. Contempt or derision between team members is an absolute recipe for disaster. Timing The destination institution/city should offer appropriate housing opportunities for team In discussing the possible involvement of medical members. Accommodations should be in a safe students and residents in international medical neighborhood, clean, and situated not too far from mission trips, an important question is “when.” the host institution to minimize the time needed It could be argued that some minimal level of for travel. If the housing is not within walking education/training should be completed at home 328 P.J. Taub and L. Silver prior to joining a medical mission. Is it better to children may not miss signifi cant classwork if take a fi rst year resident as opposed to a fourth their surgery takes place at that time. Finally, year student or are there students of any age that summer missions allow team members to pack may be better able to participate? Perhaps, rather lighter than they would if the mission occurred than the level of training, the decision to take a over the winter when temperatures are colder. student should be based on prior global experi- Students may or may not possess the same ence, the degree of maturity, and/or some demon- freedom of time. The summer between the fi rst strated interest level. Since residents can and second years of medical school is often not potentially have more responsibility, higher PGY- fi lled with clinical requirements in the hospital level residents might be considered over interns and a couple of months can be dedicated to plan- and lower level residents. For surgical missions, ning, preparation, or actual travel. Alternatively, residents in their chief year are preferred for their a student or resident can take a year away from ability to add more technical expertise to the school or training to dedicate to a medical mis- mission. sion. This time commitment may be necessary in Any mission trip takes time to plan, time to the early stages of development when approvals prepare, and time to execute. The length of the need to be obtained, contacts need to made, and trip must be considered in the planning. The trip planning is the most intense. itself is usually the least time intensive, usually spanning a week or 2. Attending physicians often dedicate a portion of their vacation time to such T r a v e l trips and cannot spend weeks or months away from their private practices or clinical depart- Travel can be a complicated endeavor if there are ments. Students have curriculum concerns and large numbers of personnel and a lot of equip- residents have rotation schedules; thus a mission ment that needs to be taken. Medical students and longer than 1 or 2 weeks may be too time con- residents can certainly participate in organizing suming for some. Having a resident away from travel plans. Airline fl ights and local transporta- the program should not place undue stress on the tion to and from the airport need to be arranged in work schedule or the call schedule of the remain- advance. Team members often arrive from differ- ing residents. Residents can often be scheduled ent cities, at different times, on different airlines, for a month on a mission trip if it is part of a resi- and often on different days. Key personnel should dency block. Vacation time may also be used for arrive in advance of days for equipment and missions. It should be noted that longer missions patient screening. also have potentially higher housing costs, meal If equipment needs to pass through customs, costs, and equipment requirements. paperwork may be needed to prevent it from Seasonality may also be important. Some being confi scated or at least held up. Often, for- countries have a rainy season, which partici- eign countries fear that equipment is being pants may want to avoid. Local holidays are a brought it to be sold on the black market. Since double- edged sword: patients are off from work, time is valuable, delays can be quite detrimental which may be a good time for a trip, but they to the mission. Students can coordinate the inven- may also be away traveling. Similarly, key local tory of supplies that are being brought on the trip personnel may not be available during the well in advance, including the serial numbers for holidays. all durable goods. This information should be Trips that involve operating on children sent to the Ministry of Health in the host country may be better scheduled over the summer (winter and copies of the receipts that it was received and back home if the destination is in the southern approved should accompany any team members hemisphere) to minimize cancellations for ear that will be traveling with the equipment so infections and routine coughs and colds. Many that they may have the information when they schools are often on break over the summer so that pass through the customs offi ce. 24 Students and Residents 329

Foreign countries are now more restrictive in Intraoperative Care what items are used during surgery. At one time, any suture material or medication could be used. Intraoperatively, students and residents should be Mission trips would gather expired suture at able to perform level-appropriate procedural tasks home throughout the year and bring it for use on such as placing intravenous and intra-arterial the trip. Nowadays, foreign hospital administra- lines, Foley catheters, intubation, emergence, and tors insist on using only products that have not charting. Because of the critical nature of anes- expired and will inspect these products before thetic and surgical care, vigilant supervision is allowing them into the operating suite. Similarly, paramount, especially during intubation, emer- durable goods may need to show proof that they gence, and key portions of any operation. This have passed a mechanical inspection. component of the mission trip has the greatest equipment requirements. Monitoring devices and ventilators may not resemble those at home and Preoperative Care attendings and residents alike should be familiar with their use prior to starting a case that requires Once at the destination, the most important pre- sedation or general anesthesia. operative task is the screening and selection of Similarly, the vast array of medications avail- patients to treat. Often the host clinicians have able at home and restocked by support personnel advertised and gathered possible surgical candi- may not be available abroad. As part of the plan- dates before the team’s arrival. Again, students ning, a list of necessary medications and equip- and residents can play signifi cant roles in the ment should be drawn up and checked against screening process with adequate supervision. availability at the institution. Anything that is Ultimately however, decisions regarding which deemed necessary at home should be brought patients will be scheduled for surgery will fall on with the team for use on the mission. In the case the attending physicians. For surgical missions, of medications and disposable devices (as well as the most junior members can participate in gath- sutures), supplies should be in their original, ering medical histories, examining patients, sterile containers and not expired. Durable equip- speaking with families, and taking preoperative ment should be registered with customs both at photographs. There can be a tremendous amount home and abroad so that they may be brought of organization that is needed in getting patients into and out of the country without suspicion (and their families) to see the necessary team from the local government. members in order to provide treatment or decide For surgical missions, junior members who on the appropriateness of surgical intervention. plan to participate either in procedures, such as Prior to beginning a week or more of operative line placement, or the actual surgical procedure procedures, an inventory of the available equip- should have had some experience in an operative ment and supplies needs to be created. Some of setting. They should understand the principles of the equipment may be brought from home, some sterile techniques and universal precautions. may be left over from prior missions, and some These practices will minimize the rate of infec- may be provided by the host institution. Surgical tious complications and the chance of inadvertent instruments need to be left at the hospital in contamination by team members. advance of the fi rst day of surgery so that they may be properly sterilized. Again, students and residents can assist in creating the inventory and Postoperative Care seeing that everything is returned at the conclusion of the trip. After the fi rst operative day, the instru- In the postoperative period, patient care remains ments again need to be sterilized for cases the paramount. The level of critical care monitoring following day. Often, some equipment can be left may not be as thorough as it is at home and for the host institution’s ongoing use. patients must be followed carefully. Here again, 330 P.J. Taub and L. Silver students and residents can play an important role. team members should be included in the program If a subsequent operative case is going, for which since they often have better knowledge and skill the attending must be present, a student and/or than their visitors. The student/resident is given resident can periodically monitor the earlier an opportunity to delve into a particular topic and patient in the recovery area and report back any also build good will and bidirectional learning changes that occur. between host and visiting team members. On the days following a surgical procedure, students and residents should employ the same practices abroad that they undertake at home. Concluding Statement These functions include morning rounds before starting the days’ cases to evaluate any postopera- In today’s medical training environment, global tive patients. Of course, there should be adequate health missions should be considered an integral supervision so that complications may be recog- part of any medical student or residency-training nized and promptly addressed. program. The decision to begin a program Another excellent role for students and resi- however should not be taken lightly but requires dents is to track outcomes. Patient demograph- signifi cant foresight and planning. Today stu- ics should be kept as a chart along with the dents and residents actively seek out programs anesthesia record, an operative note, and the with an international health component. Those record of the postoperative course, noting any with an interest in global health care should be complications. Since some complications do not encouraged to participate in such endeavors. manifest immediately, follow-up with the host Students or residents can be helpful in organizing medical team at some point after the trip is the mission or participating as a team member. In important to ascertain the health and outcome of either case, they are numerous, long-lasting ben- the patients. efi ts for both the trainee and the sponsoring institution.

Didactics References For many reasons, a didactic program while in the host country is important (but not essential). 1. Campbell A, Sullivan M, Sherman R, Magee WP. The Education and teaching reinforces the principle medical mission and modern cultural competency of reciprocal beneﬁ t to both those traveling training. J Am Coll Surg. 2011;212:121–9. abroad and those hosting foreign colleagues. 2. Twagirumugabe T, Carli F. Rwandan anesthesia residency program: a model for north-south educational Lectures can certainly be organized and planned, partnership. Int Anesthesiol Clin. 2010;48(2):71–8. but also given, by students and residents. Host 3 . www.komedyplast.org Building a Global Health Education Program in an Urban School 25 of Medicine

Natasha Anushri Anandaraja , Ram Roth , and Philip J. Landrigan

health centers in countries around the world [1 ]. Introduction Global health has become a focus of intense interest at the US National Institutes of Health (NIH), Global health has become an increasingly impor- and NIH Director Francis Collins has named tant focus of education, research, and clinical ser- global health one of his top priorities. vice in medical schools and universities. Driven Many of the new academic global health pro- by rapidly growing student and faculty interest, grams are interdepartmental and university-wide by societal recognition of the importance of the in scope. They have created curricula as well as fi eld, and by increasing support from govern- fi eld experiences in global health for trainees at ments as well as from private donors and founda- multiple levels. The 2013 Consortium of tions, the number of academic global health Universities for Global Health (CUGH) Global programs in North American institutions has Health Program Database lists 24 North American expanded from a handful 5 years ago to more than institutions as having global health tracks, path- 80 today, and another 30 have formed in academic ways, certifi cates or other formalized global health opportunities within their medical school curricula [ 1]. Seventeen institutions were listed as having post-graduate, residency-based global N. A. Anandaraja , M.B.Ch.B., M.P.H. health programs, most frequently involving Arnhold Global Health Institute , Mount Sinai Departments of Internal Medicine, Pediatrics, Medical Center , One Gustave L. Levy Place , Family Medicine, and Emergency Medicine. Box 1255 , New York , NY 10029 , USA There are currently no listings for global health Departments of Preventive Medicine & Medical residency offerings in either Surgery or Education, Icahn School of Medicine at Mount Sinai, Anesthesiology, although the authors are aware One Gustave L Levy Place , Box 1255 , New York , NY 10029 , USA of the existence of several such programs. For e-mail: [email protected] example, the department of Anesthesiology at the R. Roth , M.D. Icahn School of Medicine at Mount Sinai has Department of Anesthesiology , Icahn School of been providing international medical care for Medicine at Mount Sinai, New York , NY , USA almost 20 years through several programs involv- P. J. Landrigan , M.D., M.Sc., F.A.A.P. (*) ing many specialties (Table 25.1 ). Impoverished Department of Preventive Medicine , and underprivileged children and adults receive Icahn School of Medicine at Mount Sinai , world-class medical care and surgery in the fi elds One Gustave L. Levy Place , Box 1057 , New York , NY 10029 , USA of pediatrics, gynecology, orthopedics, otolaryn- e-mail: [email protected] gology, ophthalmology and general surgery.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 331 DOI 10.1007/978-3-319-09423-6_25, © Springer International Publishing Switzerland 2015 332 N.A. Anandaraja et al.

Table 25.1 Anesthesiologists from the Icahn School of Medicine have been participating in global outreach programs for almost 20 years Year Country Organization Year Country Organization 1997 Russia Healing the Children North East 2007 Honduras Gift of Life, Rotary Club 1997 China Healing the Children 2007 Honduras Medical Students Making Impact 1998 Russia Healing the Children North East 2008 Liberia Mount Sinai 1999 China Healing the Children 2008 Dominican Healing the Children Republic 2000 China Healing the Children 2009 Vietnam Gift of Life, Rotary Club 2000 Romania Humana 2009 Liberia Mount Sinai 2000 Dominican Healing the Children 2009 Thailand Healing the Children Republic 2000 China Children of China Pediatric Foundation 2009 Ecuador Healing the Children 2001 Romania Humana 2009 Dominican Healing the Children Republic 2001 Kenya Healing the Children 2010 Guyana Caribbean Heart Institute 2002 China Healing the Children 2010 Liberia Mount Sinai 2003 China Children of China Pediatric Foundation 2010 Liberia Mount Sinai 2004 Romania Humana 2010 Haiti Partners in Health 2004 Bolivia Healing the Children 2010 Ecuador Monteﬁ ore Medical Center 2004 Dominican Medical Students Making Impact 2010 Ecuador International Surgical Health Initiative Republic 2005 Honduras Medical Students Making Impact 2011 Liberia Mount Sinai 2005 Dominican Healing the Children 2011 Peru Komedyplast Republic 2005 Honduras Medical Students Making Impact 2011 China Healing the Children 2006 Vietnam Rotary Club 2013 Peru Komedyplast 2006 Honduras Medical Students Making Impact 2014 China Healing the Children 2006 Dominican Healing the Children 2014 Peru Komedyplast Republic 2006 Honduras Medical Students Making Impact

Recently, the hospital dispatched international completed service trips to Honduras, Belize, medical teams of surgeons, anesthesiologists, Zambia and Nigeria (Table 25.2 ). and medical students to Central America, Africa, Anesthesiologists, surgeons, fellows, residents and the Caribbean. From Angola to Zimbabwe, and a cadre of highly motivated medical students these teams provide optimal health care to the are currently raising funds and collecting dona- population and teach local residents, nurses, and tions of medical supplies for the next “Brigada” physicians, meantime forming enduring bonds of (a group of people organized for special activity) friendship. Our teams donate supplies to the local as they are called by the locals in San Pedro Sula, hospital operating theaters and clinics. Faculty Honduras. Our teams demonstrate surgical tech- team members pay their own expenses and time niques while providing care to as many people as off from their regular duties is supported by their possible by day. Evenings are spent with local respective departments. government and health ofﬁ cials as well as medi- The department of anesthesiology at the Icahn cal school students and administration expanding School has also provided continuing support our knowledge and understanding of global health and mentorship for Medical Students Making issues and offering lectures and presentations to Impact (MSMI), founded in 2001, orchestrating local colleagues. MSMI team members often international medical/surgical teams that have gain ﬁ rst-hand knowledge of diseases, syndromes 25 Building a Global Health Education Program in an Urban School of Medicine 333

Table 25.2 Anesthesiologist and medical students under with an understanding of the global burden of their supervision have provided care in many countries surgical need and a determination to affect sus- over the past 14 years tainable change in Global Health. Year Country Component of Mount Sinai We describe the development of a coherent, 2000 China MSSM & Children of China multi-level, interdisciplinary program in global Pediatric Foundation health in the Icahn School of Medicine, a large, 2003 China MSSM & Children of China Pediatric Foundation urban, hospital-based medical school in New York 2004 Dominican Medical Students Making Impact City. Our goal is to share lessons learned and Republic offer guidance to programs in other institutions. 2005 Honduras Medical Students Making Impact 2005 Honduras Medical Students Making Impact 2006 Honduras Medical Students Making Impact Evolution of Global Health at 2006 Honduras Medical Students Making Impact Mount Sinai 2007 Honduras Medical Students Making Impact 2008 Liberia Mount Sinai Phase 1: Initiating Factors and Design 2009 Liberia Mount Sinai 2010 Haiti MSSM & Partners in Health The Global Health program at Mount Sinai School 2010 Liberia Mount Sinai of Medicine was founded in 2005. Its creation was 2011 Liberia Mount Sinai 2011 Honduras Medical Students Making Impact both catalyzed and supported by increasing trainee 2011 Haiti Mount Sinai demand. This demand was evidenced by growing 2012 Dominican Mount Sinai Global Women’s numbers of resident and student international elec- Republic Health tives and by expanding participation in student-led 2012 Liberia Mount Sinai international health interest groups. Critical events 2012 Jamaica Mount Sinai were informal surveys of incoming, fi rst-year 2012 Bolivia Mount Sinai Cardiac Anesthesiology medical students in which nearly two-thirds of 2013 Dominican Mount Sinai Global Women’s these incoming students indicated an interest in Republic Health spending at least a portion of their careers serving 2013 Liberia Mount Sinai the underserved in low- and middle-income coun- 2013 Nicaragua Mount Sinai Cardiac Anesthesiology tries (LMICs). This response represented a dra- 2014 Dominican Mount Sinai Global Women’s Republic Health matic increase from preceding years and was very 2014 Liberia Mount Sinai important in demonstrating the need for global 2014 China Mount Sinai health programming to institutional leadership. The global health initiative was developed and designed through a series of structured discus- and poverty that they would otherwise see only sions among senior faculty from the Departments in textbooks. of Pediatrics, Preventive Medicine, and Medical Most dramatically, an e-mail was sent to all Education as well as the Center for Community employees at Mount Sinai Medical Center asking and Multicultural Affairs. for volunteers for an international surgical team An important early decision was a plan to focus to Haiti 2 days after the earthquake of January scarce program resources on education. A small 2010. The rapidly assembled group included grant was secured from a private foundation to orthopedic and general surgeons, nursing staff to support curriculum development. The intent was provide OR and PACU support and our anesthe- to develop a three-tiered educational program that siologists. Armed with narcotics and minimal may be visualized as an inverted pyramid: equipment for performing regional anesthesia, we performed 75 procedures. We the providers of Tier One: At the top of the inverted pyramid is the international surgical care gained much from the broadest of the three levels. It was designed to experience. The group returned to Mount Sinai provide introductory courses for the entire medical 334 N.A. Anandaraja et al. school class. The goals were to introduce all of defray program costs as well as offi ce space and our students to key issues in global health and administrative support. give them an introduction to the concept that To build a philanthropic base for the Global these problems are soluble and that there exist Health program, a Global Health Advisory Board rational approaches to problem solving. was created. This board consisted predominantly of contacts of the senior founding faculty. The Tier Two : In the middle of the inverted pyramid board had no fi duciary or programmatic respon- was seen a transitional tier. It consisted of elec- sibility for the program, but participated in fund- tive offerings for those medical students and phy- raising and promotional events, including the sicians who had become intrigued by the hosting of an annual fundraising event. In 2006, a introductory material presented in Tier One. formal proposal was successfully presented to Through these electives, medical students, resi- the family foundation which had granted the ini- dents and physicians are given the opportunity to tial planning grant, and the program received a work for weeks or months in underserved areas grant of $1,000,000 to be disbursed over 3 years. either in the United States or abroad. This grant gave the program the foundation for its growth. It supported part-time salaries for fac- Tier Three: The tier with the fewest number of ulty, provided stipends to support global health people at the bottom tip of the inverted pyramid fi eld experiences for trainees, and supported consists of longer term training programs for travel expenses to allow faculty to build partner- physicians who have made a serious commitment ships with organizations across the globe. to serving the world’s poor. These could be special fellowships of 6, 12, or even 24 months in duration. They could be located geographically Phase II: Growth of Programs either in the United States or abroad, so long as and Partners the focus is on devising sustainable solutions to long-term health problems in poor communities. Global Health in the Medical School At the time of formation of the Global Health To launch the program, four junior faculty mem- Offi ce in 2005, student global health activities bers from four departments were recruited by the consisted of independently organized clinical Dean of Medical Education based on their past electives in the third or fourth year of medical experience in global health and their responsibili- school and short clinical “mission” trips orga- ties for oversight of international activities within nized by volunteer faculty. With the exception of their home departments. These four junior fac- a brief preparatory curriculum for students par- ulty members each maintained a primary appoint- ticipating in the clinical trips, there was no formal ment within their own departments, that is, teaching in global health. Pediatrics, Preventive Medicine, Emergency To address this gap in global health education, Medicine and Internal Medicine. In addition they development of a formal curriculum was an early were each given partial salary support from the goal of the Global Health Offi ce. Global Health global health planning grant to work on develop- faculty introduced many different curricular ment of the multi-level global health training pro- offerings over the succeeding 8 years, including a gram. Leadership was provided by one of the semester-long elective “Introduction to Global senior founding faculty from the Department of Health” course, a Global Health Career Speaker Pediatrics and the Dean of Medical Education. Series, and an annual Global Health Conference. The program was initially created as an Offi ce of All of these programs continue to the present, but Global Health housed within the Department of have been continuously refi ned and improved in Medical Education. The Dean of the Medical response to continuing program evaluation. School provided a modest amount of funding To introduce all of our medical students to through the Department of Medical Education to core concepts in global health, the Global Health 25 Building a Global Health Education Program in an Urban School of Medicine 335

Offi ce developed a proposal to introduce an 18-h Health Projects rely on relationships with partner semester-long global health course to the fi rst- organizations around the globe, and provide year medical student core curriculum. This pro- funded and closely mentored 8-week-long fi eld posal was initially rejected by the Executive experiences. An online system has been created Curriculum Committee of the medical school in through which students participate in a competi- 2006. However, the Executive Curriculum tive application process. Applications are Committee encouraged the creation of a global reviewed by faculty research mentors for each health “Course-without-Walls” with the aim of global partner site, and students are matched with embedding global health topics into existing core a project site based on their interests, their level of courses. Through this “Global Health Course- prior global health experience, and their language Without- Walls,” the content of the proposed stand- skills. Successful applicants for the Summer GH alone global health curriculum was delivered Project are required to attend a semester-long through a variety of core medical school courses “Preparation for Global Health Fieldwork” including Epidemiology and Microbiology, as well course. Over the years, this course has progressed as through clinical clerkships in pediatrics, through many revisions based on participant OB-GYN and internal medicine. feedback and the evolving demands of the fi eld- Then in 2012, with the support of the Dean of work. The course currently includes mandatory Medical Education and following the placement sessions on global health ethics, cultural compe- of key Global Health faculty on the medical tency and travel safety, plus elective sessions on school Curriculum Redesign Committee, global survey design, needs assessment, database health was accepted as a stand-alone course design, and qualitative methods, among others. within the core medical school curriculum. This In the months prior to their fi eld placement, stu- was a key development. Designed to be delivered dents and mentors work collaboratively with over 3 weeks during the fi rst and second year of their partner organizations to develop research medical school, the course titled “Global Health and educational projects. Research questions and InFocus” is now a mandatory part of medical educational interventions are designed to address school education at Mount Sinai. Faculty for the the specifi c needs of the partner organization and GH InFocus collaborated with faculty from the community. Students and their mentors work Department of Health Policy and Evidence to together on the development of research method- create approximately 35 h of curriculum explor- ology and tools, and obtain approvals from both ing themes of research, clinical care, public Mount Sinai and local institutional review boards health intervention, human rights advocacy and as needed. While in the fi eld, students work under policy change within the global health agenda. the supervision of a local mentor from the partner The fi rst and second weeks of the new curriculum organization. Depending on the site and the were delivered for the fi rst time to the class of nature of the project, the students may also be 2016. Evaluations from the launch of this pro- visited by their Mount Sinai mentor for a period gram showed poor response to the largely lecture- of supervision. based sessions on social determinants of health On their return to Mount Sinai, students com- and health policy in the fi rst week of the course. plete a number of post-trip requirements before In response, the second week of the course was receiving the last installment of their summer sti- tailored to focus on more specifi c global health pend. These include the submission of an abstract topics and included expert guest speakers, inter- and poster for the Mount Sinai Medical Student active small groups, and panel discussions. It was Research Day, submission of a refl ective journal- enthusiastically received. ing assignment, completion of a debrief inter- Mentored fi eldwork opportunities have been view, and submission of an online evaluation offered to medical students and Masters of Public form. Following completion of their data analy- Health (MPH) students through the Global Health sis, students and mentors disseminate relevant program since 2009. These Summer Global information back to the partner organization. 336 N.A. Anandaraja et al.

Many students will go on to present their work at research at a global partner site. Others will be a national conference, and a smaller subset will supported in the development and submission of produce an MPH thesis or a manuscript for sub- an application to a structured fellowship or mission to a peer-reviewed publication. Since internship program. Historically, Mount Sinai 2009, 152 students have completed a Summer students have had success applying for year-long GH Project. This experience has proven to be the internship and fellowship opportunities with the cornerstone of global health education for Doris Duke Foundation, the NIH/Fogarty medical students at Mount Sinai. In contrast to International Clinical Research Scholars Program, fi eld placements offered by many other institu- and the Centers for Disease Control. tions, the success of this program rests on indi- In keeping with the program’s initial intention vidual mentorship, participation in a collaborative to provide advanced educational opportunities project rather than mere clinical observership, for a subset of committed medical students, the and the scholarly products required on comple- Global Health Dean’s Scholar Program was tion of fi eldwork. launched in 2012. Each year the Scholars pro- To meet the increasing demand for practical gram recruits two candidates from the pool of experiences and to accommodate students whose accepted medical school applicants. The program academic schedule would not permit a full provides successful applicants with a 5-year track 2-month summer experience, a new opportunity which includes a combined MD-MPH degree, a for fi eld placement was created in 2014. The Global Health Summer Project, the opportunity “Global Health India Immersion Experience” for global health clinical electives, a funded year provides an on-site learning experience focused of GH Scholarly Leave, and longitudinal mentor- on community-participatory healthcare in a rural ship. The GH Dean’s Scholar Program is now in underserved setting in India. The course was cre- its third year of recruitment. The MPH compo- ated in collaboration with the Comprehensive nent of the track is provided tuition-free for the Rural Health Project (CRHP) in Jamkhed, India. Dean’s Scholars, and fundraising continues It will be co-taught by Mount Sinai faculty and towards the ultimate goal of full tuition coverage CRHP trainers. The fi rst cohort of students has to allow scholars to graduate free of debt. been selected and consists of 15 students from MD, PhD, MD-PhD, and MPH programs who Global Health and the Graduate will travel to India with three faculty members in Program in Public Health July 2014. The directors of Mount Sinai’s MPH program, In addition to summer fi eld experiences, many like their colleagues in the medical school, students now independently undertake clinical quickly recognized the growing status of Global global health electives during their third and Health as a specialty within public health educa- fourth year of medical school. These experiences tion. The MPH program is located within Mount are organized independently by the students, but Sinai’s Graduate School of Biomedical Sciences. reviewed and approved by the Global Health pro- With their support a Global Health Concentration gram. Criteria for approval include the support of was launched within the MPH program in 2009. faculty mentors from Mount Sinai and the fi eld Guided by the standards of the Council for site, adequate external funding, a robust plan for Education for Public Health, the GH Concentration the student’s on-site activities, and engagement consists of core course requirements in research, with an underserved community. management and socio-behavioral topics in addi- Mount Sinai Global Health also supports stu- tion to specifi c global health coursework, a global dents to undertake a year of Global Health health-related practicum and a thesis. Scholarly Leave between third and fourth year of Many of the original courses within the medical school to pursue an in-depth global Global Health Concentration were created and health research project. Some of these students will taught by the founding global health faculty, all receive mentorship and funding for independent of whom had completed their own MPH degrees. 25 Building a Global Health Education Program in an Urban School of Medicine 337

Over time, each of the four founding Global health track, but remained in close collaboration Health faculty members also accepted faculty with the GHRT, sharing teaching resources and positions within the MPH program, and in 2011 fi eld sites. The support of Departmental Chairs the most senior of the group became the Director and Residency Program Directors was essential of the MPH program. These dual appointments to the creation of the GHRT. Internal pressure created opportunities for sharing of resources from residents for global health electives had and coordination of activities between the global already set the stage for this process, and the health programs in the medical school, the MPH promise of a formalized administrative process, program and the global health residency structured education, and provision of mentor- programs. ship and funding was welcomed. A number of To date, the Global Health Concentration of Departments were prepared to share the travel the MPH program offers ten courses plus a costs of their participating residents and to Master’s thesis and practicum for a total of 30 involve additional faculty in mentoring. credits. The designation of several institution- The GHRT recruitment process was designed wide educational events as credit-earning MPH with consideration of the pros and cons of pre- ver- courses, including the annual Global Health sus post-match recruitment, and with respect for Conference and the Global Health Career Speaker the challenging schedule faced by interns from all Series, creates further coursework opportunities. specialties. Accordingly, GHRT participants are This strategy also allows faculty to earn recogni- recruited through a competitive application pro- tion and compensation for their work on these cess in the penultimate year of their residency pro- events. Twenty-seven students have graduated gram, allowing a focus on clinical medicine during from the Global Health Concentration in the 5 the intern year and adequate time for global health years since its creation. coursework and fi eld work during the less demanding latter years of residency. Global Health for Residents Between one and four candidates are accepted To support post-graduate training in global health, annually from each residency program based on the multidisciplinary Global Health Residency the ability of the program to meet educational and Track (GHRT) at Mount Sinai was launched in clinical coverage requirements. Selection of can- 2006. The fi rst four residency programs to par- didates is based on their commitment to a global ticipate were the home departments of the found- health career as evidenced by past global health ing faculty: Pediatrics, Emergency Medicine, education and experiences and a personal state- and Internal Medicine, with the addition of the ment of intent. Input from the candidate’s resi- Medicine-Pediatrics Combined Residency dency director and chief resident are also sought program. as candidates must be in good standing clinically The Combined Medicine-Pediatrics program and professionally. later became a “Medicine-Pediatrics Global Once accepted to the GHRT, residents are Health Residency” which specifi cally recruited matched with a research mentor and partner orga- candidates committed to global health as a focus nization. They then work in collaboration with of their residency and career. The program incor- their Mount Sinai and on-site mentors over sev- porated an MPH with a concentration in global eral months to identify and develop a research or health into the 4-year clinical residency, and pro- educational project. This project is implemented vided support for extended fi eld placements. This in their fi nal year of residency during a 6–10 unique residency program graduated its last resi- week fi eld placement. Although a small number dents in 2014. Mount Sinai’s Psychiatry and of partner sites will provide an appropriate envi- Obstetrics & Gynecology (OBGYN) residency ronment for clinical work, the focus of GHRT programs also joined the GHRT soon after its fi eld placements is on developing skills for con- creation. Due to scheduling diffi culties, OBGYN ducting research and implementing public health eventually developed an independent global or educational initiatives in under-resourced 338 N.A. Anandaraja et al. settings. For many residents the global health The Teaching Fellowship is funded by a long- fi eld project will also fulfi ll a research require- time donor whose contribution provides salary ment imposed by their clinical program. The resi- support and travel expenses for the year-long pro- dents’ time in the fi eld is protected by providing gram. In comparison to other Global Health either call-free electives or supporting the resi- Fellowships which combine clinical responsibili- dent to bank calls with their colleagues. For ties in the USA with international activities, the emergency medicine residents additional time independent funding of this program gives may be available by manipulating clinical shifts, Teaching Fellows complete freedom from and many of these residents will go into the fi eld revenue-generating clinical responsibilities, twice during their residency. In preparation for allowing for focus on global-health-related activ- their fi eldwork GHRT residents are also man- ities and fi eldwork. dated to participate in the “Preparation for Global The fi rst Arnhold Global Health Teaching Health Fieldwork” course. Fellow was recruited in 2011. He worked with The cooperation and guidance of the Mount Global Health faculty on the design and delivery Sinai Offi ce of Graduate Medical Education has of new material for several global health courses been essential in the creation of the within the medical school and MPH program, and GHRT. Co-creation of supervisory and educa- played a signifi cant role in the development of a tional standards for global health resident experi- new 300-h course in Tropical and Travel Medicine. ences has ensured that ACGME standards are The fi eldwork component of his fellowship was adhered to while still providing for the unique carried out in Mozambique where he designed circumstances of working in resource-poor systems for evaluation of a Community Health communities. Worker training initiative. While in the fi eld he To date, the Mount Sinai GHRT has graduated also supported GHRT residents in the design 71 residents from the GHRT. and implementation of their projects, which included training HIV Peer Educators and Mobile The Arnhold Global Health Teaching Clinic staff. Fellowship The second Arnhold Global Health Teaching The Arnhold Global Health Teaching Fellowship Fellow was recruited in 2012 and came to the was established in 2011. The drivers for this ini- program with the intention to improve her teach- tiative were both a defi cit in post-residency global ing skills in underserved and cross-cultural set- health training opportunities and the need for tings. Her Fellowship was therefore designed to increasing teaching support at Mount Sinai and provide an extended experience in the fi eld. global partner sites. Following language training in the capital of Fellowship candidates are sought nationally Mozambique, she became integrally involved at with the only requirements being completion of an our rural partner site. Here she contributed to the ACGME-accredited residency program, US licen- training of several cohorts of health workers sure, and commitment to a career as a global health including traditional birth attendants, HIV peer practitioner. In alignment with Mount Sinai’s educators, community health workers, local commitment to building the healthcare workforce nurses, and a community-based Gender Based in underserved areas of the world, the Fellowship Violence taskforce. Importantly, she also devel- program was designed to provide candidates with oped connections at the academic level with the skills and experience as global health educators. local schools of medicine and public health. To this end, Fellows are funded to complete short Based on these relationships, Mount Sinai Global training courses relevant to their teaching role, to Health will now support Sinai faculty to teach at participate in the design and implementation of the local medical school and will match Mount global health curricula at Mount Sinai, and to Sinai MPH students with Mozambican MPH participate in educational initiatives for health students for collaborative Summer Global Health workers at global partner sites. Projects. 25 Building a Global Health Education Program in an Urban School of Medicine 339

The program has just recruited its third health and human rights. The inaugural issue Arnhold Global Health Teaching Fellow, who focused on global cardiology and was published will be placed at a partner site in the Dominican in January 2014. Republic. In this role she will support the local Family Medicine Residency Program, design and Global Health Partner Sites deliver curricula for an urban Community Health In 2006 an informal survey and interview process Worker cohort, and coordinate fi eld projects for was conducted by Global Health faculty to poll Mount Sinai residents and students. “experts” in the fi eld for their opinions on several The Fellowship program, although in its early education-related issues. These leaders of notable days, has already proven to be mutually benefi cial global health academic programs and non- for Mount Sinai and its global partner sites. The governmental organizations (NGOs) were asked extended on-the-ground presence of our Fellows to identify organizations around the globe that has been instrumental in the maintenance of part- could become partner sites for trainee fi eld expe- ner site training initiatives, has provided opportu- riences. Based on these recommendations, several nities for the development of academic academic organizations and NGOs were con- partnerships, and creates a stable platform for tacted and site visits were conducted in the Mount Sinai GHRT and student projects. Dominican Republic, India, Uganda, Tanzania, Expansion of the Fellowship program is therefore and Kenya. Criteria for inclusion as “partner a programmatic priority, with the ultimate goal of sites” were defi ned, memorandums of under- placing Fellows at each of our Flagship partner standing (MOUs) were created, and trainees sites (see below). began to be placed at these partner sites to carry out collaborative research, public health, and The Annals of Global Health educational projects. In 2013, the Global Health program was invited Over the following years, maintenance of to reconfi gure and relaunch the Mount Sinai some sites and attrition of others occurred organi- Journal of Medicine as a journal of global health. cally. Additionally, new partnerships arose Under the leadership of the Dean and Associate through the preexisting connections of Mount Dean for Global Health, the 79-year-old Mount Sinai faculty. As time passed the partner sites fell Sinai Journal of Medicine thus became the into one of two categories: (1) those where the Annals of Global Health. The focus of the publi- partner organizations functioned independently cation transitioned from translational research to of Mount Sinai’s input but were able to provide the health issues of disadvantaged and low- high quality practical opportunities for Sinai income communities across the globe. trainees, and (2) those where Global Health The Annals of Global Health is an open- Faculty were signifi cantly involved in program- access, peer-reviewed journal with a commit- matic assistance and research with the partner ment to publishing authors from many organization, and where Mount Sinai engage- institutions, countries, and disciplines. It will be ment in health-worker training, research, and accessible without cost to physicians, scientists, clinical care was needed and feasible. Programs and concerned citizens in countries worldwide, falling into this second category were designated including low- and middle-income countries and as “Flagship” sites. The strategic decision was countries with distressed currencies. The journal made to focus programmatic resources at these represents an opportunity for Mount Sinai to sup- sites to expand the scope of the partnerships and port and promote global health scholarship and achieve greater impact on the healthcare capacity disseminate important new concepts in global and health outcomes of the local communities. health. The journal has a particular interest in Flagship sites are currently under development in publishing articles that critically examine the Mozambique, the Dominican Republic, Liberia, and social determinants of health and disease and North Dakota. Mount Sinai trainees will be pref- those that elucidate the connections between erentially channeled to these sites for fi eldwork, 340 N.A. Anandaraja et al. with increasing commitment to the expansion of members—one from Preventive Medicine and local health-worker training activities and the one from Cardiology—as Dean and Associate development of new collaborative funding and Dean for Global Health. Under their direction, research efforts. the program was renamed Mount Sinai Global An important feature of Mount Sinai’s global Health. This designation refl ected the commit- health partnerships has been the extent to which ment of the medical school to global health. partner site projects are driven by the agenda of It resulted in a modest increase in internal fund- local organizations and communities. Due in ing, a substantial increase in program stature, and large part to our predominantly private sources of signifi cantly enhanced the program’s ability to funding and the broadness of our mission, the raise funds from philanthropic sources. Mount Sinai Global Health program has had the The appointment of the Dean for Global Health, freedom to prioritize local priorities over external whose responsibilities include oversight of global agendas. This has created truly mutually benefi - health activities throughout the Mount Sinai cial and fulfi lling relationships. Medical Center, Residency Programs, Graduate School and Medical School, also reinforced the Global Human Rights centralized structure of global health at Mount Over the past 3 years, Human Rights and advo- Sinai. This centralization counters the formation cacy have become a signifi cant aspect of global of silos within the global health community, pro- health education at Mount Sinai. The addition of moting effi cient resource-sharing, collaboration, two faculty members with expertise in these fi elds creation, and maintenance of standards for global has elevated these topics from a sidebar in overall work. The central governance and reporting sys- global health education, as they are in many tem also enables a swift and coordinated institu- global health curricula, to a signifi cant component tional response to global health opportunities and at all levels of global health training. educational needs within the Sinai community and Current human rights offerings for medical its partner organizations. students include a semester-long elective course in In 2011, Global Health leadership, faculty and Human Rights and Social Justice and a Human Advisory Board members participated in a strate- Rights and Social Justice Scholars Track, in addi- gic planning process to map out short-, mid-, and tion to mandatory coursework in human rights and long-term programmatic and fundraising goals. advocacy through the Global Health InFocus cur- Structural redesign at this stage resulted in the riculum. Residents and students are also offered defi nition of four pillars of activity within the training in the assessment and management of sur- overall initiative: Research, Education, Patient vivors of torture. On completion of training they Care, and Human Rights. Each pillar was rotate through the Mount Sinai Survivors of appointed a Director who reported to the Dean of Torture clinic to assist faculty in the examination Global Health. Although providing a useful proof clients and preparation of affi davits for asylum grammatic structure, the four pillars remained application. functionally connected with fl uidity of faculty An initiative is now underway to integrate the time and programmatic resources between them. human rights and advocacy approach across our Fundraising remained centrally coordinated with Flagship partner sites. Multi-site research to inves- the assistance of the Mount Sinai offi ce of tigate the health impacts of human rights abuses Development. and support of local human rights education will Under the agenda of the Patient Care pillar, sys- further establish Human Rights as an integral activ- tems were developed to identify and oversee the ity of the Arnhold Global Health Institute. activities of Mount Sinai faculty who were independently participating in clinical work in under- Program Structure served communities around the globe. Codifi cation In May 2010, to solidify the position of global of a set of requirements for Mount Sinai-affi liated health programs within the Mount Sinai School global health projects was a necessary prerequisite of Medicine, the Dean named two senior faculty to this process. These requirements included 25 Building a Global Health Education Program in an Urban School of Medicine 341 minimum standards regarding local supervisory collaboration, increased internal and external and partnership capacity, completion by partici- visibility, and prioritization of Global Health as a pants of online safety and health courses prior to focus for future philanthropy. Efforts are cur- travel, and creation of MOUs to be signed with rently under way to defi ne the levels, require- local partnering organizations. Creation of data- ments, and privileges of membership in the new bases to register faculty projects, and of systems Institute, and to recruit a Founding Director. to ensure adequate insurance and liability coverage for traveling faculty, was undertaken with the Program Outcomes input of the Information Technology, Legal, Risk Evaluation of the impact of the global health pro- Management and Human Resources depart- gram at Mount Sinai has been a complex endeavor ments. A team of Global Health faculty members which is constantly being reassessed and modi- formed a Site Review Committee which meets fi ed. Several levels of evaluation are required, monthly to review project applications submitted including the proximal outcome of trainee satis- through the database. The Review Committee faction with curricular offerings, the mid-term provides guidance to applicants as needed with outcomes of impact on local partner site health- the aim of bringing projects into alignment with care capacity, and long-term outcomes relating to the overarching mission of the Global Health pro- the career choices of our graduates and changes in gram. This process has resulted in the transforma- health outcomes in our partner communities. tion of existing short-term student-led clinical Currently, evaluation of trainee satisfaction mission trips into public health-oriented learning with global health curricular and extracurricular experiences, and addition of local health-worker offerings occurs through existing medical school training strategies or research projects to faculty- evaluation structures. These include individual led clinical mission trips. course evaluations, a graduation survey, an intern In 2012 an External Advisory Board was survey, and a student council survey of satisfac- recruited to provide expert guidance on the strate- tion with medical school services. Participants in gic development of the Global Health program. the GHRT participate in pre and post-track sur- The board was composed of fi ve leaders from a veys to gauge the infl uence of the GHRT experi- number of well-known academic, governmental ence on their future training and career choices. and civil society organizations. The counsel of the The impact of training initiatives at Flagship Board and the program evaluations that they sub- partner sites is monitored with varying degrees of mitted to the Dean of the Medical School provided sophistication depending on the onsite capacity. important insights and generated high-level sup- These evaluations range from simple monitoring port for the program. A critically important recom- of numbers of health workers trained and ser- mendation offered by this Advisory Board in 2013 vices delivered, to systems which include data was that Mount Sinai consider formation of a true collection on both health-worker performance Global Health Institute. The Dean of the School of and the community-level impact of their work. Medicine accepted this recommendation and Although the evaluation of the most distal pro- instructed the School’s offi ce of Development to grammatic outcomes has proven challenging, make the formation of a Global Health institute a there are ongoing efforts to investigate the impact philanthropic priority. of our global health training programs on partici- In 2013, a founding donor to the Mount Sinai pant career choices. Annual Alum Surveys are Global Health program made a generous endow- distributed to both graduated medical students ment gift, allowing the program to be elevated to who participated in a Summer Global Health its current status as the Arnhold Institute of Project and graduates of the Global Health Global Health at Mount Sinai, the 16th cross- Residency Track. Surveys of GHRT graduates to departmental institute to be created at Mount date showed that 55 % of respondents had Sinai. The institute structure is critical to the con- participated in further global health-related train- tinuing expansion of the global health mission at ing through Fellowship programs. 55 % of GHRT Mount Sinai. It will foster cross-departmental graduates continued to work with an underserved 342 N.A. Anandaraja et al. community abroad, and 90 % were working of leadership and allows for real-time feedback with an underserved population domestically. and support for emerging issues. The response rates from graduated medical Although there are disadvantages in regards to students was extremely poor, but it appears that a branding and funding opportunities for a global signifi cant proportion (75 %) have remained health initiative that is not housed within a multi- engaged in global health work through their cho- school university setting, the relatively lean sen residency programs. structure of Global Health at Mount Sinai creates effi ciency. Short chains of communication and governance enable the program to be rapidly Successes and Challenges responsive to the changing demands of the academic environment and the needs of our trainees Institutional Structure, Funding, and partner organizations. and Identity The recent acquisition of a sizeable endow- ment lends a strong foundation for the Institute. The support of leadership within both the medi- However, ongoing fundraising is essential to cal school and clinical residency programs has allow for growth of the program. Support for been a key factor for success since the inception global health education and training has only of the Global Health program. This support was recently appeared on the agenda of traditional driven by an understanding of the rising demand Global Health funding agencies. Lack of univer- for global health education from the Mount Sinai sity status has also limited the eligibility of our trainee population, and recognition of the power medical school-based program for funding of a Global Health educational program as a options. However, signifi cant support has been recruitment tool. Internal support was also gained successfully obtained through private and family through the positioning of Global Health initia- foundations, small government supported grants, tives as central to Mount Sinai’s longstanding and a dedicated group of private donors. As global commitment to social justice. Since its founding health programs continue to emerge throughout as the Jews’ Hospital of New York in 1855, the US academic centers, competition for funding institution’s mission has refl ected a commitment becomes more intense, and the importance of to the care of diverse and marginalized popula- inter-institutional partnerships and public- private tions [2 ]. This alignment of values provides justi- partnerships for funding increases. fi cation for ongoing engagement with underserved An issue which infl uences the competitiveness communities around the globe. of the Institute within the funding environment is Unlike many global health ventures at larger that of “branding”—of establishing an identity academic institutions, the centralized leadership for the program based on an area of expertise and governance structure at Mount Sinai supports related to a specifi c global health topic, geo- cohesion, resource sharing, and synergy among graphic location, population, or approach to the varied programs housed under the Global global health work. As a signifi cant function of Health Institute. Weekly meetings involving the the Mount Sinai Global Health program has been Directors of all four pillars, founding Global to convene a disparate group of global health Health faculty and key administrators, ensure con- activities under one institutional umbrella, the stant communication, group problem solving, and defi nition of a “brand” has been neither a simple collaborative decision making. Bimonthly broader task nor a priority. However, as the program has meetings involving faculty from throughout the grown and a number of areas of expertise have institution promotes participation of the wider arisen based on the strengths of key faculty and global health community. In addition, weekly the priorities of our partner sites, the pros and meetings between the Dean of Global Health and cons of branding around one or a few of these the Dean of the Medical School ensure that the areas has been debated. Other approaches to global health agenda is visible at the highest levels defi ning a brand could be identifi cation of a niche 25 Building a Global Health Education Program in an Urban School of Medicine 343 area in global health as yet unclaimed by another As noted earlier in this chapter, global health major organization or academic institution, or a training opportunities in medical school and decision based on forecasting trends in funding schools of public health have emerged rapidly and for various global health topic areas. Benefi ts of recently into an environment where no formal branding include the ability to form a cohesive global health career path existed. The challenge strategic plan for the Institute as a whole and to therefore becomes how to appropriately mentor align funding priorities, programmatic decisions Global Health trainees towards feasible and ful- and evaluation metrics around a set of common fi lling careers, and how best to support junior fac- goals. Increased clarity of messaging for fund- ulty who wish to be involved in global health. The raising and public relations purposes could also burden of debt incurred during a medical school result from a successful branding campaign. education remains a signifi cant hindrance to phy- Disadvantages of branding the program may sicians seeking to dedicate their career to under- include loss of recruitment opportunities due to served populations. Many programs, including mismatch between trainee interests and the the one described here, seek scholarship funding advertised brand of the Institute, limited ability to to allow GH trainees to graduate debt-free. Some respond to evolving partner site needs, and reduc- innovative new programs attempt to address this tion in broad donor appeal. Inability to engage barrier by combining post-training Global Health with locally defi ned needs that are not in align- service opportunities with loan forgiveness [ 3 ]. ment with the brand of the Institute is a signifi - At Mount Sinai we also strive to create Global cant concern. Health faculty appointments for our graduates. The balance between pros and cons of brand- Provision of partial salary support can protect the ing continues to be debated. However, in light of time of these young faculty members, enabling the recent formation of the Institute and the cur- them to maintain involvement in global health rent search for an Institute Director, this issue is of through roles as mentors and partner site project increasing importance. managers. Provision of scholarships for MPH tuition and additional Fellowship opportunities also broaden post-residency training opportuni- Faculty Development ties and boost competitiveness in the global health employment arena. A longstanding barrier to meeting demand for meaningful educational opportunities has been a shortage of mentorship for trainees. A signifi - Future Directions cant input of time is required to prepare a student or resident for fi eld work, to collaborate Over the past 9 years a robust program in global with partner organizations on the design of health has been established at Mount Sinai. appropriate research methodology, to assist a The Arnhold Global Health Institute now offers a trainee through local and US IRB processes, multi-level interdisciplinary educational program, and, oftentimes, to visit that mentee in the fi eld. opportunities for research, human rights advo- Currently, a small and dedicated cohort of GH cacy and patient care, and meaningful collabora- mentors work year-round to prepare trainees of tions with international and domestic partner all levels for practical fi eld experiences and sub- sites. Over the next 5 years we plan to strengthen sequent production of scholarly work. However, engagement with our Flagship sites for increased funds and offi cial processes for compensation of impact on the growth of the local healthcare mentor time and effort are limited. An institu- workforce. Reciprocal training activities will be tional commitment to recognition and support expanded, including increased opportunities for of mentorship activities is required to incentivize health workers from partner sites to rotate through and expand global health mentorship capacity at the Mount Sinai Medical System, as well as Mount Sinai. scholarship support for partnering health workers 344 N.A. Anandaraja et al. to obtain their MPH degrees from the Mount Sinai cational platforms, and mobile health applica- Graduate School. To support this commitment, tions. It is proposed that the services of the increased funding and institutional support is Global Entrepreneurship Team be provided as a sought for long-term placement of Global Health privilege of membership in the Arnhold Global faculty at Flagship sites and expansion in the Health Institute. numbers of Global Health Teaching Fellows. Many academic institutions with signifi cant international presence have created offi ces to Conclusion manage the multi-faceted issues around international engagement, including human resource and The success of the Arnhold Global Health Institute labor issues, liability and malpractice for physi- at Mount Sinai rests on the motivation provided cians practicing abroad, and requirements around by Mount Sinai’s trainees, on the support of lead- insurance, immigration and visa status, and inter- ership, on the hard work of its faculty, and, most national licensing. As Mount Sinai extends its signifi cantly, on the goodwill and collaboration of international reach, not only in terms of global its global partners. The program’s commitment to health activities but also for the purposes of aca- prioritizing partner’s needs and local capacity demic and clinical exchange with institutions in building is the best example we can provide to our high income countries, the establishment of a trainees for ethical global engagement. Over 9 similar service within the Mount Sinai operations years the program has grown immensely, yet con- structure will likely be needed. An Offi ce of tinuous self-evaluation and modifi cation are nec- International Affairs at Mount Sinai could provide essary to meet the changing demands of our this central body for the establishment of proto- trainees and partners. The global community is cols and provision of support and regulation constantly growing in its awareness of the com- around all of these activities. plexity of global health problems and its under- In addition, creation of a Global standing of how best to create lasting solutions. Entrepreneurship Team has been proposed to Through our commitment to supporting the next ensure that the expansion of activity also results generation of global health workers we hope to in increased productivity in scholarship, fund- contribute to this slow but inspirational process. raising and contribution to the global health knowledge base. Based on a model established by the Global Health Initiative of the Texas References Children’s Hospital and Baylor College of Medicine [4 ], the Global Entrepreneurship Team 1. Consortium of Universities for Global health. Available at: http://public.tableausoftware.com/pro- would consist of business, development and fi le/#!/vizhome/2013CUGHGlobalHealthProgramsD information technology support staff to provide atabase/2013CUGHGlobalHealthProgramsDatabase . assistance with planning, funding and execution Accessed 20 May 2014. of fi eld projects, as well as creative approaches 2. Aufses AH, Niss BJ. This house of noble deeds: the Mount Sinai Hospital, 1852–2002. New York: to dissemination of research fi ndings and new New York University Press; 2002. educational resources. Specifi c areas of support 3. Seed Global Health. Available at: http://seedglobal- would include assistance with creation of feasi- health.org/seedglobalhealth.org . Accessed 27 May ble business plans, identifi cation of novel fund- 2014. 4. Texas Children’s Hospital, Global Health Initiative. ing opportunities, and utilization of information Available at: http://globalhealth.texaschildrens.org/ . technology for data collection, web-based edu- Accessed 27 May 2014. Closing the Gap in Europe Through Education: A Reverse Mission 26

Gabriel M. Gurman

The fall of the Soviet Union in late 1989, almost lack of funds, a very inconsistent command of 20 years after immigration to Israel from foreign languages among young physicians, and Romania, found me as an Israeli citizen. At the the authorities’ permanent fear of manpower time I emigrated, the overall situation in Romania defection to the free world, contributed to serious was bearable and medicine was practiced at a restrictions of free travel. Availability of textbooks level not too far behind what I found in Israel, a and medical journals varied in different countries. country in a stage of full development. In both Material could not reach remote, peripheral countries medicine was somewhere on a level medical centers. In contrast, some physicians, between the wealthy parts of the world and com- scientists, and teachers from the western side of munist Eastern Europe. the continent regularly visited countries of the The fall of the Soviet Union offered a glimpse communist world, offering the local healthcare into the over-all failure of health care. The system providers a chance to learn of new achievements in was unable to answer the huge needs of the popu- medicine and related fi elds of science. lation. There was a clear discrepancy between the At the same time, anesthesiology in the west- degree of enthusiasm and dedication of the medi- ern part of Europe was leading the way to better cal staff and the availability of modern modalities patient care. In the second part of the twentieth to treat patients. The situation in anesthesiology century advances in anesthesia led to improve- and critical care was no exception. There was a ment in patient safety regulations, equipment and desperate need for modern equipment and drugs. drug arsenals in the operating room (OR) and Supplies produced in the Warsaw pact countries intensive care units (ICU), e.g., monitors, anes- only partially covered the needs. The scarce aid thesia machines, bedside lab, and X-ray avail- coming from Western Europe was not enough to ability. International organizations developed solve the problem. Contacts with medicine west codes of ethical principles; signifi cant basic and of the Soviet bloc were diffi cult to achieve. The clinical research was taking place in large hospital centers, facilitated by easy and continuous access to information. The benefi cial infl uence of * G. M. Gurman , M.D. ( ) developments on the North American continent Professor Emeritus, Anesthesiology and Critical Care , Ben Gurion University of the Negev , was felt in the western part of Europe. Beer Sheva , Israel A palpable contrast, noticed during my short Department of Anesthesia , Mayney Hayeshuah trips to some countries of the former Soviet Medical Center , B’nai Brak , Israel empire, led me to search for a way to assist col- Soroka Medical Center , Beer Sheva , Israel leagues and friends to shorten the path towards e-mail: [email protected] modern medicine.

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 345 DOI 10.1007/978-3-319-09423-6_26, © Springer International Publishing Switzerland 2015 346 G.M. Gurman

of the profession by offering them a direct view of The World Federation of Societies daily activities at a busy, up-to-date hospital. of Anesthesiologists (WFSA)–Beer The project was situated in Beer Sheva, the largest Sheva Project city in the south of Israel. Beer Sheva is a university city, home to Ben Gurion University (BGU) WFSA was aware of the problems arising from the of the Negev, which accommodates some 21,000 continuous lack of contact between the two parts of students in various faculties and research centers, the continent. In the years preceding and following including the Faculty of Health Sciences (FOHS). the fall of the Iron Curtain, different world organi- The FOHS includes a well-developed medical zations including the WFSA tried to facilitate the school that has clinical and teaching facilities for process of harmonizing the level of the profession almost all fi elds of healthcare. of anesthesia throughout the continent. After the The main teaching base was Soroka Medical fall of the communist bloc, many of Western Center (SMC), a 1,100-bed hospital, located in Europe’s leading anesthesiologists found their the immediate vicinity of FOHS. All its depart- way to countries of the communist system. They ments and clinics educate medical students and took part in national congresses, organized teach- have established post-graduate and residency ing courses, taught new techniques, and invited programs. At the time of initiation of this project, young local specialists to spend periods of time the SMC-FOHS Division of Anesthesiology and in well-organized and equipped anesthesia Critical Care employed 30 specialists and 35 resi- departments [1 ]. Table 26.1 presents a short list dents, many of them holding academic degrees of educational activities organized by various from BGU. international organizations or individuals, with The project was proposed to the Committee advantages and drawbacks delineated. for Education of the WFSA and was approved in Based on this partially successful experi- 1992 [2 ]. The questions: Why Israel? And why ence, we initiated two projects with different Beer Sheva? Deserve special clarifi cation. At that scopes. The aim of the fi rst project was to time Israeli medicine had an interesting place in expose a large number of young Eastern the world of modern medicine. Its sophistication European anesthesiologists to the modern aspects was well established. The quality of health care was high. Although characterized by easy access to up-to-date treatment for every citizen, cost was Table 26.1 Educational activities in anesthesiology signifi cantly less than that of many other devel- promoted by individuals and professional international oped countries. Even today health care accounts organizations in Europe in the fi rst years after the fall of the Iron Curtain for a mere 8 % of the gross national product compared to 17.6 % in the USA (2012) [ 3 ]. Project Advantages Drawbacks The resolution of the BGU, FOHS, and SMC Training centers • Economic • No use of in some countries • Teaching in up-to-date to host the program, together with the eagerness accordance equipment of the Division of Anesthesiology staff to teach with the • Paucity of and train, created the proper climate for imple- existing reality teachers menting the project in Beer Sheva. One notewor- Refresher courses • Unlimited • No number of immediate thy detail is that the majority of the staff spoke participants impact on the numerous languages; in addition to Hebrew and • Updating daily activity English. Several were born in counties outside theoretical Israel and afforded native speakers of Russian, knowledge Romanian, Arabic, Hungarian, Bulgarian, Educational • Wonderful • Brain drain grants for various contact with from the Spanish, Italian, French, and Portuguese. In short, periods of time in modern country of the young foreign anesthesia specialists visiting various domains medicine origin SMC were offered a chance to observe a reputable of the profession level of medicine, practiced at reasonable cost. 26 Closing the Gap in Europe Through Education: A Reverse Mission 347

The Israeli system could be a source of inspiration to ease the inauguration of the program. FOHS for those who would try to improve the healthcare assisted the project by arranging accommoda- level in their own countries where the budget allo- tions for the foreign physicians in the immediate cated to medicine was still low. vicinity of SMC, in the premises of student dor- Another point is that according to Israeli reg- mitories. The walking distance between the ulations, a visiting physician is not allowed to apartments and the hospital eased the partici- remain in the country. They may only practice pants’ approach to the special activities during medicine with the necessary permits for a fi xed the nights and weekends. The staff on duty would and limited period of time and they require con- call and inform them about a special case or treat- tinuous supervision by an Israeli physician. This ment deserving interest. Also, an agreement was regulation was an assurance that the visitor reached with FOHS stipulating the right of the would go back home after completing the train- project participants to freely access the faculty ing period. There would be no drain of qualifi ed library as well as the sport facilities of BGU. personnel from the countries involved in the We decided to ask each participant to cover project. his or her own travel expenses. This decision was based on the principle that the young physician involved in the program was supposed to be as Implementation invested as the sponsor in obtaining a place in the project. In discussions with the offi cers of the As a result of the WFSA arrangement to sponsor national societies we reached the conclusion the project, we approached the national anesthe- that paying for the airplane ticket would not be siology societies of interested countries and too heavy a burden for any of the participants. planned interviews with candidates eager to take The reality proved that this supposition was cor- part in the program. Involvement of local society rect. During the 14 years of the project in Beer offi cers participating in the selection committee Sheva there have been no cancelations due to was vital. The local leaders were expected to travel costs. know the candidates and assist in the process of The decision to bring to Beer Sheva specialists selecting individuals with the highest potential to in groups belonging to the same visiting country benefi t from the observation period at SMC. was taken after an intense discussion with WFSA The interview, usually scheduled during an offi cers. The alternative was to mix participants annual convention of the national anesthesia from different countries and offer everybody a society, was in English and good command of chance to get information about other kinds of this language was the fi rst criterion in the selec- organizations in different parts of Eastern Europe. tion of candidates. Equally important, the young This would have also facilitated better command anesthesia specialist was expected to explain of English, the only common language for all. what he/she anticipated from the observation But the accepted idea was not to separate members period in Israel. In most cases the number of can- of the same national group, and thus to accelerate didates exceeded the number of positions allo- their acclimatization with the new atmosphere cated to that specifi c country. The fi nal decision and better organize their free time (weekends and was made after review by the committee mem- afternoons) activities. bers, which always included at least one SMC staff member. WFSA decided to cover the cost of the foreign The Observation Period physicians’ stay in Beer Sheva. BGU accepted the role of controlling the funds received from The participants arrived in Beer Sheva in groups WFSA by opening a special account dedicated of three or four when the project included only solely to this project. The BGU president at that 1 month of observation, and then in pairs in the time donated a substantial sum of money in order second part of the project, when the participants 348 G.M. Gurman were offered a longer period of observation, thus Table 26.2 Topics of special interest to the WFSA–Beer giving each visiting physician a chance to become Sheva project participants in different years of its existence more familiar with one of the specialty fi elds: Year Topic critical care, obstetrical anesthesia, cardiotho- 1992 • Oximetry racic anesthesia, pain management, etc. • Capnography • Caudal anesthesia for children Each participant was integrated in the daily 1994 • Neurostimulator activity of the Division of Anesthesiology at • Pulmonary artery catheter SMC. It started with participation in the 7:00 a.m. • Invasive blood pressure monitoring meeting, which included the previous night’s 1997 • Pencil-point needles for spinal anesthesia report, a quick glance into the morning schedule, • Isofl urane replacing halothane for inhalation anesthesia and a 10-min presentation by one of the residents. 2000 • Intracranial pressure monitoring A simultaneous translation from Hebrew to • Postoperative pain relief in children English through headphones was provided by one • Hemofi ltration in ICU of the staff. • Pre-anesthesia outpatient clinic Then members of the group were assigned 2001 • Fiber-optic tracheal intubation to the activities of the morning, either in the • Pediatric critical care • Organization of a recovery (PACU) room OR non-OR areas such as the pain clinic, 2002 • Laryngeal mask preanesthesia assessment clinic, or ICU. They • Combined spinal-epidural anesthesia also took part in the consultations on the fl oor • Continuous spinal anesthesia and in any teaching activity involving the anes- • Percutaneous tracheostomy thesiology residents. When possible, the foreign • Organization of an acute pain service physicians were given a chance to take part in educational events outside Beer Sheva, such as a At no stage of the project did the average partici- national convention or a refresher course in anes- pant feel a need for clinical theoretical presenta- thesiology and related domains. Special attention tions. The access to electronic information was given to those areas that interested the for- became progressively easier in every country eign physicians. Their interest varied from involved in the program and the young specialist One year to another and from one group to was able to improve his/her theoretical knowl- another. The main explanation for varying inter- edge base by a simple process of self-learning. est in new knowledge was that gradually, the The specifi c interest started with items belong- average Eastern Europe anesthesiologist became ing to compulsory monitoring in the OR, a accustomed to new achievements in the profes- demand diffi cult to achieve in the absence of the sion. Hospitals in various countries of the eastern necessary equipment. Once the visiting specialist part of the continent started purchasing modern became accustomed to this basic equipment in equipment and drugs, and a process of reorgani- his/her own hospital, the general interest switched zation of the daily activity was evident in many to more complicated practical items, most of medical centers. Additionally, a new system of them originating from the personal subspecialty continuous education was gradually implemented interest. Also some of the foreign specialists had in many Eastern countries, with the aim of offer- the opportunity to visit and work in other devel- ing young physicians a chance to improve theo- oped medical centers (abroad and even in their retical knowledge and apply it to the daily work. own countries and cities). There they encoun- Table 26.2 shows the gradual changes in the tered modern equipment and all necessary drugs list of some topics of interest among the partici- for modern anesthesia. They also were offered pants in the project. It refl ects the progress made the opportunity to participate in international sci- by the profession in various participating coun- entifi c conventions and contact colleagues from tries during the fi rst decade of the free market more developed countries. Once back home, system and liberation from the communist system they could implement some of the things seen limits. The table reveals some interesting points. and learned. 26 Closing the Gap in Europe Through Education: A Reverse Mission 349

Table 26.3 Countries and number of participants in the WFSA–Beer Sheva project during 1992–2005 Year/country 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Total Romania 2 4 4 4 4 4 2 2 1 27 Moldova 4 4 4 4 4 4 4 4 4 36 Slovakia 4 4 2 2 2 2 16 Bulgaria 4 4 4 3 3 4 4 4 4 34 Slovenia 2 4 2 3 11 Serbia 4 4 Macedonia 2 8 10 Hungary 4 2 3 9 Belarus 1 1 Total 2 4 4 4 4 16 14 14 13 14 16 10 18 15 148

This rather new reality created the basis for Once back home, participants transmitted to changing the direction of the educational process. colleagues concepts learned at SMC and also We felt the obligation to search for other ideas tried to change practice at home This permanent that could better serve the purpose of closing the desire for progress was amplifi ed by a continuous gap between the two parts of the old continent process of improving the Eastern European con- (vide infra). ditions for work, better equipment, better drugs, During 1992–2005, 148 foreign specialists in availability of disposable items, as well as a much anesthesia, from nine countries, all younger than easier approach to information. 40 years old, took part in the WFSA–Beer Sheva On the other hand, a close observation of this project, spending between 1 and 6 months, at SMC improvement process uncovered some of the still (Table 26.3 ). Most of them were allowed only to existing fl aws of the system in the participants’ observe, but those who spent longer time in the countries. These fl aws are partially explained by the hospital got the opportunity to directly participate reminiscence of old regime obstacles and limits. in the daily activity in the OR and outside it, under The residency track was supposed to keep pace continuous supervision. Thus they got more expo- with the continuous changes in daily activity in sure than an average specialist in anesthesia is able and out of the OR, but in some countries this pro- to offer his/her patients. The observer was not cess was signifi cantly delayed. Parts of the orga- involved in patient care; he/she just observed the nization of an anesthesia department were still treatment offered to the patient. But when the guest neglected, such as the pre-anesthesia outpatient spent at least 6 months at SMC (very few cases), an clinics, acute pain service, or recovery rooms. educational license was issued by the Israeli Finally, the paucity of resources did not allow the Ministry of Health, thus the foreign physician was involvement of the project “graduates” into clini- allowed to take part in patient care under direct and cal and basic sciences research. permanent supervision of an Israeli physician. Overall, the feedback obtained both at the end Did this fi rst project signifi cantly contribute to of each observation period and during various the process of closing the gap between the two occasions visiting the involved countries proved, parts of Europe? The answer is unclear. The proj- that the WFSA–Beer Sheva project was worth- ect created a practical base for a young specialist while. The demonstrated personal development to become familiar with modern equipment and of the participants and the improvement of care in an approach to the specifi c needs of the surgical their home countries were defi nitely positive and patient. Some ethical aspects of our clinical justifi ed the fi nancial cost covered by the world activities and judgment contributed to a better organization. understanding of the limits of healthcare and the The project did not include a follow-up sys- rights of the patient. tem to determine what happened to individual 350 G.M. Gurman anesthesiologists, but we do know that upon their of healthcare. They had implemented the princi- return home some became directors of anesthesia ples of patient safety in their places of work. The departments, chiefs of professional units, and new generation of anesthesiologists possessed organizers of congresses and conventions. We also the necessary skills and knowledge to provide a know that some 20–25 % of them found their way good level of anesthesia practice in the OR and to Western Europe and are currently employed in also outside it. But the new atmosphere and foreign departments. enthusiasm that invigorated Eastern Europe anes- The WFSA–Beer Sheva project moved in 2005 thesiology lacked one item; educational skills. to the Wolfson Medical Center in Holon, Israel Internet and easy approaches to electronic infor- under the leadership of Prof. Tiberiu Ezri for mation could not offer the young physician the 7 more years. Up to 2012 it included 23 young necessary knowledge in experience regarding anesthesiologists from eastern European countries, training in the domain of teaching. such as: Slovakia, Romania, Moldova, Bulgaria, Permanent contact with our profession all Serbia, the Czech Republic, and Uzbekistan. At the over Eastern Europe very clearly showed that one initiative of WFSA, 14 specialists from Africa also of the weak points of educating the new genera- joined the project. tion of specialists was the use of old methods to The Wolfson leg of the project offered partici- teach new things. Once the need for basic equip- pants a 6-month period of training within the ment and drugs had been, at least partially, solved framework of the department of anesthesia. Each and access to up-to-date information ceased to be participant could select one of the following fi elds a problem, we felt that we had to take care of the of interest: critical care, pediatric anesthesia, system of teaching. obstetrical anesthesia, and cardiac anesthesia. During our frequent visits to those countries in Foreign physicians were permitted “hands-on” the fi rst years of the new millennium, we found experience by obtaining a temporary educational that the teaching system and methods had been license from the Israel Ministry of Health and less infl uenced by the permanent contact with the were involved in clinical practice on daily basis, other part of the continent. A simple example under the close supervision of an Israeli specialist. would help demonstrate this statement. How does A small stipend was offered by WFSA and lodg- one teach a clinical item such as acute pulmonary ing was provided by the host hospital. edema? Many years ago teachers would have approached such a subject by defi ning the disease and its etiology, explaining the pathophysiology, A New Direction in the Process presenting the symptoms, and fi nally bringing to of Closing the Gap Between East the attention of the student/resident the methods and West of prevention and treatment. But today attitudes have changed. In order to facilitate understanding The WFSA–Israel project was an important step the clinical framework of such an acute situation, in trying to close the gap between the two sides of we created a clinical scenario, in which a patient Europe. But at the same time, we became aware arrives to an emergency room with symptoms of of two important facts that demanded a change in dyspnea and cyanosis, and with cardiac pathology planning for further projects. in the past, after—let’s say—a copious meal that The fi rst was the new reality in the vast major- included a too salted main course. The student is ity of the former communist countries. Gradually asked to discuss the data, inquiring about the clin- medicine in general and anesthesiology in par- ical examination results, proposing a differential ticular was changing its characteristics and incor- diagnosis, asking for adjuvant tests, such as an porating some of the features of modern, Western X-ray and arterial blood gases, and then gradu- medicine. A new generation of specialists ally reaches the correct diagnosis. From that assumed the destinies of the specialty and had moment the path to treatment and prognosis already been exposed to new trends in organization becomes an easy one. 26 Closing the Gap in Europe Through Education: A Reverse Mission 351

In many university centers this kind of teach- Of course, young physicians still learn how to ing was absent, and the so-called “problem-based teach from other people’s experience. learning” (PBL) unheard of or not used as a “Reciprocal learning”, means that each physi- teaching tool. The explanation is simple. The cian is infl uenced by his/her colleagues’ experi- introduction of PBL in undergraduate and post- ences [1 ]. But this kind of learning proved to be a graduate medical courses necessitates special slow one. The implicit danger is that the older training of teachers and monitoring of their per- teacher could be stuck with old methods and formance [4 ]. It demands good teachers, which would consider the task of teaching a secondary cannot be obtained by a process of “spontaneous aim of his/her daily work. Thus the idea of learn- generation,” but rather by creating groups of new ing from another’s teaching colleague experience teachers, who have been taught how to teach and could lead to an undesired effect, that of “teach- how to use the proper means of teaching for facil- ing without a real teacher”! itating an easier understanding of the lesson. Creating a good and successful teacher is not a simple task. In some countries, simulation teach- Teaching the Teacher ing has been successfully used but the expense involved remains prohibitive for many areas. These thoughts created a new project, a European Azer [5 ] compiled a list of 12 qualities of a institution ( The International School for good teacher, among them: commitment to work, Instructors in Anesthesiology—ISIA ) with the an ability to interact and communicate respect, aim of preparing, in a limited number of coun- capacity to encourage clinical thinking, a proper tries outside of Israel, a group of instructors who teaching environment, interest in teamwork, as would be exposed to the modern methods of well as readiness to accept feedback and criticism. teaching theoretical and practical subjects, as Some recent studies showed the qualities that a well as the main aspects of organizing our profes- clinical teacher should achieve in order to create a sion. We considered the idea of preparing experts proper framework for training other clinicians. in clinical teaching a very important task of anes- Masunaga and Hitchcock [6 ] studied 205 residents thesiology in the new millennium. and 148 faculty in family medicine who completed Clinical teaching is important because it the Clinical Teaching Perception Inventory (CTPI) improves clinical abilities for effective thinking online between April 2001 and July 2008. The par- near the patient’s bed. It creates a tradition of ticipants ranked 28 single- word descriptors that bedside and formal transmission of clinical infor- characterized clinical teachers along a 7-point- mation and expertise. By improving the quality scale ranging from “least like my ideal teacher” to of clinical teaching we expected an improvement “most like my ideal teacher.” Their results in the teaching system in those countries that had revealed that both residents and faculty indicated been selected to participate in the project. that the ideal clinical teachers should be stimulat- The project was presented to the Committee of ing, encouraging, competent, and communica- Education of WFSA in 2004, on the occasion of the tive, and should not be conventional, cautious, or 13th World Congress held in Paris. The Committee controlling. Molodysky [ 7] emphasized that discussed the various aspects of the proposal, without specifi c training in educational methods, decided to sponsor this new European project, and clinical teachers may be less effi cient and effective advised the inclusion of a third facet. Besides the in their teaching activity. PBL items and organizational aspects of the profes- The general understanding today is that we are sion, committee members added the basic knowl- not born teachers, as we are not born car drivers. edge of using modern teaching tools. A faculty was In spite of the fact that physicians teach all their appointed and included physicians dedicated to life, they may not know how to teach. The art of teaching as well as a specialist in the art of teaching, training is to be taught and learned like any possessing comprehensive experience in teaching other skill. education techniques for physicians. 352 G.M. Gurman

The main aim of the established curriculum of each national society, thus creating the so- was to teach new methods of lecturing on clinical called snowball effect, hoping that they would be subjects, based on descriptions of real cases, able to teach other people, also young specialists including evidenced base data and basic sciences and residents in the last part of their training, the knowledge. Then the curriculum was enriched by art of teaching. adding a long series of subjects related to educational skills and anesthesia organizational items. The idea of including organizational items The Schedule and Content derived from an additional scope of the school. The faculty considered the course a good oppor- Each of the 3 weeks included: tunity to prepare students to become leaders of • Five full days the specialty in their respective countries. Due to • 10 h per day their young age, we considered the participants • Lectures and presentations by the faculty fi t candidates to obtain, in the near future, leading • Workshops positions in their own departments, hospitals, and • Rehearsals of presentations by students national societies, as well as in the professional • Teaching in small groups international institutions. • Short presentations by the students (in the last The proposed schedule included 3 weeks for 2 weeks of the course) each course, separated by a period of 6 months. As explained above, each of the classes dealt The time lapse was due to recognition of the dif- with items belonging to the three components of fi culty for a young visiting physician to abandon the program: clinical scenarios and cases, edu- his/her daily duties and family for a period longer cational skills and methods, and theoretical pre- than 1 week. At the same time, we offered the sentations of organizational aspects of the student the opportunity to start and use, even anesthesiology. before graduating, the knowledge and skills Table 26.4 presents a variety of clinical topics learned at ISIA’s fi rst classes in their own depart- that were discussed during the three classes using ments, as practical drills. In this way the student the PBL format. They covered almost all the could assess the progress attained and become domains of activity of the profession and for each aware of topics that needed more serious effort item at least one case was prepared and discussed and attention in the future classes. with the students. Discussions followed the pre- Once again we approached the national societ- sentation of each case and students were encour- ies of anesthesiologists in Eastern countries, ask- aged to review the literature and fi nd solutions for ing for candidates to take part in the fi rst planned managing the case, taking into consideration the course. We recommended the following criteria availability of equipment, drugs, and organiza- for selecting participants to the ISIA course: tion facilities (recovery rooms, intensive care • A very good command of English units, CT scans, etc.). • Readiness to participate in all three classes The second group of items in the curriculum • Commitment to take the task of organizing comprised teaching tools . It included: local similar courses. • Plan and develop a curriculum This last demand needs further explanation. • Plan a lecture or a course WFSA and ISIA faculty have opined that we had • How to use the Internet to avoid the creation of an elite group of young • How to write multiple choice questions alumni, who would be able use the knowledge • Ways to improve power point slide quality and experience accumulated during the classes • Use of simulators for teaching purposes solely for their own purpose. • How to organize interactive sessions The project was supposed to continue after the The techniques of dealing with the audience students graduated. Each national group had to were also included. The student learned how to assume the responsibility of organizing similar check the lecture hall before any presentation, courses in their own countries, under the auspices to ensure audibility and slide visibility. The 26 Closing the Gap in Europe Through Education: A Reverse Mission 353

Table 26.4 Examples of clinical cases presented and discussed 1st course 2nd course 3rd course 1. Preop assessment and preparation 1. Pediatric and neonatal anesthesia 1. Management of crisis in anesthesia 2. Critical care 2. Obstetrical anesthesia and analgesia 2. Chronic pain 3. Regional anesthesia 3. Cardiac anesthesia 3. Management of diffi cult airways 4. Acute pain 4. Neuroanesthesia 4. Outpatient anesthesia 5. Anesthesia for trauma 5. Anesthesia for the elderly 5. Immediate postoperative care importance of proper body position and language to complete questionnaires regarding their during lecture was emphasized by presenting didactic activity “at home” and to emphasize the examples of good and bad habits. The faculty diffi culties still encountered during teaching, as a worked hard to enable students to understand the self-evaluation and refl ection report. elements of teaching and to improve further practice. Later on, during the last class, students prepared short presentations; each mini-lecture was Completion of the Course discussed and critique for improvement was offered, by both the faculty staff and the other Three full courses were organized between 2007 Students. Finally, a series of state-of-the-art for- and 2012; each included 3 weeks of study. The mal lectures about organization of the profession fi rst took place in Bratislava and Belgrade, the sec- occupied an important place in the students’ ond in Predeal, Romania, and the third on the schedule. Examples of subjects included in this island of Crete. The last two courses were equally category include: sponsored by WFSA and the European Society of • Organization of a department of anesthesia Anesthesiologists (ESA). A fourth course (under a • How to equip an operating room with restricted new name of “Teaching the Teacher”—TtT) budget started in October 2013, in the framework of the • Planning a residency track in anesthesiology ESA Autumn Meeting in Timisoara, Romania. • Critical care units and high-dependency units, In order to obtain the fi nal certifi cation the stu- how do they work together? dent was expected to fulfi ll the following criteria: • Clinical research—rules and pitfalls • Attend all three classes • Sterility in the Operating Room and prevention • Participate fully in all large and small group of ICU cross-infection tasks and presentations using English • Informed consent for anesthesia • Between courses 1–2 and 2–3 they should: • Introducing new methods into routine – Teach in different styles and on different practice occasions • Organization of a pain clinic – Produces a self-evaluation and refl ection The faculty was aware of the wide differences report between countries regarding the organization of • Assignment between the fi rst two classes: the profession. Thus discussions and comments refl ect on and evaluate a teaching session— of each subject were assigned a special place planning, content, methods, and delivery and time. Students learned how some problems • During the last class: were solved in other countries or departments. – deliver a 30-min case presentation lead a The organizational sessions created a framework discussion for exchange of opinions and experience and – Demonstrate competence in delivering the offered students a different perspective about the lecture situation of anesthesiology in different parts of – Proper use of power-point presentation the continent. technique The students received “homework” tasks for – Presents three multiple-choice questions each period between classes. They were asked related to a case presentation 354 G.M. Gurman

Sixty specialists in anesthesiology from 16 of Europe. During the three classes of the ISIA countries (Table 26.5 ) graduated the fi rst three third course (2011–2012) we did not feel a sig- courses of ISIA. In addition to the Eastern Europe nifi cant difference between the background and countries, Greece, Turkey, and Malta, three coun- behavior of the students coming from either part tries not belonging to the former communist of the continent. All participants shared the same bloc decided to take part in the ISIA project. kind of defi ciencies in “know-how” in the domain The acceptance of participants from additional of modern teaching. countries was based on the fact that the need for a “Teaching the Teacher” project was global and not specifi cally restricted to the communist part The Feedback

During 2011 and 2013 questionnaires were sent Table 26.5 Countries and number of ISIA graduates to all 60 ISIA graduates, with the aim of obtain- during the fi rst three courses (2006/2007, 2009/2010, and 2011/2012) ing precise data about the impact that the school had on the development of its participants. Fifty Country Number of graduates graduates fi lled out the questionnaire (83 % Bulgaria 4 responders). Croatia 3 Three categories of questions were included in Georgia 3 the feedback form and they referred to: Greece 5 Hungary 4 1. Pre-ISIA teaching activities of each Latvia 4 participant Lithuania 4 2. ISIA impact on their teaching abilities Macedonia 4 3. Incidental benefi ts of the ISIA teachings Malta 2 Tables 26.6 , 26.7 , and 26.8 present the results Moldova 4 of the feedback. Most of the ISIA alumni did not Poland 4 have any previous training in the art of teaching Romania 4 and thus they lacked confi dence in communicat- Serbia 4 ing with the audience before taking part in the Slovakia 3 ISIA fi rst classes. Two-thirds of the responders Slovenia 4 had never used a modern system of presenting or Turkey 4 discussing a case before being exposed to ISIA Total 60 principles.

Table 26.6 Patterns of pre-ISIA teaching activities—50 responders Topic Item Number of responders Percentage (%) A. Source of teaching 1. Specifi c lectures or lessons 6 12 abilities 2. Other people’s experience 34 68 3. Specifi c books 6 12 4. No previous instructions or frontal teaching 17 34 B. Feelings during teaching 1. Fear 25 50 2. Lack of confi dence 30 60 3. Lack of communication with the audience 35 70 4. No diffi culty at all 6 12 C. Type of presentation 1. “Classical” defi nition, etiology, etc. 30 60 2. Use of a case as a starting point 9 18 3. Special slides for interacting with audience 1 2 4. Special slides for conclusions 19 38 26 Closing the Gap in Europe Through Education: A Reverse Mission 355

Table 26.7 The feedback on ISIA alumni teaching abilities been elected as offi cers of their own national after graduating the school, in comparison to the pre-ISIA societies of anesthesiology and other professional period—50 responders organizations, such as WFSA and ESA. Topic Number reporting Item better results A. Presentation 1. Content 50 The Post-ISIA National Courses details 2. Quality of slides 50 3. Ability to involve 50 One of the main objectives of the ISIA courses audience was to create a number of gifted teachers who, 4. Personal 48 in turn, would organize similar courses in their appearance own countries. The ISIA faculty did not possess B. Feelings during 1. Much better 49 the necessary tools for a precise follow up in presentations personal feeling this direction, but periodic news from different 2. Possessing greater 47 ability to teach countries reported a long series of courses orga- 3. Greater self- 47 nized by ISIA alumni. Some of them took confi dence as a responsibility to prepare courses in the frame- teacher work of the national congresses. Other courses combined topics, in which professional subjects and educational skills have been included in the Table 26.8 Answers to the question : How did the ISIA program. A rough estimation of this post-ISIA course change your personal attitude towards the organizational aspects of the profession?—50 responders activity brings the number of local anesthesiologists (residents in the last year of their training Before ISIA course After ISIA course and young specialists) to almost 200. Always interested 25 1. No change 4 Not so interested 17 2. Became alert on this topic 19 Not at all 8 3. Signifi cant impact on 27 interested daily activity Conclusions 4. Trying to change things in: • Own department 27 The two projects presented, the WFSA–Beer • Own hospital 20 Sheva/Israel project and the International School • Own country 15 for Instructors in Anesthesiology (ISIA) could be considered unique in the fi eld of medicine, not only in Europe but also all over the world [ 8 ]. Graduating ISIA changed their teaching ability: Both projects involved a large number of the graduates stated that they improved the con- trainees. tent of their presentations, the quality of slides, Whether these projects signifi cantly contrib- the ability to involve the audience in the discus- uted to closing the professional gap in anesthesi- sions, and their own personal appearance in front ology between the two geographical parts of of an audience. They felt better when they taught, Europe is unclear for several reasons. were more confi dent, and related better to the First, the dramatic changes in the political cli- audience during presentations. Most of them mate in Europe after the fall of the Iron Curtain became more involved in teaching in their own created a continuous process of clinical training place of work. Actually, in total, graduates almost for many Eastern Europe anesthesiologists doubled their teaching activities after the ISIA who have been kept, for decades, away from the course. progress made in other parts of the continent. Many became involved in a process of changing This new permanent communication contributed the organizational aspects of the profession at dif- tremendously to the unifi cation of the healthcare ferent levels: anesthesia departments in hospitals systems, utilization of up-to-date equipment as well as at local and national levels. Some have and drugs, as well as the use of the same ethical 356 G.M. Gurman principles that had been implemented in Western to teach in other countries as well as other medi- Europe in previous decades. cal specialties. As recommended by WFSA [ 9 ], a Another diffi culty in assessing the real impact group of six alumni of the ISIA 1 and 2 courses for Eastern Europe is that not all the former com- alumni [ 9], from Serbia and Greece, became munist countries have been involved in these members of the ISIA 3 course (2011–2012) fac- educational projects. Progress, if any, produced ulty and they substantially contributed to the by the above projects, could not affect all Eastern teaching program during the three classes. Europe. None-the-less some conclusions can be The optimistic conclusions of this report cannot drawn from the data. Without any doubt, the hide the fact that there is, still, a long way to the WFSA–Beer Sheva project facilitated a fi rst confi nal aim of unifying the level of the profession of tact with modern anesthesiology and its tremen- anesthesiology in Europe. The gap still exists, dous progress in the second part of the twentieth although it is smaller and progressively less century to almost 150 anesthesiologists. The par- signifi cant. ticipants could experience how a busy anesthesia The brain drain process continues, with many department performs, not only in the OR but also Eastern Europe anesthesiologists looking for in all the other domains of the specialty: critical positions in the western part of the continent. care, obstetrical analgesia, pain management, This reality is a clear proof that we are not wit- sedation, etc. nessing, yet, the complete disappearance of the For most of the participants to the WFSA–Beer differences between the two parts of the old conti- Sheva project the time spent at Soroka Medical nent. Progress is to be made in Eastern Europe in Center represented a good opportunity once back many directions, among them organization of home, to implement changes in their own depart- anesthesia departments and creation of solid ments and hospitals. Things seen for the fi rst time research centers. But without any doubt the represented a proper start for further activities with WFSA–Beer Sheva and ISIA projects opened the the aim of reducing the gap between their own way towards the unifi cation of anesthesia practice places of work and the typical modern department. in Europe. The ISIA idea was born out of the new reality of Eastern Europe. The average anesthesiologist Acknowledgments The author would like to express his there no longer needed a simple glance at what is gratitude to all those who contributed to the success of done in a modern, well-equipped anesthesia both projects: Prof. Mitsugu Fujimori (Japan), Dr. Haydn Perndt (Australia), Dr. Angela Enright (Canada), Dr. department. Many Eastern Europe anesthesiolo- Jannicke Mellin-Olsen (Norway), Prof. Paolo Pelosi gists easily reached the western side of the conti- (Italy), Prof. Eberhard Kochs (Germany), and all the nent where they could use all the opportunities to anesthesia national societies’ offi cers who assisted and enrich their knowledge and professional skills. encouraged the initiative. ISIA was supposed to create, in each of the involved countries, a cadre of dedicated and skilled teachers, who learned how to teach and References use the new training techniques in their own 1. Gurman G, Bar-Lavie Y. The education and teaching milieu. In almost all the countries that sent par- anesthesiology in Israel. Tel Aviv: Breirot; 1992. p. 56. ticipants to the ISIA courses, the anesthesia 2. Gullo A, Ruprecht J, editors. World Federation of national societies offered the ISIA alumni the Societies of Anesthesiologists—50 years. New York, necessary framework for organizing local NY: Springer; 2004a. p. 171. 3. Kane J. PBS Newshow. October 22, 2012. courses, in which the new trainees were exposed 4. Barrows HS. Problem-based learning in medicine and to those methods taught during the three classes beyond. A brief overview. In: Wilkerson L, Gijselaers of each ISIA course and thus they, by themselves, WH, editors. Bringing problem-based learning to could use those experiences in their own further higher education: theory and practice, number 68. San Francisco: Jossey-Bass; 1996. teaching activities. The ISIA graduates are recog- 5. Azer SA. The qualities of a good teacher: how can be nized as skillful teachers in their own depart- they acquired and sustained? J R Soc Med. 2005; ments and countries. Some of them were invited 98:67–9. 26 Closing the Gap in Europe Through Education: A Reverse Mission 357

6. Masunga H, Hitchcock MA. Residents’ and Faculty’s 8. Galeotti G. An Argentinian perspective of the ISIA beliefs about the ideal clinical teacher. Fam Med. course. ESA Newsletter. 2013;54:27. 2010;42:116–20. 9. Gullo A, Ruprecht J, editors. World Federation of 7. Molodysky E. Clinical teacher training. Maximising Societies of Anesthesiologists—50 years. New York, the ‘ad hoc’ teaching encounter. Aust Fam Physician. NY: Springer; 2004b. p. 201–3. 2007;36:1044–6. The Role of the Visiting Anesthesiologist in In-Country 27 Education

Julia L. Weinkauf , Marcel E. Durieux , and Lena E. Dohlman

Malawian anesthesia clinical offi cers train for Introduction fewer years and with less clinical apprenticeship than anesthesiologists or nurse anesthetists in Malawi, 2013: This country of 46,000 square miles high income countries (HICs). The training of has about 25 district hospitals and several larger Malawian anesthesia clinical offi cers and resi- central referral centers (Fig. 27.1 ), which serve a population of approximately 15 million. There are dents is largely self-directed and infrequently no local anesthesiologists or nurse anesthetists. All supervised. Although mid-level providers often anesthesia care is provided by about 100 clinical have a wealth of clinical experience and are tech- offi cers who are mid-level providers with about 4 nically skilled, their limited training in physiol- years of formal training (in general medical care). A fl edgling residency program is run by expatri- ogy, pharmacology, and the principles behind ates. It combines training at a central hospital— anesthesia practice place severe constraints on where residents are mostly supervised by clinical their capabilities, and this likely contributes to the offi cers—with a year of experience in South Africa. high perioperative mortality—approaching 5 % in The program is about to graduate its fi rst anesthesiologist in 2014. Volunteers from Health Volunteers low- and middle-income countries (LMIC). Overseas assist sporadically with training of clinical With the hospitals overloaded, the providers offi cers. overworked, those few who are involved in teach- Pennsylvania, 2013: This state of 46,000 square ing have most of their time taken up by adminis- miles has more than 250 hospitals, serving a population of about 15 million. There are 1,900 anesthe- trative and clinical issues. Compare the Malawian siologists and 3,600 nurse anesthetists. There are residency program, which has two physicians eight accredited residency programs that graduate and no administrative support, to a US residency more than 50 residents per year. program with hundreds of clinical faculty and Malawi has approximately one tenth of the dozens of support staff. As a result, even if quali- number of hospitals, and approximately 1/50th of fi ed students, adequate facilities and appropriate the number of anesthesia providers as does a US materials are present, training still may not occur state of similar size and population. In addition, simply because there are no teachers available. In addition, this vicious circle is a critical factor holding back the development of many spe- J. L. Weinkauf , M.D. • M. E. Durieux , M.D., Ph.D. (*) cialties, including anesthesiology, in many Department of Anesthesiology , University of Virginia , countries. The USA has about 25 physicians per Charlottesville , VA , USA e-mail: [email protected] 10,000 population; Malawi, Rwanda, and Tanzania, and about 20 or so other nations make L. E. Dohlman , M.D., M.P.H. Department of Anesthesia, Critical Care, and Pain do with less than 1 per 10,000 [ 1 ]. The countries Management, CHA/MGH, Boston , MA , USA with this excessively low ratio are largely in sub-

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 359 DOI 10.1007/978-3-319-09423-6_27, © Springer International Publishing Switzerland 2015 360 J.L. Weinkauf et al.

Fig. 27.1 Queen Elizabeth Hospital. (a ) Queen Elizabeth Hospital in Blantyre, Malawi, is the largest referral hospital in the country, with about 1,000 beds. ( b ) Teaching anesthesia clinical ofﬁ cers in training in pediatric advanced life support at Queen Elizabeth Hospital. Photographs M.E. Durieux

Saharan Africa (Fig. 27.2 ). In such countries, a in improving anesthesia education opportunities critical mass of teachers will have to be estab- by volunteering their time to teach overseas. lished before the cycle can be broken, and this First, we discuss some important practical con- can be done only with outside teaching support. siderations for volunteers considering teaching This disparity, the resulting impact on the work beginning with the difference between ser- health of the population, and the clear need for vice and education focused work and continuing educators demonstrate why anesthesiologists with some considerations for pre-trip planning. from HICs should become engaged in teaching This section expands on some material published in LMIC. recently [2 ]. The subsequent sections focus on In this chapter we provide practical informa- pre-departure preparation and practicalities of in- tion for anesthesia providers who want to play a role country teaching. 27 The Role of the Visiting Anesthesiologist in In-Country Education 361

Fig. 27.2 Physicians working around the world. Territory live in territories with less than a fi fth of the world popula- size shows the proportion of all physicians that work in that tion. The worst off fi fth are served by only 2 % of the world’s territory. In 2004 there were 7.7 million physicians working physicians. Note the disproportionately low number of phy- around the world. If physicians were distributed according sicians in Africa (red ). © Copyright Sasi Group (University to population, there would be 12.4 physicians to every of Sheffi eld) and Mark Newman (University of Michigan). 10,000 people. The most concentrated 50 % of physicians Reproduced under Creative Commons license

A Comparison of the Teaching and Service Volunteer Experience

The primary goal of service-based global health work is to provide medical or surgical care to the local population, while the goal of education- based global health work is to build capacity and train a workforce. When a volunteer commits to service or education, these goals will impact not only the enjoyment of the experience, but the outcome of the work. There are many models of providing service and education, or a mix of the two, but here they are contrasted in their most Fig. 27.3 Unfamiliar anesthesia equipment. Material in basic forms. use at Haydom Lutheran Hospital in Haydom, Tanzania, a large district hospital covering an extensive capture area. Facilities, Equipment, and Techniques An Oxford miniature draw-over vaporizer is used to deliver Service work focuses on treating the maximum halothane; Oxford Infl ating Bellows are used to ventilate the patient. The pulse oximeter was brought by one of the number of patients in the limited available time. authors (MED), who was teaching anesthesia medical For this reason, practitioners will often bring offi cers in the hospital. Photograph M.E. Durieux their own equipment and drugs, so as not to be dependent on the local supply. In teaching set- have to make themselves familiar with anesthetic tings, the trainees will need to be trained on their drugs, equipment, and techniques that they may own equipment with drugs that will be available not be used to, or, in fact, may never have seen or after the teachers leave. Hence, the visitors will heard of before (Fig. 27.3 ). The volunteer may 362 J.L. Weinkauf et al. need to dedicate substantial preparation prior as mentioned above, it is not uncommon to work to the teaching trip to familiarize and train her- with people who have quite extensive clinical or himself in the methods and tools used by the skill, but only a rudimentary understanding of students. physiology and pharmacology. Even a concept The practice setting is likely to be quite different such as “tidal volume” may be unknown to the as well. For example, it is not uncommon in some students, making effective teaching very chal- countries to have several operating tables in one lenging. The best approach is to be aware of and room, so that multiple surgeries take place in par- continuously challenge one’s assumptions about allel. Many locations will not have a preoperative the learners’ knowledge by obtaining immediate area for evaluating the patient or a post-anesthesia feedback. Frequent questions on the degree of care unit. understanding of material just taught can provide From a teaching perspective, infrastructure this information. For example, including and facilities may be scant or absent. There may multiple- choice questions in presentations can be very little in the way of educational facilities quickly check understanding of material pre- or classroom space, and frequently there will be sented a few slides earlier. no defi ned curriculum from which to work. Cultural mores and norms run deep and can challenge and surprise even the most effective Workload teacher. An educator needs to be mentally pre- The pace of work can be quite different between pared to fi nd one morning that all of the students service and education trips. Again, during service are absent because someone’s distant relative has missions, the team attempts to maximize the num- died and they all needed to be at the funeral as a ber of cases done, and that means starting early sign of respect. A visiting teacher needs to be and often working in the operating room until late ready for unexpected pushback during a discus- at night. Usually, little else is done during the trip. sion of ventricular fi brillation, because the stu- During education work, the volunteer has to adapt dents know from experience that none of those to local customary start and end times, which are patients survive in their hospital, so it is not worth generally quite different from those in academic instituting treatment. While it is helpful to premedical centers. Even though the hours are differ- pare by reading on the culture and religion of the ent, volunteer educators will work hard. The non- area where the teaching will be done, the reality clinical time at the beginning and end of the day is is that the visiting educator will be confronted packed with lecture preparation, test writing and with unexpected responses and behaviors. The grading, and meeting with students. In addition, it ability to adapt and improvise is an important is not uncommon to become involved—whether trait for both the service-based volunteer and planned or unplanned—in other educational activ- teacher; however, a longer duration of a teaching ities such as medical school curriculum develop- trip means there will be more surprises. ment, outside lectures, or teaching for practitioners outside the specialty. Program Duration Short- versus long-term involvement will be dis- Cultural Considerations cussed in more detail later in this chapter, but in Language barriers can be a major problem during the context of a comparison between service and both service and teaching work. For teaching, a education, it is important to realize that education good understanding of the level of education of work will require more time in-country than does the trainees, and of their background knowledge a service mission. Unless one commits to a long- and clinical experience is required. This informa- term in-country stay, this means that the individ- tion can be diffi cult to obtain, and at times the ual educator will only see a small slice of the teacher may not have worked previously with whole job. After a service mission of 2 weeks, the trainees with this mix of knowledge. For example, volunteer anesthesiologist knows exactly how 27 The Role of the Visiting Anesthesiologist in In-Country Education 363 many patients were operated on and helped; after keep well- intentioned organizations with similar 2 weeks educating local anesthesia providers, goals from duplicating each other’s work. progress may not be quite so visible, and it is In-depth interaction with the local stakeholders easy to become discouraged about long-term will assure that the program is unifi ed and com- prospects. The volunteer can mitigate the natural prehensive, that separate efforts directed at a resi- tendency to become discouraged by understand- dency or mid- level training program are aligned, ing the totality of the group’s mission, being and that all visiting faculty teach according to a mentally prepared not to see immediate results, defi ned curriculum. Ideally the local faculty and maintaining contact with people who have members are in charge of the entire process. previously worked on the same project. On the other hand, educational work often affords practi- The Audience tioners more opportunity and more time for close Practically, the level of instruction will differ personal contact and for developing friendships between programs for residents and those geared with the local teams, which can be professionally for anesthesia technicians. Philosophically, many and personally satisfying. Also, educational activi- anesthesia educators in HICs feel that anesthesi- ties come with the realization that one is adding to ologists should focus on training more physician capacity, and not in any way taking away from or providers. Whether efforts and resources should displacing local professionals. be spent on developing nascent residency programs or whether those efforts are better Program Planning expended towards improving technician training It is unfortunately only too easy to come into a is a heavily debated question. Physician anesthe- developing country with the best of intentions yet siologist and anesthesia technician programs are unprepared to really effectively help with an edu- sometimes at odds within the host country, and cational program. For each program, some the visiting educator may need to negotiate these important considerations need to be addressed. politics [3 ]. Because in over half the countries in Below we discuss how to defi ne the organiza- the world technicians or nurses with an average tional structure, tailor the message and methods of 1–2 years of training provide most of the anes- to the intended audience, incorporate technology, thesia care, it is in the best interest of the local and be sensitive to the history of medical educa- patients that technicians are optimally trained, tion in the country. Incorporating this level of and participation in their training is valuable [4 , understanding into teaching activities will 5]. At the same time, the goal of having at least increase the probability of implementing a suc- one anesthesiologist available in each hospital is cessful medical education program. an important one—physician anesthesiologists can advance anesthesia care with respect to other Program Organization medical and surgical services, they can provide In-country education programs that are driven by subspecialty services, and they can supervise and the local clinicians and administration—who are support technicians and mid-level practitioners. the only people who really understand the local Ideally for the health of the population in LMICs, needs and limitations—are more likely to accom- residencies will be started, and residents and plish their goals. Not even the most intense and technician education will have to take place frequent “scouting trips” and “evaluation visits” simultaneously [6 ]. can match local knowledge. A formal needs assessment is important and very useful for plan- Distance Learning ning the program, but it cannot replace direct Internet facilities in most parts of the world are input from local people. Local practitioners are by now capable of video uplinks of very accept- also the people who know if other outside able quality, and tele-education can be immensely groups are involved in local teaching and can valuable in many ways. As one important example, 364 J.L. Weinkauf et al.

Fig. 27.4 Distance learning. A case teleconfer- ence in progress between the anesthesiology departments of the University of Virginia and the University of Rwanda. Photograph C. Lewis, with permission

it allows a variety of specialists, not all of whom Many developing countries suffer greatly would be able or willing to travel to another from “brain drain”: For a variety of reasons, local country, to take part in educational activities. In physicians trained, at great diffi culty and cost, are addition, it allows residents or other learners to at high risk of leaving the country and fi nding see behavior modeled by their counterparts in more comfortable and lucrative employment HIC. Case teleconferences can be an excellent elsewhere [7 – 10]. To prevent this, it is important learning tool for residents in LMICs and remote that foreign teachers do more than train in techni- areas of HICs; for example, the University of cal and cognitive aspects. Working and teaching Virginia runs a monthly case conference with the in the local setting can be a truly interesting job anesthesiology residency in Rwanda (see and this needs to be conveyed to the trainees. Fig. 27.4 ), and these are being evaluated posi- They also need to be made to feel part of the tively [3 ]. Although operating room and bedside modern anesthesia world. In some ways, when teaching are an essential part of medical training one talks about techniques, drugs and approaches that cannot be replaced by distance learning, used in the western world, trainees in LMIC get a teaching be enhanced through the use of technol- glimpse into their future. Our goal as anesthesia ogy for case-based learning or simulation. A pro- educators is for them to be part of that future—in gram such as the case conferences mentioned their own country. above can maximize educational value and minimize cost for training programs in LMICs. Before You Go: Finding a Program Beyond the Curriculum and Preparing for Your Experience When physician educators arrive to teach the curriculum and implement an educational pro- Somewhere in sub-Saharan Africa: A woman of 48 gram, they become ambassadors from their years needs surgery for a uterine fi broma. Her husband is a surgeon and she told him she does not home country. What this means is that they are want general anesthesia. The husband recom- unavoidably a model for many of the trainees, mends a surgeon colleague who works in a private and this may be one of the more important hospital famous for its regional anesthesia. In this aspects of in-country teaching. A visiting physi- hospital the surgeon is also the doctor who gives anesthesia. The husband plans to assist his friend cian educator walks a fi ne line between capacity in operating on his wife. What happens? building and recruiting anesthesia providers The day of the operation, the surgeon places the away from the home country. single shot epidural anesthesia. Both surgeons 27 The Role of the Visiting Anesthesiologist in In-Country Education 365

prepare themselves for the operation and an assistant in order to increase the likelihood of a useful and trained by the surgeon is charged with taking the productive trip. blood pressure, and monitoring pulse and oximetry parameters. Before the incision, the husband If the anesthesiologist is not already aware of remarks that his wife is yawning. His friend tells an educationally oriented organization, how does him that she probably wants to sleep and asks his he/she fi nd one? Fortunately in the past 5–10 assistant to give 100 mg of propofol intravenously years there has been a strong focus on workforce to help her sleep. The propofol is given and the operation begins. After a few minutes, the hus- development and education in anesthesia and band, not hearing his wife, tries to talk to her. She other specialties by academic institutions, the doesn’t answer. When the assistant attempts to World Health Organization (WHO), and the US measure the blood pressure, it is not recordable: Government [12 ]. Good places to start looking the woman is in cardiac arrest. An anesthetist from another hospital is called to come and resus- are within the home institution, on websites such citate. He arrives 30 min later, but by that time the as the American College of Surgeons Operation patient is dead. On site there was equipment to Giving Back (OGB) [13 ], the American Society ventilate but the laryngoscope didn’t work because of Anesthesiologists (ASA) Global Humanitarian of battery failure. Outreach (GHO) [14 ], and subspecialty websites Although the details change, stories of avoid- such as the Society for Pediatric Anesthesia [ 15 ] able anesthetic deaths such as the one above are and the Society for Education in Anesthesia [16 ]. shockingly common in many parts of the world. Networking with health care workers interested The high perioperative morbidity and mortality in global health at the home institution and at in many LMICs has a number of causes, but a meetings can also be helpful. Other education- lack of well-trained anesthesia providers is cer- ally oriented anesthesia organizations that are tainly an important one [ 6 , 11 ]. As we have dis- useful are the World Federation of Societies of cussed, an increasing number of anesthesiologists Anaesthesiologists (WSFA) [17 ], Health and anesthesia trainees from high-income coun- Volunteers Overseas (HVO) [18 ], and Kybele tries are eager to travel overseas and help. Several [ 19], which are all represented in this text. An practical pre-trip steps can be taken before an opportunity for longer involvement in teaching is educational visit overseas to make it a more the newly launched Rwanda Human Resources productive, rewarding, and safe experience for for Health Program [20 ]. the visitor, the host, and most importantly for Many residents are interested in global health the patients. The following section will review the and can contribute as well as benefi t from an most critical steps in preparing for an educa- international teaching rotation. Residents can tional trip. play a special role as peer mentors to local students who may relate better and be more com- Program or Project Selection fortable asking questions of a fellow adult learner. An important fi rst step in contributing to in-country Residents are often technically savvy and innova- anesthesia training is to search for a reputable aid tive which can help to bring new and exciting organization or program that is a good fi t with the teaching techniques to a developing country. For physician’s skills, interests and values. An estab- example, one SEA HVO traveling fellow taught lished program has the advantages of having per- residents in Peru how to fi lm procedures at their formed a needs assessment and having worked hospital using a cell phone and some inexpensive out relationships between key players at the over- attachments. These fi lmed procedures could then seas site. It is important that a visiting anesthesi- be used to teach new residents how the proce- ologist not be a burden to already overworked dure is performed at their hospital. Also, resi- health care providers by making demands on dents may at times be a better source of practical their time for assistance with orientation, housing clinical information and clinical “pearls” than and transportation needs. A good organization the academic faculty. can help guide the educator with planning, com- Some anesthesia residency programs have munication, and setting reasonable expectations standing overseas teaching rotations. Residents in 366 J.L. Weinkauf et al. these programs are well advised to let their pro- • Would you be willing to work in a country gram director know early in their residency if with political, social, or religious values which they are interested in global health. Residents you don’t share? Would it be diffi cult to resist who do not fi nd an opportunity within their own judging or criticizing their ways? If so, it may institution can apply to receive a month’s schol- be best to choose another program or site. arship with the SEA HVO Traveling Fellowship. Anesthesiologists with a fl exible, patient, and Applications can be found on the HVO or SEA nonjudgmental approach and an enthusiasm for websites on December 1st each year for the fol- learning as well as teaching should do well when lowing academic year. Residents should be aware some effort has gone into fi nding the most appro- that traveling with an organization outside their priate program and site. own program may be considered an “out of program rotation” by the country’s accreditation Personal Health and Safety body. For example, according to the American The health and safety of medical professionals is Board of Anesthesiology (ABA), international too often neglected in the enthusiasm for going rotations have special requirements including overseas [21 ]. Illnesses and injuries—often (1) the rotation must occur during the fi rst avoidable—can be a disaster for the educator but 9 months of the fourth postgraduate year of can also be a burden for the host. It is a good idea anesthesia training and (2) a letter requesting to visit a travel clinic several months before leav- ABA approval must be obtained prior to depar- ing the country to get advice about vaccinations, ture for the rotation. Details on requirements for malaria prophylaxis and how to handle postexpo- residents teaching abroad can be found on the sure HIV prophylaxis. Educators who are partici- SEA website [16 ]. pating in hands-on teaching in the OR or ICU Next, the anesthesiologist should evaluate his should be aware that many of the protective bar- or her skills, values, interests, and needs and riers and devices used at home as part of univer- decide how these attributes best match with a sal precautions are in short supply or not available program. To maximize the chances of a success- in many low resource countries. Bringing gloves, ful visit for the educator and the host, this issue masks, eye protection and hats will help the visi- should be addressed when choosing a program— tor maintain universal precautions and will pre- not when in-country. A potential volunteer should vent the hosts institution from being further take into consideration the following: depleted of supplies. • How much time are you willing and able to Preparations should also include reviewing spend overseas? coverage under personal health, disability and • Do you have special health needs or concerns workers compensation insurance, asking explic- that will limit where you can visit and for what itly whether incidents that occur overseas will be amount of time? covered. The biggest threat to otherwise healthy • Do you plan to bring family members with you educators traveling internationally is road safety. and will it be safe for them? What will your Following the advice of knowledgeable locals on spouse or partner do while you are working? how to deal with in country transportation is • Do you prefer to train anesthesia providers in strongly recommended. According to the Centers basic anesthesia techniques or to educate for Disease Control (CDC), “Motor vehicle anesthesiologists with more sophisticated crashes—not crime or terrorism—are the number concepts? Some sites are more suitable for 1 killer of healthy US citizens living, working, or one or the other. traveling in foreign countries.” [ 22 ] Political • Is the anesthesiologist comfortable teaching in instability and crime are also factors to con- a hospital with equipment, drugs and patient sider when picking a country to visit. Checking conditions that he/she has only read about and with the US State Department and with home is he/she willing to learn from the hosts as organizations regarding recent blockades, dem- well as to teach? onstrations, and interruptions to travel—while 27 The Role of the Visiting Anesthesiologist in In-Country Education 367 remembering that life in one’s home country is director’s letter must be sent at least 4 months not without risk—can inform the decision of prior to the rotation and should include the whether reported risks are worth taking. following: • A description of the proposed rotation and the Making Trip Arrangements dates. Trip plans should start several months ahead of • Information about the supervision of the resi- travel with passport and visa arrangements since dent, including the position and credentials they can take much longer than one might expect. (CV) of the physician overseeing the resi- Communication is encouraged with the country dent’s training. site and, depending on the country and program, • Description of how much time the resident can be painfully slow when volunteers from HICs has spent training in and away from facilities are used to instant text, social media, and e-mail affi liated or integrated with his/her parent messages. Reasons for delays are understandable institution. given the challenges of overworked administra- • Provide assurance that the resident or fellow tors, loss of internet connections, or bureaucratic will remain enrolled in his/her accredited pro- barriers. gram while training away from the accredited Although malpractice for educators visiting a program. developing country is not yet a big concern, it is • Provide assurance that the resident or fellow is a good idea to know if and how one is covered, in good standing at the time of the request. especially if the plan is to teach through demon- • Indicate that the resident’s or fellow’s accred- stration in the operating rooms or ICU. ited program will report the training on the Increasingly, academic hospital’s malpractice semiannual Record of Training/Clinical insurance will cover physicians doing global Competence Committee report fi led for the health work that is supported by or connected to period involved [23 ] . the hospital. Travel insurance is highly recommended to Educating the Educator protect against the catastrophic costs of having to Once a program and country has been chosen, it be fl own out of the country should one become is essential to do some background work to help seriously ill or injured, and is very reasonably better prepare for the teaching experience. priced for the young and healthy. References to Reading about health and population statistics, travel insurance companies are best obtained workforce and economic conditions and country- from the home academic center, global health specifi c diseases can all be helpful in forming program administrator, or by a simple Internet “the big picture” prior to departure. Much of this search. Airplane tickets and housing arrange- information can be found on organization web- ments should ideally be completed 2 months sites at the WHO [24 ] and the Centers for Disease before departure. Control [ 25 ]. Again, there are usually special considerations Buying a general travel book for the country for anesthesia residents involved in global health can be a good way to get information about what education. More information on this process can kind of weather, food, clothing expectations, and also be obtained by members of the Society for other cultural differences will be encountered. Education in Anesthesia (SEA) on their website Many countries have an English language news- at www.seahq.net. For US residents, the trip must paper which can be scanned online for local news fi nish prior to the last 3 months of residency if it before you go. is an outside rotation. Residents must also have It is essential to try to determine the educa- the program director send a written and signed tional needs and wants of the colleagues and stu- application to the ABA for approval unless the dents overseas in order to make the most overseas program is a standing program run by the appropriate educational plan. The organization or affi liated department or hospital. The program program should be able to provide a curriculum 368 J.L. Weinkauf et al.

(if there is one), help obtain trip reports or contact • Recognizing and intervening in the case of a information from previous educators, and put total spinal volunteers in contact with the in-country director • Preventing drug and transfusion errors of training. Exchanging e-mails, communicating Introducing the WHO Surgical Safety Check by text message, or scheduling Skype conversa- List is proven to decrease morbidity and mortality tions or phone calls with local practitioners or [26 ]. It can be useful to bring handouts on moni- administrators will be important for gathering toring, fl uid management, and management of information. It is also frequently possible to common intraoperative problems. Bringing obtain permission to contact one of the students expired or open and unused airway equipment to directly before arrival. This contact can be run airway management workshops is usually immensely helpful for determining the students’ welcome and inexpensive. educational level, the hospital resources and case As discussed earlier, physician educators are mix, and types of local equipment used. also responsible for being role models for profes- However, no matter how carefully one pre- sional and ethical behavior when abroad or at pares, there will always be unexpected changes home. This can sometimes be challenging since and surprises. A common occurrence is to be the standards of care vary greatly internationally. asked to lecture on a subject for which no lesson For example, it is not standard practice in all coun- has been prepared. This will be part of the adven- tries for an anesthesia provider to be in the room at ture! Bringing ASA Refresher Courses or other all times during an anesthetic. One explanation for reviews on a laptop can be useful in this this is that there are often more surgeons and surgi- situation. cal procedures than anesthesia providers and the anesthesia provider is forced to cover more than Planning Lessons, Structuring one room at a time. There is no easy solution to Curriculum, and Finding Resources such an ethical dilemma, but how it will be han- There is a great need for quality anesthesia edu- dled should be considered before departure. cation and training in the developing world. The Anesthesia educators also promote lifetime enormity of this need can seem daunting. Even continuing education for local anesthesia provid- with a curriculum in hand, it can be diffi cult to ers. By preparing refresher courses, skills work- know what teaching will be welcome and most shops, case-based workshops, and simulation-type helpful. It can be useful to remember that courses to bring overseas, the volunteer can rein- although the circumstances might be different, force basic safety techniques as well as introduce the role of an educator overseas is basically the new techniques to local providers. Teaching how to same as at the home institution. First and fore- use ultrasound in ICU diagnosis and regional anes- most educators are obligated to teach anesthesia thesia is an example that has been quickly accepted providers to give safe anesthesia. Anesthetic in academic centers overseas (Fig. 27.5 ). Since deaths in countries lacking adequately trained recruiting and retaining trained staff is a serious anesthesia providers are reportedly often the problem in many LMICs it is important to do what result of preventable airway problems and hypo- can be done to add to a stimulating career and to volemia in young, healthy patients [11 ]. Focusing prevent anesthesiologists from feeling isolated and on the known sources of mortality in basic anes- stagnant [27 ]. Supporting in-country training pro- thetic care can be lifesaving. Common sources of grams leading to specialty qualifi cation in fi elds morbidity and mortality easily translated into like anesthesia has been shown to help retain teachable moments include: physicians [28 ]. Teaching current methods (as • Airway and ventilation management long as they can be done safely and sustainably) • Assessing and maintaining intravascular can contribute to a more satisfying and interest- volume and vascular tone ing work for the in-country anesthesiologist. • Preoperative assessment Another role educators take on at home and • Techniques for monitoring and vigilance abroad is to encourage self-education by providing 27 The Role of the Visiting Anesthesiologist in In-Country Education 369

Fig. 27.5 Teaching regional anesthesia. Daniel Vo, a Society for Education in Anesthesia/Health Volunteers Overseas Traveling Fellow in 2011, teaches ultrasound regional anesthesia techniques in the Hospital for Traumatology and Orthopedics in HCMC, Vietnam

references to books, journals, and Internet sites. The dilemmas when they occur can be helpful (see also internet is increasingly accessible in developing the section on “On Location: Tips for Teachers, countries and it is recommended to bring a list of Personal Impact, and Ethical Dilemmas” below). favorite anesthesia education internet web sites to Many of us who have spent time teaching in share with overseas students. A good example is the developing countries have made our share of cul- free anesthesia education site Open Anesthesia, tural missteps over the years. Some lessons which is associated with the International Anesthesia learned include the following: Research Society [29 ]. Open access journal articles • Avoid comments that may be construed as a and other educational materials that can be put in criticism of the country, politics, religion, or pdf format and downloaded on students’ laptops or health care. the department computers are also often welcome. • Dress and act with respect for the local norms. • Listen to the learners as to what they want to First Do No Harm be taught. Neither underestimate nor overesti- The role of the physician educator overseas must mate what local providers know. Some of also include a self-refl ection on the actual bene- them struggle with basic concepts but many of fi ts of his or her teaching as well as possible unin- us have met some truly brilliant, educated and tentional harm. Physicians who volunteer to vastly experienced anesthesiologists who have teach in developing countries often comment taught us much more than we taught them. when they return that they feel they learned more • Adjust teaching to stay within the usual local than they taught. This may be particularly true of working hours. Students may have other jobs lessons learned about health care rationing and or responsibilities they have to attend to. making do with less. Other lessons are more • Be fl exible and accommodating as much as emotionally challenging. Seeing a baby with cor- possible. rectable congenital deformities die for lack of • Learning the names of the colleagues is very equipment or a young mother with injuries left to important. die because it would be “too expensive” to operate • Be patient—change is slow. can be traumatic for the physician who trained in When traveling overseas, an educator becomes a high-resource setting. Sometimes the opposite a role model and diplomat of the profession, his occurs and the visiting anesthesiologist is asked or her home institution, and native country. The “as an expert from overseas” to participate in physician educator also becomes a student of cases she or he deems futile. Finding a mentor to another culture and health care system and a new contact at home or locally to talk over these ethical friend to many wonderful and interesting people. 370 J.L. Weinkauf et al.

On Location: Tips for Teachers, The three elements of education are: knowledge, Personal Impact, and Ethical skills, and behavioral (also known as nontechni- Dilemmas cal skills in medical education) [30 ]. Behavioral or nontechnical skills include less concrete but You are a visiting teacher doing clinical and class- crucial elements of being a good physician, such room teaching in a low-resource setting for the past as communication, knowledge-acquisition skills, 6 weeks. You have just fi nished overseeing a case in the operating theatre with a local resident. Upon and professionalism. Short-term work by its arrival to the recovery area, you fi nd a group of nature is more conducive to the fi rst two elements local nurses and doctors performing advanced car- of training. Knowledge and skills are things that diac life support (ACLS) on a patient in cardiac can be taught effectively by practitioners in for- arrest. You ask about the patient and are told that it is a mats such as lectures, case discussions, and other 20-year-old healthy woman with post-partum hem- classroom activities, as well as at the bedside. orrhage who just had a Bakri balloon placed while Expanding classroom activities into simulations she is in the recovery room. The bleeding has and workshops can provide an especially stimulat- improved, but she had a pulseless electrical activity arrest just as the procedure was fi nished, around ing environment that may result in more retention 5 min ago, and is now in asystole. There is a bag of and absorption (Fig. 27.6 ). whole blood running freely into a 16 gauge IV in Anesthesia providers in resource-poor settings her antecubital fossa. are in need of behavioral and non-technical skills You notice that the staff performing chest compressions are not following American Heart just as much as they are in need of knowledge- or Association ACLS guidelines. The compressions even skill-based competencies. This is due to are being performed at a rate of around 200 per several factors: easier access to knowledge-based minute for short bursts of 10–15 s, at which point learning materials, human resources needs that the compressor looks at the monitor to check the rhythm. lead to a lack of mentorship and senior guidance, Should you step in and perform the chest as well as the fact that developing country train- compressions yourself? Should you try to instruct ing programs often emphasize knowledge-based the nurse on how to improve the compressions elements far more than technical or especially now? Should you say something to the senior physician present? Should you wait until later, after the nontechnical skills. Doing long-term work resuscitation either succeeds or fails? What would (>3 months), or returning to the same site, allows be the most effective way to change local practice? far more opportunity to develop these nontechni- What are the ethical implications of not stepping in cal skills among local students. Indeed, repeat and thus increasing the potential for a bad outcome for this patient? volunteers have reported a sense that their regular presence resulted in a greater impact over time [31 ]. Although there is no clear evidence that any type of outreach is superior to another, there are Different Situations, Different defi nite roles for both short- and long-term Opportunities: Short- Versus involvement in the educational process. Long-Term Involvement, Teaching for Your Strengths, and Maintaining Maximizing Education Opportunities Continuity With short-term educational work, it is desirable to have an ongoing organized teaching program Short- Versus Long-Term Involvement that is fulfi lled by the short-term visiting teach- Much of the overseas global health work in anes- ers. Local audiences often graciously submit to thesiology is done as short-term surgical service teaching of topics that have been presented to trips, or “missions,” which can be service-oriented them not so long ago. This type of repetition or educational, as mentioned above. Another wastes local practitioners’ valuable educational approach is longer term involvement, including time. Typically clinical care is on hold or at least frequent visits to the same location or a long-term modifi ed when the staff is attending an educa- placement. tional conference, as there simply are no other 27 The Role of the Visiting Anesthesiologist in In-Country Education 371

Fig. 27.6 Simulation session. Expanding classroom activities into simulations and workshops can provide an especially stimulating environment that may result in more retention and absorption. Local faculty can learn to teach through these methods at the same time. Rwandan anesthesiologist Kiviri Willy teaching local operating room staff ACLS and deﬁ brillator use. Centre Hospitalier Universitaire de Kigali, Rwanda

practitioners to take over the duties. Thus, having anesthesia resident in a developing country a plan for short-term educators assures that should be similar to a CA-1 anesthesia talk in the patient care does not suffer for minimal benefi t. USA; a presentation for faculty in a developing It is important to be sensitive to the knowledge country should be similar to a presentation for base of the local practitioners. Resources for faculty in the USA, if their resources permit. One acquiring knowledge are often accessible in the may want to include a bit less information than form of online sources and materials that foreign- normally included to allow time to speak more ers have left behind or donated. The easy access slowly or with translation to an audience listen- to knowledge-based learning materials means ing to a presentation when English is their sec- they may know more than many US trainees. ond, third or fourth language. Implementing that knowledge into practice is Consideration should be given to passing limited more by lack of resources and behavioral along a particular skill, rather than general techniques than by lack of knowledge base or knowledge. For example, if one is an ultrasonog- learning materials per se. rapher or an ACLS instructor, perhaps workshops With this is mind, though they may not have can be arranged to take advantage of that exper- the materials or equipment necessary to imple- tise (Fig. 27.7 ). Other possibilities for specifi c ment advanced therapies, it may be inappropriate skill transfer could include diffi cult airway tech- to “dumb down” your teaching presuming that niques, fl exible bronchoscopy, regional anesthesia students have a limited knowledge base. By err- techniques, and many more. ing on the side of teaching to the highest level of evidence possible within the resources that they Translating Respect into Effect have available—appropriate to the audience’s Physician educators must earn local practitio- level of training, of course—one can then modify ners’ respect—it is not conferred automatically. or simplify material only if necessary. Many visiting teachers are perplexed or even Appropriately challenging conferences are the incensed when the local workers do not quickly ones that have the most impact on a local audi- believe what they say, listen to them, and start ence. In general, educators should tailor lectures practicing in that way. Realizing that the local and programs to the same level as they would at practitioners are professionals and colleagues their home institution, but in a resource- who have not had access to as many opportunities appropriate way. A talk intended for a 1st-year and resources will increase the volunteer’s chance 372 J.L. Weinkauf et al.

Fig. 27.7 Ultrasound training. Training in particular skills may be at least as useful as transmit- ting general information; use of ultrasound for diagnosis and nerve blockade is a good example. Julia Weinkauf teaching ultrasound technique to residents Gaston Nyirigira and Benjamin Semakuba, Centre Hospitalier Universitaire de Kigali, Rwanda. Photograph by Denise M. Chan, M.D.

of leaving something real behind. Impact is are often so used to visiting educators feeding greater if the teacher is respected, and respect is them information and resources, that they are earned over time. Local practitioners have devel- sometimes comfortable with this one-way fl ow of oped their practice and gained local success for a information. This approach goes nowhere. Not reason. Expect buy-in to take at minimum weeks only does the specifi c knowledge not transfer or months. well via unidirectional fl ow, but the educator One simple but frequently neglected way to misses an opportunity to develop communication earn respect and attention is to spend time learn- and approaches to processing materials. Didactic ing peoples’ names. One of the biggest barriers to sessions are generally only effective for knowl- having an impact is earning trust. Learning a per- edge acquisition, whereas exchanges between son’s name has tremendous power in establishing practitioners provide these opportunities to rapport. Physician educators should devote time develop non-technical skills. When working with to learning people’s names upon arrival, just as a local colleague, one should initiate a discussion time has been devoted to preparing teaching about what they would do or what their practice materials. Many of us have experienced (or have is. In a discussion between two colleagues, the been) a foreigner exasperated by a local learner is far more likely to feel empowered to practitioner’s unwillingness to act quickly or lis- think critically about a situation, ask questions, ten to concerns or mobilize something for a sick and integrate new concepts. Using the following patient. When then asked who it was they were question as a test to ask whether one is feeding working with, it turns out the foreigner didn’t students or supporting and nurturing them: “Am I know the person’s name, or sometimes not even doing most of the talking?” what role or service they were with. It then As a foreign worker, going around the local becomes clear why that person would not act on system to improve immediate patient care is the suggestion of a stranger. tempting. An example of this includes calling Great teachers often get students to talk more other foreigners directly for consults or expedited than they talk. In observing visiting educators, services. Using infl uence and connections in this one notes a strong tendency to move quickly to way can make the local health care system worse announcing the answer to a clinical question, since there is less drive for improvement if it is especially when struggling with communication and possible to detour around dysfunction when language barriers. In addition, local practitioners desired. Challenging oneself to stay within the 27 The Role of the Visiting Anesthesiologist in In-Country Education 373 system—even though it is slower and frustrating behavioral and nontechnical skills. Not everyone is preferable- and the experience will be richer as needs to start a project. Many of these will end up a result. If there is initiative for change among forgotten on a shelf anyway. The local practitio- local co-workers and time to support the project, ners are always the best ones to start and imple- a visiting educator can help formulate a system ment projects, whenever possible. Support them. improvement plan. Local oversight is, in reality, the only way to ensure continuity after visiting educators leave. Projects: From Idea to Continuity There are endless programmatic and systems- Personal, Career, and Ethical Issues based projects one can consider in a long-term Personal and Career Impact assignment or with repeat visits. Some of these The personal motivations for doing educational could include: work overseas are often similar to the motiva- • Starting a morning case conference or a grand tions for doing service work. These motivations rounds series or journal club series range from the altruistic desire to “make a dif- • Starting a scheduling system for the OR ference” and recognition of a global commu- • Starting an morbidity and mortality conference nity, to the more selfi sh ones such as the desire • Implementing a preoperative or postoperative to connect to a social network, and honing of evaluation system personal skills and knowledge [ 32 ]. Volunteers • Implementing an anesthesia preparedness doing educational or development work often checklist stress their desire to leave a more lasting contri- • In the ICU, standardizing rounding, consults, bution than direct care of a small number of and presentations patients, though there is no clear evidence that one • Writing locally appropriate educational guides form of volunteerism makes more of an impact for anesthesia subspecialties than another. • Implementing a quality improvement program Upon return to their home country, most • Initiating monitoring or pain control protocols volunteer educators feel that they had a positive in the PACU experience, including fi nding it personally • Organizing an emergency airway box rewarding and feeling that they contributed posi- • Organizing an emergency cart tively to the local conditions. They also report an Waiting at least a month before suggesting or improvement of their own skills and knowledge starting working on any of these projects, and [ 31 ]. Some reasons for dissatisfaction include a talking with the locals about previous attempts is lack of clarity or doubt about the utility of the desirable. Chances are that these ideas may have volunteer’s role, a perception that the local health been suggested or tried before. In general, one care workers are not motivated themselves for certainly wants local faculty approval and sincere improved conditions, and frustration with lack of involvement before embarking on these endeav- resources. First-time volunteers often expect a ors. The rule of thumb is: they must want it at fast-paced, intense, and tiring experience, and are least as much as the educator does, or it will not surprised when they fi nd that keeping business be used and will not last. hours is the norm of the local staff. This is an Finally, consideration should be made as to example of the difference between educational whether just being a “worker bee” continuing to work and service work that can contribute to dis- teach how to work within the system that is in satisfaction if not anticipated. place, might be better for building capacity in the Teaching in a foreign environment provides long-run. The pressure to “make a difference” as unique challenges that can improve teaching an educator is enormous, but simple quality skills in a way not possible in a home environ- teaching and human resource capacity building, ment. The visiting teacher is obliged to be more role modeling, and setting standards can truly sensitive to the reception of the material by make a difference, especially in the realm of local staff, constantly adjusting communication 374 J.L. Weinkauf et al. methods, speed of material delivery, as well as the relatively minor, non-life-threatening questions material itself. (such as the best way to close an incision), but Volunteers also report an increased appreciation can be the best practice for serious situations as not only for the resources available in their home well. There is no quicker way to lose the respect country, but the public health infrastructure and and attention of local workers than to disrespect hospital safety systems that have been designed and criticize their practice in the moment without to enable practitioners in developed countries to grace and humility. deliver (and patients to obtain) safer, more effec- This position must lead to an acknowledge- tive, and effi cient care. Visitors in long-term ment that, for the visiting teacher, the patient in placements who work on implementing systems front of us may not be our fi rst priority. We are and public health improvements gain greater often forced to choose between providing the best insight into the challenges of building such sys- care and providing the best educational experi- tems from scratch and of the massive benefi ts ence for the teaching audience. The visitor must they can have when successful. The paperwork decide for himself how much he can accept in the we groan over at home can suddenly seem not so way of slow or substandard care, in the hopes of a onerous when confronted with an environment lasting improvement of local practice. in which those processes, and their protective Another ethical dilemma that presents itself to benefi ts are totally absent. the visiting teacher is the redirection of the local Overseas involvement can also have an impact staff’s efforts from their patients to us, the for- on a volunteer’s professional career. The recent eigners. Foreign visitors require a lot of attention. surge in global health interest has led to increased Educators of course believe that it is an invest- involvement by departments and demand by resi- ment to leave behind a greater benefi t, but they dents and medical students to have such experi- should be mindful of minimizing the distraction. ences integrated into their training [12 ]. This Consider carefully what information and atten- creates demand for faculty with global health tion is actually needed to do the work effectively. experience and connections and the need for Does one really need to visit the laboratory or the departmental support—both fi nancial and in blood bank or the pharmacy? Imagine how many terms of non-clinical time—for volunteers. times the locals have answered the same questions to people who will not benefi t them or their Ethical Issues systems or their patients. Imagine how many The visiting teacher will inevitably encounter times they have told foreigners where the rest- ethical dilemmas ranging from minor curiosities rooms are. Disruption of the local schedule is to situations that concern patients’ well-being. unnecessary unless a benefi t can be foreseen. Volunteers need to be prepared to navigate diffi - Another ethical concern when doing humani- cult unexpected situations. tarian work is the fostering of “learned helpless- One easily identifi able ethical dilemma occurs ness.” Broadly, this refers to the concern that if when a visitor perceives delivery of poor care by the needs of a community or organization are locals, but is not directly involved, and is tempted supplied by outside sources, there will be no to intervene in the moment. When confl icts arise, internal impetus for change. This concept has we think it is preferable to err on the side of been written about extensively around the topic allowing the local health workers to direct things, of foreign aid in general, but can apply in a more rather than interject our position. A discussion or microcosmic way to work as foreign teachers as educational intervention can then be considered well. If the educator’s presence consistently sup- after the fact, consistent with one’s role as teacher plies the educational needs of a department, or rather than service provider. This arguably will even the specifi c answers to clinical questions in result in increased buy-in from the locals, more so the moment, the local practitioners may not have than stepping in the moment, which can quickly the incentive to teach, develop their teaching create resentment. This is especially true for skills, or even answer their own clinical questions. 27 The Role of the Visiting Anesthesiologist in In-Country Education 375

At an extreme, it can create incentive to neglect in low- and middle-income countries to train what would otherwise be their sole responsibility, enough residents, create the critical mass, and which is a natural response to being overbur- break the vicious cycle of insuffi cient personnel dened when someone else will handle matters. that prevents each patient from having access to There is no clear way to navigate this ethical an anesthesiologist when needed. quandary, but most visitors and programs strive to include the local workers as much as possible, and supplement and support rather than replace References their efforts. 1 . http://www.who.int/gho/health_workforce/physicians One fi nal ethical dilemma is the potential for _density/en/ . systems or organizational projects implemented 2. Durieux ME. But what if there are no teachers …? by a visitor to falter after that visitor leaves the Anesthesiology. 2014;120:15–7. country. There are infi nite numbers of projects 3. Zimmerman M, Lee M, Retnaraj S. Non-doctor anaesthesia in Nepal: developing an essential cadre. Trop pushed forward hard by visiting educators and Doct. 2008;38(3):148–50. PubMed PMID: 18628537. physicians that quickly died from lack of local 4. McAuliffe MS, Henry B. Nurse anesthesia practice support and resources when the foreigner left. and research—a worldwide need. CRNA. 2000; This not only wastes time, but is harmful in that it 11(3):89–98. PubMed PMID: 11865942. 5. Rosseel P, Trelles M, Guilavogui S, Ford N, Chu dilutes local enthusiasm for change. For example, K. Ten years of experience training non-physician if an Operating Room scheduling system is anesthesia providers in Haiti. World J Surg. attempted by many different players, locals will 2010;34(3):453–8. PubMed PMID: 19655194. be less and less likely to support the next effort at 6. Cherian M, Choo S, Wilson I, Noel L, Sheikh M, Dayrit M, et al. Building and retaining the neglected initiating a system, and subsequent attempts are anaesthesia health workforce: is it crucial for health that much more likely to fail. Failed attempts at systems strengthening through primary health care? projects are inevitable, but we should do our best Bull World Health Organ. 2010;88(8):637–9. PubMed to achieve local buy-in and support, and initiate PMID: 20680130, Pubmed Central PMCID: 2908973. 7. Opoku ST, Apenteng BA. Career satisfaction and things in a carefully organized way in order to burnout among Ghanaian physicians. Int Health. minimize these problems. 2014;6(1):54–61. PubMed PMID: 24473596. 8. Okeke EN. Brain drain: do economic conditions “push” doctors out of developing countries? Soc Sci Med. 2013;98:169–78. PubMed PMID: 24331896. Conclusion 9. Brassington I. What’s wrong with the brain drain (?). Dev World Bioeth. 2012;12(3):113–20. PubMed In-country teaching of anesthesiology is an PMID: 21790962. immensely challenging, long-term job. It can be 10. Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context—global shortages and highly rewarding, but also frustrating. A thor- international migration. Glob Health Action. ough understanding of what one is getting into, 2014;7:23611. PubMed PMID: 24560265, Pubmed and meticulous preparation on a personal and Central PMCID: 3926986. professional level will help avoid some of the 11. Enright A. Review article: safety aspects of anesthesia in under-resourced locations. Can J Anaesth. 2013; frustrations. 60(2):152–8. For our specialty all over the world to have the 12. Dohlman LE. Anesthesia education across borders. position that it enjoys in western countries, even- Curr Opin Anaesthesiol. 2013;26(6):732–6. PubMed tually, the same high standards of anesthesia care PMID: 24113269. 13. American College of Surgeons. Operation giving should apply everywhere. As anesthesiologists back. Resources for the surgical team. http://www. we are members of a worldwide community of operationgivingback.facs.org. Accessed 12 Mar 2014. physicians that should support one another. 14. American Society of Anesthesiologists. Global We should do what is best for patients on a global humanitarian outreach. https://www.asahq.org . Accessed 10 Mar 2014. scale and support well-designed overseas teach- 15. Society for Pediatric Anesthesia. Volunteer medical ing efforts. Without help, it will remain impossi- services abroad. http://www.pedsanesthesia.org . ble for the few, overworked anesthesiologists Accessed 10 Mar 2014. 376 J.L. Weinkauf et al.

16. Society for Education in Anesthesia Global Outreach 24. WHO. Global health workforce statistics. http://who. Committee. http://seahq.net . Accessed 12 Mar 2014. int/hrh/statistics/hwfstats/en/index.html . Accessed 1 17. Lo B, Honemann W, Durieux ME. Preemptive analge- Mar 2014. sia: ketamine and magnesiums reduce postoperative 25. Center for Disease Control. http://www.cdc.gov/ . 12 morphine requirements after abdominal hysterec- Mar 2014. tomy. Anesth Analg. 1998;89:A1163. 26. Walker IA, Newton M, Bosenberg AT. Improving sur- 18. De Oliveira Jr GS, Agarwal D, Benzon HT. gical safety globally: pulse oximetry and the WHO Perioperative single dose ketorolac to prevent postop- guidelines for safe surgery. Paediatr Anaesth. erative pain: a meta-analysis of randomized trials. 2011;21(7):825–8. PubMed PMID: 21208335. Anesth Analg. 2012;114(2):424–33. 27. Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, 19. Zeng J, Thomson LM, Aicher SA, Terman GW. Greysen SR, et al. Medical schools in sub-Saharan Primary afferent NMDA receptors increase dorsal Africa. Lancet. 2011;377(9771):1113–21. PubMed horn excitation and mediate opiate tolerance in neona- PMID: 21074256. tal rats. J Neurosci. 2006;26(46):12033–42. PubMed 28. Lavy C, Sauven K, Mkandawire N, Charian M, PMID: 17108177. Gosselin R, Ndihokubwayo JB, et al. State of surgery 20. Ling GS, Paul D, Simantov R, Pasternak GW. in tropical Africa: a review. World J Surg. Differential development of acute tolerance to analge- 2011;35(2):262–71. PubMed PMID: 21153818. sia, respiratory depression, gastrointestinal transit and 29. Open anesthesia. http://www.openanesthesia.org/ . hormone release in a morphine infusion model. Life Accessed 22 Mar 2014. Sci. 1989;45(18):1627–36. PubMed PMID: 2555641. 30. Larsson J, Holmstrom I. Understanding anesthesia 21. Panosian C. Courting danger while doing good—pro- training and trainees. Curr Opin Anaesthesiol. tecting global health workers from harm. N Engl J Med. 2012;25(6):681–5. PubMed PMID: 23026803. 2010;363(26):2484–5. PubMed PMID: 21175310. 31. Pieczynski LM, Laudanski K, Speck RM, McCunn 22. CDC health information for international travel, trav- M. Analysis of ﬁ eld reports from anaesthesia volun- elers’ health, injuries and safety. wwwnc.cdc.gov. teers in low- to middle-income countries. Med Educ. Accessed 9 May 2014. 2013;47(10):1029–36. PubMed PMID: 24016173. 23. American Board of Anesthesia (ABA). Training away 32. Philpott J. Training for a global state of mind. Virtual from the accredited program checklist. www.theba.org . Mentor. 2010;12(3):231–6. PubMed PMID: Accessed 9 May 2014. 23140874. Letters from Around the World 28 Ram Roth

medical students to qualiﬁ ed professionals, are Introduction seeking ways in which these ideal models can be met. As the concept of the Perioperative Surgical As Paul Pomerantz, the CEO of the American Home (PSH) grows, with the emphasis on team- Society of Anesthesiologists, noted in his report based care, anesthesiologists are well positioned in the June 2014 issue of the Newsletter of the as leaders of that team. Thus it is hardly surpris- ASA, Marshall McLuhan, the Canadian philoso- ing that anesthesiologists at every level of train- pher of communication, described earth as a ing are anxious to be at the forefront of these “global village” over 50 years ago. McLuhan exciting ventures where they not only provide also predicted the World Wide Web some 30 care but also learn valuable lessons. years before it came into reality. Since then as But it is not always smooth sailing! Shortly technology has increased and heightened our after we embarked on this book project, we began awareness of the advantages and plights of other to hear many stories from physicians returning countries, it seems almost as though the world from missions as well as from anesthesiologists has shrunk. We are moving in the direction of a in visited countries. Some spoke of accomplish- universal model of team-based care that may not ments and successes while others described pit- be realized by identical means throughout all falls and how they might be avoided. We felt it nations but quality, ethical standards, and avail- important that their voices also be heard. Thus ability of basic resources are the goals. A grow- the following vignettes, or letters, voice some of ing number of volunteers in anesthesiology, from the lessons they have learned.

R. Roth , M.D. (*) Icahn School of Medicine at Mount Sinai , New York , NY , USA e-mail: [email protected]

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 377 DOI 10.1007/978-3-319-09423-6_28, © Springer International Publishing Switzerland 2015 378 R. Roth

cannot imagine. No matter how hard you feel you Letter 1: New York to a Mission have worked on any given day, you will work harder while on a mission… and you will love Ram Roth every minute.” But back to the mission: You arrive to your des- It is Monday morning, warm even at this early tination and explore your new work environment. hour. By midday it will be a scorcher. I hope the The immediate task is to prepare the available tools air conditioner in the OR is working, but you and equipment for any eventuality that may pres- never know. I was given a brief description of ent itself. In both examples of new environments, this OR by a colleague who had worked there; the ORs on Park Avenue and in the lower and “they have everything you need… you will be middle income countries (LMIC), the anesthe- fi ne.” The space is cramped with lots of equip- siologist feels isolated. Alone he/she has to set up ment, some of it older than I am. I look for the for a safe and successful anesthetic with the capnograph on the monitor and realize it resources at hand. In a sense, all small surgical appears to be missing one. The anesthesia groups travelling abroad undergo a learning pro- machine is a Drager Narkomed® ; there is a cir- cess, improving effi ciency with the acquisition of cuit, a bag, and an isofl urane vaporizer but no experience. ventilator. It is like a dinosaur but without a While leading the anesthesia team during a heart. I rifl e through the drawers of the cart and university medical school surgical trip organized scavenge a few items so I can set up for a case. by second and fourth year medical students, I A woman I have never seen before hands me a was required to assign each of the three avail- liter of normal saline and asks if there is any- able operating rooms to our anesthesiologists. thing else I will need, “and the fi rst patient is Each room had its advantages and disadvan- waiting to see you,” she says. Who among us tages. One was small and cramped, without win- has not experienced the stress and excitement dows for the scavenging tube. Another was large of working in a new environment? and spacious but had three individual monitors The OR described above is a back room of a for electrocardiography, pulse oximetry, and fancy Park Avenue plastic surgery offi ce in blood pressure. In an effort to be fair, we planned Manhattan. The sentiment described above is only to rotate anesthesiologists through the rooms. a fraction of the intensity of emotions experienced Toward the end of the week, we realized that when one is on a mission in a foreign setting. As fairness was not as important as “owning the anesthesiologists we endeavor to control our envi- room.” Each rotation meant that the anesthesi- ronment and maintain homeostasis in our patient. ologist had to ascertain the nuances of a new Yet by defi nition, we face the unknown every day. space. On subsequent missions to the same loca- When I recruit and prepare anesthesia attendings tion we planned for each anesthesiologist to stay and residents for international missions, I encounter in his/her own room for the duration of the trip. the same cycle of emotions and anxiety. The most Once the room was set up with equipment as honest advice I can offer to new volunteers is this: desired, anesthesiologists were able to stock the “No matter how well you prepare for this mission, drawers and shelves, as they preferred, creating you will be surprised and challenged in ways you a familiar work environment. We decided that on each surgical trip we would create a guide or “playbook” in order to R. Roth record vital practical information about the expe- Icahn School of Medicine at Mount Sinai , rience. It included lists of equipment and drugs New York , NY , USA carried from the USA, identifying surplus and 28 Letters from Around the World 379 what was lacking. It contained information about power supply could occur during our absence. personnel at the site, contact information, and Communication with our hosts by phone or email assistance provided. We described rooms, equip- was poor. At best we managed to set a date of ment and workfl ow, so that good processes could arrival, but not much information was shared be repeated and others improved. This guide about the changing conditions. provided a vertical transition of information from We knew that other groups visited the same year to year. Each group learned from the experi- site throughout the year. There was a schedule on ence of their predecessors. the wall of the OR offi ce. We recognized some An early group realized that local staff mem- names of organizations listed. Had there been a bers, after having worked with our team for a few forum to share information about a particular days, brought in patients who were friends or rela- location among the volunteer caregivers, our tives for procedures. They were not screened on information could be “horizontal.” We could our fi rst day and we did not recognize them. We potentially learn from others who used the facil- were told that we had screened them and must ity and provided care the week before our arrival. have lost the records. It was a compliment to our We could be updated with the latest information. work that the staff was bringing us patients, but If they wrote a “playbook” of their mission and suddenly accommodating an additional patient shared it, we could be much more effective. We was disruptive to our workfl ow and planning. The could implement strategies they had contem- next year our team secured an ID band on each plated and report back to them and the group fol- patient assigned to have surgery as the fi nal step in lowing us for the benefi t of all. the screening process. Patients were told not to To date, there exists no such forum. Journal remove the wristband until after they were dis- articles appear with increasing frequency. charged from our care. Greater organization of effort and research of Another group complained that in order to surgical missions is becoming a focus of many contact our team on the wards, they had to ask medical institutions [1]. Guidelines for success the head nurse in the OR suite to notify the ward have been proposed [2]. Global health institutes nurse who may or may not have time to fi nd are popping up and are endeavoring to standard- someone. On subsequent trips we brought ize the approach to travel medicine or “medical walkie-talkie sets which improved our commu- tourism.” nication effi ciency. Our approach to surgical trips was developing References and maturing over time, but the evolution was slow. It would take a year to implement a new 1. Fisher QA, Fisher G. The case for collaboration among idea and see the result. Our “playbook” informa- humanitarian surgical programs in low resource tion was 11 months old. Even if were returning to countries. Anesth Analg. 2014;118(2):448–53. PMID: the same site, many changes may have occurred. 24445642. 2. Grimes CE, Maraka J, Kingsnorth AN, Darko R, Changes such as new building, a new OR, Samkange CA, Lane RH. Guidelines for surgeons on recently donated equipment from another group establishing projects in low-income countries. World J or a construction project which might disrupt our Surg. 2013;37(6):1203–7. PMID: 23474858. 380 R. Roth

gen 2 l/min to maintain adequate saturation. The Letter 2: Challenges in Delivering pediatric surgeon recommended surgery immedi- Care to a Pediatric Patient ately as development of complete airway obstruc- with a Diffi cult Airway in a tion was imminent. Resource-Poor Setting On exam, the infant was thin and listless. The mass and swelling had stented his mouth open to Grace Hsu its maximum, but with little patent area in his oropharynx. He was tachypneic and had Located in the horn of Africa, Ethiopia is home to decreased breath sounds in the right upper lung 92 million people. It is one of the world’s poorest fi elds. A CT scan fi lm indicated that the mass countries, with a per capita GDP of $410. The compressed his upper trachea and appeared to Black Lion hospital in the capital, Addis Ababa, extend beyond the thoracic inlet and into the is one of Ethiopia’s major referral hospitals. Of anterior mediastinum. Portions of his right lung the 1,421 physicians in the country, 106 are sur- were whited-out from pneumonia. geons and 14 are anesthesiologists [1]. Nurse I expressed concern about a diffi cult airway to anesthetists administer anesthesia for the rest of the pediatric surgeon, given the severe degree of the country. Access to surgical care is poor—thus swelling. We expected diffi culty ventilating, limiting most surgery to emergent or late especially with positive pressure, given the small presentations. opening in the oropharynx and the potential for It was my third day in Ethiopia. I was at the the mass encroaching into the anterior mediasti- Black Lion Hospital in Addis Ababa to teach stu- num. Even if we were successful in passing an dents in the Master’s of Science in Nurse endotracheal tube through the patient’s vocal Anesthesia program. I arrived at the hospital and cords, we might not be able to pass beyond the crowded around the operating schedule board at tracheal narrowing. The surgeon felt she would 7:00 am with a large group of other hospital staff not be able to provide an emergency surgical air- to see the assignments for the day. I was to cover way, given the neck distortion and high likeli- two rooms, a pediatric and a urology room. The hood of numerous collateral vessels in the region. fi rst pediatric case was removal of a cervical The only airway adjuncts in the hospital were lymphangioma in a 7-month-old boy. supraglottic airways, an adult-sized gum elastic With one of the students I went to the preop- bougie and an adult bronchoscope. erative holding area to see the pediatric patient. A I asked a Norwegian anesthesiologist who was very large mass distorted the boy’s right jaw, there teaching residents for 6 weeks, and another face, and neck. His face, lips, and neck were recent graduate of the Ethiopian residency pro- swollen to a point beyond recognition. The par- gram at the Black Lion Hospital to be present for ents gave us the history: The baby was born with induction. I outlined a plan for a group of students: a right neck mass but was otherwise healthy. At start with an inhalation induction to preserve around 2 months of age, the mass began increas- spontaneous ventilation and allow the anesthesia ing in size. By 5 months, he had extreme diffi - student two attempts to secure the airway. If she culty eating and was failing to thrive. He drooled was unsuccessful, an anesthesiologist would then constantly, and was unable to swallow saliva take over. Our only size-appropriate airway effectively. One week prior, he came to the hospi- adjunct was a supraglottic airway. We planned to tal for the fi rst time in his life, with pneumonia. use a small 3.0 cm cuffed endotracheal tube in He was in respiratory distress and required oxy- anticipation of tracheal narrowing. Induction and intubation proved diffi cult. The nurse anesthesia student induced anesthesia G. Hsu with halothane via mask. With loss of muscle Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, tone in the oropharynx, the patient began to Philadelphia, PA , USA obstruct and oxygen saturation dropped rapidly. 28 Letters from Around the World 381

Despite earlier discussion of the plan, under The surgical portion of the case went smoothly, stress, the student began to apply positive pressure. other than signifi cant blood loss from the venous Although ventilation was not adequate, it was collaterals draining the head and neck. A full suffi cient to keep the patient unconscious with blood volume was replaced. While considering inhalational anesthesia but also weak enough to postoperative care, I learned that the hospital did obstruct. The nurse (anesthesia student) not have a pediatric-sized ventilator. The 6-bed attempted to intubate the patient twice—but was intensive care unit had two adult ventilators that unable to see the larynx. Next, the Ethiopian would likely cause volutrauma if used for a child. anesthesiologist attempted direct laryngoscopy. Limited medical and nursing staff overnight With a shoulder roll and laryngeal pressure, she meant that no one would be available to manually obtained a grade III view and placed a 3.0 endo- support the baby’s ventilation. Thus, the patient tracheal tube successfully through the narrowed would need to breathe spontaneously through the portion of the trachea. Although there was no air small endotracheal tube without any support until leak around the defl ated cuff, we decided to con- extubated. I again enlisted the help of the tinue the case with this tube. We gave a single Norwegian and Ethiopian anesthesiologists. The dose of dexamethasone to minimize swelling Ethiopian anesthesiologist explained that it was (Figs. 28.1 and 28.2 ). extremely rare for a pediatric patient to be intubated and ventilated in the hospital. We also discussed the possibility that the patient would weaken throughout the night, breathing through a long, narrow tube. Acute airway obstruction the night after surgery was also a signifi cant risk [2]. We decided to extubate the child—again, preparing for a diffi cult reintubation. The 30 min that followed proved that the patient could not tolerate extubation—the swelling from surgical manipulation was too great. The patient did not appear to have recurrent laryngeal nerve defi cits as he was phonating; however, he quickly obstructed. We reintubated him—again, a diffi - cult task. Transfer to the intensive care unit itself was a Fig. 28.1 The cervical lymphangioma made both mask ventilation and laryngoscopy diffi cult in a setting with lim- feat. There were no fully functioning bag-valve ited airway adjuncts (supine view) masks with tubing to attach to an oxygen source. We improvised with intravenous fl uid tubing to connect the bag-valve mask to an oxygen tank. After traveling 20 ft down the hallway in a metal crib with a large oxygen tank lying at the foot, one wheel of the crib broke off and nearly caused the crib and patient to topple. The elevator ride from the fourth fl oor operating rooms to the sixth fl oor intensive care unit was also pre- carious. (The rubber mat on the fl oor of the elevator car was ineffectively covering a hole one-foot in diameter). The baby did well and was extubated by the ICU team on post-op day 1 and discharged home Fig. 28.2 Lymphangioma lateral view on post-op day 6. 382 R. Roth

The key learning points of this case were the Letter 3: Great Planning: But Not following: Everything Works – The history and physical exam are key for the anesthesiologist in formulating a plan and in Ram Roth determining the most likely things that will harm a patient perioperatively. In this case the For many years, anesthesiologists have embarked three major considerations were a diffi cult air- with surgical teams from Mount Sinai Medical way, intraoperative hemorrhage and postoper- Center in New York on short-term missions to ative ventilation. underserved countries. Not only have we been – In resource-poor settings, where airway able to help hundreds of people in these countries adjuncts are extremely limited, human but we have also garnered considerable satisfac- resources may be just as important in a dif- tion and experience for ourselves. The stories of fi cult situation. In this circumstance, the successful missions abound. On one recent mis- only airway adjunct appropriate for this 7 kg sion, however, the outcome did not go according patient was a supraglottic mask airway. It is to plan and the results were disastrous. important to involve other airway experts and team members in the case early and discuss a plan. Background – Especially when there are language and cultural barriers, it is important to have a clear Perioperative care for patients at a mission site is plan that all team members understand. In this in many ways similar to that provided in the USA case, it would have been prudent to not attempt with some adjustments or local availability of mask ventilation after obstruction during resources. A preoperative evaluation of all poten- induction. One should allow the patient to tial patients allows the surgical team to be able to emerge from general anesthesia. prioritize candidates for surgery. Local physi- – Given that this patient required this surgery cians make the initial evaluation and selection. for survival, there seemed to be little choice in The teams of surgeons and anesthesiologists then performing the operation. Some might argue have the opportunity to evaluate the need for that such high-risk cases should not be under- surgery, cardiac risk indices, comorbidities, medi- taken because a bad outcome may jeopardize cations, and airway management considerations. future missions. However, this decision falls Standard preoperative evaluation is based on more to the surgeon than to the anesthetic the guidelines of the mission site, the external team. Consideration of postoperative resources organization involved, and/or hospital of mission and availability of adequate support is crucial origin. The mission site we visited had more strin- to the decision. gent rules than apply at our institution in New York regarding preoperative evaluation, and requires cardiac clearance on all patients over the age of References 40. This is possibly due to a shorter life expectancy and generally less prophylactic care received 1. Chao TE, Burdic M, Ganjawalla K, Derbew M, Keshian C, Meara J, McQueen K. Survey of surgery and anesthesia infrastructure in ethiopia. World J Surg. 2012;36:2545–53. R. Roth 2. Ameh EA, Nmadu PT. Cervical cystic hygroma: pre-, Department of Anesthesiology , intra-, and post-operative morbidity and mortality in Icahn School of Medicine at Mount Sinai, Zaria, Nigeria. Pediatr Surg Int. 2001;17:342–3. New York, NY, USA 28 Letters from Around the World 383 by potential surgical candidates. Alternatively, it may be included to ensure that all visiting surgical groups are satisfi ed with their screening process. Patients are usually “cleared for surgery” by local cardiologists before they come to the center. All patients are admitted the night before surgery in order to minimize transportation problems and ensure preoperative fasting. Anesthesia screening also includes assessment of the availability of appropriate support following surgery and deter- Fig. 28.3 Congested liver mination that the patient will recover within the time frame of the mission with suffi cient support mechanisms in place. Induction and intubation proceeded uneventfully. Medications included fentanyl 100 ugm, propofol 200 mg, morphine 8 mg, rocuronium 20 mg. Case Anesthesia was maintained with sevofl urane in oxygen. Vital signs remained stable for about A 60-year-old woman presented with a long- 30 min into the operation (BP 110/70, heart rate 80). standing history of severe gastroesophageal Thereafter, oxygen saturation fell to the 80 s and refl ux disease and upper abdominal pain. An the blood pressure was unobtainable. open cholecystectomy was scheduled after the Phenylephrine, epinephrine and atropine were fi nding of multiple gallstones. She had a history administered. As the surgeon exposed the gall- of diabetes and hypertension. She repeatedly bladder, he noted that the liver appeared con- denied any cardiac symptoms, despite question- gested (Fig. 28.3 ). After 10 min the vital signs ing by several health care workers at different stabilized. Ventilation continued with oxygen levels. Medication included metformin, propran- 100 % while the gallbladder was exposed and olol, enalapril, and glyburide, all of which she resected. Subsequently, blood pressure was unob- took regularly. She reported that her diabetes was tainable and she was resuscitated with crystalloid well controlled. She had undergone two cesarean and vasoactive agents. The pulse returned and the sections in the distant past under spinal anesthesia. surgery proceeded with only 5 min remaining in She did not smoke or drink. There was no history the case. The patient continued to require of allergies. repeated boluses of phenylephrine and vasopres- On physical examination she was found to sin for episodes of hypotension. Attempts to gain weigh 100 kg with a height of 161 cm (BMI 39). additional intravenous access were not success- While not taking her medication her blood pres- ful. She was given a total of 1 liter of crystalloid sure was 144/91 and heart rate 78 and regular. and was breathing spontaneously via the endotra- No murmurs were identifi ed and her lungs were cheal tube as the bandages were applied. clear to auscultation. A cardiologist had seen her However, she remained unstable; blood pressure in the recent past and she reported that all was continued to decrease despite vasopressor ther- well. The plan was to schedule her operation apy and additional crystalloid via a groin central later in the week. line. Pulseless electrical activity developed and On the penultimate surgical day of our mis- full ACLS protocol was instituted in the cramped sion, 3 days before our departure, the patient was operating room. She regained her pulse on sev- transported to the operating room at 16:40 after eral occasions but the rhythm could not be sus- having fasted for 23 h. Standard monitors were tained. After more than 1 h of cardio pulmonary applied and an intravenous infusion started. resuscitation she was pronounced dead. 384 R. Roth

arrangements to cover funeral expenses. Even Discussion though we could not determine the cause of this tragic outcome we worked to obtain all additional An event such as this is devastating, not just to the information. The remainder of the day was spent family but also to the entire team of health care in obtaining as much information as we could and providers, both visitors and local. We held debrief- taking care of the patients in the ward and bonding ing sessions with the local doctors that night and with our friends and colleagues in the hospital. with the operating room staff the next day. Upon returning to our institution, we con- After returning to our guesthouse, the entire mis- ducted a formal mortality review chaired by the sion team participated in an emotional debriefi ng. Dean of Global Health. All members of the mis- Members of the team described how the experience sion team were interviewed and the patient’s affected them. Medical students and attendings records as well as perioperative surgical and openly cried, the former for having experienced anesthetic charts were reviewed. We reexamined their fi rst death in the operating room and the latter our protocols and concluded that little could be for having experienced one so unexpected. done to uncover information that was deliber- The next day was originally planned to be the ately withheld. Students and residents were given last day of surgery. The team felt that doing the another opportunity to discuss the emotional few small cases scheduled would be inappropriate impact of the tragic event. A review panel added and those cases were cancelled to be performed on a cardiac risk assessment and a mini-stress test to a subsequent mission. We began the day with a the preoperative evaluations for all missions. The debriefi ng for the nursing and operating room Global Health offi ce reviewed the institute’s mal- staff. Educationally, they were most curious about practice coverage to ensure that missions were our teamwork during cardiopulmonary resuscita- protected for claims brought at home and in tion. They had never seen a “code” except on TV countries we visit. shows. We explained how we all undergo ACLS Our next mission to the site is anticipated and training and practice responding and appreciated we were assured that we would be welcomed to that this was an area of focus for future missions. continue our work there. This certainly left us with the idea that our next mission would include an program on cardiopulmonary resuscitation for the staff. Conclusion We also explained that in our practice we investigate every detail of any death or major complica- Despite the best intentions and due to circumstances tion. We arranged for a full review of all past beyond our control, poor outcomes may still occur. records and spoke with the family. Some relevant That is the nature of medicine and surgery in the pages from her prior cardiac studies had been developing world. Cooperation with the host coun- removed and were determined to be “lost.” tries should be in place for success. There must exist Eventually, the local director of anesthesiology some degree of trust in the local physicians and learned that the patient had been diagnosed with belief that patients will give accurate information, severe heart disease, which had been revealed to as most do. Patients must be evaluated carefully by previous visiting teams and to local surgeons. skilled clinician and rejected if necessary when Surgery had been ruled out in the past. Since her their physical fi ndings or history is not compatible colic symptoms were intensifying, she determined, with obvious objective clues (e.g., morbid obesity). in consultation with her family, not to admit to any An understanding of attitudes and what may be heart problems to our team. She was rehearsed in considered reasonable and acceptable behavior in screening questions and her previous answers that other countries is very hard for many, especially would not allow her surgery to proceed. young health care workers from our modern institu- We were anxious to determine the pathology tions. Counselling should be made available to the and suggested an autopsy in the public city hospi- team, recognizing the tragedy of the case at several tal. The family refused for religious reasons. The levels and also acknowledging that global surgical hospital administrator then benefi cently made missions are a benefi cial endeavor. 28 Letters from Around the World 385

ment for diffi cult airway management and for re- Letter 4: Life-Saving “The Magic” intubation of an already diffi cult intubated patient. Wire My colleages (anesthesiologists and nurses) call it “the blue wire” or even “the magic stick,” Miodrag Milenovic because it has saved a number of lives over the last decade, especially before we became more Diffi cult airway workshops are often highly effi cient in bronchoscope use. attended and the most popular events at interna- A case in point: A 66-year-old man had been tional congresses and regional meetings. Serbian hiding out in a tree for several hours, hoping to anesthesiologists, just like others, are very keen shoot a deer. He had drunk some beer and, feeling to attend them and later on their return home to rather feverish, had ingested some cold remedy. give a “hard time” to the hospital management He was soon fast asleep and fell to the ground, dis- asking them to buy all those hi-tech, often very locating his neck at C7. In the hospital he was ini- expensive devices for diffi cult airway manage- tially stabilized in a collar but over the next 24 h, ment. Should devices be obtained, not all of us his sensory level rose to C5. The decision was are practiced to use them, because there is no made to take him to the operating room for surgi- offi cial obligation to do so and it is time cal stabilization. He had no history of prior sur- consuming. gery. A plan was made to perform rapid sequence There are a number of clinical situations when induction as he had not eaten in 30 h with in-line the anesthesiologist and intensivist cannot com- stabilization. Immediately after induction, large pletely visualize entrance into the trachea. Very amounts of fl uid and undigested food were regur- often this was the moment when we realized that not gitated. The larynx could not be visualized. Finally, so many of us are skillful enough to properly use the with fi ber-optic scope, the airway was secured. bronchoscope or other techniques available to us. Surgery proceeded without incident. He appeared One of the international scholars and an AAF to be awakening, and was trying to remove the alumnus returned from the Postgraduate endotracheal tube. We placed a bougie through the Assembly in New York with a few pieces of long tube prior to extubation. Some 4 h later, he experi- gum elastic bougies, or Eschmann Stylets. These enced some respiratory distress and we were able are tracheal tube introducers, a fl exible device to quickly secure the airway this time over the that is 60 cm (24 in.) in length, and 15 French bougie. He was successfully extubated 30 h later. (5 mm diameter) with a small “hockey-stick” Being a part of the moderately developed angle at the far end. It can be a useful adjunct for medical system but still less affl uent world, there the persistent epiglottis-only-view situations. is no doubt that our hospitals need to renew medi- Although this product has been on the market for cal equipment, but the professionals need to be almost 30 years now, probably because of the more realistic, pragmatic, and skilful to be able to small population in Serbia and the low cost, we deal with diffi culties, not relying only on the lat- have not been offered it by medical industry rep- est generation of hi-tech devices, because we resentatives in our country. It was not on the mar- may need some time to achieve much. ket in the region. From the moment we become aware of such From that time 10 years ago, when the depart- simple but excellent adjuncts as gum elastic bou- ment was given several pieces, as a gift from the gies, it is part of our offi cial demands and we still colleague who came back from abroad, long gum do not have suppliers of such simple and cheap elastic bougies have became the necessary equip- airway adjuncts. It is still not on the market. So, a number of such easy-to-carry, inexpensive, and simple-to-use adjuncts should be necessary as disposable equipment for all outreach medical M. Milenovic Department of Anesthesiology and Intensive Care missions, because small things like gum elastic Medicine, Clinical Center of Serbia, Belgrade, Serbia bougies can change anybody’s life. 386 R. Roth

Letter 5: Transfusion Conundrum the patient (Fig. 28.5 ). The blood pressure was 92/50, pulse 114, and O2 saturation 99 % on room air and the patient was complaining of nausea. She Erin Gertz did not look toxic, but was pale and occasionally retched into a small basin. A review of the chart It was the third day of a 5-day short-term surgical showed the patient had obtained preoperative test- trip in the Dominican Republic (D.R.). The fi nal ing and her hematocrit 2 days ago was 38 %. After procedure, a vaginal prolapse repair under epi- discussing the case, the anesthesia team suspected dural anesthesia, was uncomplicated and had just hypovolemia and vasodilation. Most patients fi nished (Fig. 28.4 ). Although, a middle-income come to surgery quite dehydrated and this patient country, the medical infrastructure in the D.R. is had also just received a small dose of fentanyl for limited and the local community was extremely pain. Therefore a bolus of crystalloid 500 ml was grateful for our surgical mission work. ordered and vital signs were checked every 10 min. As the patient was transferred into the recovery The in-country liaison was asked to obtain a com- room, the PACU nurse was standing beside plete blood count (CBC). Since there was no labo- another patient taking a manual pulse. That patient, ratory at this facility, the liaison explained that to a 45-year-old woman with uterovaginal prolapse obtain a “stat” CBC, the nearest private lab would and no other signifi cant medical history, had send a tech who would draw blood, return to the undergone an uncomplicated vaginal hysterec- lab, run the test and call back with the results. The tomy under general anesthesia. The estimated process would take over an hour. blood loss (EBL) was 300 ml and she was given Thirty minutes later, the patient’s blood pres- 2.5 l of crystalloid during the case. The nurse was sure was 82/47 and pulse was 125 bpm despite the concerned and asked the anesthesia team to evaluate fl uid bolus. She continued to complain of nausea

Fig. 28.4 Our operating room in the Dominican Republic

E. Gertz Global Women’s Health Division, Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA 28 Letters from Around the World 387 and now had increasing abdominal pain and our team asked what the ICU is like in the hospital drowsiness. The surgeons were alerted and on that would accept the transfer and who exactly examination found abdominal distention, tender- would take over the patient’s care. No one was ness to palpation, rebound and guarding. There able to answer these questions. The team dis- was no vaginal bleeding. The team decided to cussed whether transfer would actually be in the return to the OR for an exploratory laparotomy patient’s best interest. The lab technician then for suspected intra-abdominal bleeding. The arrived to draw the CBC. Three hours had passed patient’s trachea was reintubated and upon open- since the blood test was ordered. ing the abdomen, approximately 800 ml of blood Intravenous hydration was continued and the clot was evacuated. A small bleeding vessel was patient’s vital signs stabilized. Though she found and ligated. Total estimated blood loss remained obtunded and tachycardic, she was extu- from both procedures was 2 l. The in-country liai- bated without difﬁ culty. The reason for her altered son was asked to order blood for transfusion and mental status remained unclear. After waiting for to coordinate possible transfer to a hospital with almost 2 h, the team realized that both the arrival an ICU facility. He said delivery of blood should of blood and the transfer to another hospital might take no more than one half hour. There was no not happen (Fig. 28.6 ). One of our surgeons, reliable national ambulance service for a transfer, known to be blood type O negative, offered to so a private company would have to be hired to donate blood. After a discussion about the consent transport the patient to the local hospital. The signed prior to the surgery – we decided that the team discussed who should accompany the patient had understood the consent well-enough patient. An anesthesiologist and one of the sur- regarding a transfusion , the team decided to pro- geons were chosen. A curious medical student on ceed (Fig. 28.7 ).

Fig. 28.5 Examination of the patient Fig. 28.6 The surgeon is donating his own blood 388 R. Roth

Fig. 28.7 Blood being transfused in the patient

the team had to consider whether this included or Discussion implied consent for direct transfusion from a member of the team, without testing for infec- This case highlights a number of important issues tious disease and without cross matching. to consider. Patient outcomes are improved through effec- Much has been written about the pros and tive teamwork of the entire operating room staff. cons of short-term surgical trips [1–3]. Although Incorporating local liaisons in the team can be there is a critical need for surgical/anesthesia care challenging due to cultural and language differ- in low- and middle-income countries (LMIC), ences. Collaborative decision making between short trips by teams from high-income countries anesthesiologists, surgeons, nursing, and the local may not be sustainable and can undermine or partners led to a creative solution and fortunately overtax local resources. Capacity building and a good patient outcome. transfer of skills depends on cultural or resource appropriateness of the procedures, buy-in from local practitioners and availability of resources. References Postoperative care, follow-up, and management of delayed complications depend on the length of 1. Farmer PE, Kim JY. Surgery and global health: a view the trip, the relationship with local partners and from beyond the OR. World J Surg. 2008;32:533–6. availability of both human and material resources. doi: 10.1007/s00268- 008-9525-9 . PMID: 18311574. However, besides the obvious benefi ts for individ- 2. Wright IG, Walker IA, Yacoub MH (2007) Specialist surgery in the developing world: luxury or necessity? ual patients, short-term trips can fi ll specifi c gaps in Anaesthesia. 62(Suppl 1):84–9. care while LMICs build surgical infrastructure. 3. Shrime MG, Sleemi A, Ravilla TD. Charitable platforms Practitioners struggle for true informed consent in global surgery: a systematic review of their effective- with every procedure. When traveling abroad, cul- ness, cost-effectiveness, sustainability, and role training. World J Surg. 2014. [Epub ahead of print] PubMed. tural differences, language barriers, lack of educa- PMID: 24682278. tion, and limited biomedical health literacy further 4. Krogstad DJ, Diop S, Diallo A, Mzayek F, Keating J, complicate this issue [4]. Prior to the procedure, Koita OA, Touré YT. Informed consent in international this patient had been consented to both the sur- research: the rationale for different approaches. Am J Trop Med Hyg. 2010;83(4):743–7. doi: 10.4269/ gery to be performed and all other necessary pro- ajtmh.2010.10-0014. PubMed PMID: 20889858; cedures, including blood transfusion. However, PubMed Central PMCID: PMC2946735. 28 Letters from Around the World 389

Lessons learned: Letter 6: Notes so as Not to Make 1. When using anesthesia equipment where the Same Mistake Twice the labelling is in another language, try out the machine with a backup in place along with

Clifford Gevirtz another experienced anesthesia provider. The reducing valves may not function or be inac- Case 1: A 15-year-old Vietnamese male with a curate. Here some oil was apparently applied cleft lip presented for repair under general anes- and the needle was stuck on 70 kPa. Apparently, thesia. The anesthesia equipment consisted of it had been functioning this way for a consider- an older anesthesia machine with Russian writ- able length of time with the need for a sudden ing and a copper kettle, a portable monitor with change out not unusual event. EKG, pulse oximeter and noninvasive automatic 2. Clarify the training level of the person you are blood pressure. There was no oxygen analyzer working with; a senior medical student is not in the circuit. There was no capnometry or agent a senior anesthesia resident. The hosts had analyzer available. A twitch monitor was also given me a “senior” to work with; I didn’t utilized. The oxygen source was an H-cylinder realize that he was a senior medical student. with a two-stage pressure reducing valve in 3. Mouth-to-mouth respiration would not be place. The labeling on the tank and valves was acceptable practice today but at the time it in Russian. The needle indicated approximately seemed the only way to support the patient, clear 70 kPa pressure. The anesthetic plan was induc- mouth shields are now available which provide a tion with thiopentone, use succinylcholine for safer alternative, mouth to mask could also be paralysis and then place a RAE endotracheal utilized. Once intubated mouth to endotracheal tube. A Mapleson D circuit was to be utilized tube could be utilized in an emergency. with a table mounted Halothane vaporizer that 4. Awakening the patient could also have been had been brought in from the United States. An considered, if no further tanks were available. American anesthesiologist was paired with a local “senior,” who had checked the anesthesia Case 2: In this particular institution, there were machine that morning. two OR tables per room with a small moveable After induction with thiopentone, a mask was screen between the tables. The plan was for one placed on the patient to prove the ability to ventilate surgeon to start a case with two anesthesia provid- and the fl ush lever was turned to fi ll the bag on ers present and after the case was stable, a second the circuit. However, no oxygen fl owed to the case would be started on the other side of the circuit. The backup Oxygen tank on the machine screen. This had the advantage of there being two was then turned on, but the needle dropped to surgeons and two anesthesiologists within shouting zero within 20 s. Mouth-to-mouth ventilation distance should any complication arise. was then performed as there was no Ambu bag During a cleft palate repair, a surgeon had present. After fi ve breaths, the patient was intu- gastrointestinal distress and had to leave the OR. bated and mouth to tube ventilation continued This resulted in two patients being asleep at the until another tank was brought into the room. same time. A senior surgeon took over after Anesthesia was maintained with thiopentone completing one case and then fi nished the other. until the new H cylinder arrived. The case pro- The rest of schedule in that room was performed ceeded uneventfully thereafter. alternating between tables. Lessons learned: 1. One physician in the group should be designated as the team physician for the entire C. Gevirtz group. Complete medical histories of all team LSU Health Sciences Center, New Orleans, LA, USA members should be available and reviewed by 390 R. Roth

the team physician before embarking. When pressure. Additional intravenous access was someone takes ill, that person needs to be obtained, crystalloids and a single unit of albu- relieved without delay. Heroics such as trying min was administered (only one 200 cc vial was to operate or perform anesthesia while ill can available) and a Foley catheter was placed. There cause serious harm both to patients as well as was no blood bank in the facility. The patient was to the physician. brought back to the OR for re-exploration but 2. When traveling into malaria infested areas, it there continued to be diffuse bleeding. Another is important to ascertain which species is spun hematocrit was performed and it was 15 %. most prevalent and which antimalarial is most A direct father to child whole blood transfusion effective. Yellow fever, hepatitis A and B, was started after performing a fi eld compatibility tetanus, diphtheria, and pertussis vaccines test. However, the oozing continued and the child should also be considered before joining a arrested approximately 12 h after the end of mission (note it may a week before suffi cient surgery. levels of antibodies are produced). A com- Lessons learned: plete physical exam by the participant’s pri- 1. In this case, the parents were grateful for the mary care physician at home should also be efforts of the team. However, that may not considered prior to volunteering for a mis- always be the case. It is important to clarify sion, to evaluate suitability for working in the what happens if there is a serious complica- lesser developed country (LCD) environ- tion or a death. In some countries, e.g., in the ment. Team members with serious preexist- People’s Republic of China, medical mal- ing conditions such as coronary artery disease practice claims are treated more like a labor should seriously reconsider their participa- union dispute than as a tort claim. In other tion. In general, if a physician would be countries, e.g., Libya, health care personnel graded an ASA 3 then it is probably not a wise can be arrested if there are complications. idea to embark on a mission. In the one team Registering with your embassy to make sure member death I observed (an obese woman they are aware of your location is very helpful (approximate BMI 40) with hypertension and in case of altercations with local authorities. prediabetes), the issue in retrospect was Bring tubing along with stop cocks and large whether she should have been allowed to come syringes to perform a person to person transfusion. on a mission in the fi rst place. The etiology of this bleeding diathesis was A separate supply of medications should be never fully explained. There was no family held in reserve to treat medical emergencies history or history of easy bruising in the child. amongst the team members. Backup supplies The surgical fi eld was reviewed by three separate including a wide range of antidiarrheals, antibiot- surgeons on the mission and no surgical source ics, and non-narcotic analgesics are suggested. was detected. Emergency IV fl uids, angiocaths should be reserved and then can be left behind when leaving Case 4: During induction of a cleft lip, there was the country. a power failure with total loss of light; there were no emergency backup lights as one would fi nd in Case 3: Bleeding diathesis: A 3-year-old 11 kg the USA. Using a fl ashlight and the surgeons child underwent a cleft palate repair with mobili- head-light the induction was completed. The zation of two fl aps. Both during the procedure hosts assured us that power would be back on and in the post-operative period diffuse oozing within 20 min, which it was. The case proceeded was noted with signifi cantly more blood loss than safely and uneventfully thereafter. expected even with infi ltration with epinephrine containing local anesthetic. The patient had an Lesson learned: initial hematocrit of 32 %. A spun hematocrit in Always have a backup laryngoscope with a work- the recovery room was 23 %. The patient was ing bulb as well as fl ashlight. An iPhone with a markedly tachycardic with a narrowing pulse fl ashlight application can also be very helpful. 28 Letters from Around the World 391

The electricity supply is unreliable in many needed a few more minutes to fi nish the case LDC countries and backup plans should be in and the oxygen saturation was holding at 95 %. place. In many LDCs there are windows directly A rather heated discussion ensued and while I into the OR which may prevent total darkness, turned up the oxygen fl ow, my local assistant but the natural light provided may be insuffi cient kept turning it back down. The case was fi n- to continue with the planned surgery. ished within 8 min. Make sure that all the team members know The mouth was suctioned and the patient where the backup fl ashlights are stored. awakened without serious sequelae.

Case 5: During a cleft palate and mandibular Lessons learned: advancement case, the surgeon kept turning the Clear communication amongst the team is essen- patient’s head from side to side rather abruptly. tial. The surgeon who was from the local com- This child had a nasal intubation and the air- munity did not understand what I meant by way resistance decreased abruptly as did the extubation and thought I was just asking him to breath sounds. There was no capnograph on hurry up. Similarly, my local assistant thought I this case. The patient was spontaneously was wasting oxygen as the oxygen saturation was breathing but they were shallow breaths. The stable. When working with a mostly local team, it surgeon was informed that the patient appeared is important to have an interpreter present at all to be extubated but the surgeon said he only times (Figs. 28.8 and 28.9 ) .

Fig. 28.8 Holding area in Guyana, note 1980s equipment Fig. 28.9 A local source of milk for morning coffee with few monitors 392 R. Roth

manage postoperative pain and reduce hospital Letter 7: The Leonardo Martinez stay while improving hospital through put. The Valenzuela Hospital and the medical personal involved in these brigades is Medical Brigades devoted to teaching new surgical techniques and appropriate drug use to the local medical

Maria Portillo personal. But there are few disadvantages we must The Leonardo Martinez Valenzuela Hospital acknowledge. The foremost is the diffi culties in (San Pedro Sula) is one of the busiest hospitals in communication, given that not all the people Honduras and has also important social projects. involved speak English and Spanish. This defi - The institution hosts national and international ciency sometimes leads to delays in the cases or medical brigades (missions) year-round that help miscommunication, and requires that additional decrease the surgical waiting list at the rest of the personal become involved in the brigades to help hospitals in the western part of the country. with communication. Ideally, local medical stu- The hospital has a maternity ward equipped dents would help with translation, since they are with three operating rooms and a separate gen- familiar with the medical terminology but this is eral surgery building equipped with four operat- not always possible. ing rooms. Basic monitoring, such as ECG, O 2 Although the help provided by these medical Sat, and NIBP, is available in all of the operation brigades is invaluable, there have been complica- rooms. Arterial blood pressure monitoring and tions, possibly due to the lack of time and/or capnography are available in only one of the resources. These complications include: wound operating rooms. The staff, consisting of 6 anes- dehiscence, bleeding, and infection. Sometimes thesia technicians and 3 anesthesiologists, per- these problems have required additional surgical form on average 15 orthopedic, general surgery, interventions performed overnight when the bri- and gynecologic cases a day. In the maternity gade’s personnel are no longer available. ward some 10–15 obstetrical surgeries are done For example an interesting case occurred dur- daily. This high workload, combined with a rela- ing one of the GYN brigades. The patient was a tive lack of resources, while still maintaining 46-year female with a history of hypertension high standards of care, greatly increases the dif- and uterine myoma, but with no other signifi cant fi culties of the anesthesiologist’s job. or medical history. On physical exam she was in Every year we welcome approximately 6 vis- good general appearance; vital signs were within iting brigades that perform up to 50 surgical cases normal limits: blood pressure (BP) 140/80, heart a day. They are divided into ear nose and throat, rate (HR) 72 bpm; height 5′2″, and weight gynecology (GYN), general surgery and podia- 230 lb. Routine lab work was within normal lim- try. The advantage of these brigades is that we its. The patient underwent total abdominal hys- learn the techniques that are employed in hospi- terectomy under spinal anesthesia, with an tals around the world, not only from the surgical estimated blood loss of 600 cc. Both the intra but also from the anesthetic point of view. and immediate postoperative period were Implementing new techniques helps us better uneventful, and the patient received non steroidal analgesics and morphine for pain control. Twenty-four hours into the postoperative period, after the patient has been transferred to the surgical fl oor and upon initiating ambulation, M. Portillo Hospital Leonardo Martinez Valenzuela, San Pedro she immediately complained of diffi culty breath- Sula, Honduras ing, diaphoresis and pallor. She became uncon- 28 Letters from Around the World 393 scious. The medical team on call immediately Letter 8: From Medical Student administered additional oxygen. Vital signs were: to Resident: A Student Perspective BP 100/70, HR 140 bpm, and O 2 Sat 85 %. At on International Health Care this point perioral cyanosis was also observed. Delivery Due to the acute deterioration a decision was made to intubate the patient. Immediately after Kate Liberman intubation there was no detectable pulse and cardio pulmonary resuscitation (CPR) was initiated A doctor’s fi rst foray into international medicine is and maintained for an hour, unfortunately with- frequently as a young medical student. Filled with out success. Although the patient had received hope and excitement at their initial interview, some two subcutaneous doses of low molecular weight premedical students inquire about an institution’s heparin, the probable cause of this unfortunate international hospital interactions. Once accepted outcome was pulmonary embolism. to medical school, students are willing to apply for Despite receiving available thromboembolic medical missions by completing arduous applica- prophylaxis, the patient likely developed a throm- tions. They then painstakingly fundraise, devise bus and subsequently a pulmonary embolism due curricula, and spend extra hours after medical to other associated risks factor, such as obesity. school classes preparing. They sacrifi ce vacation Our practice was to wrap the lower extremities for a week or two of rigorous medical and surgical with ace bandages perioperatively. experience without reimbursement. What moti- As a consequence of this case, there was a vates someone to give up their time and put forth revision in the surgical prophylaxis protocols tremendous energy for this type of philanthropy? and use of donated sequential compression Students may be driven by the desire to see devices (SCD) was initiated with subsequent another system of healthcare, appreciate cultural medical brigades. The implementation of peri- differences in the approach to health, make an operative thromboembolic prophylaxis based on impact where resources are scarce, research a low molecular weight subcutaneous heparin and special interest for a master’s degree, learn a lan- SCDs has helped signifi cantly decrease the inci- guage, or perhaps travel. Everyone has different dence of this serious complication. reasons. Data from the Accreditation Council for This was admittedly a rare but devastating Graduate Medical Education (ACGME) shows a complication, highlighted because it followed steady increase in interest in global health among surgery performed during a brigade when the sur- medical students in the USA over the last three gical team had left. Had more education regard- decades. It is likely that today’s doctors who had ing perioperative thromboembolic prevention international experiences as students continue to and SCDs been available, it might have been avoided. But we have learned from the event and been able to identify techniques that we need to prevent pulmonary embolism occurring postop- K. Liberman Department Anesthesiology, Perioperative eratively especially in obese patients presenting and Pain Medicine, Brigham and Women’s Hospital, for gynecologic surgery. Boston, MA, USA 394 R. Roth seek them out in their career. Given the trending At one home, a mother came to the entryway popularity among students and physicians, it is with her two sons. As they approached us, it was crucial to discuss the implications of early global clear that one child had yellow sclera and a large health exposure on medical careers. belly. She beckoned me and a nurse through her My experiences providing medical care and home and out behind the house, where she anesthesiology abroad as a student and then as a pointed out his pale stool in a small dirt ditch. resident have been formative in shaping my Her son had hepatitis. He had stayed home from career path. Nelson Mandela said that “a good school for weeks, and she was fretful about his head and good heart are always a formidable well-being, nutrition, and future. That day, we combination. But when you add to that a literate took him to the nearest hospital for blood tests tongue or pen, then you have something very spe- and treatment. As I vaccinated his brother against cial.” In this vein, I share my personal perspective hepatitis A and B, the power of preventive medi- that will hopefully provide others—who are in cine struck me. For the fi rst time, I was able to medical school or post-graduate training— make a real impact, helping these children and insight into the lessons learned and the motiva- their parents to avoid disease. tion found through delivering patient care in an This positive experience prompted me to look international setting. for more international opportunities. I returned As a medical student at Mount Sinai School of to Honduras 3 years later on a surgical mission Medicine in New York City, I traveled to San with Medical Students Making Impacts (MSMI) Pedro Sula, Honduras, for two medical outreach supervised and mentored by anesthesiologists. missions. The fi rst was a 1-week trip during win- By this point in my career, I had matched for a ter vacation. It was 2007, my fi rst year of medical residency in anesthesiology. As a future resident, school. The administration in the global health I was curious about the role of surgical subspe- department designed a program for ten interested cialties in the developing world. I read papers students to learn about primary care in a develop- written by Paul Farmer, and I studied the World ing country. In small teams, our group worked Health Organization’s (WHO) and World with the Ministry of Health’s national vaccination Federation of Societies of Anesthesiologists’ campaign and volunteered in a public hospital’s (WFSA) websites. I began to understand that emergency department. anesthesiologists are underrepresented in medi- My most formative experience in Honduras cine worldwide. Many countries lack organized that fi rst year started on one already-hot morning training and application of evidence-based prac- in a grassy parking lot. I squeezed into the back tice. I embarked on this surgical mission hop- of a cream-colored station wagon with four ing that soon I could fulfi ll a need by working in Honduran nurses. One of them strapped speakers a medically-underserved and resource-poor to the roof of the car to announce our arrival in country. the rural neighborhood. We slowly rambled along I took a leadership role preparing for the surgical on a road that led into the mountains. On my lap, trip. My classmates and I convened in a large I held a Styrofoam box fi lled with dry ice and storage closet and planned for the number of sur- vaccines. We drove with these vaccines an hour gical supplies and amount of medication we on unpaved, and sometimes muddy, roads to a would need. We wrote fundraising letters to com- group of residences constructed of little more than panies asking directly for supplies or requesting sheets and sticks. I ducked under low-hanging funding to buy them ourselves. At the same time, electrical wires and avoided open fi re pits in order I created a curriculum that included a journal to stop at every home to collect yellow vaccine club, simulation, workshops, lectures and travel cards. After checking the name and birthday on planning (Fig. 28.10 ). After weeks of prepara- the cards, I administered the appropriate intra- tion, we were excited to fi nally be able to deliver muscular injections and oral vaccines. medical care—preoperative assessments, deliv- 28 Letters from Around the World 395

Fig. 28.10 Teaching pre-trip curriculum

ery of anesthesia, pain management and periop- medical Spanish, I fully appreciate the impor- erative medicine. Despite this intense preparation, tance of understanding a medical history and my experiences on this trip made me realize how expressing nuances of medical care in the much more I needed to grow. The basics of medi- patients’ native language. One of the most crucial cine are not enough. jobs of a physician is to communicate. Without a The fi rst patient interaction I had on this sec- fl uid understanding, it is diffi cult to be a excellent ond trip to Honduras was with broken Spanish. doctor. After taking beginner language classes as an Another interaction that expanded my under- extracurricular activity and completing two discs standing of international medicine took place in of computer language lessons my vocabulary and the recovery unit. I was visiting a middle-aged syntax left much to be desired. A translator was patient who had undergone a total abdominal assigned to provide me with assistance. I prac- hysterectomy (Fig. 28.11). After an uncompli- ticed some sentences with the interpreter. I was cated surgery, she was recovering well. Her par- trying to understand and master words, and ents and children surrounded the bed, I wanted the independence to speak on my own. I encouraging her to drink water and take her pain meant to tell a patient that “I was going to put medication. After asking the usual questions, I bandages on her legs to reduce her swelling.” was shocked to see a plastic pathology bag with However, I accidentally substituted a vulgarity her uterus on the bedside table. Her son stepped for the Spanish word “vendaje,” meaning “ban- forward and questioned if the organ needed to dage.” The patient was offended, the translator be taken for a biopsy. When I told him it did not, was amused, and I was oblivious—I did not real- he explained that he intended to plant it in their ize what I had said until later. yard underneath a new tree. He explained that Understanding the importance of clear com- the organ had been his “home” for 9 months, munication with my patients prompted me next and he wanted to honor it and his mother by to sign up for a Spanish immersion program, dur- merging it with a new living organism. This sit- ing which I lived with a family in Costa Rica and uation was entirely new to me and signifi cantly focused on language study. Now profi cient in different from patient encounters in the United 396 R. Roth

Fig. 28.11 Total abdominal hysterectomy

States. It gave me insight to the barriers of med- vides modern cardiac therapy to indigent patients. ical care in the Honduran system. The onus and As a senior resident in anesthesiology at cost of having a pathologist examine surgical Brigham and Women’s Hospital in Boston, MA, tissue fell on the patient. There was no internal I will be traveling to Kigali, Rwanda, to teach hospital system to have pathologic study of the anesthesiology. tissue. I considered how most patients in North In 2012, The Project Pacer International group America do not know what happens to their arrived at a tertiary care center, Viedma Hospital, specimens after being surgically removed. I was with 60 pacemakers that were donated by large also unaccustomed to patients wanting to inter- corporations. There were hundreds of people act with their surgically-removed parts. Most waiting patiently in a line that snaked through the importantly, I was moved by the tender gesture main lobby and extended through the cafeteria of gratitude from the son to his mother. While it and into the courtyard. Many were dressed in tra- was culturally different from the social practices ditional garb with brimmed hats, full skirts, and that I knew, it showed a love and honor of fam- thick dark braids and had deep wrinkles that ily. That was a feeling I understood from my attested to years of manual labor under the sun. own family. Since this experience, I have tried Patients had come from distant areas in the coun- to refl ect on how the perception of different try, some traveled for multiple days to be seen by behaviors can actually point towards cultural our team. commonalities. Due to the prevalence of Chagas disease, A factor in creating my rank list for residency many patients were in complete heart block. match was the ability to participate in interna- Because of frequently untreated strep pharyngi- tional medicine. I selected to do my preliminary tis, patients also presented with rheumatic heart year of training in internal medicine at the Lahey disease. The most common complaint was Clinic Medical Center in Burlington, MA. This shortness of breath and low exercise intolerance program allowed me to travel to Cochabamba, that prevented patients from working on farms Bolivia with Project Pacer International, a for family income. I saw patients in a small, hot Boston-based, nonprofi t organization that pro- exam room that had a ceiling fan circling below 28 Letters from Around the World 397 the room light. It cast a strobe effect over every Letter 9: Burnout of patient as I scrutinized the history, physical Anesthesiologists in a War-Torn exams, EKG, and echocardiogram (ECHO) to Environment determine if they would benefi t from a pacemaker insertion or a valvuloplasty. Miodrag Milenovic One patient was escorted into the exam room by the chairman of the cardiology department. Growing interest of the scientifi c community She had no chart, but the physician explained that over the past decade in burnout syndrome identi- she was in her fi rst trimester of pregnancy and fi ed problems of emotional exhaustion, deper- having respiratory diffi culty. She had a severely sonalization, and lack of personal fulfi llment for stenotic mitral valve and as her blood volume anesthesiologists. The syndrome is the result of continued to increase with her gestational age, she hard work, mental and physical exhaustion, was likely to experience worsening pulmonary stress, chronic unresolved interpersonal relations edema unless she had a valvuloplasty. During the among other factors [1]. procedure, we covered her gravid uterus with a Anesthesiologists perform highly responsible lead shield fashioned from multiple thyroid and stressful jobs, with patients whose treatment, shields such that it would not obscure her groin, recovery, or a better quality of life depends in large the entry point for the cardiologists’ wires and measure on their work and decisions. Several stud- dilators. This enabled the team to maintain a ster- ies have shown that anesthesiology is one of the ile fi eld and simultaneously protect the fetus. The most stressful specialties in medicine and as such, team successfully carried out a venous trans- anesthesiologists may be at higher risk of Burnout septal approach to the valve with minimal radia- Syndrome [2]. Burned-out anesthesiologists may tion to the lower abdomen. The adaptability of the have a higher rate of job turnover, marriage issues, cardiologists, protecting the baby from radiation drug and alcohol abuse, caffeine and nicotine addic- in a less than ideal situation with few resources, tion, suicidal ideas, and shorter life expectancy [3]. piqued my interest. They were able to repurpose Some studies suggest that chairpersons of technology in the operating room to achieve anesthesiology in the USA are prone to Burnout excellent patient care. Since then, I have devel- Syndrome because of the very stressful and oped an interest in looking at the use of common responsible job [4]. Preliminary and unpublished OR equipment in unique ways to arrive at inex- research results from Serbia shows exactly the pensive, practical and highly effective solutions to opposite, which is strongly related to personal deliver care. Ingenuity in the operating room has accomplishment and the fi nancial situation of the become one of my research interests. heads of anesthesiology departments. My experiences in providing international Although several former Eastern and South healthcare have helped me grow as a doctor and a European nations made great efforts train suffi - person. I have learned the power of applying sim- cient numbers of anesthesiologists and to improve ple medical knowledge, the need for effective the working environment, long period of political communication in a foreign language, the role of instability, military confl icts, and economic crisis cultural sensitivity and the necessity of ingenuity would seem to work against these goals. when resources are scarce and the stakes are Moreover, lack of control, unfairness, commu- high. I have cared for a diversity of patients, and nity breakdown, value confl ict, and insuffi cient they have trusted me to treat them and their fami- personal incomes in the Ex-Yugoslavia countries lies. I have—in small and large ways—made probably exert a cumulative effect on the health people’s lives better. It is with humility that of anesthesiologists. Also, opening of the I realize how privileged we are to have the resources available to us in the developed world. I am confi dent that I will travel abroad again, and M. Milenovic I encourage other students and doctors to also Department of Anesthesiology and Intensive Care explore these opportunities. Medicine, Clinical Center of Serbia, Belgrade, Serbia 398 R. Roth

European borders and professional migration Letter 10: A Reverse Mission: caused local manpower shortages in anesthesia [5]. Education, Observation, We conducted a study to determine the impact and Opportunity of many of these factors on anesthesiologists in Serbia. Voluntary and anonymous questionnaires were completed and a cross-sectional study was Elizabeth Frost conducted, with a legally acquired battery of During the World Congress in The Hague in instruments that included the Maslach Burnout 1992 and at European meetings 2 years prior, Inventory—Human Services Survey (MBI-HSS). Dr. Alex Gotta and I remarked on the style of The research population was Belgrade anesthesi- teaching and presentations; mainly that group ologists (272), employed in tertiary level public sessions such as problem-based learning were hospitals, and who constituted almost 50 % of the not offered. We were attending the conventions members of the Serbian Association of as representatives of the New York State Society Anesthesiologists and Intensivists (SAAI). of Anesthesiologists (NYSSA) to introduce the According to preliminary results, the percent- Postgraduate Assembly, our annual meeting in age of high and moderate levels of burnout among New York, and encourage attendance. It became staff anesthesiologists is disturbingly high: clear that while we might have a lot to offer, emotional exhaustion up to 80 % (high level many young anesthesiologists would not have 52.7 % and moderate level 26.8 %); feeling of the resources to participate. So the idea of an lack of personal accomplishment up to 70 % (low International Scholars program was generated. level 42.4 % and moderate level 28.8 %); and Unclear as to what fi nancial resources we might depersonalization in 12 %. Nearly 40 % admitted have but confi dent we would have at least seed that at some stage they are cynical, without empa- money from the NYSSA, we devised a program thy and not interested in patient outcome. that would invite young anesthesiologists, Departments and societies with a high percent- offering registration, hotel accommodation in age of burnout may become resigned, stagnant, New York for the duration of the meeting along and visionless. Patients are in danger of receiving with some travel expenses. Our plan was to poor quality and life-threatening care. It is very expose these physicians to what we were doing important for anesthesiologists and health care in the USA and allow them to realize what they authorities in less affl uent environments to under- could reasonably incorporate into their pro- stand the concept of burnout and to be aware of its grams at home. signs and symptoms. Recognition of the problem, In 1993, we entertained nine scholars mainly strategies to cope, and suggestions for improve- from Eastern Europe (Hungary, Lithuania, the ments should be developed. Czech Republic, Poland, Ukraine, and one from Brazil). The following year, we had almost twice References as many applicants. We formed a committee to attempt to identify those who would most gain 1. Maslach C, Leiter MP. Early predictors of job burnout from the program. and engagement. J Appl Psychol. 2008;93(3):498–512. The program has evolved over the past 21 2. Rama-Maceiras P, Parente S, Kranke P. Job satisfaction, stress and burnout in anaesthesia: relevant topics for years. In that time we have hosted 319 anesthesi- anaesthesiologists and healthcare managers? Eur J ologists from 58 countries for the 6-day program Anaesthesiol. 2012;29(7):311–9. (Table 28.1 ). Funding depended at fi rst on private 3. Lindfors PM, Meretoja OA, Luukkonen RA, Elovainio donations and contributions from the NYSSA, MJ, Leino TJ. Attitudes to job turnover among Finnish anaesthetists. Occup Med (Lond). 2009;59(2):126–9. none of which were tax deductible. In 2010, we 4. De Oliveira GS Jr, Ahmad S, Stock MC, Harter RL, Almeida MD, Fitzgerald PC et al. High incidence of burnout in academic chairpersons of anesthesiology: should we be taking better care of our leaders? Anesthesiology. 2011;114(1):181–93. E. Frost 5. Statistical Offi ce of the Republic of Serbia (2012). Department of Anesthesiology, Icahn School of Statistical yearbook of Serbia, 2012. Belgrade, Serbia. Medicine at Mount Sinai, New York, NY, USA 28 Letters from Around the World 399

Table 28.1 International scholars: history (1993–2014) Table 28.1 (continued) Country Year attended Country Year attended Argentina (3) 2001–2008 Syria (1) 2001 Armenia (1) 2004 Tanzania (1) 1997 Austria (2) 2000–2006 Tenerife (1) 2013 Bangladesh (1) 2013 Thailand (26) 1998–2013 Bhutan (3) 2004–2009 Turkey (2) 2012–2013 Brazil (4) 1993–2009 Ukraine (4) 1993–2005 Bulgaria (2) 1995–2005 United Kingdom (1) 2011 Chile (3) 1995–2000 Uruguay (1) 2012 China (1) 2002 Vietnam (3) 2005–2008 Colombia (3) 1998 West Africa (1) 2009 Croatia (12) 1999–2013 Yugoslavia (4) 1994–2002 Cuba (7) 1997–2008 Since program inception ( 1993 ) Czech Republic (18) 1993–2013 Total number of scholars 319 Egypt (1) 2011 Total number of countries 58 Estonia (1) 2011 Intl. scholars history as of 1/2014 Finland (1) 2004 France (1) 2005 successfully petitioned the Government for tax Germany (1) 2011 exempt (501c3) status as the Anesthesia Greece (2) 2009–2011 Honduras (2) 2011–2012 Foundation of New York. The foundation awards Hungary (15) 1993–2009 scholarships and grants to enhance the training India (8) 1995–2013 and education of the most enthusiastic, dedicated, Israel (3) 2001–2013 and committed anesthesiologists working in the Italy (5) 2000–2005 developing world. Jamaica (1) 2011 The program has also grown in its educational Kazakhstan (2) 1993–2007 offerings. Whenever possible, scholars are offered Kyrghyz Republic (1) 1993 the opportunity to participate in mini-workshops, Latvia (1) 2000 workshops and problem based learning discus- Lebanon (9) 1997–2004 sions. They are encouraged to participate, gratis, Liberia (1) 2009 Lithuania (5) 1993–2002 in pharmaceutically sponsored symposia in the Mexico (4) 2007–2013 vicinity of the meeting. In addition, the NYSSA Mongolia (2) 2008 and its offi cers organize a welcome reception on Nepal (23) 2001–2013 the fi rst day to introduce the scholars to each other Netherlands (2) 2013 and to learn about the organization of the NYSSA. Nicaragua (1) 2013 Attendees discuss what they hope to gain from Nigeria (1) 2013 their involvement and express their individual Peru (14) 2005–2013 interests. At a fi nal breakfast on the last day, an Poland (11) 1993–2013 informal discussion reviews how well we fulfi lled Romania (25) 1994–2009 the expressed aspirations. This event is often Russia (2) 1994–2003 spectacular in that many pharmaceutical compa- Serbia/Montenegro (17) 2004–2013 nies donate large quantities of equipment (mostly Slovak Republic (13) 2005–2013 airway devices) and publishers gift dozens of text- Slovakia (25) 1994/2012 books. A visit to a local medical center is also Slovenia (9) 1998–2013 arranged for those who are interested. South Africa (1) 2004 The NYSSA has essentially two arms; an aca- Spain (6) 1999–2013 demic aspect and a political function. The annual (continued) meeting of the House of Delegates of the Society 400 R. Roth is held during this week and the scholars are Typical of many of the comments we have welcomed. The president and offi cers of the received from the scholars are the following: American Society of Anesthesiologists attend It was a great experience for me …. I attended for these sessions giving the scholars the opportunity the fi rst time such a big anaesthesiology meeting… to hear about anesthesiology on a national level I made comparison how Slovenian anaesthesiolo- in the USA. gists and anaesthesiologists from all over the world approach problems and solve them. Of great Not infrequently, the home University or importance for me was attending the workshop for Department will help to defray some travel costs diffi cult airway management and practicing with if the anesthesiologist presents a poster of his/her all devices available. work. Not only do we encourage such participa- I deeply appreciate the possibility to see how anes- tion, but special consideration is given to thesia is being performed overseas, and the chance including these exhibits. These participants are to compare my experiences in the Czech Republic usually required to give a formal presentation on with those of other International Scholars. All lectures have brought me valuable knowledge. Not all their return to their own departments. things were new to me but it is important to know The selection process occurs several months someone is doing same or similar way. I will use in advance to allow for acquisition of appropriate my newly gained knowledge in both my medical documents. Scholars are recommended by senior and teaching practice. anesthesiologists in the United States or overseas I return to my country full of great knowledge. or by previous participants. They receive differ- Anesthesiologists of Central American countries really need this kind of support. I give three books ent fi nancial awards, determined by their applica- in the service of anesthesia. A dream come true. tion, ranging from free registration to shared hotel accommodation and some meals, work- This was a unique opportunity to bring something back home to Spain. I found that mini-meetings shop, and mini-workshop attendance, all of (PBLD’s) were far beyond more interesting than which are reimbursed after arrival. Reimbursement any other formula. We could interact directly with for airfare is usually not possible although indi- experts in the topic and get to know different points vidual members of the NYSSA and the sponsors of view from other anaesthesiologists, all over the world… we can all benefi t of sharing experiences often provide airport transportation costs and and knowledge. offer other features such as walking tours or It was a great opportunity to follow new approaches introduction to cultural events in New York City. and share experiences with my colleagues from The program is used as an award at the European other countries. And I believe we will keep in touch Anesthesia Meeting. While almost all anesthesi- with my new friends and continue to share our ologist who are selected attend the meeting, there knowledge and experiences in our practice in Turkey. still remain problems of war, lack of fi nances, Attending PGA in NYC as International Scholar inability to get time away, and visa restrictions, from the Netherlands provided me with the oppor- all of which can arise at the last moment and tunity to meet other anesthesiologists from around the world. I hope you can maintain this Program restrict travel. for many years to come! Measurable advances have occurred in the I learned a great deal and it was really valuable for my several countries involved including introduction everyday anesthesiology practice and my research in of examinations and standardization, improved Romania. I am doing my best to apply knowledge monitoring, expansion, and in some instances, particularly from acute pain management, obstetric introduction of obstetrical anesthetic services, anesthesia and intensive care. and organization of residency training programs, Immediately after coming back to my hospital in using especially, problem-based learning discus- Croatia we did changes in our local diffi cult air- sions. Participants have gone on to become pro- way protocol and included two new pieces of equipment that I acquired from PGA meeting gram directors, organizers of local assemblies industry fair. I have established several contacts and leaders at national meetings. with colleagues from abroad and hope that will 28 Letters from Around the World 401

result in stronger cooperation (scientifi c work reports back to their departmental chairs and with publishing and professional visits). The might negatively impact future selection of their meeting enhanced my professional knowledge and skills from which my department is already colleagues. Thus, absence is uncommon. having benefi ts. Benefi ts have accrued not only to the international scholars but also to members of the NYSSA It has been one of the best experiences ever for my and to the society itself. The program has afforded life. …learned a lot. ….open a new era for me… us tremendous admiration and given us much I will disseminate my experiences to our postgraduate Anaesthesiology students in Bangladesh. publicity overseas as well as cementing lasting relationships. Participants write warmly of their The day after I returned to Thailand I was on call. A large man required emergency surgery. The air- experiences and of what they have learned and way was diffi cult. I had been given a big LMA at many lasting friendships have been formed. The the PGA and I was able to save his life. We did not thorough and careful evaluations which they send have one at my hospital. to us both at the conclusion of the meeting and some weeks and months later not only help with While the majority of attendees availed them- planning of future postgraduate assemblies but selves of the many educational opportunities, one are also included in the documentation necessary might imagine that some might be distracted by for formal accreditation for continuing medical the activities of New York City during the education. December holiday season. Ahead of participation The International Scholars program has been in the Assembly, scholars are advised that failure a worthwhile endeavor and one that we hope will to attend the sessions might result in adverse continue for many years. The Future of Anesthesiology and Global Health 29 in a Connected World

Carrie L. H. Atcheson

Mobile communications offer major opportunities to advance human and economic development – from providing basic access to health information to making cash payments, spurring job creation, and stimulating citizen involvement in democratic process. Rachel Kyte, World Bank Vice President for Sustainable Development.

health care access, quality, information systems, D e fi nitions or behavioral norms. The term also applies to the private, nongovernmental organization (NGO), App Shorthand for “application.” An application and government projects that utilize them. is software that is used for business, lifestyle, or Phishing scam The perpetrator creates an open entertainment. The word application can refer to public network in a location where victims almost any software created for a task from the would expect to fi nd one (coffee shop, public Flash media player to a functional Excel spread- square, building lobby), and when victims sheet to games like Angry Birds, but it specifi - connect their personal devices to this network, cally excludes a device’s operating system [1 ]. the perpetrator can access personal informa- eHealth Health care information systems that tion (passwords, credit card information) with maintain and transmit information specifi cally the intention of committing fraud. online. These systems include epidemiological Platform The built environment within which a tracking databases, medical guidelines, patient software application runs. This may involve a information websites, online communities, and particular piece of hardware (in the case of an health care administration mechanisms. app, a particular brand of smartphone), the Massive Online Open Course (MOOC) A n operating system that governs the function of instructional curriculum offered online, free the hardware and software (e.g., iOS, Android of charge, with open enrollment. A MOOC OS, Windows, or Google), a web-based envi- syllabus may utilize audio, video, gaming, ronment (e.g., the functional course webpages readings, problem sets, tests, and individual or at edX.org or the online pharmaceutical group projects to teach content and may offer library of Lexicomp Online), or the look, feel, evaluation or a certifi cate of participation for and function of a mobile app. adequate work. The largest providers are 419 Scam Named after a section of the Nigerian Coursera and edX (free) and Udacity (paid). penal code (section 419) and also known as the mHealth The use of mobile device applications “Nigerian Letter” scam, the victim receives an and or basic mobile device technology to improve email or letter requesting an advance payment for the purpose of taxes, fees, bribes, etc. to assist a Nigerian Government offi cial in laundering C. L. H. Atcheson , M.D., M.P.H. (*) large sums of money in exchange for a prom- Oregon Anesthesiology Group , Department of ised large percentage of the money laundered. Anesthesiology, Adventist Medical Center , Portland , OR , USA The pleas are often very detailed and factual, e-mail: [email protected] with authentic-looking fraudulent documents

R. Roth et al. (eds.), The Role of Anesthesiology in Global Health: A Comprehensive Guide, 403 DOI 10.1007/978-3-319-09423-6_29, © Springer International Publishing Switzerland 2015 404 C.L.H. Atcheson

included to enhance authenticity [ 2 ]. This scam has been running successfully through Introduction the postal service, then over the internet since the 1980s, and it is estimated that $5 billion has We live in a world where more people have been extracted from victims internationally. access to a cell phone than to clean water and Smartphone A handheld mobile device that pos- sanitation services [3 ]. By 2013, mobile telecom- sesses the capabilities for mobile phone calls, munication penetration was 96 % worldwide (see SMS messaging, as well as Internet access over Fig. 29.1 )—with 89 % of households in the a Global System for Mobiles (GSM) or Code developing world having access to mobile com- Division Multiple Access (CDMA) network. munication (see Fig. 29.2 ) [4 ]. The mobile tele- SMS Short message service (SMS) provides communications industry doubles its bandwidth transmission of a 160-character text message every year and a half and is quickly expanding from one mobile phone to another or from a into rural areas. Most people in the world have mobile phone into a web-based database. access to mobile technology, and more impor-

8 7. 1 Population 7 6.8 6 5

Billions 4 3 2 Mobile-cellular subscriptions 1 0 2005 2006 2007 2008 2009 2010 2011 2012* 2013* Source: ITU World Telecommunication /ICT Indicators database

Fig. 29.1 Worldwide mobile c ellular subscriptions rela- demonstrating the increasingly universal access to cellu- tive to population. Worldwide, the number of mobile cel- lar technology. Source : International Telecommunications lular subscriptions approaches the population, Union (Branch of United Nations)

180 170 160 140 126 128 120 105 109 96 100 89 89 80 63 60 Per 100 inhabitants 40 20 Arab States World CIS Developed The Americas Africa Developing Europe 0 Source: ITU World Telecommunication /ICT Indicators database

Fig. 29.2 Mobile subscriptions per 100 inhabitants by families, or communities may share a subscription or a region. In some countries, it is common for people to hold device. Note : Commonwealth of Independent States more than one cellular subscription (e.g. one for personal (CIS). Source : International Telecommunications Union use and one for business use), while in other countries, (Branch of United Nations) 29 The Future of Anesthesiology and Global Health in a Connected World 405 tantly, people stay within a several foot proximity For example only 7 % of households in Sub- to their mobile devices 83 % of their lives [5 ]. Saharan Africa have internet access allowing Because of the accessibility of mobile tech- 16 % of the population to be online [ 4 ]. The big- nology, industries such as banking that provide gest barrier to expanding internet access in exclusively mobile services are growing expo- LMICs is cost; internet access costs 31 % of the nentially in the lowest income countries. In gross national income per capita (GNI p.c.) in 2013, 52 % of mobile money accounts were LMICs versus 1.7 % of GNI p.c. in high income located in sub-Saharan Africa, and there were countries [4 ]. nine countries in sub-Saharan Africa where citi- However, because of Facebook, Google, and zens held more mobile money accounts than other internet giants, “poorer countries in Asia, bank accounts [ 6]. This technology can and is Africa, and Latin America represent the big- being applied in the health care industry in the gest opportunity to reach new customers” [ 8]. form of mHealth initiatives. Mobile devices can The industry is poised to change. With its $19 be used to monitor heart rate and oxygen satura- billion purchase of WhatsApp, a platform that tion, and inroads are being made in other diag- uses the internet to send information via smart- nostic and imaging modalities. Indeed the use of phones, and their participation in the Internet. mHealth tools is one area where the gap between org initiative, Facebook made an investment in high income countries (HICs) and low and mid- expanding Internet access in LMICs via smart- dle income countries (LMICs) is narrow—the phones in 2013 [9 ]. As Internet costs continue World Health Organization (WHO) noted in to decrease and mobile Internet access con- 2011 that 77 % of LMICs and 87 % of HICs had tinues to increase, Internet educational plat- implemented mHealth initiatives [ 3 ]. According forms such as Massive Open Online Courses to Google Trends, interest in mHealth is increas- (MOOC) and real-time data-gathering become ing and is highest outside of high income coun- more accessible. The second section in this tries (See Figs. 29.3 and 29.4 ) [ 7 ]. The ﬁ rst chapter addresses the global health applica- section in the chapter explores the application of tions of Internet-based learning and public mHealth to surgical quality and perioperative health surveillance. medicine. Finally, the ﬂ ipside of transparency and access Personal computing and internet access lag is lack of privacy. In the last section the emerging behind access to mobile technology—especially issues of digital professionalism and privacy in a in low- and middle-income countries (LMICs). global health context are explored.

D A G C B F E H

2005 2007 2009 2011 2013 2015

Fig. 29.3 Google Trends Search Index shows interest in times in 2010 that would correspond to a search index of mHealth is growing. The Google Trends search index 100. It demonstrates growing or waning international shows the relative number of searches for a given term interest in a given topic. For the term “mHealth” interest relative to the maximum number of searches for that term. spiked after 2009 and has been growing steadily. Trend For example, if the term “health” was searched 10,000 prediction for the year 2015 is included 406 C.L.H. Atcheson

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Regional interest Region City 2005 2007 2009 2011 2013

View change over time Egypt 100 Russia 26 UnitedStates 23 India 17 Canada 9 United Kingdom 9