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Volume 6 Number 2 September 2002 ISSN 1472-8820
World Anaesthesia
news
In this issue
Focus on Education
– Training the trainers
– The Beer Sheva Project
Case Histories
A surgeon’s experience in Tibet
The management of neuroparalytic
poisoning
News from
around the world
A letter from Ethiopia
Return to Cambodia
40 years of Anaesthesia in Mongolia

Welcome
to World Anaesthesia News
The World Federation of Societies of Anaesthesiologists (WFSA) is
committed to providing safe anaesthesia for all. To this end, over many
years, increasing amounts of money have been spent on supporting
educational activities around the globe. Training centres have been
established and supported in Thailand, Israel, Ghana and Chile to
provide training to anaesthetists from the surrounding countries.
Visiting teachers/professors have been funded to spend varying
amounts of time (weeks to months) assisting in established teaching
programmes, evaluating them and acting as external examiners.
Lecturers have been funded to attend meetings of National Societies
and money has been given to Societies in developing countries to help
them organise and run such meetings.
Unfortunately, as Dr Meursing, the secretary of the WFSA, points out in her report, the
supply of money to support such endeavours is drying up. The WFSA derives its income from
three principal sources:
● a payment from each member society that is related to the number of members that Society
has – the bigger societies pay more than the small ones
● profits donated by the organisers of national and international meetings and
● income from investments.
As Dr Meursing has pointed out, income from the latter two sources is now much
reduced.
The need for continuing educational activities, however, remains undiminished and as Dr
Eguma shows in her article in this issue, largely unmet. It is appalling and very sad that, in her
survey of anaesthetists practicing in Nigeria, 43% had never been to an educational
meeting/refresher course since they qualified. In determining the educational priorities of
Nigerian anaesthetists, Dr Eguma has sought to determine what are the educational
requirement of each group so that scarce resources can best be used.
Dr Enright, the Chair of the WFSA Education Committee, is committed to maintaining
the Training Centres and continuing to support visiting teachers who can spend a significant
amount of time with their host departments as these two initiatives undoubtedly offer the best
value for money. It is probable that Societies that have previously received financial support for
their meetings or had WFSA sponsored lecturers attend will now have to bid for a smaller share
of the diminishing funds available. Their case will undoubtedly be strengthened if they can
show that they have performed a needs assessment (although I hate that term) and are
delivering what their members need in as cost effective a manner as possible.
William F Casey
The editor of World Anaesthesia
News is:
Dr W F Casey
Popes Cottage, Cheltenham Rd,
Gloucester, GL6 6TS, UK
Tel: (+44) 01452 814229
Fax: (+44) 01452 812162
Email: wfcasey@doctors.org.uk
Editorial Board
Dr Dixon Tembo (Zambia)
Email: dctembo@zamnet.zm
Prof. Rebecca Jacob (India)
Email: rebeccajacob@hotmail.com
Dr Rob McDougal (Australia)
Email:
mcdougal@cryptic.rch.unimelb.edu.au
Dr Tom Ruttmann (S.Africa)
Email: ruttmann@samiot.uct.ac.za
Dr Iain Wilson (UK)
Email: iain.wilson5@virgin.net
Dr Jeanne Frossard (UK)
Email: frossie@btinternet.com
Editor Emeritus
Dr Roger Eltringham (UK)
Email: 106147.2366@compuserve.com
Submissions to World Anaesthesia News may be sent to any of the above.
Contents
Focus on Education
Training the Trainers 1
Micronesia – Anaesthetic Refresher
Course 2001 3
Continuing Medical Education:
What do African Anaesthetists Need? 4
The Beer Sheva Project 5
News from around the world
Anaesthesia in Rural Sudan 6
Anaesthetic Experiences in
Sri Lanka 7
A Letter from Ethiopia 9
40 years of Anaesthesia in Mongolia 10
Return to Cambodia 11
Anaesthesia in Naura 13
Case Histories
News from Otjiwarongo - Nambia 14
A surgeon’s experience in Tibet 15
The management of
neuroparalytic poisoning 18
Feature Extra
PTC in the People’s Republic of
China 19
The Department of Anaesthesiology
Calabar, Nigeria 20
News and Information
Useful information 22-24
Anaesthetic websites to try 25
The African Anaesthetist 26
Working in the UK 26
The WFSA in a new century 27
Job Opportunity 5
Diary Dates 13
Book Review 21

Training the Trainers
Kester Brown
President, WFSA
Melbourne
Australia
Training the trainer is important, not only
because it makes the trainers job easier
but also because it makes them more
effective and thus gives the student a greater
chance of learning well. It is a largely
neglected area. People are too often
appointed to academic positions without any
consideration being given to their teaching
ability. The trainers are often asked to teach
but not given advice on how to do it. In a
survey, to which over a thousand
anaesthetists in Australia responded, 90 %
indicated that they participated in some form
of teaching.
Teaching is fun and it is a challenge to
do it well. Anaesthetists teach in a variety of
settings – in the operating theatre, with
simulators, in lecture rooms and, less
formally, in tutorials and discussions. They
may also develop teaching aids such as
videos and electronic presentations for the
student to work through, when they do not
have direct contact with the student.
To be a trainer it is desirable to have
been well trained oneself otherwise
misinformation or bad habits may be passed
on. Experience is a valuable asset acquired
with time that gives the teacher credibility
and makes him more convincing. An
experienced anaesthetist recognises or
foresees problems and knows how to handle
and avoid them.
Good teachers inspire their students,
usually by demonstrating their own
enthusiasm. They can convey information
simply and clearly so that it is easy to
understand. They should also teach their
students how to think and not to accept all
they are told or read without their own
critical appraisal. If a teacher can achieve
this, the students will have gained a valuable
asset and may themselves become good
teachers.
My ability as a teacher has been
acquired over many years; learning from
teachers who were thoughtful and easy to
follow, picking up ideas and tricks from
people who have worked with me and
discussing things with people who are clear
thinkers. Many ideas have come from
comments and questions raised by students
that have made me think.
There are many methods and situations
which the trainer can use to convey
knowledge to the trainee some of which I
have already mentioned. I will expand on
these and also discuss the organization of
courses and meetings.
Lectures are useful when one has to
convey information to an audience that does
not have much background knowledge,
especially if it is a large group. It should be
used to inform the students of the overall
concepts and highlight what are the key
points. Students need to gain perspective
and to understand the basic principles: the
detail can be added later. Lectures should not
try to convey too much because most people
have the ability to retain only so much in a
given time – too much detail will not be
remembered and only serves to confuse the
listener. The topic should be built up from the
basic principles to more complex points. This
is particularly important when lecturing to an
audience with widely differing knowledge
levels so that the basics can be understood
by those with least knowledge and even if
they cannot grasp the more complex points
they will at least have learnt something.
Giving a lecture is like giving an
anaesthetic where we give an extra bolus of
drug when the drug effect is wearing off. In a
lecture most people have a limited
concentration span so that the lecturer has to
do something to re-awaken the audience (tell
a not-too-funny joke or relevant anecdote,
ask a question or show a segment of video
etc) – it is like a bolus to raise the audience’s
concentration. There are a few infusion
lecturers who are so fascinating that the
audience listens attentively throughout, even
for an hour or more.
Presentation is very important. A
monotonous voice can quickly lead to loss of
interest. Try to vary the tone and volume and
put expression into it. When important points
are being made, slow down and pause at the
end so that the audience has time to think
about the point and absorb it. Non-stop, high
speed speech usually loses much of its value
because the audience cannot absorb the
information. It is unfortunate to hear a
lecture with good information being
destroyed by not adhering to these principles.
Say less and say what is important if your
message is to be clear.
Many people use visual aids during
their lectures and presentations. This is
helpful especially as nearly all anaesthetists
are visual rather than auditory learners.
Slides should not have too much information
on them, the type should be large enough to
be seen at the back of the hall and it should
in the middle of the slide. Colour choice is
important if the slide is to be easily seen.
Light colours, such as white or yellow, on a
dark background-, blue or green, are easy to
see. Generally red and purple do not show up
well. There is a danger when generating
slides on computer to fail to appreciate that
the colours chosen may not show up well
when projected. Fancy backgrounds produced
on computers do not improve clarity or the
transmission of the information.
Dual projection is less common now
that computer slides are more widely used
which is fortunate because few people use it
well. It is best when showing something on
one slide and indicating what it is on the
other. To have too much information on the
screen at one time or to use a distracting
title slide on one screen and the real
information on the other are techniques to be
avoided.
Beware of the laser pointer. It is useful
to demonstrate something but when waved
around it is distracting and when used to
point as the speaker reads text is
unnecessary, and even insulting to an
intelligent audience who learnt to read that
way in Grade one or two!
Why are so many 50 minute or one
hour lectures given when most people only
concentrate for 15-20 minutes and
sometimes less, especially after lunch? At
the World Congress in Sydney in 1996 only
two presentations exceeded 30 minutes and
yet most speakers were able to convey their
message clearly in the allotted time. This
should be remembered by all those
3
Focus on Education

Focus on Education
4
organizing congresses and meetings. Only
when you have a rare “infusion” lecturer can
one justify including a longer presentation.
Tutorials are the most useful form of
post-graduate teaching because the students
already have some knowledge and are at a
stage when they can prepare and gain more
information from reading and other sources.
There is, however, some skill required to run
a tutorial well. Ideally the group should not
be too big. Participation by all the students is
essential. This may mean that the leader
must diplomatically suppress anyone who
has too much to say and draw out the quieter
person who would not otherwise contribute.
To deal with both types requires tactful
handling of the individuals. The tutor should
not ask questions sequentially round the
class – the students will remain more alert if
the order of questioning is unpredictable.
Questions should be asked first, before the
individual is selected to answer. If not, the
person questioned will be stressed, the
catecholamine levels will rise, muscle blood
flow will increase with the fight or flight
reaction and the trainee may have difficulty
thinking of the answer, while all the others
are relaxing because they have not been
asked. If the question is asked first, all the
group can think about the answer before the
period of terror starts!
I have found a very useful method
when conducting tutorials is to give the
students a question on the general topic to
be discussed and allow them five minutes to
prepare a summary answer. This way, they
have time to organise their thoughts for their
reply before the stressful time when they are
asked to answer. Everybody has had to think
and maximise their brain activity before the
tutorial begins and they soon realize that
they are not going to be spoon fed! The
outlines can then be discussed during the
tutorial, the detail filled in and a
comprehensive, well organised answer
produced which will be useful for written or
oral examinations or just as a way of
discussing the topic at any time later.
How much should we teach? I have a
theory which I call the 70% principle where
one teaches enough for the students to reach
70% in an examination. In a non competitive
examination there is no need to teach more
detail than that because the bright students
can attain a higher standard by themselves
and any student around the pass level can be
helped to reach a clear pass level if you
teach to 70%. This entails teaching the
absolute basics well and adding some, but
not too much detail. The student then clearly
understands what are the important basics
and not become confused by all the detail.
They can fill in more detail later if they
clearly understand the basic principles.
Anaesthesia is a very practical field
and much of the training goes on in the
operating theatre and on the job. Some
people can teach easily while they are
working while others find that it is
distracting. While practical techniques are
being performed, the good teacher can
explain each step as it is done. This requires
some thought. If each step is analysed and
the ergonomics involved are considered, then
it is easy to explain and it should be easy for
the trainee to follow each step. Watching the
most skilful people and analysing how they
perform technical procedures is a good way
to learn but having it explained at the same
time is even better.
Video or similar presentations on film
or CD that have been thought out carefully
can be used as an adjunct to practical
teaching and are a way that experts who are
not present can be watched. It is also a way
to demonstrate a technique to a wide
audience. I believe it should be used as a
method of presentation more often at
congresses and meetings rather than being
relegated to a small room that hardly
anybody visits.
During an operation, there is often time
for discussion but it must not distract the
anaesthetist from observing the patient and
monitors. One of the advantages of pulse
oximeters that change the tone as the
saturation drops is that it is so easy to pick
up the change even while one is talking. In
normal conversation it is usual to look at the
person being spoken to: in the operating
theatre this would mean that the patient and
monitors would not be observed so one has
to watch these and not always look at the
person being spoken to. It is also essential to
keep an eye on the operation to observe
what is being done, to pick up any sudden
increase in bleeding or activities by the
surgeon which might influence the
anaesthetic.
Outside the operating theatre, trainees
can benefit from going round with the
anaesthetist to see how they talk to their
patients. Some people do this very well and
valuable interpersonal skills can be learned.
When visiting children, do you talk to the
parents and ignore the child except when
actually examining him or her or do you
concentrate on the child first. I personally
introduce myself to the parents and ask a
couple of questions but then spend some
time playing and talking with the child before
examining him. The parents tend to relax if
they see that you are going to be kind and
friendly to their child.
Simulators are still expensive but they
are increasingly being used in training where
they are available. They have the advantage
of taking the trainee through routines which
are useful, recognising and treating problems
and in resuscitation. Computer modelling is a
cheaper and less expensive alternative.
Trainers must review the aims and
objectives of training, where these exist, or
be familiar with the course syllabus so that
they know what has to be taught. When
teaching overseas in less developed
countries, it is important to teach what is
relevant to that place. It is useful to teach
basic science and how it applies to
practical anaesthesia and to teach or
demonstrate practical techniques that can
be used with the drugs and equipment that
is available.
The ability to organize courses and
meetings is useful. Various formats can be
used to make them more interesting. Lectures
and tutorials have been discussed. Practical
workshops and demonstrations can be held
for some subjects. Panels can be very lively,
especially if the panellists are only allowed a
brief, concise introduction to the subject
followed by comments from the other
panellists. The constant change of speaker
prevents boredom and loss of concentration.
During a course, a specialty topic such as
obstetrics can be discussed by an
anaesthetist and an obstetrician. This brings
out different issues and points of view and
has the added benefit that the two
specialists may gain a better understanding
of the problems from the others point of
view. Some imagination and the careful
selection of speakers can produce good
meetings and courses.
It may be useful to conduct workshops
for the trainers so that they can be motivated
and better informed about teaching methods
available. Practice lectures using a variety of
aids are extremely valuable especially when
coupled with constructive criticism from
fellow participants. The greatest advantage
of being a trainer, however, is that one
continues to learn, both in preparing the
lecture and from those you teach.

Micronesia Anaesthetic Refresher Course 2001
Dr. David Creasey
Anaesthetic SpR
Derriford Hospital
Plymouth UK
During my year as an anaesthetic
registrar at the Royal Hobart Hospital
in Tasmania I was fortunate to have been
given the opportunity to participate in the
annual Micronesia Anaesthetic Refresher
Course that is supported by Australian
Society of Anaesthetists. In 2001, this was
to take place at the capital of the Federated
States of Micronesia, Pohnpei. The Royal
Hobart Hospital has strong links with
anaesthesia in the Pacific mainly through
Dr. Haydn Perndt who invited me to get
involved. The course was co-ordinated by
Dr Malcolm Anderson (consultant
anaesthetist, Royal Hobart Hospital), Dr.
Okai Johnson who hosted the course in
Pohnpei and Dr. Willie Tokon, the
Micronesian co-ordinator.
The islands of Micronesia lie north of
the equator in the Western Pacific and are
the result of ancient volcanic activity.
Micronesia is spread over 3 million miles of
the Pacific and includes over 2000 islands.
These comprise eight distinct island groups.
The groups are Pohnpei, Yap, Chuuk, Kosrae
(the Federated States of Micronesia) Guam,
the Marianas, the Marshalls and the Republic
of Palau. The distance from one end of Micronesia
to the other is 2,040 nautical miles.
Micronesia is a loose collection of
different countries, united in their history of
having been the U.S. Trust Territory of
Micronesia. Although originally settled by
peoples from Polynesia, a turbulent history
has seen the islands come under the control
of the Spanish, Germans and Japanese. After
World War II, the United Nations declared
Micronesia a Trust Territory, under the supervision
of the United States. Today Micronesia
is largely independent and self-governing
So it was in October 2001, that I
found myself bound for Cairns to meet
with Dr. Scott Simpson, consultant
anaesthetist from Townsville. After some
rigorous searching in Cairns airport, we flew
to Guam where we had 4 hours to hone our
series of lectures surrounded by American
marines with machine guns. We then flew
to Pohnpei via Chuuk. We made an exciting
landing at Pohnpei where the aircraft made
full use of the whole length of the runway
and maximum reverse engine thrust. After
some more enthusiastic searching by
security officials, we emerged on Pohnpei
soil to be met by our host, Dr. Johnson.
The day before the course we had a
chance to see the island. As Dr. Johnson was
running late we made a call and found out
he was at the hospital but not in theatre as
we first suspected, but with his wife who
was in labour. Remarkably he had organised
the course whilst working a 1 in 1 on-call
and with a great deal happening at home.
We left him to his paternal responsibilities
to see Pohnpei. The island is impressive
with interesting volcanic geology, scenic
waterfalls and a remarkable set of ruins at
Nan Madol. The latter, a 2000-year-old
series of man made islands, quays &
buildings made from huge granite beams, is
an incredible testament to the ancient
peoples who developed the site. After a
packed day of exploration we collected the
inimitable Dr. Willie Tokon from the
airport and our faculty was complete.
Dr Johnson had secured a projector
for our PowerPoint presentations but we
realised we could not plug our Australian
laptop into Pohnpei sockets. A tour of
Pohnpei’s finest hardware stores looking for
an adapter proved fruitless until we returned
to the first store where a very helpful chap
took a pair of pliers to our plug & in seconds
we were able to run on Micronesian power.
Simao Nanpei, Director of Pohnpei
State Health Services, opened the course
which was attended by 6 participants from
the Federated States of Micronesia (4 from
Chuuk, 1 from Pohnpei and 1 from Yap), 1
from the Marshall Islands, and 1 from
Pulau. We then ran a four day course
covering paediatrics, airway and trauma
management, anaesthesia for the hypovolaemic
patient, local anaesthesia, peripheral
blocks, the management of near drowning
and thoracic anaesthesia. We had practical
sessions on cardiopulmonary resuscitation
and peripheral blocks (Dr. Johnson gave a
demonstration of ankle blocks leaving Dr.
Simpson with a numb foot. Dr. Simpson
demonstrated wrist blocks leaving me with a
numb hand. No one seemed to want to be
the patient after this.) Case reports were presented
and clinical scenarios on pre-eclampsia,
ectopic pregnancy and the paediatric patient
with a heart murmur were discussed.
The course was received with great
enthusiasm by those who took part especially
as the previous course, the year before, had
been cancelled due to a cholera outbreak.
Back Row: Dr. Okai Johnson, Dr. Willie
Tokon, Akapito Edgar, Aroy Modou, Kalisto
Thomas, Dr. David Creasey, Makoto Lanwi
Front Row: Dr. Jay, Arthur Olap, Dr. Scott
Simpson
This gave the course greater significance and
reinforced how important these events are
to the anaesthetists of Micronesia.
I feel very privileged to have had a
chance to take part in this course. The
anaesthetists of Micronesia do a tremendous
job in difficult circumstances as the supply
of drugs can be erratic and the maintenance
of equipment is often neglected. Courses
such as this run by the Australian Society of
Anaesthetists are an important part of
continuing education and training as well as
presenting an opportunity for anaesthetists
to discuss problems with colleagues. It was a
great experience to meet these interesting,
friendly doctors and I wish them all the best
for their next meeting in Chuuk.
5
Focus on Education

Focus on Education
6
Continuing Medical Education: what do
African Anaesthetists need?
Stella A Eguma MBBS DA FWACS
Department of Anaesthesia
PO Box 3573
Ahmadu Bello University Teaching Hospital
Kaduna
Nigeria
Introduction
Continuing Medical Education (CME)
describes those educational activities
undertaken by physicians after the
completion of formal graduate and
postgraduate training. The purpose of CME is
to enable practitioners to maintain and
upgrade their standards of knowledge, skills,
attitude and practice. Since opportunities for
medical education for anesthetists in Africa
are few, it is important that the few course
organised are structured so the practicing
anaesthetists obtain maximum benefit from
attending them. In order to run a useful and
cost-effective refresher course, the learning
needs of potential participants should be
identified and prioritised. A learning need is
the discrepancy between what a physician
ought to know and what he/she actually
knows. Trainee objectives can be identified
for the target group and a programme
consistent with the identified needs and
objectives can be implemented and its
effectiveness subsequently evaluated.
Currently, topics for update/refresher
courses are largely determined by the
personal preferences of the organisers and
their perception of perceived needs. These
may not always accord with the needs of the
participants. This survey was carried out to
identify the actual learning needs of different
groups of anaesthetists in a developing
country, Nigeria, in the hope that its findings
might help those responsible for training and
education in Africa to provide more beneficial
and cost-effective courses and workshops.
Method
Questionnaires were given to all
anaesthetists (both examiners and
candidates) attending the Anaesthetic
Fellowship examinations of the West African
College of Surgeons. The same questionnaire
was given to nurse anaesthetists at various
hospitals in the country. Information was
sought on the respondents’ grade, place of
work, number of years in anaesthetic
practice, number of courses attended since
starting in anaesthetic practice, reasons for
non-attendance at courses and perceived
areas in which the anaesthetist felt
inadequately informed and in which he/she
would like further training.
Results
Fifty three practicing anaesthetists completed
the questionnaire. Forty nine (92.5%) worked
in Teaching hospitals and four (7.5%) were in
private practice. No replies were obtained
from anaesthetists in general hospitals.
Table 1. Grades of Responding
Anaesthetists
Category Number Percentage
Consultants 8 15%
Residents 20 38%
DA holders 16 30%
Nurses 9 17%
Thirty six respondents had spent less
than 10 years in practice whilst seventeen
had been in practice for between 10 and 30
years. The majority (88%) of the latter group
were consultants or nurses.
Table 2. Course attended
No. of course No. of Percentage
attended anaesthetists
No course 23 43%
10 courses 8 15%
The eight anaesthetists who had
attended more than ten courses in their
professional life were consultants. All
respondents considered update courses to be
essential to their practice and, given the
opportunity, would love to attend such
courses regularly. The reasons given for not
attending courses were:
● Lack of information about suitable courses
● Lack of sponsorship to attend courses
● Pressure of work
● Financial constraints
Discussion
Anaesthetists all over the world have one
ultimate goal: to provide safe anaesthesia for
their patients. In order to do this effectively
they need not only to have been properly
trained in the art and science of anaesthesia
but also to keep up to date with constantly
changing trends in practice. One cannot but
agree with Last who wrote in 1991 that
“change is one of the most striking features of
our time…A large part of the medical
knowledge we possess at the end of our
apprenticeship in medical training has become
obsolete within ten years. No specialist can
remain competent without taking energetic
steps to keep in touch with the growing edge
of the specialty.”
Anaesthetists in developing countries
face a particularly difficult task in that they
have to practice safe medicine with a limited
range of drugs and equipment. Learning
resources are scarce and opportunities to
attend refresher courses are few. In addition,
their workload is often so heavy that there is
little time for academic activities. In spite of
these difficulties, both the West African
College of Surgeons and the National
Postgraduate Medical College of Nigeria do
manage to organise annual courses for
resident doctors preparing for their
professional examinations. The World
Federation of Societies of Anaesthesiologists
sends visiting lecturers to the annual meeting
of the Society of Anaesthetists of West Africa
to assist in the refresher course that is an
integral part of the meeting. Other anaesthetic
practitioners such as nurse anaesthetists
receive no organised continuing education.
Table 3. Grades of Responding Anaesthetists
Consultants Residents Nurses
Critical care medicine Critical care medecine Obstetric anaesthesia
Pain medicine Regional anaesthesia Paediatric anaesthesia
Medico-legal aspects Paediatric anaesthesia Regional anaesthesia
of practice
Statistics Pain control Anaesthesia and concurrent disease
Telemedicine Cardiopulmonary resuscitation Local anaesthetics

Undoubtedly, the rapid and tremendous
improvements in anaesthesia that have
occurred in recent years have generated a
need for both skill maintenance and
developmental training. The need for
continuing education has been realised and
some efforts have been made to organise
training. Specific training needs must now be
identified and training geared to meet those
needs. Since opportunities for continuing
medical education are few, it is imperative
that the courses that are organised are
tailored to the needs of practicing
anaesthetists.
This survey suggests that all
anaesthetists wish to update their knowledge
and skills so as to improve their practice.
Perceived learning needs, however, differed
between grades of anaesthetist. While
consultants were interested in learning more
about the fundamentals of research and
medico-legal aspects of practice, junior
anaesthetists were more interested in regional
and paediatric anaesthesia. Both groups were
interested in critical care and pain
management. The majority of anaesthetics in
Nigerian are administered by junior residents
and nurse anaesthetists. Both groups
indicated a need for further training in
paediatric and regional anaesthesia.
Common to all physician anaesthetists
was the desire to acquire more knowledge in
critical care and pain control. This indicates
that there are skill deficits in these areas that
need to be addressed. Truelove has
suggested that skill gaps may be due to lack
of resources, lack of ability, lack of
motivation or inadequate training. African
anaesthetists have motivation and the ability
and desire to do their best for their patients.
They are constrained, however, by poor
resources and inadequate training
opportunities. The practice of anaesthesia in
Africa cannot improve unless steps are taken
to enable practitioners to keep informed of
the ever-changing trends in our technologydependent
speciality.
New drugs, equipment and techniques
are constantly introduced into practice and
present new opportunities and challenges in
the management of pain, obstetric,
paediatric, regional anaesthesia and
intensive care. Our knowledge constantly
needs to be updated yet 43% of Nigerian
anaesthetists have never attended a
refresher course since qualifying. This study
has tried to establish what our training
priorities might be.
The Beer Sheva Project
Since 1992, an amazing project has
been ongoing at Ben Gurion
University of the Negev in Beer
Sheva, Israel. It has been led by one man
whose energy, drive and enthusiasm know
no bounds, Prof. Gabriel Gurman. He
recognised from his own background and
experience that young anesthesiologists in
Eastern Europe would benefit from
experience in an academic department
with modern facilities and methods.
The project began in 1992 with
anaesthesiologists from Romania. In
1995, Hungary sent four trainees. Since
then, Bulgaria, Moldova, Slovenia and
Slovakia have been participating. In all, a
total of 89 young anaesthesiologists have
taken part in the programme spending
one or two months in Soroka Medical
Centre.
They can choose to study anaesthesia
and its subspecialties or intensive care.
Beside the clinical aspects, they are also
taught about the organisation and
administration of the unit. Dr Mihai Sava
wrote: “I am one of the Romanian
anaesthesiologists who had the
opportunity to train at Beer Sheva. These
grants are very useful not only because we
got used to modern hospital technologies
but also because we learned how to
efficiently manage an Anaesthesia and
Intensive Care Department.”
All of these young anaesthesiologists
return home where they share their special
skills and knowledge with their colleagues.
Professor Valeriu Ghereg, President of the
Society of Anaesthesia and Intensive Care
of Moldova, writes “They are real
promoters of new ideas in the field of
health care reform. The impact of the
programme is not limited only to direct
participants.” The project is supported by
the WFSA, Ben Gurion University and
Soroka Medical Centre. It is a fine
example of what can happen when groups
work together. Recently, the Faculty of
Health Sciences at Ben Gurion University
announced a Post-doctoral Fellowship in
Anaesthesiology and Related Fields. This
will offer a one to two year training period
to young specialists in anaesthesia from
Eastern Europe, Asia, Africa and South
America with guaranteed research time
and training. Travel expenses and a stipend
are paid. This new initiative has sprung
directly from the Eastern Europe project
and congratulations are due to the Dean
and Faculty of the Ben Gurion University
and especially Professor Gurman for
developing it. It will be of great benefit to
all those who participate but also to their
home departments and universities.
Further information about the project can
be obtained from
Caroline Simon
Faculty of Health Science
Ben Gurion University of the Negev
Beer Sheva 84105, Israel
Tel: 972-8-6477406
Fax: 972-8-6477632
Email: caroline@bgumail.bgu.ac.il
Job Opportunity in Australia
Locum Consultant Anaesthetist required for one year the Royal Hobart
Hospital in Hobart, Tasmania. The post will commence in mid-April 2003.
The Royal Hobart department has 14 full time anaesthetists and 10
registrars in training. It serves a 300 bed University Tertiary Referral
Teaching Hospital. All anaesthetic subspecialties are represented.
Hobart is a delightful city with a population of 250,000 and is the capital
of the island state of Tasmania. There are plenty of cultural and natural
attractions/distractions to keep home-sickness away!
For further information, contact Dr Haydn Perndt at
Haydn.Perndt@utas.edu.au
7
Focus on Education

8
Anaesthesia in Rural Sudan
Paul Mwangi Iregi
iregimwangi@yahoo.com
Introduction
Sudan, the largest country in Africa with an
area of 2,500,000 sq km, gained
independence from the UK and
EgyptBritain in 1952. It lies north of the
equator and has a climate that ranges from
desertstrategically important access to
tropical forest.the Red Sea. The country is
potentially rich in agricultural produce and
boasts the biggest cotton and sugar
plantations in Africa. It also has vast
unexploited mineral resources and has
recently become an oil exporter.
The White and Blue Nile meet at
Khartoum, the capital, and the river serves
as an important route for commerce and
communication within the arid interior of
the country. Although Arabic is the official
language, English is widely spoken,
especially in the South where Arabic is
considered the language of the oppressor.
English is also the language of instruction at
the second oldest medical school on the
continent, in Khartoum, the Gordon
School of Medicine in Khartoum, called
after the colonial administrator who was
famously killed in the Mahdi’s rebellion.
The country has been embroiled in a
civil war since 1984. Simplistically, the war
is between the Islamic north and the
Christian/animist south but the southern
forces are divided into different factions.
Rumbek Regional Hospital
I started working as a non-physician
anaesthetist in Southern Sudan in 1997.
What infrastructure had survived years of
neglect, drought and famine had been
largely destroyed by aerial bombing. I was
employed by a NGO and asked to try and
establish an anaesthetic service at Rumbek
Regional Hospital.
The hospital was in need of major
reconstruction but as sufficient funds were
not available, priority was given to restoring
the operating theatre and the surgical wards.
Much of the essential building work was
done within a month and we were also able
to acquire a generator and some basic
equipment including an oxygen
concentrator, Ambu bags, a suction
machine, laryngoscopes and endotracheal
tubes. Although we were now able to
undertake minor surgery, before progressing
to major surgery, I set out to:
● Improve operating theatre nurse training
● Introduce training on pre- and postoperative
management
● Teach basic life saving techniques
● Obtain more basic equipment and drugs
● Train one or two dedicated anaesthetic
assistants.
Within one year, encouraging progress
had been made: we had established a quality
service with a low mortality and had a
substantial number of well trained nurses
with more in training.
Anaesthesia
As few monitors were available, ketamine
was my preferred agent for induction and
maintenance of anaesthesia. If intubation
was required, suxamethonium and
pancuronium were used and all patients,
both adults and children, were ventilated
manually with an Ambu bag. Reversal of
muscle relaxation was achieved with
atropine and neostigmine. Supplementary
oxygen was administered from our donated
oxygen concentrator.
Spinal anaesthesia was frequently practiced
as it was safe and inexpensive to perform.
Hyperbaric bupivacaine 0.5% was employed
for long operations such as the repair of
recto-vaginal fistulae whilst 5% hyperbaric
lidocaine was used for shorter procedures.
Ephedrine was always readily available for
manage hypotension but, as I routinely pretreated
all patients with at least one litre of
crystalloid, it was not usually needed. Postdural
headaches were rare as I used fine
spinal needles, preferring a 26g if available.
I had a supply of 1% and 2%
lidocaine for performing local infiltration
and regional blockade. I could confidently
perform foot blocks, digital blocks, Bier’s
block and brachial plexus block (axillary
approach) with little risk of failure.
Blood
Because of inadequate laboratory facilities, it
was impossible to perform safe homologous
blood transfusion. We were, however, able
to perform autologous transfusions. If the
need for transfusion was foreseen, the
patient was bled immediately preoperatively
and the volume replaced with
crystalloid and colloid. This method works
well for fit patients who are likely to need a
limited amount of blood as only a blood
bag containing anticoagulant is needed.
Alternatively, blood can be taken over
several days pre-operatively, but to do that
you need a reliable fridge! Both methods
avoid the risk of transmitting AIDS.
Paul Mwangi Iregi is a non-physician
anaesthetist who has worked in Sudan and
Somalia since 1997 and is currently working
in Sierra Leone.

Anaesthetic Experiences in Sri Lanka
(January 2001 – June 2001)
Background
Since the early 1980’s, there has been a
protracted conflict between the Sri Lankan
Government and the Liberation Tigers of Tamil
Eelam (LLTE). It has resulted in over 60,000
deaths and many more people have been
displaced from their homes. An area in the
north of Sri Lanka is currently controlled by the
LTTE and is claimed by them as a separate
Tamil state. (Editorial Note: Earlier this year,
a ceasefire was agreed and peace negotiation
are continuing)
In conjunction with the Sri Lankan
Ministry of Health, Medecins Sans Frontiere
(MSF) has an established programme that
provides medical personnel and supplies to the
Government Hospital in Mallavi, a town of
40,000 inhabitants. The hospital also acts as a
referral centre for a wider population of up to
400,000.
Getting there
I wasn’t sure how difficult it was going to be to
fulfil my long held desire to practise medicine,
and in particular anaesthetics, in a developing
country. I had explored the possibilities a
couple of years earlier, but all doors appeared
closed until I had gained the FRCA and a
minimum of 5 years experience. Now I met
these basic requirements and had no more
excuses. I applied to a couple of organisations
that I knew ran surgical programmes and
waited for their reply. Meanwhile, I spoke to
the person that mattered most on my specialist
registrar rotation: the Regional Advisor. I was
fortunate that he had done similar work in the
past and he was very enthusiastic about
allowing me time to work abroad.
I applied to MSF, a voluntary
organisation that has projects in a number of
countries around the world. They asked me to
attend an interview at the end of October
2000. The interview was an informal affair
principally discussing how I would cope as the
only anaesthetist on a placement and the
problems of dealing with difficult situations. At
the end of the interview things looked hopeful
but the nature of the organisation means that
available positions are often difficult to confirm
until the very last minute. The realisation of
what I was about to embark on began to sink
in.
For the next few weeks, I was left in
limbo. I had not been allocated a post for the
next 6 months of my training rotation but had
no definite alternative job. There was a
suggestion that I might be offered a post in
Sri Lanka starting in April. Meanwhile, I
attended a course in Bristol on anaesthesia
in difficult circumstances that was excellent
and enabled me to meet people who had
previously worked in similar circumstances.
Unfortunately, putting an Ether EMO
vaporiser back together after taking it apart
Our surgical workload was
largely determined by how
much equipment was
available at a given time.
The average was about 110
cases per month but we
sometimes had to stop all
elective procedures when
supplies were running low.
didn’t seem to be my forte but I did gain a lot
of information about anaesthesia in
developing countries.
Meanwhile discussions were under
way with the Royal College of Anaesthetists
to clarify whether what I was planning to do
would count towards my specialist
accreditation. The main stumbling block was
that I would be a lone anaesthetist with no
consultant supervision. It was decided that I
should have a distant supervisor with whom I
would regularly correspond by E-mail. This
had not been done before by the College.
Just before Christmas 2000, I received
a telephone call to say that my services were
required in Sri Lanka from the end of January.
This fitted in perfectly with the end of my
existing job. My remaining time was a
whirlwind of being on-calls, finishing an audit
project, sorting out my finances and saying
goodbye to family and friends.
Mallavi Hospital:
I arrived in Sri Lanka to the humidity of
Colombo airport, jet lagged and nervous
about what awaited me. Twenty four hours
later, I found myself in the northern town of
Mallavi. I had had little sleep for 2 days and
had crossed numerous army check points to
eventually find myself in the Tamil Tiger
Territory better known as the Vanni. I was
immediately on call.
The following day I was able to get a
better picture of the hospital itself. The
surgical ward consisted of a thatched 50
bedded unit. Multicoloured mosquito nets
were tied back in the daytime to reveal old
stained mattresses. The obstetric and labour
ward seemed more crowded and attracted a
greater number of flies than anywhere else.
There was one operating theatre with an
attached scrub room. I looked with
trepidation at the anaesthetic machine. It
was a basic Boyle’s machine with a
halothane vaporiser attached. The breathing
circuit was home made from an Ambu bag
and tubing. It was held together with tape
and it was impossible to tell how much
oxygen, halothane or air was actually being
given. The only monitoring equipment was a
blood pressure cuff and a slightly unreliable
pulse oximeter.
The drugs available were actually more
extensive than I expected. However, I was
soon to learn that as supplies were brought
into Vanni on a monthly basis from the south
of the country, deliveries were often delayed
and availability was erratic and depended on
the political situation at the time. The drugs
were also often very close to their expiry
date. Oxygen supply was a major problem. A
large J size cylinder was present but we
never knew with certainty when it would be
replaced and there was no oxygen
concentrator available. Hence, I had to
quickly learn the art of giving anaesthesia
without supplemental oxygen, which seemed
contrary to all I had previously learned in my
training.
There were a limited supply of sterile
gloves, needles, syringes and so they were
used sparingly. All equipment for spinal
anaes-thesia and surgical procedures was
sterile.
There were few other trained medical
personnel in Mallavi: a couple of doctors
took care of the medical patients while the
surgical ward was managed by 4 trained
nurses who never complained about working
long shifts. There were a similar number of
midwives and in the theatre were 5 “OT
boys”, as they were affectionately known.
The latter were unqualified but very helpful
9

10
staff responsible for all aspects of scrubbing,
cleaning and autoclaving. They also worked
in the minor theatre where suturing and
dressing changes were performed as well as
acting as anaesthetic assistants.
Operating theatre
Our surgical workload was largely
determined by how much equipment was
available at a given time. The average was
about 110 cases per month but we
sometimes had to stop all elective
procedures when supplies were running low.
The average age of our surgical patients was
29 years. Except true emergencies, all
patients were reliably starved from 4am and
brought to theatre after the morning ward
round. I attended this with the surgeon and it
was satisfying to review all our patients from
the previous day’s surgery.
Pre-operative assessments were
limited despite having a nurse translator.
Fortunately there were very few patients with
chronic medical problems – the most
common was hypertension. All patients were
weighed and had their blood pressures taken
prior to coming to theatre. The only
investigations available were red cell counts,
ESR, malaria screening and urine testing.
There were no facilities for estimating urea
and electrolyte level or performing ECGs. X-
ray examinations were possible in another
hospital an hour’s drive away once a week.
There were a significant number of
children to be anaesthetised and I soon
realised trying to gain intravenous access in
a child without pre-treatment with topical
local anaesthesia is very difficult! Gaseous
induction of anaesthesia with the equipment
available was equally challenging and I soon
found the best method of inducing
anaesthesia was a quick intramuscular
injection of ketamine (8-10mg/kg) into the
buttock. Within a few minutes, I was able to
insert an intravenous cannula in a now
relaxed child and allow the operation to
proceed. Ketamine became my best friend in
the world of anaesthesia. My previous
experience with the drug had been limited to
using minimal doses in elderly patients
having their fractured hips repaired but I soon
discovered the benefits of having a drug that
allowed patients to maintain a patent airway
and did not cause them desaturate despite
receiving no added oxygen.
I found there were large differences in
doses required to induce and maintain
anaesthesia in my patients: often they
appeared to need far more than the 1-2mg/kg
300 Sex of patients
250
200
150
100
50
0
300
250
200
150
100
50
0
intravenously quoted in the literature.
Sometimes they would seem awake and I
was concerned that they might be aware but
I was reassured by a survey I carried out. The
patients all seemed to be quite happy with
their anaesthetic and had no recollection of
their operation. They seemed to laugh off,
almost inappropriately, any dreams they had.
This may have reflected the nature of the
culture and the difficult environment in which
they lived.
Spinal anaesthesia was my other major
technique and was indicated for any
operation below the waist. As most of my
patients were very thin, my biggest problem
was avoiding puncturing the dura with the
introducer needle. During my time in Sri
Lanka, I performed 250 spinals and had one
definite spinal headache that resolved with
fluids and bed rest.
I always worried when we had to do a
laparotomy or other case that required
intubation. I would use a standard rapid
sequence induction with thiopentone and
suxamethonium and intubate the patient
using whatever endotracheal tubes were
available. I then maintained anaesthesia with
140
120
100
80
60
40
20
0
Spinal
Males
Age of patients
61
Years

there was little happening, we were able to
relax in the hammocks and try to keep cool in
the sweltering heat. Bicycle rides to a local
reservoir at the end of the day through the
beautiful surroundings were a great joy in our
lives – a two-way radio taking the place of
my usual bleep. Sunday nights were spent
watching movies at the UN compound and
hoping that we would not get called away
mid-film for a Caesarean Section. Getting
used to living within the limitations of
Mallavi was a challenge in itself. Our only
contact with outside world was via a convoy
on Tuesdays and Fridays that brought in E-
mails, letters and other provisions.
At times, it was quite easy to forget
that we were in the middle of a war zone
until a patient would be brought in with half
their foot blown off from a land mine – the
temptation of collecting coconuts from just
beyond the barbed wire having proved too
much. At other times, the shelling would
pound away in the distance sounding like
faint thunder or the locals would get very
excited by over flying aircraft.
Back to reality
Now that I am back working for the NHS, I
appreciate all the facilities and benefits we
have and take for granted. The difficulty of
finding an available intensive care bed
contrasts with having no critical care beds at
all. My work here is certainly busier and
poses different anaesthetic challenges but I
think I learnt many things from being the sole
anaesthetist in Mallavi and I am sure my
experiences will benefit me in my every day
work. The local people who appreciated
whatever we did for them, no matter how
difficult their circumstances, more than
compensated for the frustrations I
encountered.
I feel I was very fortunate to have been
able to go and work in Sri Lanka with MSF.
Getting there was certainly much easier and
less complicated than I was led to believe. It
isn’t a job that would suit everybody and
certainly the minimal pay and basic living
conditions need to be taken into
consideration when considering such jobs. I
am sure that the time I spent in Sri Lanka will
benefit both my future career and my
personal development.
Total number of cases = 431
Editorial Apology: I’m afraid I have lost the
name and address of the author of this paper.
He/she appears to be a trainee anaesthetist
in the UK and I would be grateful if he/she
would contact me.
A letter from Ethiopia
Tefera Alemu
Department of Anaesthesiology
PO Box 18728
Addis Ababa
Ethiopia
Dear Dr Eltringham,
Thank you for sending me the package of books. All arrived safely except for one
that had some damage to its cover caused, I think, by our domestic postal service. I
really appreciate your interest in spending you time, energy and money in sending
material to help us.
Perhaps I can tell you and your colleagues a little more about our department her in
Addis Ababa:
● The School of Anaesthesia was established in 1982 and since then has produced
203 nurse anaesthetists, most of whom are still practicing in Ethiopia.
● Currently we have 24 students who are reaching the end of their two year course. At
the start of the new academic year in September, we expect to enrol 25 new students.
Because of the constraints of space, particularly in the operating theatres, and to
maintain standards and safety, we cannot accept greater numbers of students for
training.
● We teach the theoretical aspects of anaesthesia in the classroom and then
introduce practical experience in the operating rooms of various hospitals. As
there are few teachers, our workload is considerable.
● Our students work in ten different government hospitals enabling them to gain
experience in different aspects of anaesthetic practice and develop appropriate
skills. Since we use so many different hospitals, I can only guess at the number
of patients our students anaesthetise.
● Our students learn general anaesthesia using intravenous and inhalational agents
and the use of muscle relaxants and endotracheal intubation. They also learn safe
spinal anaesthesia and a number of regional blocks.
The major problems we face every day are:
● A shortage of local anaesthetic agents for spinal anaesthesia especially 5%
lidocaine and 0.5% bupivacaine. Because of the poor state of our economy we
are unable to import modern anaesthetic agents such as isoflurane, atracurium,
vecuronium and etomidate.
● We are also short of laryngoscopes, endotracheal tubes, airways and monitors
such as oximeters and even ECGs.
Although we work under many constraints, we try to the maximum of our
knowledge and capacity to produce well qualified and competent nurse anaesthetists
for our country.
With best regards,
Tefera Alemu
If you would like to donate books or journals for use in a developing country, please
contact Dr Roger Eltringham (+44) 07774 276284 or
106147.2366@compuserve.com
11

12
40 years of Anaesthesia in Mongolia:
a Conference and Refresher Course report
Dr David Pescod FANZCA,
Staff Specialist in Anaesthesia
Northern Hospital
Melbourne
Victoria
Australia
In October 2001, I spent nine days in
Mongolia as a WFSA visiting lecturer
and guest of the Mongolia Anaesthesia
Society. I was involved in four days of
teaching and a two-day conference
celebrating 40 years of anaesthesia in
Mongolia.
Mongolia is a landlocked country of
some 1,565,000 square kilometres in
Eastern Asia. It consists of semi-desert and
desert plains with mountains in the West
and South West and the Gobi Desert in the
South East. The average altitude above sea
level is 1,580m. The summers are mild and
the winters long and cold.
Mongolia has a high rate of
population growth, estimated at 1.45% in
1999. The 2000 census reported a total
population of 2.38 million with 35%
estimated to be less than 15 years of age.
However the demography is in transition
with declining fertility and mortality rates
which will increase the demands on both
adult and elderly health services.
Until the 1940s Mongolia had neither
industry nor settled agriculture, with the
vast majority of people living a nomadic,
subsistence agricultural existence. After
1940, there was a rapid increase in
urbanization, industrialization and
education. However because of the
geographical conditions and very low
population density, there were significant
shortages of basic foodstuffs, electricity,
clean water and sewerage disposal. These
shortages also exist today in Ger settlements
in urbanized areas. An estimated 60,000
people live in Ger camps around Ulaan
Baatar, the capital.
Modern health services began in
1921. After Mongolia came under the
influence of the USSR in the 1940s they
rapidly developed, with strong central
planning following the Soviet model. This
emphasis on medical specialisation and
hospital based services continued until
1990s. In 1997 Mongolia had an estimated
407 hospitals with 18,436 beds.
Life expectancy is estimated as 63.6
years for males and 67 years for females.
Infant mortality rate was approximately 35
per 1000 live births and maternal mortality
157 per 100,000 live births in 1998.
Mortality among under 5 year olds is 47 per
1000 live births due to respiratory infections
along with parasitic diseases, birth trauma
and gastrointestinal illnesses. Crude death
rate in 1997 was 7.2. This represents a
marked change in the last 30 years with
decreased mortality from infectious,
parasitic and respiratory disease but an
increase in mortality from neoplasia,
circulatory disease, trauma and poisoning.
In 1998 the commonest sites of
cancer were the liver (40%) stomach (18%)
and lung (12%). Cardiovascular disease
including hypertension, stroke, ischaemic
heart disease and rheumatic heart disease is
now the leading cause of death.
Communicable disease such as viral
hepatitis, TB, brucellosis and shigellosis
remain a major health problem. The
incidence of other communicable diseases
such as tetanus, polio, pertussis and measles
has been markedly reduced whilst others
such as Hepatitis C and AIDS are emerging.
Mongolian health delivery is divided
into four levels. Level one provides basic
medical and public health services for the
nomadic population, often in remote areas.
Level two includes general practice
physicians in larger communities with level
three including towns and small cities. Level
four provides a full range of health services
and is limited to the capital city.
The restructuring of Mongolia’s health
system from a centralised to a devolved
structure has resulted in major social upsets.
Vigorous efforts are being made to improve
the management of health facilities but
minimal economic wealth and isolation
makes progress difficult.
Anaesthesia training is conducted in
Mongolia’s only university. Facilities, as in
all areas of health and education, are
limited. Textbooks are available but the
donation of several selected specialist texts
would greatly improve the library facilities.
Similarly the provision of handbooks of
anaesthesia for anaesthetists in training
would be a simple and cost effective action.
Anaesthetic educators would appreciate
supplies of basic educational aids such as
overhead projector transparencies.
Anaesthetic equipment/supplies and
hence anaesthetic practice varies between
hospitals. Although a few centres have new
equipment, most rely on old and even pre-
Soviet machines and monitoring. Few
anaesthetic drugs are available. Little
equipment is “disposable”.
Mongolia has 138 anaesthetists, of
whom 43 attended the seminars and conference.
Seminar topics included regional anaesthesia,
obstetric anaesthesia, advanced airway
management and trauma management.
There are many areas of anaesthetic
practice where guidance would markedly
increase anaesthetic skills and improve
patient care. Mongolia has a wealth of
dedicated health professionals and the
countries anaesthetists would welcome and
appreciate further support and assistance.

Return to Cambodia
Dr Gillian Davies
London, UK
Gd407@btinternet.com
Cambodia, the land of the white crocodile,
is situated in the heart of Indo-China
bordered by Thailand, Vietnam and Laos.
It has maintained a uniquely Khmer culture
although there is still much evidence of the
French colonial presence from 1864 to 1953.
Since then civil war, Pol Pot and the Khmer
Rouge and continuing political instability have
made it one of the poorest countries in South
East Asia.
International aid organizations have
been welcomed back to Cambodia since the
1991 Paris Peace Accords and in 1993-94 I
worked with the Red Cross in the North West
province of Banteay Meanchey and on the
Thai-Cambodian border. More recently, I have
been privileged to work in two very different
anaesthetic projects, each for 5 months. From
July 2000, I worked for Emergency in
Battambang and in 2001 at the Sihanouk
Hospital, Phnom Penh with BESO (British
Executive Service Overseas).
Emergency Hospital, Battambang
Batttambang, Cambodia’s second city is
situated 295 Km NW of Phnom Penh has a
population of 90,000. It is in the centre of a
rich agricultural plain where much rice and fruit
is grown and it has the best preserved French
colonial era architecture in the country. The
surrounding province has a population of 1.5
million and is the most heavily mined area in
the country. Nationwide, about 150 new mine
injuries occur each month peaking during the
dry season, (December–May) when rice is
planted. In March 2001, a record 103 mine
injuries were recorded in Battambang province
alone and it is estimated that some 6 million
mines remain undiscovered.
Eighty five percent of the Cambodian
population live in the countryside and are
engaged in subsistence farming earning less
than US$ 0.8/day. The Government can only
afford to spend US$ 2 per person/year on
health care so malaria, TB and HIV remain
uncontrolled, infant mortality is 90/1000 and
life expectancy is only 54 years.
I worked for Emergency, an Italian NGO
that has been active in Cambodia since July
1998. It aims to provide surgical care and
rehabilitation to the victims of war, those with
mine injuries and related musculo-skeletal
problems due to cerebral palsy, polio and
burns. The Emergency hospital was an
attractive 100 bed facility with 2 operating
theatres, dedicated to an Italian journalist, Ibria
Alpi, who had been killed in Somalia. It was
staffed by 138 Cambodians and 7 expatriates
and treated over 3000 in- and out-patients
annually. The facilities were low tech but
sufficient to perform about 90 operations a
month. Anaesthesia was administered by 5
nurses who had been “trained on the job” by
my predecessors. I tried to encourage them to
use what was available more appropriately, to
teach them spinals and other regional blocks
and to pay greater attention to the recovery
area so that they could work safely without
expatriate supervision.
There was not a great amount of
anaesthetic equipment available: one OMV
and one Fluotec Mark 2 vaporiser each
attached to inaccurate flow meters. Although
there was a notional ventilator for the postoperative
ward, all ventilation is done by hand
using an Ambu bag held together with
elastoplast. The paediatric circuits leaked and
were in short supply and there was a limited
range of endotracheal tubes that were
constantly reused. There was one combined
defibrillator, oximeter and ECG machine that
was moved about as required and we had 2
oxygen concentrators, an Innosar Simo-plus
and a New Life Airsep that generally worked
well but were dependent on an unreliable
town electricity supply. Oxygen was also
supplied in large cylinders from Phnom Penh
during the dry season but not during the rainy
season when the road became almost
impassable. Disposable equipment such as
syringes, needles, cannulae and size 22 spinal
needles were usually available but we lacked a
reliable suction pump.
Core anaesthetic drugs, ketamine,
thiopentone, diazepam, halothane, suxamethonium,
atropine and norcuronium were available
but there were recurrent shortages of bupivacaine,
neostigmine and ephedrine. Pentazocine,
tramadol andacetaminophen/
paracetamol were our analgesics. Hyperbaric
bupivacaine was not available.
We worked in two spacious operating rooms
using:
● Thiopentone induction only
● Ketamine for induction, maintenance and
as an infusion and also as an adjunct to
local blocks
● Halothane for induction and/or
maintenance during spontaneous
ventilation with a face mask or with IPPV
● Suxamethonium for intubation and
intermittently for short cases. Norcuronium
was used if longer muscle relaxation was
required
● Diazepam for sedation and with local
anaesthetic blocks
● Regional techniques including spinal
anaesthesia (the incidence of headache
was 15% and the failure rate 2%). Supraclavicular
and axillary brachial plexus
blocks, ankle and wrist block were all
introduced in August 2000.
● Intravenous regional anaesthesia
(IVRA/Bier’s block) with lidocaine
Table 1 – Anaesthetics Administered
Total War related: War related Recon
Emergency Elective strutive
430 46 182 203
290 patients were male, 141 female and
92 children under 12. Ketamine was the most
frequently used agent, either alone or in
combination, as shown in the following chart
Patients were being sent from the
theatre, down a long corridor to wards that
had no resuscitation facilities when I arrived.
Subsequently we used an area in ITU next to
the theatre. ITU nurses came to theatre to
learn about anaesthesia and airway
management so that post-operative care was
greatly improved.
There was a 10 bed intensive care/high
dependency ward where the patients needing
extra nursing such as those with recent mine
injuries, those who have had a laparotomy,
tracheostomy or chest drains and children who
have undergone complex orthopaedic
13

14
procedures were cared for. There was no
special monitoring and artificial ventilation was
not possible.
Sihanouk Hospital, Phnom Penh
Phnom Penh is a bustling city of 1.3 million at
the junction of the Bassac, Tonle Sap and
Mekong rivers and has been the capital of
Cambodia since 1865. Although it was French
designed with wide tree lined boulevards,
pagodas, temples and colonial villas, all the
infrastructure was destroyed when the entire
population was forcibly removed by Pol Pot in
1975. There are no skyscrapers with most
buildings being 4-6 stories high but it is again
a thriving city with a National Museum
containing Ankor sculptures, an Art Gallery,
Royal Palace and Silver Pagoda.
Sihanouk Hospital, Centre of
Hope opened in December 1996 and
is staffed and managed by Hope
Worldwide, a NGO founded in1991. It
is the best equipped and managed
hospital I have seen on any of my
visits to Cambodia and its aim is to
train health care professionals to give
first class free medical care to the
poor and needy 24 hours a day. It has
a large out-patient department that
treats 5000 patients a month, half of
whom come from outlying villages.
There are 22 medical and surgical beds
with 2 operating theatres where
approximately five general surgical or
orthopaedic procedures are undertaken
each day. No out-of-hours emergency
surgery and no paediatrics is
undertaken. The hospital has 26
Cambodian doctors selected, on
rotation, from the national hospitals,
assisted by 14 expatriate medical staff.
There is one physician anaesthetist and
three anaesthetic nurses, all Frenchtrained,
in Phnom Penh.
The two well-equipped
operating rooms had Boyle’s type
continuous flow anaesthetic machines
fitted with a halothane vaporiser and flow
meters for air, nitrous oxide and oxygen
although only the latter was used. Co-axial
circuits were used with soda lime. There was
no mechanical ventilator in the theatre but
there was an Eagle Marquette automatic
monitor for BP, pulse, ECG, O2 and CO2. There
was a reliable supply of disposable circuits,
needles, syringes, intravenous cannulae, 26g
spinal needles with introducers and a variety
of endotracheal tubes including flexometallic,
RAE and Rusch double lumen for chest surgery.
Anaesthetic drugs included fentanyl,
morphine, meperidine/pethidine, midazolam,
spinal lidocaine and tetracaine (US donated).
Shortages of fentanyl and neostigmine
occurred but there was tramadol and
pentazocine for post-operative analgesia.
Diazepam was not used. Although there were
plentiful supplies of intravenous fluids, careful
forward planning was needed to obtain enough
blood from relatives for elective surgery as the
HIV Rate is 4% and 56% of HIV positive
patients are under 25 years old.
A range of anaesthetic techniques were
used especially muscle relaxation and IPPV.
Spontaneous respiration with halothane +/-
analgesia was not used before my visit nor
were ketamine or diazepam, even when
500 Anaesthetics given
400
300
200
100
0
150
120
90
60
30
0
Total
Emerg
War rel
Anaesthetics given
Reconstr
IPPV
Hal
General
Orthop
GA, IPPV
Hal
Ketamine
Spinal
Ketamine
Spinal
Marcaine
Pontoc
indicated.
There was a comprehensively equipped
recovery area immediately adjacent to the
theatre with space for 3 beds. It was staffed by
a trained anaesthetic nurse on six month
rotation with colleagues and a theatre nurse.
During my stay, 230 surgical procedures
were performed of which 105 were
orthopaedic including tendon transfers, the
fixation of fractures and the revision of
amputations and 125 general surgical
procedures mostly thyroidectomy, mastectomy,
cholecystectomy, gastric ulcer surgery and
ovarian cystectomies. One hundred and six
general anaesthetics were given; 98 patients
were ventilated and only 8 breathed
spontaneously. Ninety five patients received
spinals of which 3 failed (2.8%) and 17
received local anaesthesia/sedation.
Hyperbaric tetracaine +/-adrenaline was used
for 47 of the spinals, bupivacaine either plain
or mixed with dextrose at the time of injection
for 40 and pre-mixed hyperbaric lidocaine for
nine.
Anaesthetics Given
The Ministry of Health has run an Anaesthetic
Nurse Training School in Phnom Penh since
1991 with support from MSF and French
universities. A two year course is run for
fifteen nurses and aims to ensure that
there is an adequately trained
anaesthetic nurse working in each of
the countries 21 provinces. Some
doctors are also trained as specialists
in Phnom Penh in a programme run by
the Ministry of Health and the
Universities of Paris and Bordeaux.
They have an opportunity to spend
some time in France for practical
training but few go to work in the
provinces when they return. All
anaesthetic staff at the Sihanouk
hospital had completed one of these
courses but were still anxious to learn
more and improve their standard of
practice.
To this end, as well as teaching
in the operating theatre, I conducted
pre- and post-operative teaching rounds
and held weekly tutorials for the
anaesthetic and recovery room staff. At
their request, I also used Mike
Dobson’s book “Anaesthesia in the
District Hospital” to teach surgical
trainees the basics of anaesthesia as
they recognised that if they were
working in district hospitals, they would
have to supervise and be responsible
for the conduct of anaesthesia.
It was gratifying to see the dedication
and enthusiasm of all the Cambodian doctors
and nurses and the improving standards of
treatment given to the countries patients who
often present late with advanced disease after
having tried traditional/herbal medicine. The
staff’s wish to improve their own knowledge
and skills for the benefit of their future patients
is a delight to see as is their search for the
education we, in the West, so often take for
granted.

Anaesthesia in the Republic
of Nauru
Dr Serupepeli Goneyali
SMO Anaesthetist
Republic of Nauru
Background
The Republic of Nauru is a twenty-one
square mile coral island in the central
Pacific Ocean, 42 kilometres south of the
equator and 1287 kilometres west of the
International Date Line. It has a
population of 12,000 and enjoys a
sunny, tropical climate with monsoons
from November to February. It was a
dependency of Australia from the time of
World War I until it gained
independence in 1968 with a democratic
presidential system of government. The
main source of income is phosphate
mining but as the phosphate deposits are
becoming depleted, off-shore financial
services are being encouraged
Health Institutions
The island has two hospitals, the Nauru
General Hospital and the Republic of
Nauru Hospital (formerly administered
by the Phosphate Mining Company) that
are managed by the Ministry of Health.
Recently the General Hospital has been
renovated to become a base for nurse
training and for public health activities.
The Republic of Nauru hospital has a
three-man recompression facility and is
currently undergoing the necessary
structural changes to cope with its
expanding clinical load. A total of nine
doctors, a dentist, twenty five nurses and
thirteen paramedical staff provide the
qualified and skilled expertise to serve
our population. Tertiary medical care is
provided by visiting specialists and by
referral to hospitals in Australia.
Health Status
Despite their isolation, Nauruans are not
immune from the illnesses of the 21st
century and its impact on their lifestyle.
Abandoning tradition ways, changing
living standards, an altered diet together
with other social and economic factors
and modern air travel have contributed
to an altered pattern of illness. Diabetes
and its complications have increased
enormously and are the main cause of
morbidity and mortality. Road traffic
injuries occupy second place. Although
infant mortality is 10 per 1,000, life
expectancy is only 61 years with 40% of
the population aged under 14 years and
less than 2% over 65 years.
Anaesthetic Practice
Anaesthetic services are basic and
support essential first-line and emergency
care such as appendicectomies, Caesarean
sections, simple orthopaedic
manipulations and the diabetic limb
debridement and amputations. Patients
requiring major elective surgery and
those with complex trauma are evacuated
to Australia. Drugs and medical gases are
obtained through the government
pharmacy service and come by regular air
and sea transport from Australia.
Thiopentone, suxamethonium,
vecuronium, ketamine and halothane
are available as are oxygen, nitrous
oxide, carbon dioxide and nitrogen.
Morphine, fentanyl, pethidine and
pentazocine are available as required.
We have lidocaine and bupivacaine in
the usual concentration for regional and
intrathecal anaesthesia. Visiting
specialists bring other drugs together
with endotracheal tubes and LMAs.
Intensive Care/High Dependancy
Unit
A single room, one-bedded unit is
reserved for very ill patients and those
who require mechanical ventilation.
Available equipment includes a Bird
ventilator (Mk VI), a LifePac Physio
Control ventilator and a Hewlett
Packard combined ECG/pulse/oxygen
saturation monitor. Whilst more
sophisticated equipment would be
useful, we lack the infrastructure and
expertise to manage and service it.
Some six years ago, a Bear 5
ventilator was purchased but has never
been used. It transpires that at least a
further twelve parts and a supply of
compressed air is necessary before it can
be operated. Advice on the purchase
and maintenance of appropriate
technology equipment is sorely needed
and would be much appreciated.
Diary Dates
7th Biennial Congress
Asian & Oceanic Society of Regional
Anesthesia and Pain Medicine
5-8 November 2003
Bangkok, Thailand
Lectures, Symposia/Panel Discussions,
Workshops
Further information: AOSRA Secretariat
39 Pradipat 10 (Phaholyothin 11)
Phyathai, Bangkok 10400, Thailand
Tel: +66 (0) 2615 7301
Fax: +66 (0) 2615 7309
Mobile: +66 (01) 836 1368
Email: cdm@cdmthailand.com
http://www.cdmthailand.com
Annual Scientific Meeting
Hong Kong College of Anaesthesiologists
& Society of Anaesthetist of Hong Kong
1-3 November 2002
Sheraton Hotel and Towers, Hong Kong
Tel: (+852) 2821 3520
Fax: (+852) 2866 7530
Email: grace.chu@fmshk.com.hk
5th South Asian Congress of
Anaesthesiology & 1st South
Asian Regional Pain Society
Congress
18-20 February 2003
Dhaka, Bangladesh
Chairman, Organising Committee:
Prof K M Iqbal
Secretary, Organising Committee:
Dr Lutful Aziz
Bangladesh Society of Anaesthesiologists
Email: kmi@bdcom.com
krahman@agni.com
SITUATION WANTED
Veteran anaestestist with 36 years
experiance, 28 years in Africa, available
for teaching and training anaestetic
personnel.
Setting up and running a modern
anaestetic management
team/department
Contact Dr. G.S Raju
Flat No. 2, Jain Building
16 Navratan Bagh, Indore 452001
Madhya, Pradesh (India)
Tel: (0091-731) 497536
Email: hemaravi@botsnet.bw
15

Case histories
16
NEWS from Otjiwarongo-Namibia
Dr Sikota Zeko
PO Box 1378
Otjiwarongo State Hospital
Otjiwarongo
Namibia
Email: zeko@ iway.na
Namibia: an overview
Situated on the south-western coast of Africa,
Namibia is truly a land of remarkable contrasts.
With a land surface of 824,269 square kilometres,
it is nearly four times the size of Great
Britain. Despite its size, its one of the most
sparsely populated countries in Africa with an
estimated population of about 1.7 million
people. The north-central part of the country is
the most densely populated area with an
average population density of 26 people per
square kilometre. The small population is
largely due to the fact that Namibia is the most
arid country south of the Sahara.
Namibia’s people are diverse; ranging
from the pastoral Himba in the northwest, to
the San (Bushmen) in the east. The San no
longer pursue an exclusively hunter-gatherer
existence, but are struggling to adapt to a new
way of life. The other major population groups
are the Owambo, the Kavango, Damara, Nama
and Herero. Smaller groups include the
Basters, Tswana, coloured and whites of
European descent.
During the Namibian winter (May to
September), temperatures in the interior range
from 18 to 25 degrees Celsius during the day.
Below freezing temperatures and ground frost
are common at night. Summer (October to
April) temperatures in the interior range from
20 to 34 degrees Celsius during the day.
Temperatures above 40 degrees Celsius are
often recorded in the extreme north and south
of the country. The coast, influenced by the
cold Benguela current, boasts a relatively
stable range of 15 to 25 degrees Celsius. Thick
fog is fairly common at night. Humidity is
generally very low in most parts of Namibia,
but can reach as high as 80% in the extreme
north during summer. The average annual
rainfall varies from less than 50mm along the
coast to 350mm in the central interior and
700mm in the extreme northeast.
The economy centres on agriculture
(mainly stock farming), fishing and mining, the
country’s most important earner of foreign
exchange. Namibia is one of the top diamondproducing
countries in the world, while
uranium, tin, copper, lead and zinc are other
important minerals. The agricultural, fishing
and mining industries account for more than
25% of GDP, while tourism is a major economic
growth area.
Namibia currently has one doctor per
3,650 people and this is one of the best doctor/
patient ratios in Africa. All major centres have
state run hospitals. In Windhoek (the capital),
there are three international standard privately
run hospitals and two State hospitals, each
with fully equipped and maintained intensive
care units. In addition to the usual range of
specialties, the latter are able to undertake
plastic surgery and thoracic and neurosurgical
procedures when surgeons from South Africa
visit. There are State hospitals in virtually all
major towns in Namibia whilst in the smaller
towns, villages and rural settlements, there are
well-equipped and staffed clinics and health
care centres operated by the Ministry of Health
and Social Services.
Anaesthetic services are available in
most major towns in both state hospitals and
private hospitals but Intensive Care facilities
only exist in Windhoek (state and private
hospitals). A basic anaesthetic training course,
lasting six weeks, is run for doctors working in
rural district hospitals at the main State
hospital in Windhoek. This equips them to
administer anaesthesia for caesarean section,
laparotomies and minor procedures.
Case History
A 17 year old male was admitted to
Otjiwarongo District hospital, 250km north of
Windhoek, in October 2001. He had a short
history of fever, left sided abdominal pain,
painful micturition and had vomited several
times. He had no significant past medical
history but had been stabbed in the left chest
wall one year previously. He had made a full
recovery from this incident and had no
respiratory sequelae.
On examination, he had mild dehydration
but no pallor or jaundice. BP 110/70, RR
12/min, PR 96/min, Temp 36 degrees Celsius.
He was tender in the left hypochondrium and
renal angle but with no evidence of peritonism.
Laboratory investigations including a full
blood count, urea and electrolyte estimations
and liver function tests were normal. Urinalysis
revealed modest proteinuria and so he was
given antibiotics for a presumed urinary tract
infection.
A few days later, he developed localised
signs of peritonitis with well-defined mass in
right iliac fossa extending to the suprapubic
area. Needle aspiration of the swelling
revealed pus. His temperature had risen to 39
degrees Celsius, BP 120/80, PR 80/min, RR
20/min. Laboratory tests showed a white cell
count of 16.4 x 109 /l with 83.3% neutrophils.
A chest X ray showed the remnant of a knife
blade in the left infrascapular area (Fig.1 & 2).
The patient required emergency surgery
to drain the intra-abdominal abscess but, in
view of the incidental finding on the chest X
ray, it was thought wisest to refer the patient
to the Central hospital in Windhoek for further
evaluation and management. There an
uneventful laparotomy was performed later the
same day.
The patient was referred back to
Otjiwarongo hospital two weeks later with the
piece of knife still in his chest and made an
uneventful recovery.

A Surgeon’s experience of an Interplast
visit to the roof of the world, Tibet
Peter & Pat Brown
Canberra
Australia
Peter Brown. (pbbrown@webone.com.au)
It was in January 2000 that I received an
invitation from Prof Paolo Morselli, a
Plastic & Reconstructive Surgeon from
Bologna Italy, to join a voluntary
international Interplast1 team to work in
Lhasa, Tibet during their northern summer.
This was an opportunity not to be
missed. My theatre sister wife, Pamela and I
had previously worked in Saigon in the early
1970’s and later with Interplast Australia2
in the southwest Pacific, Papua New Guinea
and Southeast Asian countries. Not only
was this an opportunity to help the Tibetan
people but also an opportunity to work
with an international team in plastic and
reconstructive surgery.
The Interplast team was thirteen in
number, 3 Plastic Surgeons (Italy, USA and
Australia), 3 Anaesthetists (Canada, Italy
and Germany), 1 Paediatrician (USA) and 6
Nurses (USA, Italy, Holland and Australia).
Thus three Continents were represented,
Australia, Europe and North America; it
was truly an international team that came
together in Kathmandu, Nepal to travel on
Back: Dr Bai, Dr Song, Elsa Gerritsen
(Netherlands), Dr Stuart Neil(Canada), Dr
Paul Schueller (Germany)
Front: Dr JJ Keyser(USA), Dr Da Wa, Dr
Paolo Morselli(Italy), Dr Lu Xiang, Dr
Den Zin , Interpreter Margrit Elliot(USA),
Monica Bargani(Italy), Dr Lorena
Pasnini(Italy), Dr MJ Pionk(USA), Sandra
Dore(USA), Pamela Brown(Australia), Dr
Peter Brown(Australia)
to Lhasa, in order to bring our expertise in
plastic & reconstructive surgery to those in
need (Fig 1). Travel into Tibet and entry
visas were arranged for us by a Nepalese
tour operator who also organised two buses
to get to the airport: one for us and one for
our luggage.. Our luggage weighed about
250 Kg more than allowed but the tour
operator had influence and excess charges
were waived.
The flight to Lhasa from Kathmandu
took about one and a half hours by China
Southwest Airlines and a fine view of the
Himalayas could be seen from the aircraft.
Lhasa airport is situated on the bank of the
Brahmaputra river between steep mountains
a long way outside the city. On arrival we
were herded across the tarmac to the
terminal, constantly being exhorted by the
military not to take photographs. When the
Customs officials saw the quantity of
luggage we had, they decided that it was too
much to examine immediately and told us
to take it all to the hospital and that they
would come and inspect it “next week”. The
team was then greeted by the senior Chinese
surgeon in Lhasa bundled into a small bus
for the trip into the city. The road followed
the river and the scenery was spectacular
with high mountain ranges on either side.
The mountains were devoid of vegetation
and had evidence of multiple large landslips
due to the extreme temperatures during
winter.
Our hotel in Lhasa was directly
opposite the Jokhang Monastery that dates
back to AD 539. The Monastery is in the
old Tibetan area known as the Barkhor and
is the home of several hundred monks. A
stream of chanting Tibetans constantly
circled the building in a clockwise direction
with prayer wheels spinning or prostrated
themselves on the ground to pray.
As Lhasa is some 12,000 ft above sealevel,
we were all interested in the effects of
altitude and each member was affected to a
greater or lesser degree. Out of interest, on
arrival, we measured our oxygen saturations
with a portable oximeter and found that the
readings were 88-90% and they remained at
this level until our departure. There was
some debate as to whether Diamox was of
any help in combating the effects of the
altitude. Some members of the team had
already started taking 250mgm per day and
after a few sleepless nights, we all started to
take it. Diamox on its own did not solve the
problem of obtaining a good night’s sleep
but was essential if one was to be able to do
a full day’s operating.
Our work was to be at the Lhasa
Municipal People’s Hospital, a hospital of
about 300 beds and one of three in Lhasa.
After a formal welcome for the team from
Dr Lu Xiang, the President (Chief
Administrator) of the Hospital and an
oncologist who was fluent in English as he
had spent some time in Australia, we got
down to work. The room was turned into a
clinic and we started examining the patients
that had been assembled for us. This was
done with the help of two Chinese interns
who interpreted for us. The patient was first
examined by the surgeons. A history, the
findings on clinical examination and the
proposed operation, if indicated, was
recorded. Then a Polaroid photograph was
taken and stapled to the patient’s notes. A
number was allocated to the patient and put
on a wristband as we had no hope of
identifying them from their name either in
Chinese or Tibetan. The patient then went
to the paediatrician (as most were children)
for screening and from there to the
anaesthetists. The case-records were then set
aside for scheduling of operation. This
system worked extremely well and it was a
methodical way of organising our workload
when communication with our patients was
a major problem. During the first two days
we examined 140 patients and 84 were
selected for surgery. The operating lists were
then scheduled to take place throughout the
rest of the visit. Most of the patients had
cleft lips or palates or were children with
joint deformities due to post-burn
contractures.
The senior Chinese surgeon, Dr Tang,
informed us that he would like our help
with a breast reconstruction on a patient on
whom he proposed to perform a Halsted
radical mastectomy. The patient had
advanced breast cancer with skin and nodal
involvement and chemotherapy had been
commenced. Breast reconstruction was
unlikely to be feasible but we offered help
with closure of the surgical defect after
mastectomy. There was much negotiation
about the best time to carry this out. The
second week suited us best but he wanted it
17
Case histories

Case histories
18
done earlier. Finally it was decided to
schedule it for the second week of our visit -
or so we thought.
In the meantime, the anaesthetists and
nurses had prepared the operating theatre: a
large room with two tables sharing a single
ceiling mounted light, the main light for
one table and the smaller satellite light for
the other table (Fig 2). Fortunately we had
brought with us a small autoclave, as local
sterilising facilities were limited. Other
equipment and supplies included anaesthetic
and diathermy machines, supplies of
anaesthetic drugs, antibiotics and dressings,
disposable surgical drapes and gowns.
The Lhasa Operating Room
The first operating day was a Monday.
It always takes time to get going on the first
day and for everyone to find their feet in a
strange environment. Surgery continued
until 7.00 p.m. which was quite late enough
as we were all suffering, to a greater or lesser
extent, from the effects of the altitude. Most
days we operated for ten to twelve hours.
With two tables but three surgeons and
three anaesthetists, it was possible to rest a
surgeon and anaesthetist while the other
two teams worked. The Chinese interns
assisted with all operations but it was
disappointing that the older Chinese
surgeons did not involve themselves in the
theatre work.
On the second operating day, we were
greeted on arrival by the senior Chinese
surgeon who advised us that he had his
patient for a Halsted mastectomy ready on
the operating table. We told him that there
was some mistake as we had agreed we
would help him with closure of the
mastectomy defect the following week. He
was not to be deterred so we rescheduled
our day’s patients. After some delay, he
performed a very radical Halsted mastectomy
and we were presented with a 20 x
15cm chest defect to close. We were able to
do this with a latissimus dorsi flap, fortunately
without further incident and the patient
made a good recovery. The Chinese surgeon
was genuinely grateful for our help in treating
his patient and we considered the goodwill
gained was an important aspect of our visit.
We had come prepared to give lectures
on Plastic & Reconstructive surgery,
Anaesthesia and Paediatrics. A lecture
afternoon had been arranged and an
interpreter booked: unfortunately he did
not have a good grasp of English let alone
medical terminology but we discovered that
much information could be transferred
visually. A laptop computer had been
brought by Paolo Morselli to demonstrate
nasal reconstruction. Stuart Neil, assisted by
M. J. Pionk gave a masterly demonstration
on pre-operative selection of patients with
the use of simple diagrams and then
proceeded to demonstrate monitoring
equipment using his colleague, Paul
Schueller as the patient. With the help of a
35mm slide projector provided by the
Hospital, I spoke on the use of pedicle flap
repairs in various parts of the body and J. J.
Keyser spoke on the management of hand
infections. The audience displayed keen
interest and we think understood the
content of the lecture despite the problems
with translation. There is always a lack of
audiovisual equipment in developing countries
and this needs to be remembered when
preparing any teaching. It is often necessary
to bring your own equipment and be
prepared to improvise if the electricity fails.
The younger doctors and nurses were
also keen to learn or improve their English.
Two members of our team conducted
English classes each morning from 8-9am.
These classes were well attended and, judged
by the noise and laughter, thoroughly
enjoyed by the teachers and pupils.
The weekends provided an
opportunity to see some of the country. On
the first Sunday, the hospital administrator
invited us to tour the Potala Palace, the
home of all the Dalai Lamas since 1649.
This spectacular building is very important
to the Tibetans and is still occupied by
monks but they seemed to be strictly
supervised. No photography was permitted
inside the Palace and the Potala police
enforced this rigorously when we were
conducted through numerous chapels and
mausoleums for the deceased Dalai Lamas.
On the second Sunday, we were
invited to a picnic at a sacred lake by the
name of Yamdrok-Tso. Imagining that we
were going to a lake near the river, not far
away, we set off in the hospital minibus. We
met another hospital vehicle, the
ambulance, containing all the Chinese
doctors with their wives and children at a
refuelling stop. We continued in convoy
past the airport and began to climb through
a steep ravine. Our driver seemed to be in a
hurry and overtook every vehicle in sight as
we climbed higher and higher through the
clouds, negotiating hundreds of hair-pin
bends cut into the side of the mountain.
There was no marking on the edge of the
road and a brief look down revealed a sheer
drop of 700 to 1,000 feet. After an hour of
hard driving, we reached the top and our
destination, the sacred lake, could be seen
some 500 feet below on the other side.
At the lake edge, we were led to a
barge with a diesel engine bolted to the
stern. The boatman smoked constantly and,
once the team were aboard, decided to refuel
from an open can of diesel fuel. In
order to start the motor a piece of cloth was
held in a pair of pliers, dipped into the
diesel fuel and then ignited with a cigarette
lighter. One crewman then cranked the
engine while the burning wick was held
over the air intake. Eventually, the engine
fired and the barge headed across the lake, a
journey of 30 minutes. There were no
lifebelts to be seen. The surrounding
mountains reached into the clouds, for we
were now at 15,000 feet above sea level.
Interestingly, the extra 3,000 feet did not
trouble the team members but the Chinese
doctors were all complaining of headache.
The whole mountainside was silent but
covered with wild flowers: there was no
noise from human activity and no birdsong
- just the sound of water lapping at the
lake’s edge. The Chinese had brought lunch
but the weather had deteriorated and most
of the lunch was eaten by a group of young
children who had appeared from nowhere,
like a pack of jackals. The boat was
successfully restarted and an uneventful
journey made back to the other side of the
lake. By now it was raining and the return
journey appeared even more frightening in
prospect.
At the top of the mountain, before the
start of our descent, the driver stopped the
vehicle, took out several white scarves and
ran to a small shrine where there were many
other scarves and flags. He placed his scarves
there and offered a short prayer for a safe
return journey! He drove back, tail-gating
the vehicle ahead and overtaking other

vehicles, generally passing on the outside
edge of the road. The passengers closed their
eyes and hoped that the rear wheels
remained on terra firma. On arrival back to
safety, we commented on the dangerous
nature of the road to the local doctors.
Their reply was that many vehicles went off
the road each year and there were never any
survivors.
At the end of the first week a young
boy with a severe neck contracture from a
burn was referred for treatment (Figs 3 &
Above: Tibetan boy with burn contracture
(frontal). Below: Tibetan boy with burn
contracture (lateral)
His neck contracture posed not only a
surgical, but also an anaesthetic challenge.
Fortunately we had the expertise to deal
with both. It was clear that blood
replacement might be needed for any
operation. Not being certain of the
availability and compatibility of blood in
Lhasa, a member of the French educational
team who had brought the boy to us offered
to donate blood for him as she was O Rh
negative and therefore a universal donor. A
plan for relieving the neck contracture was
made and anaesthesia induced. A laryngeal
mask was used during the initial release of
the contracture. Two of us then worked on
his neck and division of the neck
contracture from ear to ear through the
dense scar tissue was begun. Gradually the
contracture was released and his neck
extended, the distance between his lower lip
and upper chest gradually increasing until a
normal neck contour appeared. His airway
was then maintained by withdrawing the
laryngeal mask and replacing it with an
endotracheal tube. The next problem was
how to repair the large skin defect that now
measured about 20 cm in vertical length
from lower lip to upper chest. Our preoperative
plan was to use a long skin flap,
from each side of the neck extending down
to the shoulder tip, to be brought across to
the midline to resurface the neck. This now
appeared feasible and was accomplished
with viable skin flaps covering the anterior
neck but leaving a large chest, lower lip and
chin defects to be covered (Fig 5). Large
confidence. He will be able to stand upright
and look another of his height in the eye. If
we had done no other surgery, helping this
young Tibetan boy and improving his
quality of life would have made the trip
worthwhile.
Our last day was fully occupied with a
review of each case, removing sutures and
giving instructions on future management.
We were all inundated with white prayer
shawls given to us by patients as a gesture of
thanks. The last night in Lhasa was a team
dinner in a restaurant at the foot of the
Potala and a time to reflect on the work
done and the friends we had made. The
team of professionals from six different
countries had come together voluntarily to
do what they could to help those in need in
Tibet. These people are always special and it
was interesting to see how each performed
so well in their own discipline and
functioned together as a team. There was
satisfaction that, after nearly three weeks of
working together, we had seen 142 patients
and operated on 84 with no complications.
The quality of life of those treated had been
improved and the local doctors and nurses
had seen what could be achieved.
Case histories
4). A French educational team had come
across him living in a secluded village and as
he could not attend school, his future was
grim. The French team took a photo of him
and sent it to Paris in the hope someone
there might be able to help him.. The photo
was sent to London and eventually found its
way back to Paolo Morselli in Lhasa. The
boy’s plight was extreme; the contracture
caused his neck to be fixed in flexion to
such a degree that his lower lip was fixed to
his upper chest and the remainder of his
chest scarred from shoulder to shoulder
down to his upper abdomen. There was no
expertise in Tibet to treat him and the
possibility of him being treated elsewhere in
China or overseas was remote.
Tibetan boy with with graft in situ
sheets of skin grafts were taken from his
thighs to complete the repair of these areas.
Enough blood had been transfused to
replace what had been lost and his
condition remained good throughout the
operation. At the time of our departure, he
was making an uncomplicated recovery. No
doubt there will be need of further surgery
in the future, but the major part of the
correction had been achieved and he should
be able to look to the future with more
Peter & Pamela Brown with prayer wheels
in the background
The Tibet Interplast International
team (Fig 6). had finished their work and it
was to be one of the more memorable visits
we have made to any countries. It was not
the easiest because of the altitude and
because of the dominance of the Chinese in
Tibet but our patients were mostly Tibetans
and they appreciated the help we were able
to offer.
1. Interplast is an international organisation
but functions on a national basis. Its purpose is
to provide Plastic and Reconstructive Surgery
Continued on the next page
19

Case histories
to the citizens of developing countries
throughout the world. Surgeons, anaesthetists
and nurses work in a voluntary capacity and
the organisation is funded by donation from
sources such as Rotary International, some
specific government funding and corporate
and private donors. Interplast Australia is a
non-profit aid organisation that has been in
existence since 1983 and sends voluntary
teams to 50 destinations in countries in the
Southwest Pacific and Southeast Asia. The
teams generally consist of 2 plastic and
reconstructive surgeons, 1 anaesthetist and one
theatre sister. The duration of the visits is two
weeks. Apart from surgery, teaching is undertaken
with the aim that the hospital staff will
become proficient in the techniques used.
2. Ever since their time in Saigon, Peter and
Pam Brown have taken their skills in plastic
and reconstructive surgery to many countries
in the Far East. It is therefore very appropriate
that their efforts have been formally recognised
by the Australian Government. Peter Brown
has been awarded the Australian Medal for
service to medicine, particularly in the field of
plastic and reconstructive surgery, and to
overseas medical aid programmes and they
have both received formal certificates from the
Australian Government for their contributions
towards assisting developing countries to reduce
poverty and achieve sustainable development
signed by the Prime Minister and the Minister
for Foreign Affairs.
Neostigmine-Glycopyrrolate and Antisnake Venom
for Management of Neuroparalytic Poisoning
20
Drs Shashi Kiran, Balbir Chhabra & Preeti Goyal
Department of Anaesthesiology and Critical Care
Post-Graduate Institute of Medical Sciences
Rohtak-124001, Haryana
India
Gupta3@vsnl.com
goyalpreeti@hotmail.com
Introduction
Envenomation by snakes of the Elapidae family,
commonly found in India, is characteristically
neuroparalyic in nature. The interesting
similarity of its electrophysiological features to
myasthenia gravis and the limited availability of
antisnake venom have prompted interest in the
use of anticholinesterese therapy.
Case Report
A 30 year old man presented in the Accident
and Emergency Department after being bitten
on the dorsum of his right foot by a snake. His
blood pressure was 160/100. pulse rate 92
beats per minute and respiratory rate 14 breaths
per minute with a good tidal volume. He had
dilated pupils, ptosis, generalised muscle
weakness and difficulty in swallowing but a
good cough reflex.
After first aid and the transfusion of
antisnake venom, he was admitted to the
Intensive Care Unit for observation. Within two
hours of admission, his respiration became
shallow and blood gas analysis showed a
respiratory acidosis. He was intubated and
artificial ventilation started. He was given
fifteen vials of antisnake venom over 12 hours
and neostigmine 2mg every four hours together
with glycopyrrolate 0.2mg. Over the next day,
his condition gradually improved and it was
possible to wean him from the ventilator after
72 hours. His muscle weakness resolved
completely, he was able to swallow, had a good
cough reflex and his pupil size returned to
normal.
Discussion
Envemonation by members of the Elapidae
family results in neuroparalytic features due to
the curare-like action of the venom. Ptosis is
usually the earliest paralytic manifestation
followed by involvement of the muscles of the
palate, jaw, tongue larynx and the muscles of
swallowing. The chest muscles and diaphragm
are involved later and cause respiratory failure
as occurred in our patient.
As well as general care and respiratory
support, antisnake venom (ASV) is generally
administered. ASV is a neurotoxin-specific
immunoglobulin that accelerates dissociation of
the neurotoxin/acetylcholine receptor complex.
Unfortunately there is no consensus on the
effective dose of ASV or indeed if it is of any
value whatsoever. In several trials, there has
been little or no change in morbidity or mortality
after ASV was used and there appears to be no
correlation between the dose of ASV
administered and the size or site of the snake
bite or the species of snake.
As snake venom can cause
pathophysiological features similar to
myasthenia gravis, neostigmine has been
suggested as an alternative therapy. Pandey et
al. first added neostigmine to conventional
treatment with ASV in 1969. They observed a
dramatic improvement in neuroparalytic
symptoms in 65 patients and recommended that
it should be administered to all patients with
paralytic symptoms. Moreover, Bomb et al have
recently condemned the use of ASV and
suggested that anticholinesterese drugs and
good supportive care are all that is necessary.
Neostigmine can be given as 50-100
micrograms/kg four hourly or as a continuous
infusion. Edrophonium has also been used in
doses of 10mg in adults and 0.25mg/kg in
children as a test and, if a positive response
occurs, converting to the longer acting
neostigmine. As there is no consensus on the
optimum treatment, we elected to use
neostigmine 2mg four hourly together with ASV.
Although atropine is often used before
neostigmine to counteract its muscarinic effects,
as it is a tertiary ammonium compound it
crosses the blood brain barrier. This can result in
a central anticholinergic syndrome with
confusion and prolonged muscle weakness. We,
therefore, decided to use glycopyrrolate as
unlike atropine, it does not cross the blood brain
barrier.
We are not sure whether ASV or
neostigmine resulted in the early favourable
outcome for our patient but their coadministration
certainly resulted in a rapid
neurological recovery. Therefore, we
recommend glycopyrrolate-neostigmine with
ASV for the management of patients with
neuroparalytic symptoms following snake-bite.

Introducing Primary Trauma Care (PTC) to the
Peoples’ Republic of China May 19 - 31 2002
Stephen Swallow
Specialist Anaesthetist
Hobart
Tasmania
PTC in China
The Peoples’ Republic of China is one of
the two most populous countries in the
world and one that is undergoing a period
of rapid economic and industrial
development. The rising number of traffic
accidents and workplace injuries is placing
an increasing burden on medical facilities
particularly in rural and remote areas. This
impression is confirmed both by anecdotal
comments by experienced medical
practitioners and also by data from studies
such as the Global Burden of Disease
study1 and ‘the Neglected Epidemic’: Road
Traffic Injuries in Developing Countries2.
Our decision to introduce the Primary
Trauma Care (PTC) courses into the
Peoples’ Republic of China was based on a
fortuitous coincidence of events. Following
a meeting of the Australian and New
Zealand College of Anaesthetists (ANZCA)
in Hong Kong in May 2001, there was a
satellite meeting in Beijing. I spoke about
PTC at that meeting and with the assistance
of Dr T W Lee, President of the Hong
Kong College of Anaesthesiology, we staged
a demonstration trauma scenario.
Dr T W Lee has been a strong supporter
of the Primary Trauma Care programme
in mainland China. At the Beijing meeting
Professor Lize Xi’ong, Head of Department
of Anaesthesia and Intensive Care, Xijing
Hospital in Xi’an invited me to speak in more
detail about PTC at an Intensive Care Meeting
in Xi’an in September 2001 and has
been instrumental in introducing the concept
of PTC to the Peoples’ Republic of China.
The PTC Programme in China
In May 2002, we ran a two day instructor
course in Hong Kong where we inducted a
group of 14 emergency medicine,
anaesthetic and intensive care specialists
from Hong Kong and 2 specialists from
Xi’an into the methodology of PTC. Many
of the Hong Kong instructors were already
experienced ATLS or APLS instructors.
We divided these doctors into four
groups of four that went to Xi’an, Beijing,
Shanghai and Kunming. The course
directors were Douglas Wilkinson (UK) in
Shanghai, Tim Gray - emergency medicine
physician, Royal Melbourne Hospital, in
Beijing and Stephen Swallow (myself) in the
other venues. Mrs. Diane Wilkinson was
the educationalist for the courses. Professor
Peter Cameron, currently Professor of
Emergency Medicine at the Prince of Wales
Hospital, Hong Kong on sabbatical leave
from the Royal Melbourne Hospital,
instructed on the programme in Xi’an.
The Plan
The plan was to run a two day trauma
course followed by a one day instructor
course for 16-24 experienced medical
practitioners in each venue. The doctors
that we inducted into the methodology of
PTC would then form a local committee
which, with appropriate support, would
then run courses in the more remote parts
of their provinces in China.
The Reality
Xi’an
On the way from the airport to the hotel,
on the evening before the course, we were
advised that there would be ‘a few extra
people’ perhaps between 100 and 200. On
the first morning, there were 160 delegates
from all over China. We modified the first
two days so there were more
demonstrational elements. Small group
teaching with groups of 40 was interesting!
The instructor course ran with 20
participants along the lines that we had
proposed and we ended up with a strong
local PTC committee willing to organize
and run future PTC courses.
Shanghai and Beijing
We met with only limited success in these
two cities for several reasons: Professor Lize
Xi’ong in Xi’an, my primary PTC contact
in China is unusual amongst anaesthetists in
China in that he has strong interests in
Intensive Care and major trauma
resuscitation. His anaesthetic colleagues in
Beijing and Shanghai confine their sphere of
influence to activities within the operating
theatre and to anaesthetic research. We had,
therefore, recruited representatives from the
wrong specialty to effectively promote PTC.
Emergency medicine is just starting to
develop as a specialty in its own right in
China. Directors of emergency
departments in the principle cities of China
face an enormous task to develop good
emergency medicine systems for their whole
province. There is a significant drop in
staffing levels, expertise and resources once
one leaves the major cities and ventures into
the countryside.
The director of the Beijing Chaoyang
Hospital is anxious to develop a programme
of post graduate education in emergency
medicine and is keen to promote PTC.
There is a recognition that when the
Olympic Games come to Beijing in 2008,
21
Feature Extra

Feature Extra
Beijing’s’ ability to look after foreign visitors
who are accidentally injured will come
under close scrutiny.
We plan a return visit to Beijing in
October 2002.
Kunming
By a happy chance, the primary contact in
Kunming was Dr Xu Wang Bin. He has
worked for 6 years in specialist anaesthetic
and intensive care practice. A year ago, he
was one of two specialists given the position
of Director of the Emergency Department.
He is committed to improving the standards
of emergency care particularly in rural
Yunnan province.
The programme in Kunming ran
smoothly and we trained 24 emergency
medicine doctors. The PTC committee in
Kunming includes Dr Xu, a senior Army
doctor in charge of 17 trauma centres and
the medical director of the ambulance
service in Kunming.
Issues
PTC, ATLS and a lack of surgical
representation
It is not the intention of PTC to
exclude surgeons and it was unfortunate
that the one surgical instructor from Hong
Kong that we were able to recruit was
unable to take part as a result of other
commitments. We view the PTC and ATLS
programmes as mutually complementary.
The target audience for PTC is junior
doctors, registered nurses or health officers
working in a small remote hospital with
inadequate facilities whilst that for ATLS is
surgical, anaesthetic and emergency
medicine trainees and specialists in the
teaching hospitals of the larger cities. We
encourage ATLS to develop a programme in
mainland China.
Scenarios and small group teaching
These methods of teaching were unfamiliar
to our Chinese audience although they were
interested to use these techniques in the
future.
The future for PTC in China
We are optimistic that PTC is a useful
programme for the Peoples’ Republic of
China. We have gained strong acceptance
in Xi’an and Kunming and a level of
interest in Shanghai and Beijing.
The teaching material, slides, manuals
and instructor manuals have all been
translated into Chinese script and our
instructors in Hong Kong and at our
regional office in Australia will be the key
workers who will continue to support PTC
in China.
It is clear that emergency medicine is
the specialty that will take ownership of
PTC in China and a joint Australasian and
Chinese emergency medicine and PTC meeting
is planned for Beijing in October 2002.
Conclusion
We received lavish hospitality wherever we
went in China and were made to feel most
welcome. There is no doubt that modern
China is an outward looking country with
much to contribute to the rest of the world.
It is important that we develop friendships
with doctors in the Peoples’ Republic of
China. My three visits to China over the
last year have given me a much improved
knowledge and understanding of this large
and important country. I strongly
encourage other anaesthetists, who have not
done so to visit and teach in China.
Acknowledgements
This project was financed by the Australian
Society of Anaesthetists. Abbott Australasia
also provided financial support for the
preliminary visits to China in 2001.
References
The Global Burden of Disease Study.
Lancet 1997
The Neglected Epidemic: road traffic
injuries in developing countries. Vionand
M, Nantulga and Michael R Reich. BMJ
324, 11 May 2002, 1139-1141
22
The Department of Anaesthesiology,
University of Calabar, Nigeria
Dr Ini Abasi Ilori
Dr Sylvia G Akpan
University of Calabar Teaching Hospital
Nigeria
The city of Calabar on the south east coast
of Nigeria has given its name to a
variation of filariasis known as the
Calabar swelling (loa loa) and the poisonous
Calabar bean (Physostigma venenosum). The
latter was first described in 1846 by the
Scottish missionary, Dr William Freeman
Daniel, and was used for trial by ordeal. Its
local name is Esere, hence eserine for the
phyostigmine alkaloid.
Calabar is a quiet and tidy seaport with
only one access/exit road through the
surrounding mangrove swamps. It was at one
time the capital of Nigeria and has one of the
oldest secondary schools in the country. The
dominant local language is Efik and Efik
women have a reputation for being alluring
and lovable. The traditional dish they cook of
vegetables and dried fish is said to intoxicate
men such the Calabar is also known as the city
to Come And Live And Be At Rest.
The University of Calabar is one of the
third generation Nigerian universities. Although
the Teaching Hospital was formally established
in 1982 it grew out of St Margaret’s Hospital
that was founded in 1897. The hospital now
serves the 320,000 population of the city as
well as acting as a referral centre for the entire
Cross River and Awka Ibom states as well as
West Cameroon (formerly part of Nigeria). The
hospital has 508 beds and is managed by the
Federal Ministry of Health. From the main
theatre one can view the surrounding
mangroves and the Atlantic Ocean.
The Department of Anaesthesiology
serves the specialties of general surgery,
otorhinolaryngology, ophthalmology, burns and
plastic surgery, maxillo-facial surgery, urology,
orthopaedics and trauma surgery as well as
obstetrics and gynaecology. Unfortunately, as
the supply of water, electricity and medical
gases can be erratic we do not practice hi-tech
anaesthesia! Although we often have to
improvise, we practice subarachnoid and
epidural anaesthesia as well as 3-in-1 and
sciatic blocks to minimise blood loss. Ketamine
is frequently used for total intravenous
anaesthesia. We use a variety of muscle
relaxants but only have one volatile agent,
halothane. We have a 3-bedded intensive care
unit but it is only occasionally used. Our two
Blease ventilators, donated by the
Hammersmith Hospital, cannot be used due to
lack of spare parts. When we have to ventilate

critically ill patients we have to do so manually
with a self-inflating bag. A simply battery
operated ventilator suitable for both adults and
children would be tremendously useful in our
hospital.
(Editorial note: Perhaps they would find
the Glostavent described in World Anaesthesia
Vol. 6, No. 1 useful).
Our department is staffed by
consultants, residents and nurse anaesthetists.
The Faculty of Anaesthetists of the National
Postgraduate Medical College of Nigeria
regulates training in anaesthesia. Training lasts
4-5 years and candidates for the Fellowship
have to pass a three part (primary, parts 1 and
11) examination. Our department is accredited
to undertake part of this training but trainees
have to move to Lagos, Ibaden or Enugu to
gain experience in cardiothoracic and neuroanaesthesia.
We have successfully trained two
consultants. The first Nigerian trainee to spend
time with Dr Roger Eltringham in the UK came
from Calabar and is now a fellow of the West
African College of Surgeons and is training
anaesthetists at a Teaching Hospital in
northern Nigeria. The second spent time with
Prof. Rocke as a WFSA trainee in South Africa,
is a fellow of the National Postgraduate
Medical College and is now a consultant in
Calabar.
We enjoy the services of two
consultants from the Nigerian military: one is a
senior naval officer currently attached to the
naval base at Calabar; the other is a retired
army colonel. The foundation professor of
anaesthesia in this department has recently
returned home after working overseas and,
although retired, has donated funds towards
developing our teaching infrastructure. We
have seven residents at various stages in their
training; five have already gained the Diploma
in Anaesthesia.
As elsewhere in Nigeria, we have
difficulty attracting new entrants to the
specialty as anaesthesia is not as financially
rewarding as other specialties. However, we
feel that if we can provide the necessary
training aids, books and journals so that our
residents can pass their examinations at the
first attempt, we will be able to attract and
keep the young doctors who rotate through our
department on their national youth service
year. We, therefore, hope to be able to twin
with an anaesthetic department is a developed
English-speaking country so that we can offer
our trainees 3-6 months of exposure to modern
anaesthetic practice. If you can help, please
contact us.
Email: bidemiilori@yahoo.com
Feature Extra
Book Review
Oxford Handbook of Anaesthesia
Allman KG & Wilson IH Oxford University Press, pp 1139
This book assumes a basic knowledge of
anaesthesia and aims to offer practical advice
and guidance to the practicing anaesthetist. It
has some forty major contributors, all now
working in the UK although many have had
considerable previous experience elsewhere.
The first section, chapters 1-12, covers
pre-operative assessment and considers the
anaesthetic implications of pre-existing
medical conditions. Sections II (chapters 13-33)
considers anaesthesia for the major surgical
specialties with sections III and IV covering
obstetrics and paediatrics respectively. Section
V is concerned with the management of
anaesthetic emergencies. Section VI (chapters
37-48) usefully considers a number of practical
issues such as blood transfusion, the
management of inoculation injury and death on
the table. Acute pain management is discussed
in section VII and regional anaesthesia in section
VIII. The book concludes with a drug formulary, a
series of suggested infusion regimes and lists
of normal values. Also included are an
apparatus checklist, a list of anaesthetic web
sites and, on the flysheets, protocols for
advanced life support, failed intubation and the
management of anaphylaxis.
Although not a book to attempt to read
from cover to cover, it is very reader friendly
with a comprehensive index. The chapter authors
attempt to offer, based on their experience
and normal practice, guidance to the reader on
the management of a variety of everyday and
sometimes very unusual scenarios. Each
section is clearly set out so that it is easy for
the reader to find the information they seek.
Inevitably, there are omissions, even in a
book of over one thousand pages of small print,
and one might wonder if grafting a section on
regional anaesthesia on to the text would be of
any value: it is. This book offer sensible and
readily accessible advice to anaesthetists
facing a problem they rarely encounter and is a
valuable resource for anyone asked to prepare
a lecture at short notice.
As it says on its cover, this book is a
concise yet comprehensive guide for all
anaesthetists. In developed countries, both
trainees and established practitioners should
find it a useful vade-mecum and for
anaesthetists in developing countries who
have to manage every situation with minimal
resources and no super-specialist to advise and
support them, it will be invaluable.
At less than £20 (approx. $30 or € 30),
this book is spectacular value for money. We
suggest you order a copy immediately.
Carola Andrick, Consultant Anaesthetist
Mbarara University Hospital, Uganda
William Casey
UK
23

Useful Information
Useful Information
World Federation of Societies of
Anaesthesiologists (WFSA)
7th Floor, Imperial house
15-19 Kingsway
London
WC2B 6TH,
United Kingdom
Tel: (+44) 020 7836 5652
Fax: (+44) 020 7836 5616
Email: office@wfsa-office.org
info@wfsa-office.org
Courses in Anaesthesia for the
developing world.
Oxford (UK): July (annually).
Contact: Dr. M. Dobson
Department of Anaesthesia
John Radcliffe Hospital
Headley Way,
Headington,
Oxford,
OX3 9DU, UK
Tel: (+44) 01865 221589.
E-mail: michael.dobson@ndm.ox.ac.uk
Bristol (UK): December (annually).
Contact: Dr. Claire Jewkes
Department of Anaesthesia
Frenchay Hospital,
Bristol,
BS16 ILE,
UK
Tel: (+44) 01179 701212.
Remote Situations, Difficult
Circumstances, Developing
Country Anaesthesia
Hobart or Launceston (alternate years),
Tasmania, Australia
Contact: Dr Haydn Perndt
Royal Hobart Hospital
GPO Box 1061-L,
Hobart,
TAS 7001
Australia
Email: haydn.perndt@utas.edu.au
Primary Trauma Care Foundation
The foundation exists to improve the
management of trauma in the developing
world. It has organised training courses in
the South Pacific, Asia, Africa and South
America.
Contact: Dr Douglas Wilkinson
313 Woodstock Road
Oxford
OX2 7NY
UK
Email: PTC@nda.ox.ac.uk
Equipment collection and distribution
to the developing world
Contact: ECHO
Ullswater Crescent
Coulsdon,
Surrey,
CR3 2HR,
UK
Tel: (+44) 020 8660 2220
Carelift International Inc.
185 Walnut Street (Floor 22)
Philadelphia P.A. 19103,
USA
Tel: (+1) 215 535 3590
Dr. William Rosenblatt
REMEDY
Dept. of Anaesthesia
Yale University School of Medicine
333 Cedar Street,
New Haven
CT 06510,
USA
Book Aid International
39-41 Coldharbour Lane
Camberwell,
London,
SE5 9NR,
UK
Tel: (+44) 020 7733 3577
The organisation is interested in receiving
recent complete sets of journals and newish
text books. These are collected free and
distributed by Rotarians.
Society for Education in
Anaesthesia
International members are invited to join this
Society that promotes techniques and
excellence in the teaching of Anaesthesia.
520N Northwest Highway
Park Ridge,
Illinois 60069-2573,
USA
Tel: (847) 825 5586
Fax: (847) 825 5658
Email: sea@asahq.org
Web: www.seahq.org
The TOKTEN Project
Expatriate nationals returning to their country of
origin are invited to apply for the post of project
expert. Each project is sponsored by the United
Nations who would meet the cost of international
travel and pay a subsistence allowance ($90/day).
Applications should be made to the Minister of
Health of the host developing nation.
Technical Assistance at Low Cost (TALC)
Books, videos etc at low cost
Contact: PO Box 49
St Albans
Herts
AL1 5TX
UK
Tel: (+44) 1727 853869
Fax: (+44) 1727 846852
www.talcuk.org
Douleurs Sans Frontieres (DSF)
Goals
1. To participate, to create or to encourage any
structure involved in the treatment of pain and
suffering (cancer pain, AIDS, acute pain etc).
2. To search for therapeutic methods, to provide
training and to propagate knowledge about
pain and suffering especially in developing
countries
For further information contact:
Docteur Alain Serrie
Hôpital Lariboisière
2, rue Ambroise Paré,
75010 Paris, France
Tel: (+33) 1 49 95 81 77
Fax: (+33) 1 49 95 69 98
Email: alain.serrie@lrb.ap-hop-paris.fr
24

or Docteur Jacques Meynadier
Centre Oscar Lambret
BP 307-59020 Lille cedex,
France
Tel: (+33) 3 20 29 59 89
Fax: (+33) 3 20 29 59 97
Email: j-meynadier@o-lambret.fr
The International Committee of
the Red Cross (ICRC)
The ICRC acts to help all victims of war and
internal violence, attempting to ensure
implementation of humanitarian rules
restricting armed violence.
Contact: ICRC,
Recruitment Division
19 Ave. de la Paix,
CH-1202
Geneva,
Switzerland
or your local society.
Email: http://www.icrc.ch
Overseas Doctors Training Scheme
(UK)
Anaesthetists seeking recognised training
posts in the UK should apply to:
Bemard Johnson, Adviser
Royal College of Anaesthetists
8 Russell Square,
London
WC1B 4JX,
UK
Tel: (+44) 020 7637 4104
Emain: info@rcoa.ac.uk
www.rcoa.ac.uk
The SOROS Foundation
will consider applications from anaesthetists
in Eastern and Central Europe for support for
limited periods of study in the UK.
Applications should be made in advance to
the branch office of their country of origin
whose address may be obtained from:
The Soros Foundation
400 West 59th Street
New York,
NY 10019,
USA
Tel: (+1) 212 548 0600
Fax: (+1) 212 548 4600.
E-mail: osnews@sorosny.org
Teaching Videos:
The following titles are available at £5 each:
1. Servicing the EMO & Tri-Service vaporisers
2. The oxygen concentrator
3. The Manley multivent/Glostavent
4. Servicing the anaesthetic machine
Contact: Dr. R Eltringham
Gloucestershire Royal Hospital
Gloucester,
GLI 3NN,
UK
Tel: (+44) 01452 394786/394194
Fax: (+44) 01452 394485
E-mail: 106147.2366@compuserve.com
Job opportunities in the
developing world
These are listed in a bimonthly magazine
produced by the International Health Exchange.
Contact: Ms Isobel McConnan
8-10, Dryden Street
London,
WC2E 9NA,
UK
Tel: (+44) 020 7836 5833
Fax: (+44)020 7379 1239
E-mail:
health exchange@compuserve.com
www.ihe.org.uk
US volunteers wishing to spend
periods working in developing
countries
Contact: Dr. Lena Dohlman
Health Volunteers Overseas
c/o Washington Station, PO.
Box 65157
Washington DC 20035-5157,
USA
Tel: (+1) 202 296 0928
Fax: (+1) 202 296 8018
Committee Chair
Overseas Teaching Program
American Society of Anesthesiologists
520 N. Northwest Highway
Park Ridge,
IL 60068-2573,
USA
World Anaesthesia
This organisation works to improve standards
of anaesthesia throughout the world. In
conjunction with the WFSA, it produces two
publications, World Anaesthesia News and
Update in Anaesthesia* (an add-on textbook)
published twice-yearly. The annual subscription
is £10. For further information
Contact: Dr. C Collins
Department of Anaesthesia
Royal Devon and Exeter Hospital
Barrack Road,
Exeter,
Devon
EX2 5DW,
United Kingdom
Tel: (+44) 01392 411611
* also available on:
http://www.nda.ox.ac.uk/wfsa
Courses on Anaesthetic Equipment
Maintenance
One week residential courses for anaesthetic
technicians are organised at the NHS training and
conference centre. Applications should be sent to:
Geoffrey Dillow
Conference Centre,
Wotton under Edge
Gloucester,
GLI2 8DA,
UK.
Association for International
Development of Anaesthesia
(A.I.D.A.)
Contact: Professor Stanley Samuels
Department of Anesthesia
Stanford University Medical Centre
Stanford,
California,
USA
Tel: (+1) 415 723 6411
Fax: (+1) 415 723 8544
Email: Samuels@Ieland.stanford.edu
Useful Information
25

Useful Information
26
Useful Information continued
Commonwealth Medical Awards
Available to citizens of Commonwealth
countries for limited periods of postgraduate
study within the UK. Applications should be
addressed to:
The Medical Awards Administrator
Commonwealth Scholarship Commission
36 Gordon Square
London
WC1H IPE,
UK
Medecins Sans Frontieres (MSF)
offers assistance to populations in distress,
to victims of natural and man-made disasters
and to victims of armed conflict. They require
volunteers for both long and short-term
projects. If you are interested in obtaining
more information, contact them at:
MSF
124-132 Clerkenwell Road
London
ECIR 5DL,
UK
Tel: (+44) 020 7713 5600
Fax: (+44) 020 7713 5004 or
11 East 26th St.
Suite 1904
New York NY 10010,
USA
Tel: (+1) 212 679 6800.
Email: http://www.msf.org or
http://www.dwb.org
Merlin
5-13 Trinity Street
London
SE1 1DB
Tel: (+44) 20 7378 4888
www.merlin.org.uk
WHO Liaison Officer
Dr M Dobson
Nuffield Department of Anaesthetics
The John Radcliffe Hospital
Headley Way
Headington
Oxford,
OX3 9DU,
UK
Tel: (+44) 01865 221589/741166
Fax: (+44) 01865 221593/453266.
E-mail: michael.dobson@ndm.ox.ac.uk
If you wish to advertise your organisation on
this page (free-of-charge), please contact:
The Editor Dr W F Casey
Popes Cottage,
Cheltenham Road,
Painswick,
Gloucester,
GL6 6TS,
UK
Tel: (+44) 01452 814229
Fax: (+44) 01452 812162
Email: wfcasey@doctors.org.uk
Produced and Distributed by:
Media Publishing Company
Media House,
41 Crayford Way,
Crayford,
Kent
DA1 4JY,
UK
Tel: (+44) 01322 558029
Fax: (+44) 01322 558524
E-mail: MediaPublishers@aol.com
Electronic Publication
of “Update in
Anaesthesia”
● “Update in Anaesthesia” is an
education journal produced by “World
Anaesthesia”, widely distributed and
acclaimed in many developing
countries.
● An electronic version of “Update”
including back issues is now available –
you can read it on your computer
screen (using suitable free software),
and download and/or print all or part
of it for reference.
● If you have an Internet connection you
can access “Update” at
http://www.nda.ox.ac.uk/wfsa It can be
viewed with either a graphical browser
(looks prettier) such as Netscape or a
text-only browser such as Lynx.
● If you don’t have Internet access but do
have a computer, we can post you the
same material on floppy disk with
instructions on use. (N.B. This only
applies to developing countries.)
● You do not need the latest and most
expensive computer to make use of
Electronic Update: a 286-PC should be
adequate. If you need technical advice,
please write to Dr Mike Dobson,
Nuffield Department of Anaesthetics,
John Radcliffe Hospital, Oxford, OX3
9DU, UK., or send an Email request
to: michael.dobson@ndm.ox.ac.uk
● An electronic version of “World
Anaesthesia Newsletter” (incorporating
“Anaesthesia Worldwide”) including
back issues in similar format is also
now available at the same Internet site.

Anaesthetic web sites to try
Resources
Anaesthesia & Critical Care Resources on the Internet
(AACRI)
Anesthesia Web
Anesthesia International
Audio Digest Foundation
Australian Society Overseas Aid
Bandolier (Evidence-based medicine)
Echocardiography
Gaseous anomaly
GASNet Anesthesiology Home Page
International Anesthesia Research Society
Illustrated Regional Anesthesia
Medical World Search
Primary Internet resources for anaesthetists
Primary Trauma Care Foundation
Society for Education in Anaesthesia
The National Library of Medicine
The Trauma Organisation
University of Chicago
Virtual Anaesthetic Machine
Virtual Anaesthesia Textbook
Virtual Museum of Anesthesiology
World Anaesthesia Online
http://www.eur.nl/cgi-bin/accri.pl
http://www.anesthesiaweb.com/
http://www.geocities.com/anestint
http://www.audio-digest.org
http://www.asa.org.au/committess/oseasaid
http://www.jr2.ac.uk/Bandolier
http://www2.umdnj.edu/shindler/echo.html
http://www.anaesthesia.ml.org
http://gasnet.med.vale.edu
http://www.anaesthesia-analgesia.org
http://weber.u.washington.edu/~aelizaga/regional/welcome
http:/.mwsearch.com/
http:/gasnet.dundee.ac.uk:1081/mirror/vat/MajRes.html
http:/www.nda.ox.ac.uk/wfsa/dl/html/pages/ptc.htm
http:/www.www.seahq.org
http://www.nsbi.nlm.nih.gov/PubMed/
http://www.trauma.org/
http://www.airway.bsd.uchicago.edu
http://www.ufl.anest.edu/van
http://www-usvd.edu.au/su/anaes/VAT/VAT.html
http://umdas.med.miami.edu/aha/vma
http://www.nda.ox.ac.uk/wfsa
Websites to try
Journals:
African Anaesthetist
Anaesthesia
Anaesthesia and Analgesia
Anaesthesia and Intensive Care
Anesthesiology
British Journal of Anaesthesia
JAMA
NEJM
Science
The Internet Journal of Anaesthesia
http:/www.africananaes@lycos.com
http://www.blackwell-science.com/ana
http:/anaesthesia-analgesia.org
http://www.aaic.net.au/home.html
http://www.anesthesiology.org
http://bja.oupjournals.org
http://www.ama-assn.org/public/joumals/jama/jamahome-html
http://www.nejm-org/content/index.asp
http://www.sciencemag.org/
http://www.ispub.com/journals/ja.htm
Associations:
American Society of Anaesthesiologists (ASA)
http://asahq.org
Anaesthetic Research Society
http://www.ars.ac.uk
Armenian Society of Anaesthesiologists
http://freenet.am/~armanest
Association of Anaesthetists of Great Britain & Ireland
http://www.aagbi.org
European Academy of Anaesthesiology
http://www.eaa.euro-anaesthesiology.org/
International Society for the Study of Pain http://www.halcyon.com /iasp
International Trauma Anaesthesia & Critical Care Society http://www.trauma.itaccs.com
National Confidential Enquiry Peri-operative Deaths
http://www.ncepod.org.uk
Obstetric Anaesthetists Association
http://oaa-anaes.ac.uk
Royal College of Anaesthetists
http://www.rcoa.ac.uk/
Society for Ambulatory Anaesthesia
http://www.sambahq.org
Society for Critical Care Medicine
http://www.sccm.org
Society for Computing and Technology in Anaesthesia http://www.scata.orh.uk/programs/list.html
Society for Education in Anesthesia
http://anesthesia.ccf.org:8080/sea/index.htm
Society for Obstetric Anesthesia & Perinatology (SOAP) http://www.soap.org
Society for Paediatric Anaesthesia
http://www.uams.edu/spa
South African Society of Anaesthesiologists
http://www.sasaweb.com
World Federation of Societies of Anaesthesiologists
www.anaesthesiologists.org
The editor would be delighted to hear of other sites that might be of interest and to learn of any site addresses that are incorrect or no
longer function
27

News and Information
The African Anaesthetist
Dr. David Nekyon
Dept. of Anaesthesia
Mulago Hospital
Kampala
Uganda
How often has someone wanted to contact
an anaesthetic society or a department of
anaesthesia in Africa and not known
where to start! If I wanted to attend the
annual conference of an African society in,
say, Cameroon I would not have a clue on
how to find out when and where it would
be held.
It was because of such frustration
that I have started the ‘African
Anaesthetist’ website. After teaching
myself HTML codes and messing around
with Dreamweaver software on Sunday
afternoons it is finally ready.
The website consists of several pages
and includes links to web pages that I have
found interesting and helpful as they are
practical and often appropriate for my
situation. Lecture notes, tutorials and
practice manuals are all easy to find.
The list of links is quite extensive
and constantly being updated. Links may
take you to whole websites or more often
just to particular parts of a site, thus bypassing
a lot of unnecessary preambles and
making it less likely that the surfing
anaesthetist will get lost!
There is a discussion group where
fellow anaesthetists can drop comments
and hopefully engage in lively debate. A
chat room will be added if the demand for
it is high enough. There is an African
survey in which you can vote and instantly
see the results. The current survey is
looking at the availability of an assistant to
apply cricoid pressure during an obstetric
anaesthetic.
You will also find a link to a website
that offers online MCQ exams and gives
you your results as well as one to an online
clinical game called ‘surgeons and dragons’
that should test your clinical judgment.
There is also slowly growing list of
addresses of academic departments and
societies of anaesthesia in Africa. This
should hopefully help overcome the
difficulties we face in trying to contact
each other. If your country’s address is
missing just get in touch and it will be
added immediately
(africanaes@lycos.com).
I have also included a diary of
conferences in Africa and some
international ones that may be of interest
to African anaesthetists. Please contact me
and tell me about your meetings.
The website is designed so that even
the most techno-phobic African
anaesthesiologist should be able to
navigate his way around and find what he/
she is looking for. I hope the site will
become a useful resource for both the
working anaesthetist and the specialist
trainee enabling them to increase their
knowledge.
The website address is
http://africananaesthetist.tripod.com
Contact the Editor: africanaes@lycos.com
Working in the UK
28
We frequently receive requests from
doctors in the developing world for
information about working in the
UK. They request help with registering with
the General Medical Council, sponsorship,
finding jobs and taking (or avoiding the need
to take) the Professional and Linguistic
Assessment Board (PLAB) exam.
It is difficult to give accurate advice as
the rules are complex and constantly
change. To work in the UK, you need to
register with the General Medical Council. If
you qualified in the UK or from a medical
school in Australia, New Zealand or the
West Indies, certain universities in Hong
Kong, Singapore and South Africa or the
University of Malaysia before December
1987 you should have no difficulty obtaining
full registration. Likewise, if you graduated
from a medical school in another European
Economic Area (EAA) state and are a
national of an EAA state or have right of
abode in the EAA, you will have no
problems. If you do not have right of abode
in the EEA but qualified from a medical
school listed in the WHO list of approved
medical schools, you have rather more
hurdles to clear before you can be
registered. You will need to obtain
information about visa requirements and
passing the Professional and Linguistic
Assessment Board examinations (PLAB &
IELTS). If your medical school does not
appear on the WHO list, contact the GMC
before trying to proceed.
Recently, the UK government has
encouraged the recruitment overseas of
doctors and others with skills that are in
short supply in the UK (the Highly Skilled
Migrant Programme). Slightly different rules
apply to this group but anaesthetists are not
currently among those being recruited
There are now a number of websites
that provide accurate and up-to-date advice
that you may find helpful. You should find
much of the information you require at:
The General Medical Council:
www.gmc-uk.org
The National Advice Centre for Postgraduate
Medical Education:
www.britishcouncil.org/health/nacpe
Professional and Linguistic Assessment
Board (PLAB)
www.britishcouncil.org./health/nacpme/
plab.htm
International English Language Testing
Scheme
www.ielts.org
The Department of Health:
www.doh.gov.uk/medicaltrainingintheuk
www.doh.gov.uk/internation-recruitment
The Royal College of Anaesthetists
www.rcoa.ac.uk
The World Health Organisation
www.who.int/health-servicesdelivery/med_schools/
UK Foreign Office
www.fco.gov.uk/ukvisas
UK Immigration Service
www.ukimmigration.com/hsmp
UK National Health Service
www.nhs.uk

The WFSA in a new century
The world at large – not only in
anaesthesia – has changed more
than usual in the past year. We
seem to have moved away from dialogue,
debate and argument to more and more
dramatic violence. The events of
September 11, 2001 were the ultimate and
disastrous demonstration. On a smaller
scale though, around the world, suicide
bombings for other –sometimes
incomprehensible - causes took place.
Imagine: your child goes to school
in the morning, never to return, because
one of her fellow students was not
allowed to sit an exam and decided to kill
the responsible teachers. Your child was
in the way. Your husband, a fireman in
New York goes to work in the morning,
never to return because of the
inconceivable event of a hijacked
aeroplane crashing into the World Trade
Centre. In horror and disgust, all of us
around the world were listening to our
radios and glued to the TV screens. We
mourn all the victims of this senseless,
useless violence, and convey our
sympathy to all the relatives, colleagues
and friends. May it change our own
attitude and behaviour in life so that at
least some good comes out of these
horrific events; if all of us brought a little
peace around us in our world, maybe - in
the end it could have a roll on effect.
Another remarkable change is the
emphasis on money making and the lack
of it at the moment. Anything – even in
health care or education - must be cost
effective at least, or preferably make
money, otherwise it is not considered
useful. For the past three to four World
Congresses, it was generally accepted that
any surplus facilitated the educational and
publication efforts of the World
Federation of Societies of
Anaesthesiologists. We, the organisers,
were proud of having contributed to the
world of anaesthesia at large. Being cost
conscious during and prior to the World
Congress, and with the help of industry
and the registering delegates, it became
possible to establish training centres in
countries where no training was available.
The organisers of the last World
Congress in Canada, despite being very
successful in attracting a large attendance
and providing excellent scientific content,
met with a grumbling industry and some
less than willing invited speakers.
Nevertheless, they managed to make a
significant contribution towards the
training programmes in Thailand, Ghana,
Israel and Chile. Until now being invited
to address the delegates of the World
Congress had been considered an honour:
now some speakers demand first class
airfares, accommodation and a fee.
Industry, faced with mergers
(becoming bigger and wealthier as they
merge but fewer in number), are reluctant
to commit themselves to the next World
Congress in Paris. Yes, the economy has
been less buoyant and yes, we all have to
tighten the belt, but do anaesthesiologists
have to contribute to the widening of the
economic gap between us and our
colleagues of the less affluent world?
Would it not be possible for all the
anaesthesiologists in the well-to-do world
to donate from their own personal money
US$100, £100 or € 100 per year? That is
two units of each currency per week that
means one daily newspaper less, or half a
bottle of wine, or... ? With such money,
WFSA could establish Anaesthesia Schools
in all those less affluent parts of the world
and we could truly serve to -
Make available the highest
standards of anaesthesia,
resuscitation and pain relief to
all peoples of the world
Michael Rosen, the chairman of
WFSA Foundation, has found willing ears
in the Association of Anaesthetists of
Great Britain and Ireland. They will
launch an appeal in their September
Newsletter, asking for a voluntary
donation from their members with the
regular subscription to the Association.
The Australian Society has done this for
years for their projects in the Pacific
Ocean. Which of our National Societies
is going to follow these examples? Yes, of
course we need transparent and clear
budgets for all these exercises. We will
know however where our donations go.
This ought to be an effort of no more
than ten to twenty years. We may even
see it to completion in our own lifetime.
Eventually there will be enough
anaesthesiologists trained to provide safe
anaesthesia and pain relief to their own
people.
National Member Societies
Both Ruth Hooper and Rose Zawazawa
are energetic in their endeavour to make
the WFSA database of national member
societies correct and up to date. Please
note a number of changes in the address
list. New applications for membership
have been received from Surinam, West
Indies, Netherlands Antilles, Mozambique,
Ethiopia, Botswana, and Brunei.
Executive Committee and Officers
Just two weeks after September 11, most
of us managed to attend a very successful
2nd All Africa Anaesthesia Congress in
Durban, South Africa. Both the African
Regional Section as well as the South
African Society of Anaesthetists is warmly
congratulated on a successful meeting,
both scientifically as well as socially. We
look forward to the next meeting in
Tunisia (2005). The members of the
Executive Committee studied closely the
(negative) budget as accepted in Montreal,
Canada. They requested the Treasurer and
Finance Committee to revise this to a
budget which would be in balance from
2003 onwards. All administrative costs
have been brought down to less than 50
% of the total budget. It was also decided
that those societies that paid dues in 2003
would be in good standing to attend the
General Assembly in 2004.
Standing Committees
The Education Committee has now
established and actively supports four
training centres. All the members of the
Education Committee are active within
their region. More than twenty countries
were visited by teachers or instructors on
refresher courses, mostly Asia, Africa and
South America. Eastern Europe is also
being well supported by Confederation of
European National Societies of
Anaesthesiologists. Douglas Wilkinson
29
News and Information

News and Information
and his Primary Trauma Care Team have
captured the interest and blessing of the
World Health Organisation with the
Primary Trauma Course. We extend our
warmest congratulations and apologise for
the unfortunate omission of news of their
activities in the previous annual report.
The Publication Committee, quietly
and unassuming go their way and
distribute anaesthesia literature in both
printed and electronic form. Update has
an ever-increasing number of daily hits, in
September there were 70,598 visitors to
their web-site from 131 countries, an
average of over 90 ‘hits’ per day! We look
forward to seeing the same success to the
WFSA web-site!
The Statutes and Bylaws committee
is studying how the process of the
credentialling before the General Assembly
can be streamlined. The confusion and
chaos just before such a meeting is
disturbing for everyone. Unfortunately,
the bylaws allow delegates to register up to
24 hours prior to the General Assembly:
when they have managed to come and
attend, we do not wish to refuse to allow
them to participate. Additionally, not all
delegates of a National Society are aware
whether they are one of their society’s
official delegates or an alternative delegate.
It is of the utmost importance that
delegates names are handed to the WFSA
secretariat in good time to facilitate the
workings of all our committees.
Specialist Committees
The Pain Relief Committee has developed
both a basic and an advanced course in
Pain Management which were run for
participants following the 11th Asian
AustralAsian Congress in Kuala Lumpur
in July of this year and subsequently run
in several other places in the region.
The Paediatrics Committee is active
with training scholarships in Paediatric
Anaesthesia in South America. The
European arm (FEAPA) held successful
courses in Germany and Slovenia.
The Obstetrics Committee is
supporting a postgraduate course in
obstetric anaesthesia in Malawi this year
and investigating the possibility of
extending this in the East African region
in 2003.
The Safety and Quality of Practice
Committee has elected a new chairman::
Prof Alan Merry has taken over from Prof
Klaus Geiger, whom we thank for his
efforts in this task. Prof. Merry hopes to
embark on an international monitoring
study and has planned a teleconference in
the near future with his committee
members.
It is hoped that all specialist
committees may be able to develop
courses accompanied by a distance
learning programme, and contribute these
programmes to the WFSA Schools of
Anaesthesia. This would surely be an
example for the medical world at large!
Office and Administration
WFSA has tightened its belt like
everybody else in the world. We have
moved to a smaller office on the 7th floor
of the same building (same phone and fax
numbers, same address), and we reduced
the administrative staff to one in London
(Ruth Hooper) and one in Malawi (Rose
Zawazawa). I am very grateful to Michael
Vickers (Immediate Past President) who
volunteered to help in the London Office.
His background knowledge of WFSA
affairs has been a great help to Ruth and
myself.
WFSA is going electronic: you will
therefore find this annual report in
electronic form in your e-mail or, if we do
not have your e-mail address, on a floppy
Oxford Instructors Course
Primary Trauma Care
7-8th February 2003
diskette by post. You may save it or print
as many copies as you like. By the time
you receive this annual report, the WFSA
web-site will have been launched in early
August, 2002
www.anaesthesiologists.org
Your comments will be appreciated!
Next World Congress of
Anaesthesiologists - Paris 2004
In two years time, we will meet in Paris.
The President, Honorary Secretary and
Administrative Co-ordinator were warmly
welcomed in Paris last May. To organise a
World Congress in these more difficult
financial times, and to maintain the vision
of a truly world congress with speakers
from all around the world, is not an easy
task. Our French colleagues are leading
the way by electronic communication and
they have many other firsts:
● This will be the first World Congress
to be combined with an Annual
Meeting of a Society, in this case the
French;
● The book of abstracts will only be
available on CD-ROM (no more
excess luggage on the way home!);
● Slides will be replaced by computer
presentations: those who want to
present with slides will have to have
their slides scanned in locally.
We wish our French colleagues
under the wise guidance of Phillippe
Scherpereel, Claude Martin and Michel
Pinaud and their professional congress
organiser, Colloquium, success with their
impressive efforts to make this 13th World
Congress, almost our fiftieth birthday a
soaring and unforgettable success. Please
register on the web-site:
www.wca2004.com and book the dates in
your diary: 17 – 23 April 2004.
Anneke E.E. Meursing, Netherlands /
Malawi, July 2002.
Registration Fee £175.00
Further information may be obtained from ptc@nda.ox.ac.uk
30

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World Anaesthesia Database
Why not join World Anaesthesia today for the modest fee of £20 (or equivalent) if you work in a first world country? Membership is free to
those working in developing countries. Just complete the form below and forward it to the Secretary with your cheque.
Name: ................................................................................................................................................................................................................................................
Address: ............................................................................................................................................................................................................................................
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World Anaesthesia Database
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Speciality: ........................................................................................................................................................................................................................................
Grade: ..............................................................................................................................................................................................................................................
Age: ................................................................................................................................................................................................
Male ■ Female ■
Experience overseas:
Please list the countries where you have worked (other than your home country). Please add: the places in those
countries, the dates and the type of work you were engaged in. (e.g. Disaster Relief, Support for refugees, Area of
War/Conflict, Longer term medical missionary or secular relief agency work). Continue on a separate sheet if
necessary:
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Clinical Investigations
World Anaesthesia Database continued
Particular interests:
(e.g. subspecialities of anaesthesia/care of the critically ill, education, distance learning, appropriate research writing,
disaster relief, conflict situations, medical missionary, long term secular:
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Languages spoken: ....................................................................................................................................................................................................................
Availability:
Are you happy to answer enquiries relevant to your experience/expertise? ■ Yes ■ No
Are you able to write for WA publications? ■ Yes ■ No
Are you available for working visits abroad? ■ < 1 month ■ 1 to 6 months
How much notice do you require? ■ 2 weeks ■ 2 months ■ 6 months ■ > 6
Any comments: ..........................................................................................................................................................
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Please complete this form as accurately as possible and return to:
Dr. C. Collins, Secretary, World Anaesthesia
Dept. Anaesthesia, Royal Devon and Exeter Hospital (Wonford), Barrack Road, Exeter, Devon EX2 5DW
United Kingdom Tel: (+44) 01392 411611
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