Chapter 133

Implications for Humanitarian 

Anesthesia 

George A. Gregory 

133 

CHAPTER 

Many people in developing countries live their whole lives without 

having congenital anomalies repaired. Patients with congenital 

heart lesions, for instance, may die for lack of a surgeon, anesthesiologist, 

equipment, hospital, or operating room. Some die 

because they lack funds to pay for the surgery. Organizations in 

many developed countries provide free plastic, orthopedic, cardiac, 

or ophthalmologic surgery for poor people in developing countries. 

These programs, in one form or another, have existed for ore than 

100 years: missionaries went to Africa and Hawaii in the 18th and 

19th centuries and established hospitals to care for needy patients. 

In the mid-20th century, Orbis and the ship Hope began providing 

care in developing countries for patients with ophthalmologic and 

other problems. In 1969, Interplast (Mountain View, CA) began 

providing free reconstructive surgery for needy patients who had 

cleft lips, cleft palates, and burns. 1 Now more than 100 organizations 

throughout the world provide similar care. Unfortunately, there is 

no regulation of organizations providing care, and mortality rates 

are higher than those in developed countries for the same surgery. 2 

The purpose of this chapter is to discuss the environment in which 

these surgical trips take place and to describe ways that needed care 

can be provided in austere environments. 

There are many ways for organizations to deliver care for these 

patients. Some organizations consist of a few people that work 

together all of the time. Others consist of large groups of people 

who seldom or never have worked together. This chapter is written 

from the point of view of a larger organization that provides care 

for poor people in developing countries, but the principles 

discussed can be applied to small as well as large groups. 

GOALS 

The primary goal of most medical nonprofit organizations working 

overseas is to provide free, safe, effective care for poor patients. 

These groups seek to provide a level of care commensurate with 

that provided at home. A second goal is to educate local physicians 

and nurses and to provide them with the resources that will allow 

them to deliver needed care themselves. 

Needy patients receive care from overseas groups in one of 

several ways. First, a group of physicians and nurses from a 

developed country goes to a less-developed country and provides 

direct care to patients (e.g., surgery). They treat a number 

of patients during each short trip, but many patients remain 

untreated. A second and more effective way to provide care is to 

give local surgeons, anesthesiologists, and nurses the education, 

equipment, and materials they need to do the surgery themselves. 

ORGANIZATION 

Organizations that provide free care for poor patients in developing 

countries are generally not-for-profit, although there is no 

reason they have to be. Funding for these organizations usually 

comes from private industry and from individuals. Larger organizations 

have a board of directors that oversees the running of the 

organization and aids in fund raising. The board of directors 

provides guidance to a chief executive officer (CEO). The CEO is 

responsible for the day-to-day running of the organization and for 

fund raising. A chief medical officer (CMO) provides medical 

leadership and visits possible new surgical sites and deals with 

local governments and physicians. The CMO is the liaison between 

the medical personnel and the organization’s administration. 

Larger groups have surgical, anesthesia, pediatric, and translator 

committees that may meet several times a year to set policy for 

each group. Many organizations have a steering committee that is 

made up of members of each of these groups and is responsible 

for setting policy for trips and for sending these policies to the 

CMO, CEO, and board of directors for action. One of the most 

important components of these organizations is the supply department, 

which organizes donated and purchased supplies for trips 

and sends them at the appropriate time to the appropriate location 

so teams can do their work. 

Surgical teams are made up of volunteers who may not have 

worked together and must now work as a team in less-than-ideal 

conditions. Teams include a team leader, anesthesiologists/nurse 

anesthetists, surgeons, operating room and recovery room nurses, 

a pediatrician/general practitioner who is responsible for pre- and 

postoperative care of the patients and the health of the team, and 

translators. Some teams include physical therapists, dentists, dental 

technicians, and/or speech therapists. 

Team members must adapt easily to change and must be able 

be to get along with each other in difficult and often fatiguing 

situations. Egos must be left at home. The extreme poverty of some 

sites is especially difficult for some team members. The anesthesia 

providers, nurses, surgeons, and translators usually have leaders 

who are responsible to the team leader. The team leader is in 

charge of the entire trip and deals with local physicians, hospital 

authorities, and others. The role of each team member must be 

made clear at the outset and people should stay within those roles. 

It is a good idea to have team members meet via a telephone 

call several weeks before the departure time. This phone call allows 

people to introduce themselves to each other and for the organization’s 

administration to make themselves known to the team. 

Questions can be answered, and the team can be told the kind and

2174 PART 6 ■ Specific Considerations 

quantity of surgeries to expect. The administration can make clear 

the goals of the trip and the rules of team conduct. 

Sexual harassment, either physical or verbal, is not to be 

tolerated and may result in a team member being sent home for 

engaging in these activities. Romantic liaisons with a team member 

or a local person may threaten the present trip and future trips 

to that site. Logistic details such as living arrangements, costs to 

the team (meals and other expenses) should be made clear. Team 

members should be told approximately how much money they 

will require for expenses. One member of the team should be 

designated as the “team physician”; the most appropriate person 

for this role is the pediatrician/general practitioner, if there is one 

as part of the team. This person should be made aware of health 

problems of team members (e.g., diabetes, asthma) before the trip 

begins (not during the phone call, for reasons of confidentiality). 

If infectious diseases such as avian flu are prevalent at the trip site, 

the team should be told how sick team members will be treated 

medically and how they will be evacuated home. Team members 

who have previously been to the site can address local customs 

and dress code. Drugs, tobacco, and alcohol use can be discussed 

and the rules made clear by the organization’s leaders. Giving 

individual gifts or money to patients or their families often causes 

problems, because one group may perceive that they received a 

lesser gift than another. The organization can indicate during the 

phone call that the organization will give the same gift to each 

patient/family and avoid these problems. Often the hosts at a site 

give small gifts to team members. It is difficult to refuse these gifts 

without seeming rude. 

TEAM LEADERSHIP 

Each trip should have a team leader who is responsible for the dayto-day 

running of the trip and for solving problems. Each specialty 

group (anesthesiologists, surgeons, nurses, etc) should have a 

leader who deals with the day-to-day details of the trip related to 

their specialty. Trips function better when there are frequent 

discussions between the leaders and the team members. Having 

team meetings at breakfast or dinner, when everyone is together, 

is one way to accomplish this. Cases for the day or any problems 

that occurred with the surgery schedule can be discussed. Before 

the first surgery takes place, it is helpful to have a team meeting 

to orient team members to the site and let them know where the 

fire extinguisher, emergency oxygen tanks, emergency drugs, defibrillator, 

and so on are located. During this meeting, team 

members can be told how to contact the pediatrician/general 

practitioner during the day and how emergencies will be handled, 

especially if a patient must return to surgery for any reason. If a 

patient requires intensive care, some organizations put the patient 

in the hospital’s intensive care unit (ICU) and others have an 

anesthesiologist and a postanesthesia care unit (PACU) nurse care 

for the patient in the PACU. If an anesthesiologist and nurse are up 

all night caring for a patient, they may be tired and not function 

well the following day. This may necessitate canceling some 

surgery. Canceling cases may be difficult, but if it is safer for 

patients it must be done. A surgeon, anesthesiologist, nurse, and 

translator should make rounds after dinner and see all patients 

operated upon that day to determine whether there are any 

problems and if the patients have adequate pain relief. The same 

group can take night call that night. The hospital must be able to 

contact the team leader at all times, including night and weekends. 

CHOOSING AND EVALUATING SITES 

Although different organizations use different models for site 

selection, it is generally considered best if organizations are invited 

to provide surgery in a country by physicians, governments (local 

or federal), or service groups (Rotary clubs, Lions clubs, etc). If 

local medical professionals are not involved in the invitation, they 

may feel the trip was forced on them and refuse to work or 

cooperate with the team. Government officials also must be aware 

of the invitation. Without the government’s cooperation, the team 

may be denied entrance to the country and may be prevented from 

doing surgery. After all, it is the government that allows team 

members to practice medicine in their country without a license. 

Most countries allow us to practice medicine, nursing, and so on 

in-country without having a license to do so, for the time we are 

there. Malpractice insurance is seldom available for this type of 

work. To date, there have been no lawsuits for such care. Host 

physicians are responsible for all interactions with the team and 

the parent organization. The host must be able to communicate 

with the organization’s offices by e-mail or by telephone. 

When an organization considers performing surgery in a 

country, a letter asking certain questions should be sent to whoever 

it was that proffered the invitation, such as questions regarding the 

stability of the government and whether bribes are expected to 

permit teams to work in the country are important. It is illegal for 

Americans to take or give bribes in this situation, according to the 

Foreign Corrupt Practices Act (http://www.justice.gov/criminal/ 

fraud/fcpa). Whether it is safe for foreigners to be in the country 

must be addressed. 

Are there sufficient patients who require the type of surgery 

that can be provided? If there are, how will they be recruited? Will 

newspaper, television, and radio advertisements be used? Who 

will place the advertisements, when will they be placed, and who 

will pay for them? Are similar surgical groups working in the area 

and when were they last there? If other teams have been in the area 

recently or recruiting was inadequate, insufficient patients may be 

available to make the trip cost-effective or satisfying for the team 

members. 

The parent organization and CMO must make clear to the host 

what type of surgery the team can and will do. Orthopedic 

surgeons will not repair cleft lips and plastic surgeons will not do 

pelvic osteotomies. It is then up to the host physician(s) to find 

appropriate candidates for surgery. The host(s) must be willing 

and able to provide needed follow-up care for the patients after 

the team leaves. Ideally, this person should be a surgeon who will 

be the focus of teaching during a trip and who has the potential to 

lead her/his own team and provide the same type of surgery for 

poor patients in the future. For burn patients in particular, the 

personnel and the facilities must be available for postoperative 

care, including splinting and physical therapy if required. 

Who will help with customs, transport of the team and 

equipment from the airport to the hotel, and from the hotel to the 

hospital? Will someone be available every day to help solve 

problems? If the team’s equipment is confiscated or delayed by 

customs, as it sometimes is, how will this problem be resolved? Is 

there a locked, safe room in which to store equipment and drugs? 

Who will have access to this area at night? How will the team 

access this room at night if they must provide emergency surgery? 

Is the operating environment adequate? Are there sufficient 

rooms in which to perform surgery without compromising patient 

safety or the ability of local surgeons to care for their patients? 

How many operating rooms will be available to the team? Placing

CHAPTER 133 ■ Implications for Humanitarian Anesthesia 2175 

two operating tables in one room and having two teams operate at 

the same time, as is done daily in many developing countries, is 

usually safer because anesthesiologists can share equipment when 

necessary and can help one another if a problem arises. Surgeons 

can easily consult with each other about the surgery. Teaching is 

improved because local surgeons and anesthesia personnel can be 

shown interesting findings and techniques. At times the operating 

rooms can be very crowded and noisy. (If they are, as your mother 

said, “patience is a virtue.”) 

Is safe, well-maintained anesthesia equipment available? 

Anesthesia vaporizers may not have been serviced for years, if 

ever, making it impossible to know what concentration of anesthetic 

is being delivered. Is oxygen available? If so does it come 

from the wall, from tanks, or from concentrators? Are replacement 

oxygen tanks available on-site? Can empty oxygen tanks be 

replaced quickly? Can they be accessed rapidly 24 hours a day? 

Are the hose fittings on the reducing valves the same as those on 

the hoses and regulators brought by the team? If not, how can this 

problem be solved? One possible solution is to rent appropriate 

equipment from firms in the country where the work will be done. 

This is rarely possible; when it is, the rental costs may be excessive. 

Is oxygen available for transport of the patient from the 

operating room to the PACU? The distance between these two 

areas can be great enough that oxygen desaturation will occur by 

the time the patients arrives in the PACU if added oxygen is not 

used during transport. This is especially true when surgery is 

performed at altitude (Table 133–1). 

The 20 patients described in Table 133–1 were studied at greater 

than 10,000 feet (3,048 meters) above sea level. They breathed 

100% oxygen for 5 minutes in the operating room before being 

quickly taken to the PACU, which was about 50 yards (46 meters) 

away. No oxygen was available for transport. Ten of the patients 

were hyperventilated to an end-tidal PaCO 2 

of 20 to 25 mmHg 

before leaving the operating room to cause apnea. They remained 

apneic during transport and their SaO 2 

was acceptable upon arrival 

in the PACU. Patients who were not hyperventilated breathed 

spontaneously during transport and had lower initial SaO 2 

s on 

arriving at the PACU. 

Are gurneys or stretchers available for transport of patients to 

the PACU, or does someone have to carry the patient? Carrying 

larger patients is a problem. Is oxygen available in the PACU? Does 

it come from the wall or from tanks? How many oxygen outlets are 

there? Will one or more patients have to share the same oxygen 

source? Is suction available from the wall or from a suction 

machine? Is suction available for each patient? Are monitors 

available? Can heart rate, noninvasive arterial blood pressure, 

electrocardiogram (ECG), and SpO 2 

be monitored? If not, the 

team must provide appropriate monitors for use in the PACU. 

Although there are many ways to do things, organizations 

usually do not charge patients for services they receive from 

visiting teams. During the site visit, hospital administrators and 

TABLE 133-1. Oxygen Saturation Upon Arrival in the 

Postanesthesia Care Unit (PACU) 

SaO 2 

in PACU 

Without 

SaO 2 

in PACU With 

SaO 2 

in Operating Hyperventilation, Hyperventilation, 

Room, % (No.) % (No.) % (No.) 

100 (20) 86 ± 8 (10) 95 ± 6 (10) 

others should be made aware that this is the policy of the organization. 

Some hospitals have been known to extract fees from 

patients for care provided by visiting teams. 

Discrimination against anyone on the basis of color, race, or 

religion is strictly prohibited. Nonprovision of care is based solely 

for medical reasons or the inability of the team to perform the 

required surgery. Competent translators are required throughout 

the trip, both for patient care and for teaching. 

Is the hotel clean and free of “varmints”? Does the hotel have 

hot water and electricity? Is it safe to leave personal belongings 

such as cameras, laptops, and other equipment in the hotel? Will 

it be safe to leave these items around the operating and recovery 

rooms? The cost of this equipment is more than the income 

received by many doctors over several years. How will lunch be 

provided and who will provide it? What will the cost be? Will the 

organization pay for lunch? Is there malaria, dengue fever, bird 

flu, HIV, and so on in the area? Plans for acute and long-term care 

of infected team members should be clearly defined. AIDS is 

endemic in some developing countries. This increases the risk to 

team members who are accidently stuck with needles from 

infected patients. A rapid HIV test kit should accompany each 

team so the team physician can quickly determine if the person 

from whom the blood originated is HIV-positive. If the patient is 

HIV-positive and the team member is HIV-negative, there is a 4- 

hour window from the time the needle stick occurs to treatment 

with appropriate drugs to reduce her/his likelihood of becoming 

infected. By taking drugs such as combivir with them, the team 

physician can treat potentially infected team members quickly and 

plan for their evacuation home. It is better not to count on 

obtaining these drugs within the country where the team is 

working. It may not be possible to acquire them in the requisite 4 

hours. 

CHOOSING PATIENTS FOR SURGERY 

Candidates for surgery should be healthy and have an American 

Society of Anesthesiologists (ASA) physical status 1 or 2. Whether 

children with congenital anomalies (other than those for which 

they are receiving surgery) are appropriate candidates for surgery 

by these groups should be determined on a case-by-case basis. 

Patients with clefts, orthopedic anomalies, and ophthalmologic 

anomalies are usually appropriate candidates, assuming they have 

no other serious anomalies and the blood loss will be small. 

Patients with congenital heart disease other than those scheduled 

for cardiac surgery or patients with significant lung disease (e.g., 

severe asthma) are seldom appropriate candidates for surgery by 

visiting groups. Patients with syndromes that include cardiac, 

respiratory, renal, hepatic, or facial anomalies that make it difficult 

to ventilate the patient’s lungs with a bag and mask are not 

candidates for surgery, because their perioperative complication 

rates may be excessive. If a team cannot operate on the patient, 

attempts should be made to find surgery for the patient within the 

country or in another country. Patients with chronic undernutrition 

are seldom candidates for surgery because they heal poorly. If 

the team can help improve the patient’s nutritional state by helping 

the family purchase food, it may be possible for the patient to have 

surgery at a later date. 

WORK ENVIRONMENT 

The environment in which visiting teams and local physicians and 

nurses must work can often be difficult. Hospitals range from


makeshift buildings in a jungle that are used rarely, or only when 

teams from developed countries go there to perform surgery, to 

hospitals that are quite modern but may only be open when 

visiting teams are there because the government lacks sufficient 

funds to staff and furnish the hospital. In between are many 

hospitals with multiple problems. Electricity is available in most 

hospitals, although it may cut off several times a day. When it does 

the team has to rely on backup systems. The site visitor must 

determine if there is a backup electrical generator and if it actually 

works. Battery-operated headlights and bright, focused flashlights 

will usually suffice until the electricity is restored. The water 

supply may be unclean and may cut off several times a day. Many 

sites are warm and humid. Others are cold, especially those located 

in high mountains (e.g., the Andes or Himalayas). Teams going to 

high-altitude sites should be prepared to deal with high-altitude 

pulmonary and/or cerebral edema in team members. 3 Because 

most team members live near sea level, sudden changes in altitude 

may induce one or both of these problems if the person is 

susceptible. 

ORGANIZATION OF THE TRIP 

Screening 

Many teams hold a clinic the day after they arrive at a site to 

determine who will receive surgery. More than 200 people may 

show for evaluation; not all will be appropriate surgical candidates. 

Many appropriate candidates will be denied surgery because there 

is no room on the surgery schedule for them; they can be told to 

return the following year. All patients must be seen and examined 

by the surgeons to determine if it is possible to do the required 

surgery. The pediatrician/general practitioner must clear the 

patients medically for surgery; the anesthesiologist must determine 

the risk of anesthesia and potential intra- or postoperative 

problems. These evaluations overlap, which usually prevents 

inappropriate surgery from taking place. Acute or chronic illnesses 

commonly prevent surgery from taking place. Children with an 

upper respiratory tract infection (URI) are not candidates for 

surgery during a trip, because the potential risk for airway 

problems is too high. 4 Patients who have an URI should not be 

treated with antibiotics and told to return for surgery the following 

week. Even if they do not have problems during surgery, many 

patients who have an URI may have respiratory and airway 

problems in the PACU. 5 Whether to proceed with surgery is a joint 

decision by all physicians who saw the patient. It may be possible 

to accomplish surgery safely, but it may not be possible to provide 

the level of postoperative care required. If this is the case, the 

surgery should not take place. 

There is often pressure from the team, from local physicians, 

and from hospital administrators to operate on patients because 

the patient came from far away. This may be her/his only chance 

to have surgery. However, if there are good medical reasons to 

delay or to not perform surgery, it should not be done. 

Patients usually arrive at the hospital the day before surgery. 

The pediatrician/generalist evaluates them and determines if they 

have had an intercurrent infection or other problem after the clinic 

visit. Information provided during the clinic visit must be 

confirmed. Patients or their families may hide or alter information 

(such as regarding fasting) if they think disclosing that information 

will prevent surgery from occurring. A thorough physical 

examination and further questioning about heart, lung, renal, 

central nervous system, and hepatic disease is required. Many 

patients in developing countries have asthma that has never been 

diagnosed or treated. A careful asthma history and examination 

are mandatory. If a patient is found to have bronchospasm, the 

surgery may have to be delayed while appropriate therapy is 

begun. It is not uncommon to find patients who have significant 

asthma and have never been treated for this problem. Laboratory 

work is done and blood for transfusion is ordered if needed. If a 

blood transfusion is needed, a family member may have to donate 

blood for the patient. Most organizations pay the costs of blood 

banking and laboratory tests. 

The patient/parents are informed during the clinic visit and 

during preoperative rounds the night before surgery when they or 

their child must be made NPO. NPO times are the same as those 

of the ASA: 6 hours for milk, formula, or solids; 4 hours for breast 

milk; and 2 hours for clear liquids. Clear liquids are fluids the 

patient/parents can see through (water, apple juice). Many people 

in developing countries believe that patients require a hearty 

breakfast before surgery to assure a good outcome. If they fear that 

the surgery will be canceled if the patient drank or ate, they may 

not tell the anesthesiologist that they or their child is not NPO. 

Families must understand the reason for NPO and the dangers of 

eating or drinking before surgery. On the morning of surgery the 

anesthesiologist should again question the patient/parents about 

the NPO status. You might find they ate steak and eggs an hour 

ago. Asking “What did you have for breakfast?” is usually more 

effective than asking “Did you eat or drink anything this morning?” 

The former often catches them off guard and they disclose 

what they ate or drank. 

Young children can be premedicated with a mixture of 

midazolam and 30 to 50 mL of cola, depending on the patient’s age. 6 

Place 0.5 to 1.0 mg/kg of midazolam in a small cup and show them 

the cola container; pour cola into the cup and hand the cup to the 

parents to give to the child. Children will almost always drinks the 

mixture quickly. After 15 to 20 minutes, the child will be relaxed 

and can be taken to the operating room for the induction of 

anesthesia. Adding 2 to 3 mg/kg of ketamine and 0.5 mg/kg of 

midazolam to a cup, along with cola, and having the child drink the 

solution usually produces a sleeping child in 15 to 20 minutes. Half 

of the oral ketamine and midazolam are metabolized by the firstpass 

effect. 7 Naturally, the children are afraid of strangers and do 

not want to leave their parents. Premedication overcomes the 

reluctance of many of these patients. It also facilitates the induction 

of anesthesia, especially if the anesthesiologist does not speak 

the local language. Local physicians seldom premedicate infants and 

children. If we teach them to do so, we must also teach them the 

potential problems and the postoperative care of premedicated 

patients. 

Mixing 0.9 ml of lidocaine (1%) and 0.1 ml of sodium bicarbonate 

in a 1-mL syringe and using a 30 or 32-gauge needle to 

inject 0.2 to 0.5 mL of the solution into the skin prevents the pain 

of injection and of catheter insertion. When the I.V. is in place, 

0.05 to 0.2 mg/kg of midazolam can be given intravenously. Rectal 

premedication is not used in some countries due to cultural taboos. 

Equipment 

Most groups take all surgical supplies and instruments, monitors, 

drugs, and anesthetics required with them to the site. Narcotics 

and other schedule II to IV drugs should not be taken into the 

country unless one wishes to become familiar with the inside of


the local jail. Fentanyl is readily available in most countries. Table 

133–2 is a list of the drugs commonly taken on trips. Many of these 

drugs can be purchased in the country where the team will work. 

However, one should be aware that drug names are often different, 

and language barriers can further increase the risk of making a 

drug error. The dosage of drugs from local companies may be 

different from the dosage of drugs usually used by team members, 

which increases the risk of administering an incorrect dose of drug 

during an emergency. It is best to check the dose to be given with 

a colleague before administering the drug. Drugs drawn into 

TABLE 133-2. Drugs Commonly Provided by Teams on Medical Trips 

Vagolytics, Vasopressors 

Atropine sulfate, injectable, 0.4 mg/mL, 1-mL vial 

Ephedrine sulfate, injectable, 50 mg/mL, 1-mL vial 

Epinephrine, injectable, 1:1000 (1 mg/mL), 1-mL ampule 

Glycopyrrolate, injectable, 0.2 mg/mL, 1-mL vial 

Neuromuscular Blockers, Reversal Agents 

Succinylcholine chloride, injectable, (Quelicin), 200 mg 

(20 mg/mL) 

Rocuronium (Zemuron), 0.45–0.65 mg/kg for tracheal intubation; 

0.05–0.2 mg/kg if reparalysis is required, 50-mg vial 

Vecuronium (Norcuron), 0.08–0.1 mg/kg, 10-mg vial 

Neostigmine methylsulfate, 0.5 mg/mL, 1:2000, 10-mL vial 

Analgesics and Sedatives 

Ketamine HCL (Ketalar), injectable, 100 mg/mL, 5-mL vial 

Nalbuphine (Nubain), injectable, 10 mg/mL, 1 mL ampule 

Naloxone HCL (Narcan) injectable, 0.4 mg/mL, 1 mL ampule 

Butorphanol tartrate, injectable (Stadol), 0.5–2 mg, 2 mg/mL, 

1 mL vial 

Tramadol (Ultram), 2 mg/kg up to 100 mg/dose; maximum 

dose 300 mg/day, 100-mg tablets 

Anti-Emetics, Steroids, and Antihistamines 

Diphenhydramine HCL (Benadryl), injectable, 50 mg/mL 

Droperidol, injectable, 2.5 mg/mL 

Metoclopramide HCL injectable, 10 mg/mL 

Major Anesthetic Agents 

Sevoflurane (Ultane), 250-mL bottle 

Isoflurane (Forane), 250-mL bottle 

Propofol 1% (10 mg/mL), 20-mL vial 

Local Anesthetics (Not for Spinal or Epidural) 

Bupivicaine HCL 0.5%, injectable (Sensorcaine), 50-mL vial 

Lidocaine HCL 2%, injectable (Xylocaine), 50-mL vial 

Lidocaine 1% plain, 50-mL bottle 

Lidocaine 1% with epinephrine, 50-mL bottle 

Antibiotics 

Cefazolin, 1 gm, 1-gm vial 

Sterile water for injection, 50-mL vial 

Antibiotic ointment (1-oz tube) 

Cephalexin, 250-mg capsules (500/bottle) 

Cephalexin, 500-mg capsules (100/bottle) 

Bacitracin ointment, 32-oz packets 

Other Drugs 

Adenosine injectable, 6 mg (3 mg/mL) (Adenocard), 2-mL vial 

Albuterol USP, inhaler 

Atropine sulfate, injectable, 0.5 mg (0.1 mg/mL) 5-mL-PFS 

Calcium gluconate 10% (0.465 mg/mL), 10-mL vial 

Dexamethasone phosphate, injectable, 4 mg/mL (Decadron), 

5-mL vial 

Dextrose injectable, 50% in water, 25 g (0.5 g/mL), 50-mL vial 

Dopamine HCL injectable, 200 mg (40 mg/mL), 5-mL vial 

Epinephrine injectable, 1:10000, 1 mg (0.1 mg/mL), 10-mLprefilled 

syringe 

Furosemide injectable (Lasix), 20 mg/mL 2-mL vial 

Hydralazine HCL, 20 mg/mL, 1-mL vial 

Labetalol hydrochloride injection, USP (5 mg/mL), 20-mL vial 

Lidocaine HCL, 2% (Xylocaine), 100 mg (20 mg/mL), 

5-mL-PFS 

Metoprolol tartrate, 1 mg/mL, 5-mL ampule 

Phenylephrine HCL, injectable, 1% (10 mg/mL) 

(Neosynephrine), 1-mL vial 

Sodium bicarbonate, injectable, 4.2% (Infant), 10-mL-PFS 

Sodium bicarbonate, injectable, 8.4%, 50 mEq (1mEq/mL), 

50-mL vial 

Verapamil HCL, injectable (2.5 mg/mL), 2-mL ampule 

Vasopressin, 200 units/10 mL, 10-mL vial 

Nitroglycerine, sublingual, 0.4 mg (25/bottle) 

Dantrolene sodium injectable (Dantrium), 20 mg, 60-mL vial 

Sterile water for injection for Dantrium, 50-mL vial 

Intralipid 20%, 250 mL 

Lidocaine HCI 2% PFS, 5 mL 

Amiodarone, 50 mg/mL, 3 mL 

Sodium bicarbonate, 1 mg/mL, 8.4%, 50 mL 

Glucose (dextrose) 50%, 50 mL 

Calcium chloride 10%, 10 mL 

Mannitol 25%, 50 mL 

Sterile water, 1000 mL 

Furosemide (Lasix), 10 mg/mL, 2-mL vial 

Mineral oil 

Methylene blue, 1-mL vial 

Analgesics 

Acetaminophen suppositories, 120 mg, 12/box 



Acetaminophen with codeine solution, 120 mg/12 mg/5 mL/1 tsp 

Acetaminophen with codeine tablets, 300 mg/30 mg 

Tylenol infant drops, 80 mg/0.8 mL/1 dropperful 

Tylenol children’s liquid, 160 mg/5 mL/1 tsp 

Tylenol regular strength, 325 tablets 

Tylenol liquid (extra strength), 500 mg/tbs (15 mL) 

Tylenol caplets (extra strength), 500 mg 

Children’s Motrin suspension, 100 mg/5 mL/1 tsp 

Motrin infant drops, 50 mg/1.25 mL 

Ibuprophen (Motrin IB) 200-mg caplets 

For Aspiration Pneumonia 

Antibiotic: amoxicillin, 875-mg tablets 

Antibiotic: amoxicillin, 400-mg tablets 

Inhalation: albuterol, 2.5 mg/3 mL unit-dose vials 

Epinephrine, 1:1000, 1-mL ampule 

Anti-Inflammatory 

Dexamethasone phosphate, injectable, (Decadron), 4 mg/mL, 

5-mL vial 

Sepsis 

Ceftriaxone sodium (Rocephin), 1-g vial 

Lidocaine HCL 1%, 50-mg vial 

Narcotic Antagonist 

Naloxone HCL, 0.4 mg/mL, 1-mL ampule


syringes should not be used for multiple patients. Emergency drugs 

should be drawn up daily and discarded at the end of the day. 

Some people argue that because children seldom have ventricular 

fibrillation (VF), a defibrillator is not required on trips. The 

counter-argument is that children of varying ages, and some 

adults, are treated on these trips and can develop VF. Also, supraventricular 

and ventricular tachycardia can occur with inadvertent 

intravascular injection of epinephrine by the surgeon. Successful 

treatment of these dysrhythmias may require cardiac shock. For 

these reasons, a defibrillator must be immediately available. 

It may be impossible to determine when and if locally available 

anesthesia machines have been serviced. Consequently, it is safer 

to use anesthesia equipment, including vaporizers, brought by the 

team. Portable anesthesia machines are available that have many 

of the features of larger machines. These small machines are 

durable and function well in hot and cold climates. The vaporizers 

are both pressure- and temperature-compensated. Standard halothane, 

sevoflurane, and isoflurane vaporizers can be used with 

them. Halothane is the most common inhaled anesthetic used in 

developing countries but is disappearing from many hospitals in 

developed countries. Consequently, many young anesthesiologists 

and nurse anesthetists have no experience using it. A medical trip 

is not the place to learn to do so. Many trip sites have halothane 

vaporizers. If the team’s isoflurane or sevoflurane vaporizers fail, 

there is a tendency to try and solve the problem by placing a 

different agent in a halothane vaporizer. This may lead to the 

delivery of very high concentrations of anesthetic. As pointed out 

by Fisher et al., the isoflurane vaporizer can deliver 5% halothane; 

an enflurane vaporizer can deliver 10% to 12% halothane when 

the vaporizer is set to 7%. 8 The following must be emphasized: We 

do not mix drugs and vaporizers at home. We should not do so 

on trips. It is too dangerous. 

Patient monitoring should include oxygen saturation, body 

temperature, heart rate, arterial blood pressure, ECG, and end-tidal 

CO 2 

. 9 Anesthetic gas concentrations are not measured routinely. A 

precordial stethoscope keeps the anesthesiologist attached to the 

patient during the case and may help detect respiratory and cardiac 

problems early. However, if the operating room is noisy, it may be 

difficult to hear cardiac and respiratory sounds with a precordial 

stethoscope. A preoperative note should be placed in the patient’s 

chart along with a copy of the anesthetic record. Anesthetic records 

should contain the same information recorded in the United States, 

Canada, and Europe. Returning a copy of the anesthesia record and 

the surgery and anesthesia notes to the sponsoring organization 

will aid in quality improvement evaluations. 

Although it is better to use new circuits and endotracheal tubes 

for each patient, most anesthesiologists living in developing 

countries routinely reuse circuits and endotracheal tubes. Some 

anesthesia providers do this on trips. If they do, the circuits must 

be washed with soap and water and dried between cases. Endotracheal 

tubes must be cleaned with soap and water and scrubbed 

with an endotracheal tube brush to remove all blood and mucus. 

Once the tubes are clean, they should be soaked in Cidex OPA 

(Johnson and Johnson Co.) for 10 to 20 minutes to sterilize them. 

Then they should be rinsed thoroughly with large volumes of 

sterile water to remove all traces of the Cidex. Cidex OPA 

effectively kills both bacteria and viruses (including the HIV virus) 

and is not irritating to tissues. This is a very acceptable protocol for 

reuse of endotracheal tubes if it can be followed in a busy 

operating room. If the protocol cannot be strictly followed, a new 

endotracheal tube is required for each patient. 

Wall suction may not be available. If not, portable suction 

devices can be used by anesthesiologists for the induction and 

awakening from anesthesia and by the surgeons during surgery. 

Suction catheters that enter the airway, nose, or mouth should be 

discarded or, if they must be reused, they should be thoroughly 

cleaned and sterilized after each patient use. 

Mechanical ventilators are seldom available in the operating 

rooms of most sites. Consequently, most patients breathe spontaneously 

throughout surgery. If a Jackson-Reese system is used 

to deliver anesthesia, gas inflows should exceed 1.75 to 2 × the 

predicted minute ventilation of the patient (minute ventilation = 

respiratory rate × tidal volume) to prevent CO 2 

rebreathing. These 

high flow rates can deplete the oxygen supply of the hospital in 

a short time. Circle systems save gas, are low-resistance, and 

are economical. Ambu bags should be available in both the PACU 

and the operating rooms for emergencies (e.g., when the oxygen 

supply fails). 

Endotracheal intubation is often required on trips, especially 

when the surgery is performed on the face or mouth. RAE tubes 

are the standard for oral/facial surgery. Surgeons frequently place a 

throat pack during oral surgery to prevent blood from entering the 

trachea and to reduce the amount of oxygen and anesthetic gases 

that leak into the mouth. Every member of the operating room team 

is responsible for assuring that throat packs are removed before 

endotracheal tubes are removed. Deaths still occur from retained 

throat packs. 10 Since most patients undergoing intraoral surgery 

breathe 100% oxygen, there is always the possibility that an airway 

fire will occur. The three things needed for a fire are present: 

>30% oxygen, a spark source (cautery), and a combustible material 

(endotracheal tube). Surgeons must constantly be aware of the 

danger of airway fires and prevent the cautery from touching the 

endotracheal tube. Laryngeal mask airways (LMAs) are commonly 

used to provide an airway and can be used for intermittent positive 

pressure ventilation with normal lungs. They do not prevent 

aspiration of blood or gastric contents, and they have a large dead 

space (Table 133–3). The end-tidal CO 2 

is often 60 to 70 mmHg 

during anesthesia when a LMA is used. The smaller the child, the 

higher the dead space–induced CO 2 

. The elevated CO 2 

is usually 

not a problem, but can contribute to the total anesthetic level. 

ANESTHETIC TECHNIQUES 

General Anesthesia 

Because many of the patients on trips are children, general 

anesthesia is frequently used. In most cases, a mask induction is 

done with sevoflurane. Once the patient is asleep, an I.V. is placed 

and 1 mg/kg of lidocaine (without epinephrine) plus 0.5 mcg/kg 

of fentanyl (or 0.5 mcg/kg of fentanyl and 1 mg/kg of propofol) 

can be given to facilitate tracheal intubation. These “cocktails” 

prevent or blunt stimulation of the airways associated with 

TABLE 133-3. Dead Space of Laryngeal Mask Airways (LMA) 

LMA size 

Dead Space (mL) 

1.0 6 

1.5 7 

2.0 7 

2.5 13 

3.0 22


endotracheal intubation. Preventing stimulation of these reflexes 

is especially important, because children may have undiagnosed 

asthma. Intraoperative narcotic administration reduces the need 

to use high concentrations of inhaled anesthetic. Because N 2 

O is 

seldom available, many anesthesiologists switch from sevoflurane 

to isoflurane to reduce cost. Isoflurane may also reduce the 

incidence of postoperative dysphoria. 11 

Since most patients breathe spontaneously during surgery, 

muscle relaxants are seldom used. If muscle relaxants are used, the 

patient’s lungs must be ventilated by hand when no mechanical 

ventilator is available. Succinylcholine is reserved for airway 

emergencies because succinylcholine has been associated with 

masseter muscle spasm 12 and death. 13 Spontaneous ventilation 

allows the patient to breathe if the endotracheal tube is accidentally 

dislodged. It also reduces the amount of oxygen expelled into 

the pharynx, lessening the likelihood of an airway fire during oral 

surgery. If there is no need to hand ventilate the patient’s lungs, 

the anesthesia provider is free to do other things, including give 

aid if an emergency occurs with another patient. 

Awakening from anesthesia is frequently a dangerous time. 

Pharyngeal blood may narrow the nasal passages and cause 

laryngospasm. Closure of a cleft palate can significantly reduce 

the space available for the tongue, especially if some degree of 

Pierre Robin syndrome exists. This increases the likelihood of 

upper airway obstruction. Patients should usually be awake before 

the endotracheal tube is removed. If no oxygen is available for use 

during transport to the PACU, patients should demonstrate 

adequate oxygen saturations while breathing room air before 

being taken to the PACU. 

REGIONAL ANESTHESIA 

Spinal, caudal, and epidural anesthesia and peripheral nerve 

blocks are commonly used in appropriate patients. Nerve stimulators 

are very helpful when performing peripheral nerve blocks, 

especially if the needle must go through a burn scar. Ultrasoundguided 

blocks are seldom available. Block anesthesia is cost 

effective and can reduce operating room turnover time if the block 

is placed before the previous surgery ends. An extra anesthesiologist 

can help with this. Blocks done in infants and children are 

usually done during general anesthesia. Continuous infusion of 

local anesthetics or narcotics into epidural catheters for postoperative 

pain relief is rarely done because the infrastructure 

required for the postoperative care of the patients is lacking. 

Single-shot caudal blocks with local anesthetics can be done for 

postoperative pain when appropriate. Peripheral nerve blocks are 

effective for hand and extremity surgery. Before doing a block one 

must be certain that the patient can be adequately monitored 

postoperatively for potential complications. Bilateral infraorbital 

nerve blocks with 0.25% bupivacaine decrease the postoperative 

pain associated with cleft lip repair. Injecting 0.25% bupivacaine 

with 1:200,000 epinephrine into the wound edges or bilateral 

sphenopalatine ganglion blocks also provide postoperative pain 

relief after cleft palate repair. Nerve blocks reduce the need for 

postoperative narcotic administration and the risk for airway 

obstruction and apnea. 

POSTOPERATIVE PAIN RELIEF 

Regional blocks effectively reduce postoperative pain. A combination 

of a regional block and oral or rectal analgesics are even 

more effective. Rectally administered acetaminophen (40 mg/kg) 

reduces pain associated with lip and peripheral procedures. Half 

of this dose (20 mg/kg) can be administered rectally 4 to 6 hours 

later if the patient is not taking oral medications by then. Once 

patients are taking oral medications, the dose of acetaminophen 

can be reduced to 15 mg/kg with a maximum of 1 gram of drug 

every 6 hours. The combination of acetaminophen and codeine is 

commonly used to relieve moderate pain. Administering the 

appropriate dose of oral acetaminophen (15 mg/kg to 1 g maximum) 

provides the correct dose of codeine. Ten percent of people 

cannot convert codeine to morphine and get no pain relief from 

codeine. They will have some pain relief from the acetaminophen 

that accompanies the codeine. 

Fentanyl, methadone, and morphine effectively relieve postoperative 

pain, but morphine and methadone are unavailable in 

many countries. Intravenous nalbuphine 5 to 10 µg/kg provides 

mild sedation and good postoperative pain relief. Adequate pain 

medication reduces agitation in the PACU and may reduce 

unwanted bleeding. Intravenous ketorolac effectively relieves 

postoperative pain, but its use is often limited by the perception 

that ketorolac causes bleeding. 

Many patients in developing countries have never taken a drug 

of any kind before arriving at the hospital for surgery. As a 

consequence, narcotics may be metabolized more slowly than they 

are in patients from developed countries. Reduced narcotic 

metabolism may cause respiratory depression or apnea with 

commonly-used doses of narcotics in drug-naive children. When 

used, narcotics should be titrated to effect. If respiratory depression 

occurs, naloxone can be titrated to restore breathing without 

reversing pain relief. The beneficial effects of most narcotic 

reversal agents last 30 to 45 minutes, whereas narcotic effects may 

be longer. Therefore, patients given naloxone must be observed 

for more than an hour after administering the drug to assure that 

respiratory depression does not recur. 

POSTOPERATIVE CARE 

Responsibility for patient care in the PACU usually is the purview 

of the anesthesiologist, who is responsible for providing pain relief, 

correcting airway problems, administering appropriate fluids, and 

discharging patients to the ward. Standing PACU orders have their 

proponents. However, it is usually better to write specific orders 

for each patient, including the type and quantity of fluid to be 

administered per hour; the type, dose, and frequency of pain 

medication administration; whether and when the hemoglobin 

concentration should be determined; who should be called if 

problems arise; and how to reach that person (walkie-talkies are 

very helpful in for this purpose). The number of PACU beds 

usually equals the number of operating tables. Oxygen is required 

for each patient. Monitoring includes SaO 2 

, arterial blood pressure, 

heart rate, respiratory rate, and body temperature. Many 

patients are febrile after surgery due to elevated environmental 

temperatures or to surgery on infected areas. The latter seeds the 

circulation with bacteria. Excessive bleeding should prompt the 

PACU nurse to seek help, save the bloody sponges for review by 

the surgeons, and determine the patient’s hemoglobin concentration 

with a hemoglobinometer. Nurses working in the PACU 

usually care for no more than two patients at a time. 

The pediatrician/general practitioner assumes care for patients 

after they are discharged from the PACU. Many hospital wards in


developing countries have one nurse for more than 50 patients, 

especially at night. Consequently, postoperative care becomes the 

purview of the family. The family must assure that their family 

member receives sufficient pain medication, that I.V. fluids are 

administered and do not run out, and that postoperative wound 

care is done. The pediatrician or general practitioner must teach 

the parents to provide this care and tell them to contact the ward 

nurse if there is a problem. Discharge of patients from the hospital 

is the joint responsibility of the pediatrician/general practitioner 

and the surgeons. The family should be taught to care for the 

patient’s wound, including boiling water and cooling it before using 

it to cleanse the wound. Patients should go home with all of the 

materials (dressings, tape, antibiotics) needed for their wound care. 

Before discharge form the hospital, the family should be given a 

date, time, and place to return for suture removal if required. 

Before the team arrives, there should be a plan to manage 

postoperative complications that occur after patients are discharged 

from the hospital, especially when the team is no longer 

in the country. A host surgeon who is capable of providing this 

care is identified and provided with the resources needed. He or 

she usually removes sutures from patients who underwent surgery 

during the last week of the trip. 

Complicated procedures should be done early in the trip. 

Doing large procedures just before the team leaves for a weekend 

away or during their last week in the country may lead to 

unwanted problems. If possible, all patients should be discharged 

from the hospital before the team departs the site. 

QUALITY ASSURANCE 

Quality assurance (QA) is required to evaluate complications and 

untoward events. If a serious event occurs (e.g., death, near death, 

need for intensive care, return to the operating room for bleeding), 

the complication should be discussed by the team shortly after it 

occurs. The discussion should be nonaccusatory and should seek 

to determine the facts, much as a root cause analysis is performed 

in hospitals in the United States. Once the facts have been gathered 

and the cause(s) of the event determined, steps can be taken to 

prevent the complication from occurring again. Information 

collected should be sent to an interdisciplinary QA committee for 

further review. Each person involved in the event should send a 

written account of the event to the QA committee. If questions 

remain, the head of the committee can call people to obtain more 

information. Even events that lead to no harm (e.g., laryngospasm 

or return to the operating room for bleeding) should be reported 

to the QA committee so the committee can determine if there is a 

systemwide problem. 

Cardiac and respiratory arrest and death occur more commonly 

on trips than in developed countries. Fisher et al. 2 clearly 

outlined a method of dealing with these problems. This includes 

stopping surgery for a period of time to determine the cause(s) of 

the problems and to deal with peoples’ feelings. Not allowing 

people to express their feelings may interfere with the care of 

subsequent patients. A discussion should take place with family 

members shortly after the event so the family understands the 

problem and its possible causes. Host colleagues are usually very 

helpful with the family, because they understand the language and 

the culture and are best able to understand family needs. Also, the 

host must remain in the country and will be the one who will have 

to deal with the aftermath of these events. Discussions of deaths 

with host country sponsors are very important. 

EDUCATION 

One of the primary goals of a trip is to provide education that will 

help local physicians, nurses, and technicians provide surgical care 

for the patients themselves. The reasons why local groups cannot 

provide this care usually include lack of training, facilities, equipment, 

and people. Teams, not just surgeons, are needed. Teaching 

someone to do craniofacial surgery without someone who can 

provide an airway for the patient or people and facilities to 

appropriately care for the patient postoperatively is dangerous. If 

the site lacks the resources to do the surgery safely, the parent 

organization may be able to help the team succeed by helping the 

team acquire the needed equipment and supplies. 

Every trip is a chance to teach and learn; education is usually 

bidirectional. Physicians and nurses in the countries visited have 

devised interesting and ingenious ways of providing care for 

patients in systems that lack many things, 14 and we should learn 

from them. If we ask local anesthesiologists several months in 

advance of the trip if they are interested in didactic or other 

teaching, appropriate people can be staffed on the trip and time 

can be scheduled for teaching. If the site has residents, it can be 

determined if they can work with the team. 

What subjects do local physicians and nurses want discussed? 

Giving canned lectures that interest us but are of no benefit to the 

local doctors and nurses is a waste of time. Almost every site is 

interested in the difficult airway, block anesthesia, fluid and 

electrolytes, and blood replacement. Local anesthesia providers 

want to know how they can provide an airway safely for patients 

who have a difficult airway, and they want to know how to do it in 

the environment in which they work. There probably is no 

fiberoptic bronchoscope within hundreds or thousands of miles. 

Most local anesthesiologists have never heard of, let alone seen, a 

Glide scope. Teaching how to use these devices is seldom helpful. 

Teaching how to use a lightwand, however, especially if the team 

can leave a lightwand and stylets with them, may be life-saving. 15 

Showing them how to use very expensive anesthetic techniques 

may also be a waste of time if the local system cannot afford the 

drugs and equipment required. Teaching them to provide appropriate 

fluids and electrolytes, postoperative care, and postoperative 

pain relief is important. Hospitals in many countries do not 

provide narcotics or analgesics for postoperative pain relief. The 

patients or their families must buy the drugs from a pharmacy. If 

the family cannot afford the drugs, the patient receives no postoperative 

pain relief. Teaching practitioners how to use inexpensive 

drugs and techniques for pain relief will be advantages to 

many people. 

Another method of teaching is to send a visiting educator to a 

site to teach a specific technique or method. Visiting educators 

can be surgeons, anesthesiologists, nurses, or physical or speech 

therapists. The goal is to have local physicians, nurses, and therapists 

do sufficient procedures with the visiting educator to become 

proficient at doing them themselves. Visiting educators are less 

expensive because only one or two people go to the site. Like other 

trips, the outcome of these programs should be evaluated at the 

end of the course and 6 months as well as 1 year later. Did the local 

people actually use what they were taught? If so, was it used to 

treat the poor? If what they learned was not used, what prevented 

them from doing so? Was it lack of facilities, lack of equipment, or 

lack of patients? The parent organization many be able to help 

correct these deficits. 

Local teams can provide surgery for more poor people at a 

lower cost than visiting teams. Some organizations make this


TABLE 133-4. Cost of Doing Surgery: Teams From 

Developed Countries vs Local Teams During a 5-Year Period 

Foreign Teams 

Local Teams 

4800 patients 5800 patients 

$750 per operation $300 per operation 

83 surgical expeditions 6 sites 

1,162 volunteers 6 surgeons plus local staff 

Outcomes—good 

Outcomes—good 

Data are from Interplast, Mountain View, California. 

possible by providing equipment and supplies and by paying teams 

to do the surgery. Surgery by local groups costs about half as much 

per patient as it does for a team from a developed country to do 

the same procedure (Table 133–4). 

By funding local teams, more patients can be treated more 

quickly and often at a more appropriate time in development. For 

example, cleft lips can be repaired when infants are 3 to 4 months 

of age, as they are in developed countries. This assumes that the 

anesthesiologists are comfortable and capable of caring for very 

young infants. Cleft palates can be repaired before patients begin 

to speak (usually at 10–11 months of age), which usually prevents 

long-term speech problems. Dislocated hips can be treated early. 

Local teams can provide effective follow-up of patients after surgery. 

Problems such as palatal fistulas can be dealt with immediately. 

Visiting surgical teams many never know a fistula occurred. 

How can we monitor the quality of surgery performed by local 

teams? One method is to provide the surgeon with a computer 

and a digital camera to take pictures pre- and postoperatively and 

send them to a group of volunteer surgeons for review. If standards 

are met, the local group is paid. 

Despite the best efforts of many people, surgery will, unfortunately, 

continue to be performed in many places by visiting 

surgical teams, because there is no one to train. 

Another way to educate is to establish Web sites that are available 

to anesthesiologists and surgeons in developing countries. 

This provides ongoing education and fosters increased local 

capacity. Surgeons can contact the Web site, present a case and the 

problem(s) associated with it, and send pictures of the lesion. 

Volunteer surgeons can comment on how they would solve the 

problem(s), keeping in mind the conditions in the country where 

the patient resides. Surgeons working in developing countries can 

also comment, and they often have better, more practical solutions 

to the problems than volunteers from developed countries. Anesthesiologists 

can send potentially difficult cases for discussion, and 

volunteer anesthesiologists can describe how they would solve the 

problem. 

Physicians, nurses, and technicians in most developing 

countries often cannot afford textbooks or journals. Providing 

them with recent journals is very helpful, assuming there is 

someone who can translate the material into the local tongue. 

Giving them CDs of recent conferences provides up-to-date information. 

In some places, physicians have no stethoscopes. Providing 

them with inexpensive stethoscopes is greatly appreciated. 

Team members, who return to the same location several years in 

a row, will better understand the needs of the physicians, nurses, 

and hospital and will be in a better position to help them. Leaving 

equipment people cannot use or do not know how to use results 

in the equipment being placed in a closet and forgotten. Broken 

equipment that cannot be repaired will sit unused, possibly 

forever. 

The most effective way to teach is to use the 8 or so hours a 

day in the operating room for one-on-one discussions and 

demonstrations. PowerPoint lectures on a laptop computer can be 

used effectively to convey information, assuming you speak the 

language or have a translator. There is no better way to find out the 

strengths and weaknesses of a person than to spend 8 to 10 hours 

with them in the operating room and to ask questions. If you 

cannot answer some of their questions, you can go to the Internet, 

find the answers, and give the answers to them the next day. 

Surgeons can determine if there is someone who can be trained to 

lead a group that will perform the surgery themselves. Working 

together in the operating room is a great way to build relationships. 

CONCLUSION 

Trips are an exciting way to improve care in developing countries. 

Being able to help patients and to contribute to the development 

of physicians, nurses, and technicians is rewarding and is a great 

way to give back for all we have. For the right people, medical trip 

work can be an exciting part of their practice. 

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anesthesia and plastic surgery in developing countries. JAMA. 1984;252: 

3152–3155. 

2. Fisher QA, Nichols D, Stewart FC, et al. Assessing pediatric anesthesia 

practices for volunteer medical services abroad. Anesthesiology. 2001;95: 

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3. West JB, Schoene RB, Miledge JS. High Altitude Medicine and Physiology. 

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tract infection: still a dilemma? Anesth Analg. 2005;100:59–65. 

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events in children with recent upper respiratory tract infections. 

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6. Gutstein HB, Johnson JL, Heard MB, Gregory GA. Oral ketamine 

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monitoring during anesthesia at Harvard Medical School. JAMA. 1986; 

256:1017–1020. 

10. Gray H, Brett C, Worthington J. Retained throat packs represent a 

potentially catastrophic airway hazard. Anaesth Intensive Care. 2006;34: 

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11. Bortone L, Ingelmo P, Grossi S, et al. Emergence agitation in preschool 

children: double-blind, randomized, controlled trial comparing sevoflurane 

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12. Ramirez JA, Cheetam ED, Lawrence AS, Hopkins PM. Suxamethonium, 

masseter spasm and later malignant hyperthermia. Anaesthesia. 1998;53: 

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13. Rosenberg H, Gronert GA. Intractable cardiac arrest in children given 

succinylcholine. Anesthesiology. 1992;77:585–588. 

14. Hodges SC, Mijumbi C, Okello M, et al. Anesthesia services in developing 

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Chapter 133

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