Chapter 133

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2180 PART 6 ■ Specific Considerations 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
CHAPTER 133 ■ Implications for Humanitarian Anesthesia 2181 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. REFERENCES 1. Samuels SI, Wyner J, Brodsky JB, Laub DR. A successful model for 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: 1315–1322. 3. West JB, Schoene RB, Miledge JS. High Altitude Medicine and Physiology. 4th ed. London: Hodder Arnold; 2007. 4. Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Anesth Analg. 2005;100:59–65. 5. von Ungern-Sternberg BS, Boda K, Schwab C, et al. Laryngeal mask airway is associated with an increased incidence of adverse respiratory events in children with recent upper respiratory tract infections. Anesthesiology. 2007;107:714–719. 6. Gutstein HB, Johnson JL, Heard MB, Gregory GA. Oral ketamine preanesthetic medication in children. Anesthesiology. 1992;76:28–33. 7. Thummel KE, O’Shea D, Paine MF, et al. Oral first-pass elimination of midazolam involves both gastrointestinal and hepatic CYP3A-mediated metabolism. J Clin Pharmacol Ther. 1996;59:491–502. 8. Fisher QA, Politis GD, Tobias JD, et al. Pediatric anesthesia for voluntary services abroad. Anesth Analg. 2002;95:336–350. 9. Eichhorn JH, Cooper JB, Cullen DJ, et al. Standards for patient 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: 119–120. 11. Bortone L, Ingelmo P, Grossi S, et al. Emergence agitation in preschool children: double-blind, randomized, controlled trial comparing sevoflurane isoflurane anesthesia. Paediatr Anaesth. 2006;11:1138–1143. 12. Ramirez JA, Cheetam ED, Lawrence AS, Hopkins PM. Suxamethonium, masseter spasm and later malignant hyperthermia. Anaesthesia. 1998;53: 1111–1116. 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 countries: defining the problems. Anaesthesia. 2007;62:4–11. 15. Fox DJ, Matson MD. Management of the difficult pediatric airway in the austere environment using the lightwand. J Clin Anesth. 1990; 2:123–125.
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Chapter 133

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