There is a global anesthesia crisis

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A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

There is a global anesthesia crisis: too few people trained to give anesthetics for surgery and obstetrics worldwide. The Lancet launched a commission to look at the needs for global surgery, which identified the issues starkly. While international disease control efforts have started to tame infectious diseases like malaria, HIV/AIDS, and tuberculosis, with “only” 4 million people dying from infectious diseases each year. Annually, 16 million – yes, four times more – die from lack of essential surgical and anesthesia care.

What’s even more concerning is “5 billion people lack access to safe, affordable surgical and anesthesia care when needed,” and “143 million additional surgical procedures are needed each year to save lives and prevent disability.”

Witness a far too common example of the latter – an obstetric patient dying from obstructed labor because the cesarean section that she so desperately needs is not available: there is no surgeon nor physician anesthesiologist to provide the care.

As a consequence of such findings, and in an attempt to increase needed anesthesia services, the Overseas Training Program (OTP) was established in Tanzania by the American Society of Anesthesiologists (ASA)in 1991.

Today, the OTP continues that work having co-developed anesthesiologist residency training programs in Kigali, Rwanda (since 2006), and at the Georgetown Public Hospital in Guyana (since 2016). Created together with locally trained anesthesiologist specialists, these residency training programs have set up the virtuous cycle of building anesthesia services within these African and South American countries. Volunteer physician anesthesiologist teachers from the United States travel to train residents in these countries. The residents then graduate as specialists, and in turn, tutor the next cadre of Rwandan and Guyanese residents in a sustainable way.

In 2014, I first met the irrepressible Dr. Alex Harvey at Project Dawn – a repurposed former clinic that doubles as both housing for volunteers (upstairs) and a teaching facility (downstairs) in Lelystad, Georgetown. Alex and I had previously only worked together by email to coordinate a Lifebox pulse-oximeter training program for Guyanese clinicians traveling to the training site to receive instruction in the device’s use.  Schooled here on how to apply the finger clip to best measure a patient’s blood oxygen values and – using both simulated scenarios and video instruction – learning adjustments of anesthesia practice, guided by this new monitoring device, that could improve the safety of their care. The group of 40 clinicians returned to the hinterland – well-satisfied and with a new Lifebox in hand – after a full day of training.

“We need help,” Alex said, offering a glass of Eldorado rum, after inviting me to dinner at her home that night. Dr. Harvey, an English-trained Guyanese anesthesiologist, had returned to her country with a vision. She wanted to establish a proper residency training program, but needed anesthesiology teachers to help in the endeavor.

And so, now, some three years later, I was back – acting as a volunteer teacher in the newly established program with Alex in the operating room conducting a complex kidney transplant. We had a Lifebox pulse-oximeter beeping on the anesthesia machine signaling adequate oxygenation, but no radial arterial line to monitor the patient’s blood pressure.  Critical, because the patient suffered from malignant hypertension, but the necessary electronic monitoring device was not available. So instead, I used a technique that I had learned many years ago in Cape Town. I showed the two Guyanese residents, Dr. Onica Higgins and Dr. Youlanda Hendricks, how to fashion a simple saline manometer connected to the artery – colored with methylene blue for easy visibility. The blood pressure readout from an attached measuring tape, graded in milliliters of water, above the patient’s heart.

I was teaching the residents the essence of anesthetic management – simple solutions to complex problems – and providing clinical instruction, case discussions, and lectures according to a curriculum that Dr. Harvey had designed for the four-year residency program. Accompanying me those two weeks was a fellow American anesthesia resident, Dr. Whitney McLeod, who had chosen to come to Guyana and was training there under my supervision.

Housed at Project Dawn together with other volunteers, Whitney and I were sitting out on its balcony overlooking the lily-lined water canals that led to the nearby sea wall built to protect Georgetown from the encroaching Atlantic Ocean. Being our last night before we traveled back to America, we were reflecting on whether our volunteer efforts had made a difference, when we heard a sound from the darkness below. Puzzled, we peered into the darkness. Project Dawn was situated in a field and surrounded by an imposing fence with a 24-hour guard – going out after dusk was far from safe for innocents abroad.

We were relieved to hear two familiar voices – Onica and Youlanda – bringing gifts of thanks for our efforts. Having just finished their O.R. duties, they were worried we would already be asleep. Though the best gift we could ever get, we received two years later. Upon graduation, Dr. Youlanda Hendricks had joined Dr. Alex Harvey as a new faculty member – perpetuating the virtuous cycle of increasing anesthesia services in Guyana.

Berend Mets is chair, ASA Global Humanitarian Outreach Committee, and author of Waking Up Safer? An Anesthesiologist’s Record. He can be reached at his self-titled site, Berand Mets, and on Twitter @Dr_B_Mets.

Image credit: Shutterstock.com

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