Low resource international anesthesia tips

Healthcare jobs with pay you can see.
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
shepardsun

shepardsun

Full Member
10+ Year Member
Joined
Feb 5, 2010
Messages
656
Reaction score
551
Members don't see this ad.
Hi all, apologize if there is a thread for this that I haven't yet found.

I'm privileged for the opportunity to do an international rotation for a bit in a country with relatively limited medical resources. Mainly pediatric ENT cases. Was interested to see if anyone had any tips or tricks they have successfully employed for these types of trips. Thanks in advance.
 
Are you bringing your own supplies; using their supplies or a mixture of both?

Either way being familiar with the equipment is beneficial. Just as a example Leur-Lock tubing may not be the standard, it could be the tubing that requires needle access or bulb laryngoscopes handles vs the modern fiberoptic.
 
JobsFan said:
don’t exhaust their resources doing things your way
Click to expand...

Exactly, practice using as few items as possible. For example -

Avoid opening up meds to just “have ready” like phenylephrine/ephedrine/propofol, don’t open and pre-label syringes “just in case,” don’t open and pre-stylet several ETT sizes (better yet, don’t use a stylet unless you have to). For the same patient, if you are planning to give multiple anti-emetics try to reuse syringes if they stay clean (Zofran & Haldol for example). Refill the same syringe with more propofol. Run really low gas flows to conserve inhaled agents.

I have incorporated a lot of the above into my daily practice personally. There was a time in residency I’d have 3x 20 mL syringes of propofol drawn up and ready to go. It was excessive and wasteful!
 
Another thought I just had is, where I was, even though we brought our own medications, we would dip into their medication supply and more often than not their meds came in ampules, so having filtered needles (if that’s your sort of thing) would be nice as well.
 
I use 1 syringe all case, just have a 30cc or 50cc depending how much prop you need for induction, and draw up all meds into it save yourself some labeling and syringes. I try to reuse the mask and face strap for recovery by using an oxygen tubing and hooking it in to the mask so rather than opening up another non re-breather.
 
2Fast2Des said:
I use 1 syringe all case, just have a 30cc or 50cc depending how much prop you need for induction, and draw up all meds into it save yourself some labeling and syringes. I try to reuse the mask and face strap for recovery by using an oxygen tubing and hooking it in to the mask so rather than opening up another non re-breather.
Click to expand...
You're assuming they have a lot of oxygen to waste
 
AdmiralChz said:
Exactly, practice using as few items as possible. For example -

Avoid opening up meds to just “have ready” like phenylephrine/ephedrine/propofol, don’t open and pre-label syringes “just in case,” don’t open and pre-stylet several ETT sizes (better yet, don’t use a stylet unless you have to). For the same patient, if you are planning to give multiple anti-emetics try to reuse syringes if they stay clean (Zofran & Haldol for example). Refill the same syringe with more propofol. Run really low gas flows to conserve inhaled agents.

I have incorporated a lot of the above into my daily practice personally. There was a time in residency I’d have 3x 20 mL syringes of propofol drawn up and ready to go. It was excessive and wasteful!
Click to expand...
I was about to say, is there a reason this can’t be done here?
Then I read your last paragraph. Kudos to you.
We are way too wasteful a country. I see it all the time with the CRNAs. All these excess syringes and crap that ends up in the trash. Most people never think about where it goes after. And what a waste of resources it is.
 
I've had friends go on mission trips and have things like running out of O2 and Sevo in the middle of the case happen. Probably some poor planning on their part, but have a plan A B and C like you do everyday in a more modern OR.
 
chocomorsel said:
I was about to say, is there a reason this can’t be done here?
Then I read your last paragraph. Kudos to you.
We are way too wasteful a country. I see it all the time with the CRNAs. All these excess syringes and crap that ends up in the trash. Most people never think about where it goes after. And what a waste of resources it is.
Click to expand...

CRNAs I work with freak out when they see I only have 1 syringe, it's a foreign concept to them. But the amount of waste even 1 small case produces is staggering. Think about urology cases, how much water is used up, especially when when fresh water may become the new oil in the future, or even the giant bags for irrigation, dialysis, etc. If only there is a way to recycle medical plastics
 
Gas is very expensive. Use as little as possible. Low fresh-gas flows, etc. Do a spinal or regional block for everything you can. Hysterectomy? Spinal. Bowel case? Spinal. Anything urologic? Spinal.

I have a close friend who is a full-time missionary doc (FP trained). He does all the medicine, surgery, anesthesia, etc. Doing a spinal with a pulse ox as the only monitor with intermittent manual BP happens all the time.

Another friend does lots of mission work. He'll often run all the anesthesia for 3-4 patients with a spinal on board at a time. Yes, that means people are left unsupervised while he rotates between them.

I'm not saying you should do that, but standards are different in the rest of the world. Don't let your presconceived notions of the "right" way get in the way of helping people.
 
Thanks everyone for the replies. We're bringing all of our own supplies so as to not use any local resources but it has definitely been a little bit of an adjustment with the idea of re-using syringes, tubes, LMAs, etc.

Limited sevo so planning on running very low flows. The one thing we do have out the wazoo is precedex, interestingly enough.

My main discomfort at this point is not having all of my emergency drugs cracked and drawn up. I'm the kind of guy who makes sticks of little and big epi at the start of every day at home "just in case" (though it's saved my butt and helped me look really slick more than a few times). Lots of peds cases which at home would always get their own pre-measured doses of emergency atropine, sux etc.

Another random thought- as someone who was never really good at the engineering/mechanics concepts of machines, these portable ones are really forcing me to dig back to what I remember of the early Miller chapters to review closed vs open circle systems, etc. Great experience so far.
 
Ferrismonk said:
Gas is very expensive. Use as little as possible. Low fresh-gas flows, etc.
Click to expand...


We had an old timer who would turn the FGF off and run closed circuit anesthesia after inhalation induction on our quick (7-10min) strabismus cases. We do bring inspired and expired gas monitoring on our trips.
 
nimbus said:
We had an old timer who would turn the FGF off and run closed circuit anesthesia after inhalation induction on our quick (7-10min) strabismus cases. We do bring inspired and expired gas monitoring on our trips.
Click to expand...
True closed circuit would require a glass stopcock and liquid Iso/Sevo no?
 
SaltyDog said:
How long until the gas mixture got hypoxic?
Click to expand...

He’d have it shut down for the whole 10min case in most toddlers. At the end of the case, he’d open everything up. We use these machines which actually allow a FGF of zero.

8E919A4A-17FE-42F6-92E9-431D23AAFB5A.jpeg


You may have worked with him. Initials are JH. He was also the first guy to use capnometry at Children’s before it was an ASA requirement. He wheeled the machine from room to room on a cart.
 
Last edited:
Ferrismonk said:
Gas is very expensive. Use as little as possible. Low fresh-gas flows, etc. Do a spinal or regional block for everything you can. Hysterectomy? Spinal. Bowel case? Spinal. Anything urologic? Spinal.
Click to expand...

I'm not sure how embellished this story is, but I was taught by a guy who went to a very poor area of Africa many years ago to teach a handful of nurses how to perform anaesthesia. I think the country had one anaesthetist (I think from Europe?) in the capital city; but if you didn't live near the cIpital then you were **** out of luck. In the rural regions the medical practices were proper bush medicine and some bigger cities had some physicians/nurses, but traditional healers were the core providers. If you needed a section or emergency surgery you were in deep trouble.

So my mentor fellow went over to teach some nurses how to give an anaesthetic. The idea was they could have a handful of nurses in these non-capital cities who could do the airway/spinal while the main physician/nurse did the other stuff. It was to open up these regions to visiting international surgeons to do very low-risk procedures, which had previously been restricted to the capital.

The stories he told were ridiculous. He had to teach a select number of "the best of the best" nurses how to give a safe anaesthetic in places that might not even have reliable electricity in something like 10 weeks. The nurses were selected from returning nationals who got the best score in nursing school in a nearby country (this country had no medical/nursing school and was colonised by the French). The returnees were given an outdated copy of Miller's to prepare some 3-4 months prior to the hands-on process. When he arrived he found out that not all of them could read English particularly well as their nursing school had been in French... So half of them had been learning English while reading Miller's in the space of a few months.

Resources out rural were zero. Regional or bust. No monitoring, nothing. I think they had an abundance of pethidine or similar that some altruistic hospital had shipped to them a year or so ago because it was about to expire (it was all out of date now).

Some of his students ended up being the teachers of the next generation and he'd impressed something about high-spinals onto them, because through their chinese-whisper teaching strategy over the years their treatment for anything unusual (loss of consciousness/dizzy/N+V/confusion/whatever) had evolved into placing the patient steep head-up. Any deaths were chalked up to an extreme rate of "high spinals."

An O+G surgeon went to the same country to do some humanitarian work some years later. They refused to ever do humanitarian work again after seeing the absurd mortality rate during sections in that country. I think they did CPR 4 times in their first week with 1 death on the table and 2 tubed in their brand new ICU with significant neurological deficits. O+G doc tried appealing to them re: brain perfusion in steep head-up and what the most likely cause of these patients significant haemodynamic collapse had been (rarity of pressors there at that time). They were told it was just a case of 4 high spinals...

Careful what you teach people over there!
 
Last edited:
shepardsun said:
Thanks everyone for the replies. We're bringing all of our own supplies so as to not use any local resources but it has definitely been a little bit of an adjustment with the idea of re-using syringes, tubes, LMAs, etc.

Limited sevo so planning on running very low flows. The one thing we do have out the wazoo is precedex, interestingly enough.

My main discomfort at this point is not having all of my emergency drugs cracked and drawn up. I'm the kind of guy who makes sticks of little and big epi at the start of every day at home "just in case" (though it's saved my butt and helped me look really slick more than a few times). Lots of peds cases which at home would always get their own pre-measured doses of emergency atropine, sux etc.

Another random thought- as someone who was never really good at the engineering/mechanics concepts of machines, these portable ones are really forcing me to dig back to what I remember of the early Miller chapters to review closed vs open circle systems, etc. Great experience so far.
Click to expand...
Precedex is a first world drug; won't be of any use where you're going.
Take 1mg of epi, squirt it in a 250ml bag and you'll have enough for the whole mission.
 
dhb said:
Precedex is a first world drug; won't be of any use where you're going.
Take 1mg of epi, squirt it in a 250ml bag and you'll have enough for the whole mission.
Click to expand...

Not unless JCHAO has anything to say lol. I want to see the reaction of those guys if they're plopped in one of those places, they would shut down every hospital lol
 
Plenty of sub-saharan african countries have little to no medical specialists which is often something people don't consider when travelling.
I've heard 2 credible stories: one girl in Ivory Coast hit her head on a hike: sub-dural + no neurosurgeon = death, and one ended with a total colectomy from an appendicitis in BF Marocco.
 
woopedazz said:
I'm not sure how embellished this story is, but I was taught by a guy who went to a very poor area of Africa many years ago to teach a handful of nurses how to perform anaesthesia. I think the country had one anaesthetist (I think from Europe?) in the capital city; but if you didn't live near the cIpital then you were **** out of luck. In the rural regions the medical practices were proper bush medicine and some bigger cities had some physicians/nurses, but traditional healers were the core providers. If you needed a section or emergency surgery you were in deep trouble.

So my mentor fellow went over to teach some nurses how to give an anaesthetic. The idea was they could have a handful of nurses in these non-capital cities who could do the airway/spinal while the main physician/nurse did the other stuff. It was to open up these regions to visiting international surgeons to do very low-risk procedures, which had previously been restricted to the capital.

The stories he told were ridiculous. He had to teach a select number of "the best of the best" nurses how to give a safe anaesthetic in places that might not even have reliable electricity in something like 10 weeks. The nurses were selected from returning nationals who got the best score in nursing school in a nearby country (this country had no medical/nursing school and was colonised by the French). The returnees were given an outdated copy of Miller's to prepare some 3-4 months prior to the hands-on process. When he arrived he found out that not all of them could read English particularly well as their nursing school had been in French... So half of them had been learning English while reading Miller's in the space of a few months.

Resources out rural were zero. Regional or bust. No monitoring, nothing. I think they had an abundance of pethidine or similar that some altruistic hospital had shipped to them a year or so ago because it was about to expire (it was all out of date now).

Some of his students ended up being the teachers of the next generation and he'd impressed something about high-spinals onto them, because through their chinese-whisper teaching strategy over the years their treatment for anything unusual (loss of consciousness/dizzy/N+V/confusion/whatever) had evolved into placing the patient steep head-up. Any deaths were chalked up to an extreme rate of "high spinals."

An O+G surgeon went to the same country to do some humanitarian work some years later. They refused to ever do humanitarian work again after seeing the absurd mortality rate during sections in that country. I think they did CPR 4 times in their first week with 1 death on the table and 2 tubed in their brand new ICU with significant neurological deficits. O+G doc tried appealing to them re: brain perfusion in steep head-up and what the most likely cause of these patients significant haemodynamic collapse had been (rarity of pressors there at that time). They were told it was just a case of 4 high spinals...

Careful what you teach people over there!
Click to expand...
It's true. My FP mission friend worked a missionary hospital in BFE west Africa. People would come from days away because they knew at least the Christians wouldn't kill them on purpose or require bribes. They did have 2 African CRNAs, but they had to get rid of them because they were always stealing things, so now the FP doc does the anesthesia if needed.
 
dhb said:
and one ended with a total colectomy from an appendicitis in BF Marocco.
Click to expand...

I’m aware of some missionaries that had their kids’ appendices prophylactically removed prior to their long term trip.
 
shepardsun said:
My main discomfort at this point is not having all of my emergency drugs cracked and drawn up. I'm the kind of guy who makes sticks of little and big epi at the start of every day at home "just in case" (though it's saved my butt and helped me look really slick more than a few times). Lots of peds cases which at home would always get their own pre-measured doses of emergency atropine, sux etc.
Click to expand...


I used to do this in residency as well - mix a bag of phenylephrine, epinephrine, have sticks of atropine, etc ready to go...but you’ll come to realize how wasteful it is. How often do you actually use those medications? You may look slick once in a blue moon when you need to use them, but the vast majority of the time you’re just adding to the landfill (unless you’re doing something horribly wrong during your cases). Anything you can do to cut down on cost (without compromising patient safety) should be welcomed.

Additionally, you will become more comfortable acting quickly with intention in those scenarios where **** unexpectedly does hit the fan.
 
My residency place moved towards prefilled phenylephrine syringe at 100mcg/mL shortly after I graduated. Very nice to have available and I rarely had to crack one open.
 
SaltyDog said:
There was a thread on here where @militarymd described his plan for anesthetizing himself for an appy if necessary while stationed at gitmo.
Click to expand...
Yeah, I dunno if I'd trust those Florida anesthesiologists 1/2 an hour away either.
 
You must log in or register to reply here.

Similar threads

N
Tips - Setting up Anesthesia Group?
Replies
20
Views
2K
DesiredMemberName?
DesiredMemberName?
S
Anesthesia
Replies
2
Views
1K
SuxDrugs&Rocuronium
SuxDrugs&Rocuronium
L
Emory Anesthesia
Replies
24
Views
4K
We'llBeDoneIn15Minutes
W
S
Anesthesia Resident Arrested
Replies
22
Views
4K
aneftp
A
T
Open Anesthesia Cities
Replies
11
Views
2K
aneftp
A
Top