John G. Brock-Utne - Anesthesia in Low-Resourced Settings: Near Misses and Lessons Learned

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Historically, the medical mission trip was the most common form of engagement in Global Health by anesthesiologists. In generations past, mission had a different meaning. Albert Schweitzer, a humanitarian and physician, won the Nobel Peace Prize in 1952 largely for his philosophy, Reverence for Life. His most notable work was the foundation of a hospital in Gabon in 1913, a hospital that has been rebuilt twice, but still provides service and sees patients today.

Over time, Global Health has evolved into its own field of study and has largely shifted focus towards building local capacity to strengthen healthcare systems through education and research. Many Global Health experts have even called into question the value and motivations of short-term, service-based mission work, citing ethical considerations and neocolonialism.

However, if you ask the countless patients whose lives have been changed from recto-vaginal fistula repairs when local surgeons do not exist, or the babies delivered safely by foreign physicians, or the child who no longer suffers from malnutrition after his cleft palate repair, then these mission trips receive resounding support. If you ask the 50,000 patients seen each year at Albert Schweitzer hospital, one could assume they support his mission.

Only when you work in a setting where resources are more constrained than your own do you realize the vast amounts one can take for granted. We cancel cases if the temperature and humidity are not perfect, while many operating rooms have open windows, unreliable electricity and lack running water. Individual tourniquets used for each and every patient can be substituted by tying the same latex glove around the arms of the days patients. Disposable gowns, drapes and masks are reusable cloth in other settings. Some anesthesia providers have never seen an end-tidal carbon dioxide waveform, and some EKG monitors use tiny needle electrodes. Oxygen, air and suction are not piped through the walls of most facilities. In fact, medical air is largely unavailable. Astonishingly, so is medical oxygen.

Using industrial oxygen instead of medical-grade oxygen for hypoxemic patients, using tap water instead of distilled water for ventilator humidification systems, using an adult blood pressure cuff on a paediatric patient these are real dilemmas faced daily by those working without the basic resources required for patient care. Providers are forced to make choices between the ideal, the less than ideal and the unthinkable, to get patients through surgery and critical illness. Although tough choices often inspire innovation from which we all should learn, there are many occasions where patient safety is compromised. Learning to maintain a narrow balance is the goal for any anesthesiologist working when resources are constrained.

The accounts in this book give historical context, exploring equipment most have never seen, medications no longer available, and a time before vigilance for patient safety with standard monitoring. In addition to practical learning points, this book poses common ethical dilemmas still relevant in todays global health practice. How do you obtain informed consent with cultural awareness? What should be done to prevent the donated equipment graveyards? What can we learn from traditional medicine providers? Through thoughtful case discussions, readers are given fair warning that challenges always arise when working in new settings, but solutions are usually local. In rural practice, these dilemmas continue to arise, not only abroad, but in our own backyards. For the anesthesiologists working in remote areas with fewer resources, for the anesthesiologists providing clinical service in foreign environments, for any anesthesiologist about to embark on a mission trip, this book will provoke considerations you did not have previously. You will be more prepared.

I am sure you will be surprised that there are 54 independent countries in Africa. There are also other countries outside of Africa that are mentioned in the case studies. They are included separately at the end. The information about all these countries includes its population, language and religion.

Algeria is a North African country with a Mediterranean coastline and a Saharan desert interior. Many empires have left legacies here, such as the ancient Roman ruins in seaside Tipaza. In the capital. Algiers, Ottoman landmarks are seen from circa 1612. Population: 42 million. Official language Arabic. Religion: Islam.

Angola is a Southern African nation whose varied terrain encompasses tropical Atlantic beaches, a labyrinthine system of rivers and a Sub-Saharan desert that extends across its southern border into Namibia. The countrys colonial history is reflected in its Portuguese-influenced cuisine and its landmarks including Fortaleza de So Miguel, a fortress built by the Portuguese in 1576 to defend the capital, Luanda. Population: 31 million. Official language: Portuguese spoken by 80% of the population, but there are six other African languages spoken. Religion: Christian.