Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Anesthesia in the Third World
What and How Much Do I Bring?
The answer to this question requires significant forethought, discussion with the
surgeons and nurses and knowledge of the concomitant medical diseases that might
be endemic to the population you intend to operate on.
Some locals, particularly in rural areas, but certainly in some large cities as well,
do not have compressed oxygen tanks, nitrous oxide, or inhalation agents, such as
italothane or isoflurane. When ventilators are available the lack of parts and/or timely
maintenance can present significant problems. It is incumbent upon the anesthesia
providers to ascertain with as much certainty as possible, the need to transport alternative
anesthesia delivery systems. Although the literature is replete with alternative
delivery systems, 1-4 the injunction by Whitten 5 “KIS KIS” (keep it simple, keep it
safe) certainly summarizes an important principle for the delivery of anesthesia care.
At a minimum, each anesthesia provider should personally bring a tool box consisting
of your own laryngoscope handles, as assortment of blades and batteries, of
endotracheal tubes, suction catheters, your favorite tape, essential emergency drugs
and alcohol swabs (Table 1). Additional blood pressure cuffs, intravenous (IV) tubing,
syringes, needles, breathing circuits, reducing values for oxygen cylinders,
scavaging hoses, portable monitoring equipment, vaporizers (must be packed with
extreme care), and ventilating bags packed separately should be transported as well.
Anesthesia providers should also personally pack enough scrubs, masks, hats, gloves,
shoes covers, and other items of personal preference.
The answer to the problem of what to bring is, again, partly resolved by determining
the types and number of surgical cases to be performed at a particular site.
The author has volunteered with Operation Smile International, Norfolk, VA since
1988. The George Washington University Department of Anesthesiology Annual
Mission to Mexico 1984 to 1988 and conferred with colleagues who have volunteered
with Interplant and Operation Orbis. On average these organizations perform
6-10 operations per day. 6,7 With two of these organizations approximately
one-third to three quarters of the cases would be infants and children, 8,9 most involving
facial deformities. Cases involving upper and lower abdominal surgery would
require more time and fewer cases would be done per day.
Although commercially prepared resuscitation kits are available and can be used
separately, the author prefers using a separate drawer in the tool box to include
drugs that deal with emergency situations, i.e., cardiac arrest, cardiac dysrhythmias,
malignant hyperthermia, shock, etc. A specific code or crash box must be located
centrally and in the PARR. The usual anesthetic drugs and local anesthetics are in
another drawer: atropine, thiopental, muscle relaxants, reversal agents, naloxone,
ketamine, etc.
It is critical for volunteers to understand the circumstances in which they will be
working. The author’s maxim has been and continues to be “anything that can go
wrong, will eventually go wrong.” This however does not have to detract from a
wonderful experience for the volunteer and a significant contribution to fellow human
beings. Volunteering in a developing country is not an experience for everyone.
The volunteer can be overwhelmed by literally hundreds of variables and situations
unlike anything they have experienced in their home countries. Many underdeveloped
countries have unspeakable poverty, malnourishment and diseases that the
volunteer has only read about. It is very easy to become overwhelmed by the needs
of not only the patients, but their families and communities as well. It is critical for
the providers to take care of themselves and their team members’ needs.
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