Global Surgery & Anesthesia

Ann -

This is a very hopeful model for all low resource settings. The American Society of Anesthesiologists began training non-physician providers in Africa for anesthesia in 1991, and many NGOs (MSF) are doing the same in other settings.

K A Kelly McQueen, MD, MPH

Dear Colleagues,



I am very pleased to see this posting. It is an acknowledgement of a fundamental consideration in Health Services Development. Surgery and Anaesthesia are inseparable. I grew up on an island where I was determined to return to practice after my training in medicine and specialization in Anaesthesia. My experience over the past 25 years is instructive and I will give a few snippets to illustrate and amplify the theme of this discussion.



While in training I made it my duty to learn all I can even from other specialities where I was not formally assigned simply because I knew that one of my long term objectives was to return to a resource poor setting. Therefore, I needed to be well equipped to handle all emergency situations and manage most common conditions no matter what specialty. One failing of modern medical training in the "developed" countries is that persons become too super specialized to function outside of their specialty. I still conduct a thriving General/Family Medicine Practice. I have been able to use that platform for Advocacy and Patient Education while leading the development of Specialty Anaesthesia and Critical Care Services on the island.



During my formative ...

Dear Colleagues,



I am very pleased to see this posting. It is an acknowledgement of a fundamental consideration in Health Services Development. Surgery and Anaesthesia are inseparable. I grew up on an island where I was determined to return to practice after my training in medicine and specialization in Anaesthesia. My experience over the past 25 years is instructive and I will give a few snippets to illustrate and amplify the theme of this discussion.



While in training I made it my duty to learn all I can even from other specialities where I was not formally assigned simply because I knew that one of my long term objectives was to return to a resource poor setting. Therefore, I needed to be well equipped to handle all emergency situations and manage most common conditions no matter what specialty. One failing of modern medical training in the "developed" countries is that persons become too super specialized to function outside of their specialty. I still conduct a thriving General/Family Medicine Practice. I have been able to use that platform for Advocacy and Patient Education while leading the development of Specialty Anaesthesia and Critical Care Services on the island.



During my formative years I observe that surgeons would be recruited to work on my island but will not stay very long, simply because they had to function in both roles as surgeon and Anaesthetist at the same time and hence they were limited to doing only minor procedures. That was one of my main motivation in the choice of a specialty.



In 2001 I did a review of the volume of surgical work done in Nevis. This clearly demonstrated that when there were trained anaesthesia providers the volume of surgical work dramatically increased, additionally the number of surgeons and the complexity of caseload also increased. This paper was presented at the All Africa Anaesthesia Congress held in Durban South Africa, in September 2001. It provoked quite a lot of interest and discussion.



When I trained in Glasgow for the FRCA my colleagues there would ask me what am I going to do with all that training?? Well I am pleased to report that since my return home in 1996 I have witnessed a transformation of the health services on this island. We have had a stable resident surgeon(s) and been able to retain OB/Gyn and a compliment of visiting sub-specialist surgeons. One of our surgical recruits went and sub-specialized in Urology and now does a visiting practice on a regular basis. There is now no need for any emergency surgical cases except ophthalmologic, Cardiac, complex multi-trauma and neurosurgical cases to be referred off island. The recent recruit of a Paediatrician has strengthened the provision of care to sick neonates. Particularly Emergency Caesarean sections and Laparatomies no longer need to be referred to the other island. Imagine the scenario of transferring such cases by sea in the middle of the night. Any transfers that are now done to the neighboring island take place after patients are stabilized and mostly because of a social/political reasons. Transfers further afield are of complex cases requiring diagnostic and Intensive support which we are presently not equipped to provide.



Additionally we have been able to provide intensive care support for up to 6 weeks and a recent cursory review indicate a 70% success rate to survival to discharge from Intensive care. Recently we had three such patients simultaneously.



I have been ably supported by two Nurse Anaesthetists and a third is about to complete training. All trained in Jamaica. The first two were trained soon after I started my training in anaesthesia. Therefore on my completion of training they were already in place. Together we have provided a formidable service of saving lives and reducing morbidity by strengthening the surgical care program. There is also a developing cadre of certified Critical Care trained nurses to complement the Anaesthesia team. Our general nurses are now no longer terrified of managing a ventilated patient and are showing an increasing interest to be trained in Intensive Care Nursing.



Prior to my return from training the local government eventually realized the need to recruit both an Anaesthetist and a surgeon simultaneoulsly until local personnel were trained. It is pleasing to note that this help came from Africa - the government of Nigeria



Best regards to all



Glenville E. Liburd FRCA

Thank you for your insights and for sharing with the group your amazing experience. As you say- for surgical services to be an effective and sustainable part of a health care system requires both providers in anesthesia and providers in surgery (as well as a cadre of skilled/interested nurses). Having one physician trying to do both anesthesia and surgery is not practical in the long-term and does not form a stable basis for building surgical capacity.

Nadine


Nadine B. Semer, MD, MPH, FACS

I'd like to echo Nadine's comment. Congratulations on making such strides in your surgical and intensive care. Thank you for contributing such an enlightening and personal experience, one that illustrates the need to improve training and recruitment in the global surgical and anesthesia workforce.