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Anaesthesia Provision in Low Income Countries- A Different Crisis

January 2012
(Vol 3, Issue 1)
Dr Justine Lowe Consultant Anaesthetist, St Mary's Hospital, Imperial College Healthcare NHS Trust Welcome to the Humanity First Medical update.
Not only is the word “anaesthesia” difficult to

With these updates, we aim to keep you informed about Humanity First medical activities and talk about the latest in news and controversies, in relation to our line of work with these updates. Please visit our website Humanity First Medical for more about our activities, contribution to this newsletter or to contact members of the Humanity First Medical team. I wish our readership a very happy 2012 and would like to invite you all to the Humanity First Medical Open day (please see details below). I welcome and thank Dr Justine Lowe for taking time out of her busy schedule and writing a very interesting article for us. Dr

pronounce and spell, the role of the “anaesthetist” in the care of sick patients is often poorly understood. Surveys have found that whilst most people know the anaesthetist “puts you off to sleep for your surgery,” many do not realise that whilst the patient is “asleep”, the anaesthetist ensures the patient's body systems (cardiovascular, respiratory, brain, kidneys, blood and temperature to name just a few) are supported and cared for, minute by minute, whilst the surgeon is busy concentrating operating on a designated body part. It can take a medical anaesthetist the same amount of time to train as a surgeon (up to 10 years after medical school in the UK), so they are well qualified to know how surgery and disease can affect a patient's body and exactly what to do should problems arise. This is particular relevant to very sick patients. The aim of this article is to highlight how good anaesthetic care can make a significant difference in surgical outcome especially in low income countries. Any improvement in secondary health care must take into account the need for well trained staff in anaesthesia.

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News Updates Lowe is based at St Mary's hospital, London, runs the anaesthetic training programme and regularly writes for medical journals. Stating the obvious, effective anaesthesia and pain relief forms the basis of all operations for children and people of all ages, ranging from delicate eye operations to open heart surgery. Lack of effective and safe anaesthesia will affect our ability to perform operations and this article helps us to better understand these issues. Finally, on behalf of the Humanity First Medical team, we would also like to the thank B BRAUN for their generous donation and sponsorship of the 6th Humanity First International Disaster Response Course held in UK.
In most high income countries, anaesthetists (or “anesthesiologists” in American speak) may be found be in many areas of a busy hospital. Not only can they be found in the operating theatres with the surgeons, they may be found in the emergency department (ED ) helping ED physicians resuscitate a critically ill patient; on the wards ensuring patients are medically optimised before surgery or in the post-surgical care area making sure patients wake up warm and pain free. They may be found on the intensive care unit looking after the sickest of patients or on the labour ward with the obstetricians and midwives helping people become parents in a safe and least distressful way. They may be involved in prehospital care with the paramedics, stabilising patients at a trauma scene before transferring them by helicopter or ambulance to hospital or even in an outpatient clinic treating patients with debilitating chronic pain conditions. The list could go on and is the reason why the anaesthetic department may be the largest medical department in a hospital compared to any other medical specialty.

Unfortunately the availability of good anaesthetic care is not uniform worldwide. In the UK, we are privileged to have 12,000 anaesthetists to serve a population of 64 million 1. That's one medical anaesthetist to every 5,000 people. In many low income countries, there may only be one medical anaesthetist to several million

HUMANITY FIRST MEDICAL OPEN DAY
Sat, 7th of January 2012 (9AM - 5PM) Charles Clore Lecture Theatre (Seminar Rooms 3 &4) Education Centre, St Marks Hospital, Northwick Park, Watford Road Harrow, Middlessex HA1 3UJ

people, and less in remote rural areas 2 . Because of this, many low income countries employ anaesthetic nurses, practioners, or technicians and even then, this skill is a scarce resource 3.

Every procedure carries a risk. In the UK, serious anaesthetic related complications are relatively rare and your risk of dying is reported to be approximately 1 for every 180, 000 general anaesthetics 4 . This is a very rough guide and the patient's medical problems and type of surgery need to be taken into account. However, to put this into perspective, death by murder in the UKis 5.6 per 100,000 5. So having an anaesthetic for your surgery in the UKis very very safe.

On behalf of the Humanity First Medical team I wish everyone a happy 2012. Over the years Humanity First Medical has come a long way. You may be aware that the Humanity First Medical has been responding to disasters since 1992 and 2012 marks the 20th year. Based on years

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of experience we now offer a regular training programme in the UK and USA. We encourage all new members joining the team to attend this course. Related to the course, we have now published the second edition of the Humanity First Medical practical manual. Those who have attended the course and visited the website will also be aware of our longer-term projects in various countries. We are however most aware of the continued need to develop further. We should continue to plan ahead and think about best possible ways to help people in need, the ONLY reason, for existence of our charity. This can best happen with your active participation. We wish to shape the future Humanity First Medical with your help and would like to invite you on the 7th of January to the Humanity First Medical Open day held at Charles Clore Lecture Theatre in St Marks Hospital in London. The day includes some lectures with a number of open forum seminars on the day. It will also be a great opportunity for us to meet and share ideas informally and we look forward to meeting as many of you as possible on the day. The implications of this shortage may be especially illustrated with the current maternal mortality statistics in the low income areas of the world. One woman in the world dies every minute because of pregnancy related complications 9 . 75% of these deaths occur in sub Sahara Africa and South Asia1. For any family, the death of any young mother is a tragedy. The impact on the surviving family and children, especially in these countries, is immeasurable. Some of the leading causes of obstetric death are major haemorrhage, obstructed labour or infection. These conditions often need an emergency surgical procedure and therefore an anaesthetic to be treated adequately or be life saving 10 . The Humanity First Medical Open day is being held on the 7th of January 2012 at the Charles Clore Lecture Theatre in St Marks Hospital. It is a full day active programme and starts at 9 AM. Those driving from outside London please invest in a Sat Nav now, and suggest this to include the purchase in your 2012 resolutions. Maps are boring but if you still wish to use one, I will recommend google maps. I believe there is a car park charge (Around 10£) and am not aware if it is free on Saturdays. Those coming by train, here is a guide: There is hope. Humanity First is aiming to address this significant disparity in the provision of anaesthetic care in developing countries. This includes a long-term From Watford Junction and Watford High Street... British Rail trains go to Kenton approximately every 20 minutes. The journey time is about 20 minutes. From Euston... British Rail trains go to Kenton approximately every 20 minutes. The journey time is about 25 minutes. From Marylebone... British Rail trains go to 1. Walker I, Bogod D, Wilson I. Editorial- Anaesthesia REFERENCES programme of infrastructure development, knowledge transfer and provision of resources where they are desperately needed in emergency care, trauma and surgery. Furthermore, delayed or lack of appropriate obstetric or resuscitation treatment contributes to the unacceptably high neonatal mortality in these low income countries where 4 million new born babies per year die 11. Any hope in improving either of these WHO Millennium goals need to ensure access to both safe surgical and anaesthetic care is addressed. The best sustainable way to do this is through education. In comparison, it has been reported that in some poorly resourced countries, anaesthetic related deaths are as high as 1 patient death for every 150 anaesthetics 6 . The reasons are complex but differences in training (e.g. some practioners are only trained for one year), lack of important monitoring or resuscitation equipment, drug shortages, including oxygen, and a lack of qualified medical support significantly affects the ability to provide timely and safe anaesthetic care and therefore good surgical care 7, 8 .

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Harrow-on-the-Hill approximately every 30 minutes. The journey time is about 10 minutes. From East London and The City... The Metropolitan line runs from Aldgate in the City, via Baker Street, through to South West Hertfordshire and Buckinghamshire. Please note that not all Metropolitan lines stop at Northwick Park station you may need to change at Baker Street for an 'all stations' service. From Northwick Park Station... It is a 10 minute walk to the hospital. From Kenton Station... It is a 20 minute walk to the hospital or a short bus ride. From Harrow-on-the-Hill... It is a short bus or taxi ride to the hospital. The taxi fare is about ¬£4 each way. in developing countries. Anaesthesia, 2007; Supp1: 23. 2. Malenka D, Rosenfeld A. Maternal mortality in resource poor settings: policy barriers to care. American Journal of Public Health, 2005; 95:200-203. 3. Zimmerman M, Lee M, Retnaraj S. Non-doctor anaesthesia in Nepal: developing an essential cadre. Trop Doct, 2008;38:148. 4. Cook T., Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br. J. Anaesth, 2011; 106(5):632-642 5. http://www.guardian.co.uk/uk/2010/jan/21/murdersdrop-home-office-figures<accessed 30/10/2008> 6. Ouro-Bang’na Maman AF, Tomta K, Ahouangbevi I look forward to meeting you on the 7th. For any queries (including selection of 'best' sat nav) please ring Dr H Khan on 07790 030773 or Mr S Rasheed on 07930 381339. Please email drsrasheed@hotmail.com if you wish to attend the day. S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa. Tropical Doctor, 2005; 35: 220–2. 7. Hodges SC et al. Anaesthesia in developing countries: defining the problems. Anaesthesia, 2007; 62:4-11. 8. Walker I. Anaesthesia in developing countries. A risk for patients. Lancet, 2008; 371:968-969 9. Grady K. Building capacity for anaesthesia in low resource settings. BJOG, 2009;116 (Suppl. 1):15–17. 10. Khan KS, Wojdyla D, Say L, Gulmezoglu MA, Van Look PFA, et al. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006;367:1066– 74. 11. Lawn JE, Cousens S, Bhutta ZA, Darmstadt GL, Martines J, Paul V, et al. Why are 4 million newborn babies dying each year? Lancet, 2004;364:399–401

Please visit our website Humanity First Medical for more about our activities, contribution to this newsletter or to contact members of the Humanity First Medical team.

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