Incomplete and biased.

Jury-rigged anesthesia machine

Recently one of my colleagues returned from a large teaching institution in the medically under-served world – let’s say West Africa. We visit this institution frequently and have done so for many years. What he found on this trip was disheartening, and he noted problems in a report for the hospital administration. None of these problems are novel to those who deliver anesthesia in under-served environments - there are plenty of national surveys in the literature reflecting similar shortages. However, I think his observations are a useful illustration of problems facing our colleagues in the under-served world, even when they work in a teaching institution that receives regular donations of equipment, manpower and personnel from abroad.


[Hyperlinks in this section are to standard recommendations regarding that particular issue.]

1. Broken anesthesia machines. Two modern machines have been sitting broken in a hallway for over two years. In the meantime, older machines are cannibalized and jury-rigged to provide anesthesia for major surgery in newborns, children and adults. One operating room is closed for lack of a reliable anesthesia machine.
2. Ventilators. In addition to #1, the only mechanical ventilator (partially working) in the labor and delivery unit was taken away (“for repair”). Now, mothers requiring mechanical ventilation are held in the general operating rooms. Ten to fifteen emergency Cesarean sections are performed each day in these critically compromised conditions. This places further stress on the overstretched operating room resources (see #7).
3. Monitors. There are days with no working pulse oximeters. There are no anesthetic gas monitors. There are few automatic blood pressure monitors.
4. Neonatal resuscitation equipment. There is one working incubator; another has been broken for over two years. There are no neonatal resuscitation supplies (i.e. appropriately sized endotracheal tubes, newborn oral airways, small suction catheters, small face masks and pediatric laryngoscopes and blades). There are no bulb suction devices, so that no newborn is suctioned at the time of birth.
5. Basic anesthesia supplies. Endotracheal tubes, suction catheters, blood pressure cuffs, suction machines, and basic anesthesia medications are few, and scattered about the OR suite. They have to be located for each individual surgery (see #7).
6. Building maintenance. 
• In one of the operating rooms all the lights are out except the surgical lights making it very difficult to mix medications, watch the patient, observe the monitors and ensure the broken anesthesia machine / ventilator are working.
• The operating room suite, walls, cabinets, and shelves are filthy.
• There is very limited availability of soap and few working toilets in the hospital.
7. Logistics. Surgeons wait for hours to begin their surgeries because of #1 & #5. There is so much surgical back-log:
• Patients die in the Emergency admittance overflow area before they can have surgery.
• Patients lie in the halls for days with open fractures.
• The Burn Unit is full, and burn patients are kept in the Emergency Area. They are given general nursing care (not burn-specific) when (and if) overworked ER staff is available. 

Operating room table from the 1940s
- currently in use

One of the major contributing factors to the lack of equipment and supplies is theft. Monitors and boxes of supplies are regularly stolen from any unlocked storage facility. Consequently, almost everything is locked up and it takes much time and effort to locate the key-holder and gain access to the paltry supplies.
Pleas for help from the Anesthesia Department to the hospital administration have gone unanswered despite numerous fact-finding "committees" - the anesthetists have given up any hope for improvement.
This institution is one of two main teaching medical centers in the country, and yet conditions at other facilities are far superior. We believe these conditions so adversely affect the teaching of medical students, house staff, nursing and nurse anesthetists students as to defeat the educational mission of this institution.

Of course, there is no single, quick or easy solution to (any of) these problems. As always, the ‘system’ is to blame.  So, here’s my incomplete, biased, stream-of-consciousness list of things that need to change:

• The hospital administration must develop revenue streams, and prioritize the critical care services. Prices of vital equipment are dropping (state-of-the-art pulse oximeters are now available for less than $250). Consequently large scale provision can now be undertaken by institutions and/or charitable organizations. Donations cannot be the predominant source of consumable supplies – they are variable in type / quality / consistency, and the long-term goal must be self-sufficiency.
• Medical equipment must be engineered that is cheaper, less reliant on regular / sophisticated maintenance, and can reliably function in more austere settings. There's a very nice TED talk on this issue by Erica Frenkel.
• First the national educational system must get primary and secondary education in order. Then it must train more technical maintenance personnel. It’s naïve (although it would be nice) to imagine that the big medical equipment manufacturers will start offering extended maintenance contracts on donated / bottom of the range equipment; but with technical training, the creative and adaptable workers of the third world could better maintain this equipment.
• The level of professionalism / financial desperation among hospital workers has to be improved. There are studies in which health-care professionals state that they would be less likely to leave their native countries if they felt more valued / respected in their careers (and not just paid more money). Perhaps if they felt more valued / respected they may be less apathetic about their jobs (i.e. clean the shelves properly) and less likely to steal equipment.
• The road system and legislation must be optimized in order to reduce the enormous trauma toll. By 2020, road crash injury is predicted to be the third leading cause of disability-adjusted life years lost in low- and middle-income countries. This is a common editorial subject in local newspapers, and the WHO just declared the next 10 years "The Decade of Action for Road Safety", but the toll keeps rising.

• Continuing medical education must be enhanced to maintain the skills and knowledge of health care workers, prevent bad habits and improve the safety of patients. The scarcity of such opportunities is cited as one reason for emigration by many health-care workers (e.g. here and here). In an environment with limited equipment / medications, a robust, up-to-date knowledge of anatomy, physiology and pharmacology is of paramount importance.

Anyone have anything to add ?

[Follow-up. There have been unfortunate consequences to the poor maintenance of poor equipment. Read my post about it here.]