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Volume 4 Number 2 ISSN 1472-8820

World Anaesthesia
news
In this issue Clinical Investigations
Manpower in Pre-op tests
West Africa Epidurals in Mali
– Which way
Case Reports
forward? CS Gas induction
Heroin condom ingestion
Challenges in the
developing world News from
around the world
– Albania, Ethiopia, Eritrea
The mature and Zambia
anaesthetist
WA & WFSA News
Welcome to World Anaesthesia News
“Anaesthesia Worldwide” has now metamorphosed into “World Anaesthesia News” with
a new look and a new international editorial board. It is no longer the journal of the
World Federation of Societies of Anaesthesiologists (WFSA) but is supported by a
Contents
generous grant from the Federation. Feature articles
Anaesthesiologists are often confused by the relationship between the WFSA. and World
Anaesthetic manpower in West
Anaesthesia. I hope that the articles in this issue on each of these organisations will make
Africa 1
matters clear. Essentially, the WFSA is a federation of societies of anaesthesiologists as its name Challenges in the developing
suggests whilst World Anaesthesia is a group of individuals with similar aims, namely “to make world 2
available the highest standards of anaesthesia to all the peoples of the world.” Naturally, the two The mature anaesthetist 4
organisations work closely together and try to support each other’s endeavours.
This issue of World Anaesthesia News continues the tradition of publishing articles from News from around the world
individuals and societies in developing countries. At the end of these articles (from Ethiopia,
A message from Albania 6
Eritrea and Zambia) I have added a few statistics on gross domestic product (GDP), infant
mortality and life expectancy. The figures are all too familiar: GDP is under US $1000 per A history of anaesthesia services
capita, infant mortality approaches 100/1,000 and life expectancy is less than 50 years. In the in Eritrea 7
developed western world, comparable figures are GDP $20-30,000, infant mortality 5-6/1,000 A letter from Ethiopia 8
and life expectancy 70-80 years. The figures for parts of Eastern Europe and the former USSR
The WFSA in Zambia 9
lie somewhere in between. With so little available to be spent on health, it is easy to be
pessimistic but all the authors remain optimistic about the future in their countries
Clinical investigations
I would also commend to you Prof. Thara Tritrakarn’s essay, based on a talk he delivered
at the World Congress in Montreal in June. He concludes that if we in the West can help train Epidural anaesthetic practice
a single anaesthetist who returns to his or her home country, we will have made an
in Mali 11
immeasurable contribution to the improvement in health care in that country. There is our Pre-anaesthetic tests in
challenge for the new millennium. ASA I and ASA II patients 12
The editorial board and I look forward to hearing your thoughts, critical or otherwise of
our efforts and of receiving your contributions to future editions of World Anaesthesia News. Case Histories
Anaesthetic consideration of
William F Casey Heroin condom ingestion
CS Gas induction of anaesthesia
14
15

Useful information 16
The editor of World Anaesthesia Dr Rob McDougal (Australia) Anaesthetic websites to try 18
News is: Email:
Dr W F Casey mcdougal@cryptic.rch.unimelb.edu.au Feature Extra
Popes Cottage Gassing in Guinea
Cheltenham Rd Dr Tom Ruttmann (S.Africa) – on and off ship 19
Gloucester GL6 6TS, UK Email: ruttmann@samiot.uct.ac.za A detached retina in the land
Tel: (+44) 01452 814229 of yaks and yetis 21
Fax: (+44) 01452 812162 Dr Iain Wilson (UK) Pigs might fly! 22
Email: wfcasey@doctors@org.uk Email: iain.wilson5@virgin.ne
The WFSA 23
Editorial Board Editor Emeritus The constitution of World
Dr Dixon Tembo (Zambia) Dr Roger Eltringham (UK) Anaesthesia 24
Email: dctembo@zamnet.zm Email: 106147.2366@compuserve.com A letter from Dr Iain Wilson 25

Prof. Rebecca Jacob (India) Submissions to World Anaesthesia


Book Review 12
Email: rebeccajacob@hotmail.com News may be sent to any of the above.
Anaesthetic Manpower in West Africa

Feature Stories
– which way forward?
commenced in 1970 and at the West years with only 6 Fellows of Anaesthesia; a
Dr O A Soyannwo & Prof. E O Elegbe
African Medical College in 1979. In their ratio of 1:49.
Department of Anaesthesia early years, both colleges produced a total of The Diploma in Anaesthesia
University College Hospital 75 fellows in Medicine and Surgery but programme of the West African College of
Ibadan, only one in Anaesthesia. We have looked at Surgeons, a constituent College of the West
Nigeria. the impact of the West African Postgraduate African Post-graduate Medical College
Email: wemimak@infoweb.abs.ne Medical College training on anaesthetic (WAPMC) was commenced in 1990. This
manpower development. programme yielded 56 diplomats within the
5 years studied. However, 30 (53%) of these
Introduction Methods and Material diplomats were also pursuing the Fellowship

S ince the introduction of ether in 1846,


anaesthesia has witnessed many
innovations in the drugs, equipment and
The number of candidates who registered
for the examination of the West African
College of Surgeons Fellowship in
programme.

Discussion
techniques used. The Schimmelbusch mask, Anaesthesia from April 1992 – October Postgraduate medical education based in the
EMO and standard Boyles machine have 1995 was collected from the West African West African sub-region has been pursued
been replaced with computerised anaesthetic Postgraduate Medical College. The records with vigour since the early 60s by experts in
and monitoring equipment for the safe were reviewed to establish the number of all specialties. These teachers, who generally
administration of anaesthesia. The wider candidates that actually attempted and those had their training in overseas institutions,
range of drugs available allows a flexibility of who passed examinations of the College in were determined to train their junior
techniques suitable for novel and April and October of each year. The ratios colleagues locally at reduced cost to provide
demanding surgical procedures and patients’ of anaesthetist to surgical graduates were improved medical services. The dearth of
varying medical conditions. Thus, advances determined. The number of anaesthetists anaesthetists has, however, continued, with
in surgery have been possible largely due to trained through the Diploma programme the ratio of anaesthetists to the general
modem anaesthesia. over the same period was also obtained and population being at least 1:300,000
Many of the early pioneers of the number that proceed to the Fellowship compared to 1:10,000 in developed
anaesthesia were surgeons like James programme was determined. countries. In a recent survey of 52 hospitals
Simpson, physician to Queen Victoria, who in 15 states of Nigeria, nurse anaesthetists
popularised the use of chloroform. By virtue Results provide service with physician anaesthetists
of their eminent position in the medical The Faculty of Obstetrics and in 50% of hospitals and were the sole
world, they advocated and championed the Gynaecology attracted the highest number providers of anaesthesia in 20% of the
use of anaesthesia, sometimes against of postgraduate trainees with a steady hospitals including some teaching hospitals.
considerable opposition. increase in the number of candidates Although nurse anaesthetists provide useful
The Association of Anaesthetists of attempting the examinations from 275 to assistance to physician anaesthetists in many
Great Britain and Ireland was founded in 312 candidates over the five years of the parts of the world, strict guidelines are
1932, whilst the first examination for the survey. There were between 91 and 101 necessary to ensure the safety of patients. In
Diploma in Anaesthesia was held in 1935, candidates at Part 1, 22 to 58 at Part 2 the Gambia, surveys have shown that
the same year that a chair in anaesthesia was and 16 to 40 Fellows produced per year. problems such as post-operative fluid and
created in Oxford. The status of anaesthesia This was closely followed by the Faculty of electrolyte imbalance, septicaemic shock,
in Great Britain, on a par with other Surgery producing 16 to 39 Fellows per difficult airways and intercurrent medical
medical and surgical specialties, was secured year. Anaesthesia had only 9 to 27 diseases occur in 65% of surgical patients
in 1948 with the introduction of the candidates at Part 1, 17 to 26 at Part 2 and require the expertise of physician
National Health Service. Since then, and zero to 2 Fellows per year. A total of anaesthetists if outcome is to be improved.
anaesthesia in the developed countries has 2,963 candidates sat for the primary Anaesthesia as a career is unattractive
advanced very rapidly, become very safe and examination of the various surgical to both medical students and interns
thus allowing advances in surgery. specialties viz. Obstetrics and Gynaecology, because of the “behind the scene” nature of
In West Africa, training of Surgery, Dental Surgery, Ophthalmology the specialty and their lack of adequate
anaesthetists locally to Diploma level and Otorhinolaryngology, but only 93 exposure to it during their training.
commenced in 1967 with the creation of candidates sat the anaesthetic primary. This Unfortunately, the areas where anaesthetists
the first autonomous Department of produces a ratio of 32 prospective surgeons are primary care providers such as in
Anaesthesia at the University of Lagos. Post- to l anaesthetist. The end point of the Intensive Care, Resuscitation, and Pain
graduate fellowship training in Nigeria training produced 292 Surgical Fellows in 5 Therapy Clinics are poorly developed or

1
non-existent in most African hospitals. they then may find the specialty postgraduate training in surgical specialties,
Feature stories

Thus, the few doctors that join the specialty interesting and fulfiling as a potential only a few are interested in anaesthesia. It
find the work unrewarding especially when career. was initially thought that one year’s training
they are presented with poorly prepared The Diploma in Anaesthesia to Diploma level might ease the manpower
patients, have a restricted range of programme should be re-structured and shortage but since the training is based at
anaesthetic agents with little monitoring supported by Governments. For example, tertiary institutions, most of the trainees
equipment and inadequate resuscitation medical officers already in service could be decide to continue to the Fellowship
faculties. It is, therefore, not surprising that sponsored during their training and then be programme and this reduces the number of
despite the efforts of many within the sub- made to serve for a specified period in clinical anaesthetists working in the
region, the specialty remains unattractive. government hospitals before they would be secondary level of health care.
Many of the few locally trained anaesthetists eligible for further sponsorship for the
quickly migrate from West Africa to more Fellowship programme if that is what they Conclusion
attractive areas where there is a shortage of wish. Such a move will not only provide Advances in surgery have been
anaesthetists. Even our locally trained improved services at the secondary level of possible largely due to innovations in
Diplomats have found favour with the health care delivery but will reduce the drift modem anaesthesia. However, whilst there
Nigerian Government’s technical assistance of trained anaesthetists into urban private are enough anaesthetists in most
scheme and they are sent to work in other hospitals. developed countries to allow sub-
countries. At the tertiary level, accreditation specialisation there is profound shortage of
What then is the way forward when criteria for surgical departments should anaesthetists in West Africa. The situation
anaesthetists are under pressure to provide require adequate anaesthetic and resuscitative is being made worse as few undergraduates
services for sicker patients undergoing an facilities in the hospital. West African or new medical graduates are willing to
increasing range of surgical procedures? countries with compulsory National Service consider anaesthesia as a future career. At a
Only a combination of strategies can Schemes should allow the year to be spent in recent meeting of the West African
redress the widening gap between the anaesthesia and other specialties with chronic College of Surgeons in Conakry, Guinea
numbers of trained anaesthetists and manpower shortages. Further, efforts must in 1999, 146 new fellows were admitted
surgeons in the sub-region. Since medical be made to ensure that essential facilities for to the College, six of whom were
education should respond to the health the safe practice of anaesthesia be provided at anaesthetists, a ratio of 1:24. Of the six,
needs of the community, the time all levels of health care and that those who three were Nigerians, 2 were from Guinea
allocated solely to anaesthesia in the provide it are financially adequately and 1 from Gabon.
medical students curriculum should not be remunerated. These measures will not only
less than eight weeks and the specialty promote the growth of anaesthesia in the Acknowledgement
should form one of the options for intern sub-region but also improve standards in We wish to thank Professor Kayode Odusote.
training before full registration. New surgery and critical care medicine. Secretary, West African Postgraduate Medical
graduates should have an opportunity for This study has further confirmed that College for his invaluable assistance in data
locum appointments in anaesthesia and despite the large number of doctors seeking collection.

Challenges in the Developing World


Prof. Thara Tritrakarn little access to anaesthetic services. Many capita in US dollars in 1999. Countries with a
lives are lost because surgery and high GNP have plenty of doctors, low patient
Siriraj Hospital,
anaesthesia are inaccessible to patients and per doctor ratios and low infant mortality
Mahidol University,
their families. There is a great shortage of rates. In countries with lower GNPs, the
Bangkok, anaesthetists in every developing country number of patients per doctor and the infant
Thailand with ratios as high as 1 million potential mortality rises.
Email:sitti@mahidol.ac.th patients to each anaesthesiologist. Without In countries with a low per capita GNP
t is 154 years since the birth of anaesthesia adequate anaesthesia, surgery cannot (below US $1,000 per annum), priority is
I on October 16th 1846 when ether was first
used. Anaesthesia has contributed to the
progress and the health and welfare of
millions of people suffers.
usually given to primary health care to reduce
the incidence of infectious diseases, to
advances made by all branches of surgery, reduce maternal and infant mortality and to
intensive care and pain management and, in Economics and Anaesthesia reduce malnutrition. Anaesthesiology is
the developed world, anaesthesiologists are Economic, political and social factors ignored. In Laos, ten anaesthesiologists serve
respected and highly paid members of the influence the priority given to health care and a population of 5.3 million, in Cambodia, 20
medical profession its various specialties including anaesthesia. anaesthesiologists seek to serve 10 million
On the other hand, in many parts of the In Table 1, thirteen countries are listed by the and in Bhutan, there are no physician
developing world, would-be patients have gross national product (GNP) or earnings per anaesthetists at all. What few anaesthetists

2
Table 1: Relationship of economy to health care indices and anaesthesia manpower

Feature stories
Country GNP/US$ Pop. Infant mortality Pt. per doctor No. anaesthetists Pt. per anaesthetist Nurse anaesthetists
USA 31,400 273m 7 387 23,300 11,500 Yes
Japan 30,300 126m 5 522 4,200 20,000 No
Singapore 21,800 4m 5 667 130 26,000 No
Hong Kong 24,700 6m 5 772 150 40,000 No
Malaysia 3,100 22m 12 1,477 250 88,000 No
Thailand 1,850 62m 26 2,461 500 124,000 Yes
Indonesia 460 207m 60 6,786 350 591,000 Yes
Pakistan 492 136m 88 2,000 400 340,000 No
Laos 258 5m 94 4,300 10 500,000 No
Bangladesh 289 130m 90 12,500 200 650,000 No
Vietnam 310 79m 34 2,300 400 197,000 Yes
Cambodia 270 10m 110 9,000 20 500,000 Yes
Nepal 225 23m 88 12,000 80 287,0000 No

there are, work in teaching hospitals in large equipment and serve the poorer sections of Drugs and equipment
cities. In smaller towns and cities, surgeons the community. In smaller cities, anaesthesia Selecting appropriate drugs and equipment is
or general practitioners, nurses or technicians is often administered by nurses or another challenge for anaesthesiologist who
administer anaesthesia. Surgical mortality is technicians working under the supervision of have trained in western or developed
high and the risks of anaesthesia often medical doctors or entirely unsupervised. In countries and grown used to using state-of-
exceed those of surgery. countries such as Thailand, Indonesia and the-art drugs and equipment. With limited
In countries with a moderate per capita China, nurses administer 70-90% of budgets, cost benefit ratios have to be
GNP (US $1,000-10,000), more money is anaesthetics. carefully considered. Propofol and
available to be spent on health and Anaesthesiologists in developing sevoflurane cost 20-30 times more than
secondary and tertiary care receive some countries work very hard. They strive to thiopentone and halothane. Is a slightly
priority. Hospitals are better equipped and offer safe anaesthesia to their patients shorter awakening time worth that extra
staffed and specialisation is encouraged. despite having a limited range of drugs and cost?
Anaesthetists are in high demand but few in equipment. They are, in addition, often Electronic monitors frequently break
number and rarely work outside large cities. responsible for patient care in Intensive down if not properly maintained and they are
Only in countries with a high GNP are there Care Units, for supervising nurse costly to repair. Anaesthesiologists in
sufficient anaesthetists but their services can anaesthetists, purchasing drugs and developing countries must decide what are
be very expensive. equipment and being responsible for the the most appropriate monitors for them.
maintenance and repair of equipment. Pulse oximeters detect hypoxia before clinical
Anaesthesia in the developing Journals and textbooks are scarce and signs are evident and are probably of greater
world opportunities for post-graduate education, value as the sole monitor than an ECG,
The ultimate goal of anaesthesiologists is the either at home or abroad, are few and far capnograph or oxygen analyser.
same worldwide: “the provision of safe between. Research is difficult or
anaesthesia for all.” It is much easier to impossible. Their status and income is Human resource development.
achieve this goal in rich and developed often lower then that of surgeons and Many developing countries do not know how
countries where anaesthesiologists are not physicians and many anaesthesiologists many anaesthetists they need but should
only equipped with knowledge but have the have to undertake several jobs to earn implement a realistic human resource plan
drugs, equipment and support facilities they enough to support their families. for anaesthesia. The mix of the workforce
need. Like other health professionals they should be made explicit: whether all
enjoy good working conditions and have Politics and health care. medically qualified anaesthetists or is there a
sufficient income to maintain their families In the developing world, when governments continuing need for nurse anaesthetists. In
and their social status. change everything including health budgets countries where there is a shortage of
In less affluent, developing countries it and priorities change. It is essential for doctors, an entirely medically qualified
is a greater challenge. Anaesthetic practice anaesthetists to win the support of anaesthetic work force is inappropriate and
can vary considerably, even within a given politicians and the community at large and to nurse anaesthetists are vital and
county. In the larger centres, medical schools, impress on them the importance of indispensable. Appropriate and concurrent
teaching hospitals and private clinics are anaesthesia to public health if they are to plans for their development have to take
usually well equipped. Public hospitals often make any substantial improvements in place alongside those for physician
have poorer facilities, fewer drugs and less patient care. anaesthetists.

3
Because of low income, low Australia in the Pacific and France in

The Mature
Feature stories

professional status and a perceived lower francophone Africa.


quality of life, anaesthesia remains an To prevent and influx of foreign medical
unattractive profession. Support for its
development from politicians, government
and health providers is essential. Foreign
graduates to the United States, increasingly
difficult and expensive examination hurdles
have been introduced (ECFMG & USMLE).
Anaesthetist
support may also be initially needed to start Only the most determined foreign medical
and develop suitable training programmes. graduates are able to enter the United States Rebecca Jacob
and they often find themselves involved in Professor & Head, Dept of Anaesthesia
Improve professional esteem sophisticated basic research divorced from The Christian Medical College and Hospital
and popularity clinical medicine and irrelevant to the actual Vellore,
Anaesthesiologists in the developing world practice of medicine in their home countries.
India
must constantly prove to their surgical The gap between clinical medicine in the
colleagues their ability, knowledge, skill and United States and in developing countries is
Email: rebeccajacob@hotmail.com
professionalism. Their contributions to
Intensive Care, trauma management,
resuscitation and pain management will
becoming wider by the day.
In the United Kingdom, the fees
charged to foreign students were
A mong the definitions of the word
“mature” given in Chambers Dictionary
are “full development” or “perfection”.
gain them recognition and win them dramatically increased in the 1990s to Maturity and chronological age do not
professional esteem. They must show £17,000 (US $25,000) per year and continue necessarily go together. We associate youth
medical students and young doctors that to increase by 10% per year. These with quick motor function but a certain
anaesthesia is an interesting and exorbitant fees are an effective barrier amount of ineptitude. Conversely, we
intellectually satisfying branch of medicine preventing students travelling to the UK to associate age with experience and common
combining anatomy, physiology and study medicine and anaesthesia. The image sense and hope that, as we mature,
pharmacology with a clinical knowledge of of the generous British gentleman experience and common sense added to our
medicine and surgery and technical encouraging learning and scholarship will basic knowledge will more than compensate
anaesthetic skills. Anaesthesia makes gradually change that of the stingy, niggardly for our slowing motor function.
surgery possible and safe, relives patients and selfish profiteer. If changes do not occur Anticipation and the prevention of problems
of pain and saves lives from trauma and in the USA and the UK, immeasurable become the norm.
critical illness. damage will be done to medical education in Sometimes though, experience doesn’t
the developing world. go hand in hand with common sense. We
External help may take unnecessary risks such as not
In 1950, the World Health Organisation Give a helping hand wearing gloves when obtaining intravenous
(WHO) established an anaesthesia training More than half the world’s population has access. How many of us ‘mature’
centre in Copenhagen, Denmark. It ran a one very limited access to anaesthetic services anaesthetists have encouraged our junior
year training course for anaesthetists from but there are a large number of anaesthetists colleagues to get immunised against hepatitis
developing countries until 1973. Many in the developed world who can help their and have not got immunised ourselves?
doctors completed the course and then colleagues assist these people. Universities, So, what are the qualities associated
returned home to become the pioneers of national societies and organisations and with maturity? I would suggest they include
anaesthesia in their homelands. Some, individuals can play an active role in the a lot of common sense coupled with
however, gained specialist qualifications development of anaesthesia not only at professional skills, confidence, and an ability
and decided to stay in the West and enjoy a home but also at a regional and world to maintain good interpersonal relationships
more affluent life-style than would be community level. If only 1% of them helped and to work as part of a team. Coping with
possible at home. train a single anaesthetist from a a stress is also a major element of maturity.
More recently, the World Federation of developing country who then returned home Managing a family and having a
Societies of Anaesthesiologists (WFSA) has to train their juniors, the standard of fulltime job can be extremely stressful. When
been active in establishing training courses anaesthesia in their respective countries we are young, we make the decision to find
for anaesthetic personnel around the world. would rise immeasurably. But be careful; do a partner, have children, and perhaps drop
The Bangkok Anaesthesia Training Center not give them internationally recognised and out of “the system “ for a while. When we
(BARTC) was established in 1995 by the marketable qualifications. It is human nature resume our professional careers there is
WFSA and the Royal College of to seek to emigrate to where one can enjoy inevitably conflict between our professional
Anaesthesiologists of Thailand (RCAT) to a higher standard of living. Encourage them and family responsibilities. In my country,
train anaesthesiologists from similar to go home and help their fellow very rarely does a woman give up her
countries (Laos, Cambodia, Vietnam) who countrymen. profession because of domestic pressures.
would then return home and become the The joint or extended family usually helps
future trainers in anaesthesiology, thus This essay is based on a talk given at the out and the ready availability of dependable
raising standards in their respective World Congress of Anaesthesiolgoy, Montral live-in maids is also a great help. Yet the
countries. Other developed countries have 2000. The bold print above is mine, not the worries of having a sick child at home,
helped elsewhere: Canada in Nepal, author’s (Ed) attending parent/teacher meetings, preparing

4
for school examinations or handling woman as they are to a man. Irrespective of
Electronic

Feature stories
recalcitrant teenagers are all part of the whether the primary cause of stress is dom-
process of maturing and learning to cope. estic or professional the two often interact

Publication of
The older anaesthetist may often has causing profound consequences to both.
to cope with intercurrent illness such as It has been said that it is very lonely at
diabetes, ischaemic heart disease or arthritis the top: it is, but it is very challenging as

“Update in
and remember to take a handful of tablets well. Find ways of dealing with the
every night Living with busy on-call associated stress. Find a partner, friend or
schedules and the inevitable disruption of colleague to whom you can unload your

Anaesthesia”
sleep also becomes increasingly difficult. troubles and frustrations without fear of it
What about the “normal’ business of being misconstrued or repeated elsewhere.
menopause? Only those who have gone Develop skills of control, assertiveness and
through a stormy peri-menopausal period diplomacy. It is important to learn to
can understand the feeling of inadequacy, respond appropriately to verbal aggression. ● “Update in Anaesthesia” is an education
the inability to react rapidly in a situation Non-verbal behaviour and body language are
journal produced by “World Anaesthesia”,
which was formerly considered a challenge important in the way messages are conveyed
but easy to handle, the embarrassment of and received. Learning how to say ‘No’ for widely distributed and acclaimed in many
“hot flushes”, and the sudden feeling of “I good reason, being assertive without being developing countries.
can’t carry on”. When one is young, one aggressive and appearing co-operative help
never imagines that declining levels of oestr- establish rapport and are conducive to better ● An electronic version of “Update” including
ogen can lead to so much emotional trauma. collaboration with colleagues and students. back issues is now available – you can read
Having to work with a variety of When in a position of responsibility,
it on your computer screen (using suitable
people: surgeons, nurses, technical staff and back your staff and colleagues. Do not jump
free software), and download and/or print
other anaesthetists can be pleasant and to conclusions. Do not magnify mistakes or
fulfiling. However, there is also the potential minimise successes. Never let your staff all or part of it for reference.
in our close working environment for down: their trust and faith in you is
difficult interpersonal relationships. This is invaluable. It is important that all members ● If you have an Internet connection you can
more stressful if one has reached a position of a department support each other as access “Update” at
of responsibility. You are responsible for the factions within departments are extremely http://www.nda.ox.ac.uk/wfsa It can be
smooth running of the operating rooms, for destructive.
viewed with either a graphical browser
being diplomatic when there is a confront- Time management is also important
(looks prettier) such as Netscape or a text-
ation between a surgeon/nurse and a fellow and it should be understood that time
anaesthetist, for providing a shoulder for a cannot be expanded infinitely to meet only browser such as Lynx.
junior consultant to cry on, for knowing all demands. Preserve personal time, pursue
the answers to a postgraduate’s questions hobbies, indulge in regular physical exercise ● If you don’t have Internet access but do
and, of course, for finding time to deal with and remember to relax. Let these time-outs have a computer, we can post you the same
all the administrative load that finds its way help put the stresses of life in their proper material on floppy disk with instructions on
to your desk. prospective.
use. (N.B. This only applies to developing
In addition, when women are It is important to recognise the things
countries.)
successful in their careers, they can that can be changed and have the courage to
unwittingly arouse feelings of jealousy, anger change them, to accept those you cannot
and a sense of unfairness in their male change and to have the wisdom to know the ● You do not need the latest and most
colleagues. It is a tremendous advantage to difference. Knowledge, experience, pre- expensive computer to make use of
have a partner who is self assured and planning and an understanding of one’s Electronic Update: a 286-PC should be
confident in his own right rather than one limitations are signs of a mature anaesthetist. adequate. If you need technical advice,
who feels inadequate and is unsure of As time goes on, we see our influence on the
please write to Dr Mike Dobson, Nuffield
himself. A husband who feels threatened by work we do, on our colleagues, students and
his wife’s success can prove to be very friends. We also see their influence on our
Department of Anaesthetics, John Radcliffe
difficult to live with. lives and on our outlook on life. Hospital, Oxford, OX3 9DU, UK., or send an
Fear of the future is very real. Some The prayer of the mature anaesthetist Email request to:
may be blasé with a feeling of ‘I will be able could be: michaeldobson@ndm.ox.ac.uk
to ride this out’ but more often than not, “Lord give me love and common sense
one feels the inadequacies of old age And standards that are high, ● An electronic version of “World Anaesthesia
advancing and can’t help wondering whether Give me calm and confidence
Newsletter” (incorporating “Anaesthesia
one’s deteriorating skills will adversely affect And please, lord, a twinkle in my eye.”
one’s patients. Loss of a beloved partner at
Worldwide”) including back issues in similar
this stage is also very traumatic. Financial This essay is based on a talk given at the World format is also now available at the same
security and independence are as vital to a Congress of Anaesthesiology, Montreal, 2000 Internet site.

5
A Message from Albania
Dr Aposotol Vaso practice and used what were
Anaesthesiology Department then the most modern
Trauma Centre general and regional
Central Military Hospital anaesthetic techniques. In the
Tirana mid-1960’s he was joined by
Albania Dr Besim Elezi who was the
Email: 106147.2366@compuserve.com first Albanian to be trained in
anaesthesia in Western

A
lbania is an often forgotten Europe, in Denmark. He
country of 28,00 sq. km (a little subsequently left anaesthesia
bigger than Israel) on the west to become the spiritual and
coast of the Balkan peninsula, north of scientific leader of surgery in
Greece and separated from Italy by the Albania.
Adriatic Sea. The population is 3.3 million The 1970’s saw a generation of We have a limited range of drugs
and the official language is Albanian, an doctors trained in Eastern Europe and the available: thiopentone, suxamethonium,
Indo-European language that has little in Peoples Republic of China. Among them pancuronium, fentanyl and morphine. We
common with other European languages. was another surgeon, Dr Maksut Drrasa, also have nitrous oxide and halothane.
Historically, Albania was part of the who was the first to introduce epidural Medical textbooks are also in short supply
Roman and then the Byzantine Empire. For anaesthesia into routine practice. In the and only a very limited range of books
over five hundred years until independence late 1970’s and early 1980’s, a cohort of and journals can be found in the
in 1912, it was part of the Turkish Ottoman anaesthesiologist trained at the University university library. There are no anaesthetic
Empire. From the end of the World War II of Tirana started to enter practice and only textbooks or journal written in Albanian.
until 1990, it was one of the most extreme then was it possible to introduce a Through the initiative of Dr Mihal
and isolated communist states in the world. comprehensive anaesthetic service for the Kerci, a conference on Anaesthesia and
Today, it is a parliamentary democracy with whole country. Intensive Care will be held in the Albanian
Tirana, a city of approximately 500,000, as A Department of Anaesthesia was Trauma Centre in Tirana in September
the capital. established at Tirana University headed by 2000. The Tirana Trauma Centre has a 14-
In the last ten years, since the fall of Dr Tritan Shehu who, ten years later, bedded ITU, 10 operating theatres, 13
communism, our country has undergone became the first Professor of Anaesthesia anaesthesiologists and about 60 general,
massive social and economic changes that in Albania. He also established the orthopaedic, neuro- and vascular surgeons.
have been made more difficult by the Albanian Association of Anaesthesiology Cardiac, paediatric, plastic and other
turmoil in our large neighbour, the former in 1993 but, because of adverse surgical specialties are practised at the other
Republic of Yugoslavia. The health care circumstances, it is yet to organise a affiliated university hospitals in Tirana.
system has not been immune to these conference or publish a journal. Despite the difficulties outlined
changes and, although still under state The training of anaesthetists is above, Albanian anaesthesiologists
control, now has an insurance-based and a organised by the Ministry of Health in co- provide anaesthesia for a wide range of
private sector. operation with the University of Tirana. surgical procedures and have a heavy
Although Albania’s only Medical Training lasts four years and encompasses workload. They try to keep up to date
School was founded in 1952, the practice theoretical and practical aspects of anaesthesia with progress in the specialty and apply
of anaesthesia dates back to the 1920’s and is undertaken in the central hospitals of modern methods and techniques
when Austrian and Italian surgeons used Tirana. Unfortunately, the trainees have only whenever they can.
ether and regional anaesthesia in the Civil old, and by western standards, very out-dated I wish to express my thanks to Dr
Hospital in Tirana. Dr Shiroka, the equipment at their disposal. Most intensive Turchetta from Italy who has helped us
pioneer of modern surgery in Albania used care units lack basic equipment such as ECG make contact with the WFSA and
these methods, as did other Albanian monitors, oximeters and capnographs and we supplied us with “Update” and to my
surgeons who trained in Austria and Italy. can only monitor the pulse and blood colleagues Drs Mihallaq Prifiti, Maksut
Endotracheal anaesthesia was introduced pressure manually. Our trainees, therefore, Drrasa and Mihal Kerci helped me prepare
in the 1950’s, again by surgeons. have little opportunity to put their theoretical this article on anaesthesia in our country. I
In 1961, the first specialist Albanian knowledge into practice and it is impractical would be more than happy to answer any
anaesthetist, Dr Mihallaq Prifti, who had for them to attempt to undertake scientific questions or correspond with anyone who
trained in St Petersburg in Russia, entered research. contacts me at the above address.

6
A History of Anaesthesia Services in Eritrea
hospitals in Asmara moving from
one to another. As Ethiopia
increased its control over Eritrea,
Italian health personnel were
systematically marginalised and
finally worked only in hospitals
caring for the Italian community.
They were replaced by doctors
who came from the socialist block
of Eastern Europe, from the Philip-
pines, Israel, Egypt, Sudan and
also some from Ethiopia itself and the Italian At the same time, the demand for
nuns were mostly replaced by Eritrean nurses. anaesthetists was increasing and three years
In 1963, Dr. Gose started a nine – month later in 1969, the Ministry of Health of Ethiopia
course in anaesthesia at the then Princess decided to gather all those who were working
Tsehai Haileselasse Hospital in Addis Ababa as anaesthesia assistants through out the
Kessete Teweldebrhan and two nurses from Eritrea; namely Mengistu country and gave them a six month intensive
Health Science Institution Iasu and Bekit Hagheray completed the course training course to try and increase the number
PO Box 4947 and returned to work in Asmara. They would and quality of practising anaesthetists. Three
Asmara also take it in turn to work in the hospital in of the participants were from Eritrea and
Eritrea Massawa for a week or a month at a time. returned there at the end of their course. In
he history of anaesthesia in the emerging Later, a Bulgarian anaesthesiologist was addition, the government of Ethiopia decided to

T state of Eritrea is inextricably linked with


the history of its colonial occupation. Italy
occupied Eritrea for 50 years up and until 1942
employed and in 1969, she was asked (by the
Eritrean Health Authorities) to train her own
anaesthesia assistants. Three nurses, namely,
open its own school of anaesthesia for nurses
in the capital. I was selected by the Minister of
Health to establish the school of anaesthesia
and the Italians, doctors, nurses and catholic Yosief Michael, Araya G/Tensae and Asmelash and became its first director in September
nuns, together with their indigenous assistants G/Mariam were on the initial course. A short 1982. In the 10 years that followed, 8 nurses
ran all health services. time after they completed of the course, from Eritrea trained in anaesthesia. . Two of
During the British occupation which Asmelash was taken to Addis Ababa and a them subsequently died and one went abroad
followed (1942 – 1952), health services were little later, Araya joined the Eritrean Liberation but the remainder are currently working in
run by the British Colonial Administration but Struggle to fight for Eritrean independence. Eritrea.
incorporated existing services run by Italians Anaesthetists continued to be in very After Eritrea gained its independence
who stayed behind in Eritrea (after the defeat short supply in both Eritrea and Ethiopia so in from Ethiopia in 1993, those who had received
at of Italy). The latter provided most health 1974, the Ministry of Health of Ethiopia and anaesthesia training in the field during the
care for the civilian population through catholic the World Health Organisation (WHO) jointly Liberation Struggle were given up-grading
mission clinics and hospitals. opened a School of Anaesthesia at the Duke of courses and were licensed as nurse
When the British left in 1952, Eritrea Harar Hospital (now Tikur Anbessa Hospital) in anaesthetists. A further group of 16 nurses
became a Trust Federation with its own Addis Ababa under the directorship of Dr. was given a one-year course in anaesthesia in
government administering internal affairs Hermann Waldvogel from Switzerland. 1996 run jointly by Simon Haile and
within a Federation with Ethiopia. Health Eighteen nurses were enrolled in the initial Ghebrebrhan Haile in 1996. Following this, a
service remained based on the Italian colonial course including the author. However, at the national survey on the quality and range
legacy although additional doctors were end of the course in 1976, I was not allowed to anaesthesia services in Eritrea was undertaken
employed from Germany and the European return to Eritrea but was assigned to work in in late 1998. Based on the results of this
socialist block. The most significant thing that Nekemt (Western Ethiopia). Simon Haile and survey, a workshop was organised in
took place during this period was the opening Habte Hailemelekot (two of my fellow Eritrean December 1998 by the Department of Human
of the Itegue Menen School of Nursing, now nurse anaesthetists) soon left their Resources Development of the Ministry of
the Asmara School of Nursing which was assignments in northern Ethiopia and joined Health of Eritrea. At this workshop, it was
opened in collaboration with the American the Eritrean Liberation Struggle and started to decided that Ghebrebrhan Haile and myself
“Point – 4” Aid programme in 1955. train others in the liberation army in prepare a curriculum for a two-year course in
In 1962, Ethiopia annexed Eritrea and the anaesthesia. The WHO-sponsored school of anaesthesia for nurses. This was done and the
Ethiopian Ministry of Health ran the Eritrean anaesthesia in Addis Ababa closed soon after new nurse anaesthetist training programme
Health Service. At this time, the only qualified because of the Marxist revolution that was officially opened with the enrolment of
anaesthetist in Eritrea was Dr. Leonardo Silla overthrew the Ethiopian emperor and the the first batch of 15 students in September
who was trained in Italy. He worked in three descent of the country into civil war. 1998.

7
A letter from
At present Eritrea still has a major Association of Nurse Anaesthetists in 1984.
shortage of nurse anaesthetists and there are The association was originally founded by Dr.
no medically qualified anaesthetists in the Herman Waldvogel in 1976 but was dissolved

Ethiopia
country. Consequently there is a mismatch by the Marxist Regime in 1978. I was
between the increasing demands of an privileged to serve as president of the society
expanding health service and the anaesthesia for four terms.
work force. However, there is a strong In 1989, I was sent to the U.S.A. for
determination to solve this problem although further training and after getting my degree in Testahun Fetene Desta
we still lack basic teaching aids, books and 1991, I returned to the school of Anaesthesia East Gojjam
journals and need more teaching staff. with an American professional license and an Region 3
However, I am sure that we will achieve much expectation that I could continue to be an Debremarcos Hospital
in the near future. agent for change by continuing to educate PO Box 37
Some of you who know me from the first nurse anaesthetists and by so doing, be able to Ethiopia
WFSA Refresher Course in Nairobi, Kenya or decrease the mortality and morbidity of the

I
the first Symposium for Nurse Anaesthetists surgical population in general and of women am a nurse anaesthetist and work at a
which was held in Lucerne, Switzerland or who and children in particular. district hospital in the Bahir Dar region
have read what I have previously written about After my colleagues and I had trained of Ethiopia, north of Addis Ababa, the
my long-term plans for anaesthesia in Ethiopia over 180 nurse anaesthetists, in June 1998, I capital. It is a fertile low-lying area where
may ask what am I doing in Eritrea and why I was suddenly ordered to take leave and on tea, coffee, sugar cane, maize and a range of
have abandoned my plans for anaesthesia in August 21 1998, my passport and other fruits are grown. The population of the reg-
Ethiopia. A little biographical detail may be of documents were confiscated and I was ional is over 200,000 and the administrative
value. deported from Ethiopia with two of my language of the region is Amharic. Malaria,
I was born to a small farming family in children. I was forced to leave my wife and upper respiratory tract infections, TB, intes-
Eritrea in 1946 and was brought up there. I another child of 3 years behind. The main tinal parasites and tropical skin infections
graduated from the School of Nursing in reason for this was the border conflict are the most common health problems.
Asmara, the capital of Eritrea, as a Nurse and between Ethiopia and Eritrea and I am of The district hospital was built 26 years
Nurse Midwife in 1967. At this time Eritrea Eritrean ethnic origin. My wife and youngest ago but for the last 24 years the operating
had been annexed by Ethiopia and the then son were finally deported four months later. theatre has not been used. With the help of
Imperial Government of Ethiopia decided to Despite what has happened to me, I colleagues, the theatre was cleaned and we
assign all graduating male nurses to other have no resentment towards Ethiopia as I have started to discuss with the hospital Medical
provinces of Ethiopia. I was assigned to the worked in the Ethiopian Health Services for Director and through him with the
Nekonen Haileselassie Hospital in Harar, more than 30 years. I have a vision that Ministry of Health in our region what could
(Eastern Ethiopia). Other then the matron, I transcends ethnic origins and political be done about the absence of anaesthetic
was the first nurse and nurse midwife to be boundaries and believe that we in the health drugs, equipment and medical gases. It was
assigned to the biggest hospital in the professions should remember that bacteria, resolved to try and obtain the necessary
province. I worked day and night as the nurse protozoa and viruses recognise no such drugs and equipment although this was
in charge of the surgical and maternity wards, boundaries. likely to take many months.
as an operating room assistant to the surgeons My ultimate wish is to see peace and As I was determined to make the
and obstetricians as well as attending difficult harmony return to the Horn of Africa, so that theatre operational as soon as possible, I
deliveries, collecting blood for transfusion we anaesthetists can organise ourselves at a decided to make the long journey to Addis
whenever it was necessary and undertaking regional level, host Regional Scientific Ababa, some 400km, to try and obtain
administrative duties. Mothers in obstructed Symposia and work towards the WFSA goals what we needed. I would like to thank those
labour and those with foetal distress were of “safe anaesthesia for all” by conscientiously hospitals in Addis that understood my diffi-
frequently referred to our hospital from places discharging our professional responsibilities culties and helped by donating drugs, airways
which were 70 – 12O km. away because there like our colleagues in other regions of Africa and endotracheal tubes. On my return, we
was no one with anaesthetic skills in the and beyond. were able to start surgery and now perform
referring hospitals. Many of the mothers died 15-20 emergency operations each month.
due to ruptured uterus or sustained permanent Editorial Note: Most of these are on pregnant women or for
injuries such as vesico-vaginal fistulae. I Eritrea regained its independence from bowel obstruction or appendicitis.
therefore decided to study anaesthesia and be Ethiopia in 1993. It has an area of 121,300 Our staff consists of one surgeon,
part of the solution. sq km (approximately half the size of the UK) provided by MSF for one year, one trained
In 1974, I joined the WHO-sponsored and a population of 3.9 million. It is one of nurse, two health assistants and me, a nurse
School of Anaesthesia in Addis Ababa and six the poorest countries in the world with a per anaesthetist. When we operate the nurse
years later in September 1982, I was able to capita GDP of $660. Life expectancy is scrubs, one health assistant acts as a surgical
found and become the director of the Ethiopian approximately 55 years and infant mortality is assistant and the other as a runner. All are
School of Anaesthesia for Nurses, a position I 76/1,000. A cease-fire and truce was finally trained to apply cricoid pressure and can
held for almost 17 years. I was also agreed in the border war between Ethiopia assist me when necessary. We are all on duty
instrumental in resurrecting the Ethiopian and Eritrea in June 2000. 24 hours/day.

8
The WFSA in
Zambia
Dr Dixon Tembo
Nkana Mine Hospital
Kitwe
Zambia
Email: dctembo@zamnet.zm
ambia is one of the many countries from
Z the developing world that has benefited
greatly from the activities of the WFSA
Education Committee. It is important to have
some knowledge of the situation in Zambia
I would like to describe how I manage 1.5%. As I did not expect the procedure to to understand just how important the
a typical patient. I assess the patient pre- last long, I did not intubate the patient but contribution being made by the WFSA is to
operatively and if necessary, insert a naso- administered mask anaesthesia. The the practice of anaesthesia in this country.
gastric tube to avoid Mendelson’s syndrome operation was uneventful and after 20 As in Malawi, clinical officers
and a urinary catheter. I also check my minutes the surgeon told me he had administer most anaesthetics in Zambia.
anaesthetic machine and suction apparatus finished. I turned off the halothane and Some of these are very experienced and are
and prepare my drugs and intubation started to wake the patient. to be found practising anaesthesia even in
equipment. When the patient comes to the Unfortunately, without saying the private sector. The majority have been
operating theatre, I check the pulse and anything to me, the surgeon re-inserted his trained at the School of Anaesthesia, which
blood pressure again and insert a cannula in forceps and thus precipitated a major is run by the University Teaching Hospital
a vein. I pre-oxygenate my patient for 5 problem for me. Immediately, the patient in Lusaka for the Ministry of Health.
minutes before starting to induce became restless, started to cough, developed Physician anaesthetists are to be found only
anaesthesia and my assistant applies cricoid facial spasm and became deeply cyanosed. I in the three central hospitals in the country.
pressure for all emergency operations. suspected that he had total laryngeal spasm. Most of these are from Cuba, Eastern Europe
I have a basic range of drugs: I did not panic, as I knew how to treat it and former Soviet states. Some are very good
ketamine, halothane, suxamethonium, with suxamethonium. Unfortunately, the but nearly all have language difficulties that
gallamine, atropine, neostigmine and 5% suxamethonium was in the main theatre so can make the teaching of anaesthesia a little
lignocaine for spinal anaesthesia and an I sent my health assistant for it. Meanwhile, difficult.
Acoma anaesthetic machine but no I increased the oxygen flow and tried to Anaesthesia has a very low profile and is not
ventilator so that I have to ventilate obtain a good seal with my mask. After I a popular option amongst medical students
paralysed patients by hand. This can be had injected 25mg of suxamethonium, I as a field of specialisation. At the last count,
difficult when I also have to draw up more was able to ventilate the patient but there were six indigenous Zambian physician
drugs or check the pulse and blood pressure. laryngeal spasm persisted. I gave a further anaesthetists, only three of whom are
Post-operatively, all the theatre staff assist in 25mg and this abolished all spasm and practising in the country; the remainder are
positioning and monitoring our patients made ventilation easy. I am delighted to say working as expatriates elsewhere on the
until they recover. the patient subsequently made a full planet. The three Zambian physician
Anaesthesia is usually uneventful but recovery and is now well and healthy again. anaesthetists in the country were sponsored
sometimes I do have problems. One patent I am now wary of giving even the at undergraduate and post-graduate level by
in particular sticks in my mind: I don’t shortest anaesthetic by mask alone without the country’s mining industry for which they
think I will ever forget his name or the day securing the airway and am also determined are currently working. The mining companies
and date of his operation. He was a 30-year- to keep suxamethonium immediately to have four other physician anaesthetists,
old male who came to theatre at 1.50pm on hand during all my anaesthetics. It is true expatriates on contract, working in their
4 January 1999 for a haemorrhoidectomy. that there is no such thing as a “simple” hospital system. All the anaesthetists
The procedure was carried out in our small anaesthetic. working for the mining industry are in the one
minor operating room next to the main Editorial Note: northern province where there are mining
theatre. As there was not room for my usual Ethiopia is the oldest independent country in operations and they serve a population of
drug container, I left it in the main theatre. Africa; and has an area of 1,127,000 sq km. about 2.5 million. The other 8 million souls in
After my usual assessment and pre- The population is 59 million. Like its the country depend on clinical officer
oxygenation, I induced anaesthesia with neighbour Eritrea, it is a poor country with a anaesthetists.
intravenous atropine, diazepam and per capita GDP of $560. Life expectancy is The membership of the Zambian Society of
ketamine and maintained it with halothane 40 years and infant mortality is 124/1,000. Anaesthesiologists is open to all practising

9
anaesthesia: clinical officers and the three Prof. Henry Bukwirwa from Uganda in the draw on the Federation’s support as we
active physician anaesthetists. The Society’s near future. continue to strive for first world anaesthesia
activities have been greatly hampered of late The profile of anaesthesia has been in our third world setting.
by the current harsh economic climate in the greatly raised by these persons as we have Editorial Note:
country. The pharmaceutical companies who taken advantage of their presence during the Zambia is a large country with an area of
donated generously to the Society in the past Refresher Courses to expose medical 752,000 sq. km (three times the size of the
are all in dire economic straits and are even students to them, in small group tutorials, UK) but with a population of only 9.6
unable to support the Society’s subscription away from the main course. The WFSA has million. The per capita GDP is $880. In
to the WFSA. But it is not all doom and also donated books, which are up to date recent years life expectancy has fallen because
gloom. With the help of the Education texts, and are invaluable resource materials. of the AIDS epidemic and is now only 37
Committee of the WFSA, Bill Casey and “Anaesthesia Update” is a much sought after years. Infant mortality is 91/1,000.
Haydn Perndt in particular, we have managed publication which I have
to hold Refresher Courses every year for the been distributing to
past 5 years. These are important meetings medical officers and
for us as they are the only time that interns. These
anaesthetists in the country get together to contributions by the WFSA
renew their knowledge and get up to date have supplemented the
information on current anaesthetic practice. efforts of the Society in
The WFSA, the Association of Anaesthetists Zambia to promote safe
of Great Britain and Ireland and the Intensive anaesthetic practice, as
Care Society have contributed to these has our participation in the
activities by sending eminent persons in teaching of trauma
world anaesthesia as lecturers and resource management led to a
persons. Roger Eltringham, Ray Sinclair, Mal greater appreciation of the
Morgan, Nigel Webster, Peter Curry, Bill “ golden hour “ after
Casey, Tony Rocke to mention but a few, have trauma.
participated in our Refresher Courses. We We appreciate the
look forward to the participation of Prof. assistance of the WFSA
Adrian Bosenberg from South African and and we will continue to

guidelines. The use and benefits of the

Book Review laryngeal mask airway are appropriately


discussed given its value as an adjunct to
airway management and its increasing
availability in developing countries (if
Anaesthesia at the District drawings. Draw over anaesthesia and the sometimes only after 40 autoclavings). A
attendant equipment including oxygen section on propofol is now included in
Hospital (Second Edition) concentrators are well covered, as is response to its increasing availability and
M B Dobson. WFSA/WHO publication. ketamine – often the saviour of the non- likely future reductions in cost. New
specialist. Paediatric and obstetric emphasis has been placed on the safe and
anaesthesia are well detailed and a useful appropriate use of blood products in
More than 10 years after it first appeared; chapter describes the management of co- accordance with WHO guidelines.
a revised second edition of this book has existing medical conditions and their This book will continue to be a
been published. Aimed at non-specialist relevance to anaesthesia and surgery. practical asset to those non-specialists
medical officers practising anaesthesia in Important changes however have been providing anaesthetic services throughout
hospitals with limited resources, this made to the text. User feedback and field the world. It is also well worth a read for
book provides clear and concise testing throughout the world of the original both medical students and trainee
information on how to do it. manual has led to a closing of the loop and anaesthetists as well as those planning to
Many excellent features of the original improvement of the sections on intubation work in or visit locations with limited
edition have been retained. The text is and rapid sequence induction. A description anaesthetic facilities.
straightforward and easy to read and covers of the use of the Glasgow Coma Scale is a
a wide spectrum including basic principles, welcome addition to the section on trauma. Andrew Longmate
anaesthetic techniques, drugs and Changes in modern anaesthetic practice are Consultant Anaesthetist
equipment and care of the critically ill. The reflected with updated advice on pre- Stirling Royal Infirmary
text is illustrated with the superb line operative fasting and resuscitation Scotland

10
Epidural Anaesthetic Practice in Mali

Clinical Investigations
Prof. Abdoulaye Diallo Sex Number of patients Percentage
Chief of Anaesthesia and Intensive Care, Point G Hospital, Bamako, Mali Female 1395 67.1
Male 683 32.9
Summary Total 2078 100
In spite of its many advantages, epidural anaesthesia has hitherto
been little used in Mali. This paper reviews 2,078 patients who Three quarters of the patients were ASA classes I or II but a
received epidural anaesthesia between May 1993 and December significant number were ASA III and IV.
1999 in Bamako. The majority were female (1395 versus 683 male)
and their ages ranged from 15 to 107 years. ASA class Number of patients Percentage
Patients underwent a variety of surgical procedures principally ASA I 976 43.9
in obstetrics/gynaecology (916) and urology (703). The epidural was ASA II 587 29.9
most commonly performed at the L3-L4 interspace (1418). ASA III 319 16.0
Bupivacaine was used on 1043 occasions, followed by lidocaine ASA IV 196 10.2
(461) and ropivacaine (172). Total 2078 100
No major complications occurred and the expected side effects
were recorded: major hypotension (0.43%), moderate hypotension During the time of the study, a total of 14,179 operations were
(8.28%), inadequate anaesthesia (3.95%) and post-operative carried out at the three participating hospitals.
headache (0.38%).
Because of its many advantages, epidural anaesthetics should Centre Epidural Spinal General Total
be considered for all surgery below the umbilicus in developing Anaesthetic
countries.
Point G 1736 2848 7992 12,576
Hogon 183 19 634 836
Introduction Farako 159 52 556 767
Epidural anaesthesia has been practised since the early days of the
Total 2078 2919 9182 14,179
last century and offers a relatively simple and cost-effective method
14.6% 20.6% 64.8% 100%
of providing anaesthesia for sub-umbilical surgery. Nevertheless, it
was been little used in developing countries such as Mali. The aim
Epidural anaesthesia has grown more popular over the years of
of this study was to evaluate the technique after it started to become
the study: in 1992, it accounted for only 0.1% of all
popular in anaesthetic practice the early 1990s in Bamako, Mali.
anaesthetics administered. In 1993, it was 2.2%. By 1997, this
had grown to 7.1% and it was 14.6% in 1999.
Patients and Method
Prospectively, between May 1993 and December 1999, 2078
Epidural anaesthesia by specialty.
patients undergoing sub-umbilical surgery at three centres in
Indication Number of patients Percentage
Bamako (Point G Hospital, Hogan and Farako Medical Centres)
were studied. All patients undergoing sub-umbilical surgery who Gynaecology
consented to epidural anaesthesia were included. Those with the & obstetrics 916 44.1
classical contra-indications to spinal anaesthesia such as Urology 703 33.8
coagulopathies, local infection or patient unwillingness were General surgery 346 16.7
excluded. Delivery 68 3.3
All the patients in the study had a lumbar epidural, were Orthopaedics 45 2.2
assessed pre- and post-operatively and the following information was Total 2078 100
recorded:
● identification The average duration of the epidural block was 192 minutes and
● place of recruitment the range was from 130 to 315 minutes.
● clinical and laboratory data
● anaesthetist’s qualifications Local anaesthetic used.
● name and quantity of drug used Agent Number of patients Percentage
● level and time of epidural puncture (with or without catheter) Bupivacaine 0.5% 1043 50.2
● quality of sensory, motor and sympathetic block Lidocaine 0.2% 461 22.2
● any adverse incidents or complications Bupivacaine 0.5% +
Lidocaine 0.2% 318 15.3
Results Bupivacaine 0.25% 84 4.7
2078 patients were studied, the majority of whom were female. The Ropivacaine 1% 172 8.2
average age was 46 years and the range from 15 to 107 years. Total 2078 100

11
Pre-anaesthetic tests in ASA I and ASA II patients
Clinical Investigations

before routine surgical procedures: what is


necessary in Africa?
Binam F*, Mbanya DN**, Takongmo S*** Kingue S*”* and Beyiha G* Patients and methods
*Department of Anaesthesiology, This prospective and descriptive study was carried out in
**Department of Haematology, Yaounde, Cameroon between May – December 1998. Patients
***Department of Surgery, booked for pre-anaesthetic consultation in the Yaounde Military and
****Department of Internal Medicine, Central hospitals were recruited for the study. These hospitals
University of Yaounde, Cameroon. undertake more than 50% of all surgery in the city and the Central
Email:binam@syfed.cm.refer.org hospital caters for the health needs of patients of all origins and
social classes.
Summary All data was recorded using a structured questionnaires
The aim of this prospective and descriptive study was to evaluate the designed to obtain information on each patient’s surgical pathology,
pre-anaesthetic tests performed on ASA I & II patients undergoing past medical history and current clinical state. Patients were
routine surgical procedures in Yaounde, Cameroon. Four hundred grouped according to a modified ASA classification as follows:
patients were evaluated in this study of whom 91 % were ASA I or II. ASA I: a normal healthy patient
The mean age of these patients was 39 years and an average of 4.7 ASA II: a patient with mild systemic disease
tests was performed on each patient (range 1 – 8 tests). These were ASA III: a patient with severe systemic disease
mainly full blood counts (99%) and prothrombin and whole blood ASA IV: a patient with severe systemic disease that is a constant
clotting times (89.8%). 15.8% of these tests yielded abnormal results. threat to life
Abnormal results were found in 45% ASA I & II patients, mainly ECGs ASA V: a moribund patient who is not expected to survive without
(36.1%), haemoglobin levels (26.1 %) and chest X- rays (21%). the operation
Complications occurred in 60% of the patients assessed (57.5% of The tests performed as part of the pre-anaesthetic
ASA I & II patients). Haemodynamic and haematological complications assessment and their results were recorded. These tests included
had the highest incidence (44%). full blood counts (FBC) for haemoglobin, haematocrit and platelet
Complications were significantly more frequent in patients with estimations; blood electrolytes, basic coagulation screening tests,
anaemia. This study showed that the measurement of haemoglobin renal function tests, fasting blood sugar, ABO and Rhesus blood
levels remains indispensable for asymptomatic patients in this grouping as well as electrocardiograms (ECG) and chest X-rays. The
environment. The other tests had no discriminative value and should impact of these tests on the patients’ peri-operative course was
only be performed when clinically indicated. then evaluated.
The progress of patients during surgery and in the first 24
Introduction hours following surgery was closely monitored. The immediate post-
Pre-operative laboratory tests may have an important role in the operative period was defined as the first few minutes after surgery,
prevention of adverse events in the peri-operative period. Such tests the recovery time as the first two post-operative hours. All incidents
can be divided into three groups: or deaths that occurred and their time of occurrence were recorded.
● those performed to evaluate the impact of an existing problem, Incidents were classified as major if they affected a patient’s
● those performed to provide a reference value and recovery or prolonged the hospital stay or minor if they had no
● tests for the pre-operative detection of asymptomatic conditions impact on the patient’s expected recovery. Technical incidents
In populations where abnormal results are uncommon, there is no occurring during anaesthetic care were also recorded.
justification in performing tests in the latter two categories. Thus The impact of abnormal test results in ASA I & II patients was
patients in groups I & II of the American Society of Anaesthesiologists compared with that in ASA III patients by studying their association
(ASA) classification should only have tests that are clinically indicated. In with the incidence, nature and severity of recorded adverse events.
developed countries where these recommendations have been Means, standard deviations, frequencies and proportions were used
implemented, no adverse effects on patient outcome have been reported. to express results while the chi square test was used to compare
In Africa, similar selective testing has been advocated. However, the groups. Values of p< 0.05 were considered to show statistical
in view of the pathological conditions common in Africa and the significance.
difficult conditions under which much surgery is performed, the
epidemiological basis for such selection has not yet been established. Results
This study was, therefore, undertaken to review the pre-anaesthetic A total of 400 patients were enrolled in the study. Their mean age
tests performed on our patients and their effect on peri-operative was 39 years (range 3 months to 83 years). The sex ratio was 1.2:1
complications. in favour of females.

12
General surgery involving the digestive tract and the abdominal other abnormal test results and adverse incidents

Clinical Investigations
wall (29%) and gynaecological and obstetrical surgery including Two deaths occurred (0.5%); one from acute hypovolaemic shock
hysterectomies (28.5% of cases) was most frequently performed in an ASA I & II and the other from a post-operative coma.
followed by orthopaedic surgery (19.7%).
A significant past history was recorded in 77 patients (19.25% Discussion
of the sample). It mainly consisted of cardiovascular diseases such as The patients in this study were mainly young, healthy people in ASA
hypertension, asthma, and pulmonary and upper airway disorders. One groups I & II. Most authorities would, therefore, not have requested
case of sickle cell anaemia was noted. all the tests we performed in this study.
263 patients (65.7%) were classified as ASA I and 97 (24.3%) as Abnormal tests results were significantly more frequent in ASA
ASA II. The remaining (10%) were classified as ASA III. Of the ASA I group III than in groups I & II as might be expected but a past medical
& II group, 17.8% had a significant past medical history compared to history without clinical repercussions did not influence the incidence of
32.5% in the ASA III group. abnormal results: 70% of ASA I & II with significant past medical history
Surgery was performed in 327 patients under general had normal results. Whereas abnormalities were recorded in 45% of
anaesthesia (81.7%) and in the remaining 18.3% using regional ASA I & II patients in the present study, other authors of similar studies
anaesthesia (72 spinal and one epidural). The mean duration of in Africa have found a much lower incidence. In our study, ECGs and
surgery was 116 minutes (range 45 – 276 minutes). chest X-rays were considered abnormal in 31% and 21% of instances
respectively, a much higher rate than in other studies. This is probably a
Laboratory test results refection of the subjective nature of many of the abnormalities seen and
A total of 1921 tests were requested but only 1910 were actually confirms the poor sensitivity of these tests.
performed. An average of 4.7 tests was carried out per patient (range We recorded a high incidence of anaemia (26.1%) in ASA I & II
1-8). The most frequently requested tests were FBCs (99% of patients. A study in Côte d’Ivoire noted a similar incidence of 22%
patients), the prothrombin (PT) and whole blood clotting times (WBCT) whilst Haberer reported an incidence of only 1.8% in France. This
(89.8%) and fasting blood sugar (77.3%). 71.8% of these tests were difference between the African and French data is probably due to
requested by the surgical staff prior to anaesthetic assessment and endemic parasitic infections such as malaria and intestinal worms as
the remaining 28.2% by anaesthetic staff. well as malnutrition in Africa. In a previous study, Binam et al. found a
Three hundred and one tests (15.75%) were abnormal. In the prevalence of severe anaemia in 21.6% of ASA I & II patients, rising
ASA I & II patients, ECGs, haemoglobin levels and chest X-rays to 62% and 48.2% in children aged 0-1 year and 1-5 years old
showed most abnormalities. No abnormalities were observed in the respectively. Measuring the haemoglobin level is, therefore, a simple
clotting screens (WBCT & BT). A significantly greater number of test and highly sensitive method of detecting anaemia.
abnormalities were found in the ASA III patients (90%) compared to Complications were recorded in 60% of the patients studied; a
those in ASA I & II (p<0.0005). In ASA I & II patients with a significant much higher incidence than in other African studies, but comparable
past medical history, 33% had abnormal test results. Of the 193 cases to that recorded in the peri-operative period in some European studies.
in whom blood grouping was requested (48.3% of all cases), 8 As in those studies, most of the complications that occurred were due
patients (2%) were of rarer groups (O and AB) or were rhesus to haemodynamic problems. A high incidence of adverse incidents is
negative. not normally expected in ASA I & II patients but may be related to the
large number of haematological abnormalities we detected.
Complications A higher still incidence of complications occurred in ASA III
A total of 316 complications were recorded in 240 patients (60% of patients, but there was no significant difference in the complication
those studied), 44.3% of which were abnormal haematological indices. rate between the patients in groups ASA I & II and group ASA III who
There were 15 major incidents reported in 12 patients (4.7% of all had haematological abnormalities detected on screening. This
incidents), including 3 cardiac arrests; 3 post neurosurgical comas and 5 suggests that it is the degree of anaemia rather than the ASA status
convulsions, two of which followed anaesthesia with ketamine. Most that is the best indicator of potential problems and indeed, one of the
incidents occurred peri-operatively (55% of cases) and were more deaths recorded was in an ASA II patient with severe anaemia.
frequent after surgical procedures that lasted for more than 60 minutes. Two major incidents (convulsions) occurred in this study that
There was a significantly higher incidence of adverse incidents in were attributed to ketamine which had been used as it was the only
ASA III patients compared to those in ASA groups I & II (82.5% and anaesthetic agent available. Minor technical problems were common.
57.5% respectively, p=0.0038). Among the patients with any Due to a lack of trained staff and adequate equipment for monitoring
complication, major incidents were recorded in 4.3% of graded ASA I & and managing these problems, these minor incidents can lead to
II (including two cardiac arrests) compared to 9.1 % in the ASA III group. fatalities in our environment. This should be considered when
Adverse incidents occurred in 129 patients with abnormal test selecting appropriate pre-operative tests, as should the likely length of
results. However, there was no statistical difference in the number of surgery as the incidence of complications increase if surgery lasts
incidents occurring between those in ASA groups I & II and those ASA longer than 60 minutes.
group III.
Among the ASA I & II patients with abnormal test results, major Conclusion
complications were found in 4.9% of them compared to 7.1 % of Only the haemoglobin level should be measured routinely in all African
those in ASA group III group. Adverse incidents were seen to occur patients undergoing surgery, as abnormal results in other tests were
more frequently in patients with anaemia than in those with a normal not directly correlated with adverse outcomes. Other tests should only
haemoglobin level (p< 0.0005). There was no correlation between be requested when indicated by the patient’s condition.

13
Anaesthetic Considerations of Heroin
Case Histories

Condom Ingestion
Dr V Mwafongo Absorption,
Muhimbili Medical Centre Distribution and
Dar Es Salaam Excretion
Tanzania Heroin is better
Email: hdna@muchs.ac.tz absorbed orally than is
morphine. However, it
Introduction undergoes extensive first
Recently many countries have seen an pass metabolism and
increase in the number of young men and only morphine is
women smuggling drugs, often heroin, detectable in the blood
hidden within their body cavity. This after oral administration.
practice has become common in Dar Es Its high solubility
Salaam, the main port of Tanzania. Between enables it to enter the
January 1997-July 1999, six individuals brain more rapidly than
were admitted to Muhimbili Medical morphine. It is
Centre after being arrested at the airport approximately 40%
suspected of smuggling ingested drugs. protein bound and its
They were aged from 22-50 years and had psychotropic effects can
swallowed 30-80 packets of drugs. Four last up to 6 hours. The
patients passed their drugs per rectum but “recreational” dose and
two needed emergency laparotomy for acute the toxic dose vary
obstruction. widely depending on tolerance. It is mainly respiration, miosis, bradycardia or
The drugs are usually concealed in excreted in the urine as free and conjugated hypothermia. The triad of coma, pinpoint
condoms and swallowed a few hours before morphine. Heroin shares the analgesic, pupils and respiratory depression in a
checking-in for their flights. An anti- euphoric, sedative and respiratory patient suspected of ingesting heroin can be
diarrhoeal is usually taken at the same time. depressant effects of morphine but is regarded as diagnostic.
(Fig.1) The drug packets vary in size from considered more potent due to its greater Before surgery such patients should be
10mgs to 4gms and are very susceptible to solubility. treated by
rupture. If this happens in the gastro- ● Gastric lavage if there is oral ingestion
intestinal tract, the courier may develop Anaesthetic Considerations ● Tracheal intubation and ventilation
acute narcotic poisoning. Alternatively, the Patients ingesting heroin condoms can ● Naloxone 0.1mg/kg repeated as
packets of drugs can cause acute intestinal present for surgery because of pure outlet necessary until adequate respiration is
obstruction. obstruction or because of manifestations of achieved
acute narcotic poisoning. If time and ● Antibiotic prophylaxis to prevent
Pharmacology of Heroin circumstances permit, the urine can be aspiration pneumonia
Heroin (Diamorphine or 3,6 tested for the heroin metabolite, 6- It should be remembered that the
Diacetylmorphine) is a weakly basic monoacetylmorphine. half-life of Naloxone is 20-30 minutes
compound with a pKa of 7.83. It was Patients with obstruction should be treated whilst that of heroin is 3-4 hours. It may,
introduced into clinical practice in 1898 as in the standard manner: therefore, be necessary to give repeated
a remedy for cough and as a treatment for ● No premedication is necessary doses or an infusion of Naloxone as the
morphine dependence. It was found shortly ● A rapid sequence induction with patient may appear to recover but then lapse
thereafter to be as potent a cause of Suxamethonium and cricoid pressure into coma again after some hours.
addiction as morphine and its manufacture should be performed Once the patient has been resuscitated,
was banned in the United States in 1924. It ● Narcotic analgesics should be used if anaesthesia can be induced as for patients
is still widely used in the United Kingdom there is no evidence of poisoning with obstruction as outlined above. The
as an analgesic particularly in palliative care ● Standard monitoring should be used induction dose of anaesthetic should be
where its high solubility is considered a per-operatively and post-operatively. cautiously titrated and narcotics or other
particular advantage. It is also, unfortun- If any of the narcotic packages have analgesics are unlikely to be needed. Careful
ately, a popular drug of misuse and its use ruptured, the classical signs of narcotic post-operative monitoring of vital signs is
can be detected by finding its metabolite, 6- poisoning may be evident such as essential and the patients should be cared for
monoacetylmorphine in the urine unresponsiveness or coma, slow or shallow in an Intensive Care Unit.

14
CS Gas Induction of Anaesthesia!

Case Histories
Dr. S. Balachandran stab wound, an emergency laparotomy was Dibenzoxazepine (CR gas). CS gas (named
Dr.G. Morton arranged. The patient was transferred from the after Carson and Stoughton) is 10 times more
Specialist Registrars in Anaesthesia Accident and Emergency unit to theatre potent as a lacrimator than CN gas but
Dr. P. Clyburn uneventfully. Immediately before induction otherwise, less toxic. CS is a crystalline solid,
Consultant in Anaesthesia (approximately two hours after exposure to CS dissolved as 5% w/v in Methylisobutyl
University Hospital Of Wales gas), he had a heart rate of 110 per minute, ketone (MIBK) with nitrogen and after being
Cardiff CF4 4XW blood pressure of 120/78 mm Hg and arterial sprayed; it solidifies on the skin and clothes.
Wales oxygen saturation of 96%. It reacts with sulfhydryl groups and other
nucleophilic sites. It can cause tissue injury

Introduction
This case highlights the and necrosis probably from the biochemical
inhibition of important enzymes such as
Anaesthetising a patient who has been potential risks to the pyruvic decarboxylase and it also has the
sprayed with CS gas is a rare event that can be
associated with unusual difficulties. We report
anaesthetist after ability to generate bradykinin both in vivo and
vitro.
the problems we encountered whilst exposure to CS gas. Aerosols used by the police deliver a 5%
anaesthetising such a patient and suggest solution of CS dissolved in Methylisobutyl
guidelines for future management. Following pre-oxygenation, anaesthesia ketone and symptoms develop immediately
was induced with etomidate 20mg and muscle after exposure to atmospheric concentration as
Case History relaxation obtained with suxamethonium low as 0.0026%. Eye, nose, mouth, respiratory
A 53 year old, obese (110 kg) man was 100mg whilst cricoid pressure was applied. tract and skin symptoms predominate, the
admitted to the Accident and Emergency Unit Immediately after laryngoscopy, the second most common being ocular burning and pain,
with a self- inflicted stab injury to the author experienced intense lacrimation, conjunctival oedema, lacrimation, rhinorrheoa,
abdomen, One hour prior to admission he had sneezing, coughing and pain in the eyes but salivation, dyspnoea, tachypnoea,
been restrained by the police with the help of managed to pass the tracheal tube between laryngospasm, bronchospasm, cough,
O-Chlorobenzylidene malononitrile (CS gas) the vocal cords, confirmed by capnography. The haemoptysis, haemetemesis and contact
because he was violent and deemed to be a first author immediately took over the care of dermatitis. Inhalation pneumonitis, pulmonary
danger to himself and others. On admission, the patient but also experienced the same oedema and even fatal respiratory arrest have
the patient was conscious and responding symptoms while trying to insert a nasogastric been reported.
appropriately to questions. His heart rate 120 tube with the help of a laryngoscope. After our experience with this patient,
per minute, blood pressure 80/50 mm Hg and The patient underwent a small bowel we suggest the following guidelines when
his arterial oxygen saturation on 15 litres of resection and was electively admitted to the managing patients who have been exposed
oxygen through a facemask was 95%. He Intensive Care Unit postoperatively and later to CS gas.
didn’t have any other injuries. His past medical transferred to the ward where he made an i) Have two anaesthetists present
history included hypertension treated by uneventful recovery. It was twelve hours before throughout the procedure.
atenolol. the symptoms experienced by the authors ii) Decontaminate the patient as much as
completely disappeared. possible before inducing anaesthesia
As small bowel was This case highlights the potential risks to i.e. remove contaminated clothes, wipe
the anaesthetist after exposure to CS gas. off excess CS crystals and keep the
protruding through the a) Excretion of gas from the respiratory patient in a well ventilated room.
tract continues for several hours after iii) Wear a facemask, gloves, apron and
stab wound, an exposure of the victim to CS gas. goggles when close to the patient.
emergency laparotomy b) The anaesthetist may be affected by CS iv) Have a fan blowing over the
gas being expired by the patient during patient and stay upwind of the patient
was arranged. examination of the airway including whenever possible.
laryngoscopy. v) Inform the recovery and ward staff of
After taking appropriate precautions to c) Exposure of attending staff to CS possible ill effects of CS gas and
prevent secondary exposure of staff to CS gas, gas may be sufficient to render them ensure the patient is nursed in a well-
his clothes were removed and put in a plastic incapacitated and potentially compromise ventilated area and breathing
bag and he was given humidified oxygen patient safety. humidified oxygen.
through a facemask. Two 14g intravenous In conclusion, although no serious
cannulae were sited and one litre of Discussion problems occurred from this encounter with
Hartmann’s solution was transfused, which The most common teargases are O- CS gas, it is not hard to imagine how patient
increased the blood pressure to 110/74 mm Chlorobenzylidene malononitrile (CS gas), 1- safety could have been compromised had
Hg. As small bowel was protruding through the Chlorocetophenone (CN gas) and there not been two anaesthetists present.

15
Useful Information
Useful Information

World Federation of Societies of Book Aid International The SOROS Foundation


Anaesthesiologists (WFSA) 39-41 Coldharbour Lane will consider applications from
8th Floor, Imperial house Camberwell anaesthetists in Eastern and Central
15-19 Kingsway London SE5 9NR Europe for support for limited periods of
London WC2B 6TH UK study in the UK. Applications should be
United Kingdom Tel: (+44) 020 7733 3577 made in advance to the branch office of
Tel: (+44) 020 7836 5652 The organisation is interested in receiving their country of origin whose address may
Fax: (+44) 020 7836 5616 recent complete sets of journals and be obtained from:
Email: wfsa@compuserve.com newish text books. These are collected free The Soros Foundation
and distributed by Rotarians. 400 West 59th Street
Courses in Anaesthesia for the New York
developing world. The TOKTEN Project NY 10019
Oxford: July (annually). Expatriate nationals returning to their USA
Contact: Dr. M. Dobson country of origin are invited to apply for Tel: (+1) 212 548 0600
Department of Anaesthesia the post of project expert. Each project is Fax: (+1) 212 548 4600.
John Radcliffe Hospital sponsored by the United Nations who E-mail: osnews@sorosny.org
Headley Way would meet the cost of international travel
Headington, and pay a subsistence allowance ($90/day). Teaching Videos:
Oxford OX3 9DU. Applications should be made to the The following titles are available at £5
UK Minister of Health of the host developing each:
Tel: (+44) 01865 221589. nation. 1. Servicing the EMO & Tri-Service
E-mail: michael.dobson@ndm.ox.ac.uk vaporisers.
Technical Assistance at Low Cost 2. The oxygen concentrator
Bristol: December (annually). (TALC) 3. The Manley multivent/Glostavent
Contact: Dr. Claire Jewkes Contact: David Moreley 4. Servicing the anaesthetic machine
Department of Anaesthesia Institute of Child Health
Frenchay Hospital Guilford Street Contact:
Bristol BS16 ILE London WCIN 1EH. Dr. R Eltringham
UK UK Gloucestershire Royal Hospital
Tel: (+44) 01179 701212. Gloucester GLI 3NN
The International Committee of UK
Equipment collection and the Red Cross (ICRC) Tel: (+44) 01452 394786/394194
distribution to the developing The ICRC acts to help all victims of war Fax: (+44) 01452 394485
world and internal violence, attempting to E-mail: 106147.2366@compuserve.com
Contact: ensure implementation of humanitarian
ECHO rules restricting armed violence. Job opportunities in the
Ullswater Crescent Contact: ICRC, Recruitment Division developing world
Coulsdon 19 Ave. de la Paix These are listed in a bimonthly magazine
Surrey CR3 2HR. CH-1202 produced by the International Health
UK Geneva Exchange.
Tel: (+44) 020 8660 2220 Switzerland or your local society. Contact:
Carelift International Inc. Email: http://www.icrc.ch Ms Isobel McConnan
185 Walnut Street (Floor 22) 8-10, Dryden Street
Philadelphia P.A. 19103 Overseas Doctors Training Scheme (UK) London WC2E 9NA
USA Anaesthetists seeking recognised training UK
Tel: (+1) 215 535 3590. posts in the UK should apply to the Tel: (+44) 020 7836 5833
Dr. William Rosenblatt Bemard Johnson Adviser Fax: (+44)020 7379 1239
REMEDY Royal College of Anaesthetists E-mail:
Dept. of Anaesthesia 8 Russell Square health exchange@compuserve.com
Yale University School of Medicine London WC] B 4JX.
333 Cedar Street UK
New Haven Tel: (+44) 020 7637 4104
CT 06510.
USA

16
Useful Information
US volunteers wishing to spend Association for International WHO Liaison Officer
periods working in developing Development of Anaesthesia Dr M Dobson
countries (A.I.D.A.) Nuffield Department of Anaesthetics
Contact: Contact: The John Radcliffe Hospital
Dr. Lena Dohlman Professor Stanley Samuels Headley Way
Health Volunteers Overseas Department of Anesthesia Headington
c/o Washington Station Stanford University Medical Centre Oxford OX3 9DU
PO. Box 65157 Stanford UK
Washington DC 20035-5157 California Tel: (+44) 01865 221589/741166
USA USA Fax: (+44) 01865 221593/453266.
Tel: (+1) 202 296 0928. Tel: (+1) 415 723 6411. E-mail: michael.dobson@ndm.ox.ac.uk
Fax: (+1) 202 296 8018. Fax: (+1) 415 723 8544.
Email: Samuels@Ieland.stanford.edu
Committee Chair
Overseas Teaching Program Commonwealth Medical Awards If you wish to advertise your
American Society of Anesthesiologists Available to citizens of Commonwealth
520 N. Northwest Highway countries for limited periods of organisation on this page (free-
Park Ridge, IL 60068-2573 postgraduate study within the UK. of-charge),
USA Applications should be addressed to the please contact:
Medical Awards Administrator
World Anaesthesia Commonwealth Scholarship Commission The Editor
This organisation works to improve 36 Gordon Square Dr W F Casey
standards of anaesthesia throughout the London WC1H IPE Popes Cottage
world. In conjunction with the WFSA, it UK
produces two publications, World Cheltenham Rd
Anaesthesia News and Update in Medecins Sans Frontieres (MSF) Painswick
Anaesthesia* (an add-on textbook) offers assistance to populations in distress, Glos. GL6 6TS
published twice-yearly. The annual to victims of natural and man-made
subscription is £10. For further disasters and to victims of armed conflict. UK
information They require volunteers for both long and Tel: (+44) 01452 814229
short-term projects. If you are interested Fax: (+44) 01452 812162
Contact: in obtaining more information, contact
Dr.Ray Sinclair them at: Email:
Dept of Anaesthesia MSF wfcasey@doctors.org.uk
Royal Truro Hospital (Treliske) 124-132 Clerkenwell Road
Truro London ECIR 5DL
Cornwall TR1 3LJ UK Produced and Distributed by:
UK Tel: (+44) 020 7713 5600 Media Publishing Company
Tel: (+44) 01872 274242. Fax: (+44) 020 7713 5004. or Media House
* also available on:
http://www.nda.ox.ac.uk/wfsa 11 East 26th St. 41 Crayford Way
Suite 1904 Crayford
Courses on Anaesthetic Equipment New York NY 10010 Kent DA1 4JY
Maintenance USA
One week residential courses for Tel: (+1) 212 679 6800. UK
anaesthetic technicians are organised at the Email: http://www.msf.org or Tel: (+44) 01322 558029
NHS training and conference centre. http://www.dwb.org Fax: (+44) 01322 558524
Applications should be sent to:
Geoffrey Dillow E-mail: MediaPublishers@aol.com
Conference Centre
Wotton under Edge
Glos.GLI2 8DA
UK.

17
Anaesthetic web sites to try
Useful Information

Miscellaneous
Anaesthesia & Critical Care Resources on the Internet
(AACRI) http://www.eur.nl/cgi-bin/accri.pl
Anesthesia Web http://www.anesthesiaweb.com/
Audio Digest Foundation http://www.audio-digest.org
Bandolier (Evidence-based medicine) http://www.jr2.ac.uk/Bandolier
Echocardiography http://www2.umdnj.edu/shindler/echo.html
Gaseous anomaly http://www.anaesthesia.ml.org
GASNet Anesthesiology Home Page http://gasnet.med.vale.edu
International Anesthesia Research Society http://www.iars.org
Illustrated regional anesthesia http://weber.u.washington.edu/~aelizaga/regional/welcome
Medical World Search http:/.mwsearch.com/
Online Mendelian Inhertitance In Man http://www3.ncbi.nlm.nih.gov/Omim/
Primary Internet resources for anaesthetists http:/gasnet.dundee.ac.uk:1081/mirror/vat/MajRes.html
The National Library of Medicine http://www.nsbi.nlm.nih.gov/PubMed/
The Trauma Organisation http://www.trauma.org/
University of Chicago http://www.airway.bsd.uchicago.edu
Virtual Anaesthesia Textbook http://www-usvd.edu.au/su/anaes/VAT/VAT.html
Virtual Museum of Anesthesiology http://umdas.med.miami.edu/aha/vma

Journals:
Anaesthesia http://www.blackwell-science.com/ana
Anaesthesia and Analgesia http:/anaesthesia.ucsf.edu/webdocs/aa/
Anaesthesia and Intensive Care http://www.aaic.net.au/home.html
Anesthesiology http://www.anesthesiology.org
British Journal of Anaesthesia http://bja.oupjournals.org
JAMA http://www.ama-assn.org/public/joumals/jama/jamahome-html
NEJM http://www.nejm-org/content/index.asp
Science http://www.sciencemag.org/
The Internet Journal of Anaesthesia http://www.ispub.com/journals/ja.htm

Associations:
Anaesthetic Research Society http://www.ars.ac.uk
Association of Anaesthetists of Great Britain & Ireland http://www.aagbi.org
International Trauma Anaesthesia & Critical Care Society http://www.trauma.itaccs.com
Royal College of Anaesthetists http://www.rcoa.ac.uk/
Society for Ambulatory Anaesthesia http://www.sambahq.org
Society for Critical Care Medicine http://www.sccm.org
Society for Computing and Technology in Anaesthesia http://www.scata.orh.uk/programs/list.html
Society for Education in Anesthesia http://anesthesia.ccf.org:8080/sea/index.htm
Society for Obstetric Anesthesia & Perinatology (SOAP) http://www.soap.org
Society for Paediatric Anaesthesia http://www.uams.edu/spa
South African Society of Anaesthesiologists http://www.sasaweb.com
The American Society of Anesthesiologists (ASA) http://asahq.org
The International Society for the Study of Pain http://www.halcyon.com/iasp
World Anaesthesia Online http://www.nda.ox.ac.uk/wfsa

The Editor would be delighted to hear of other sites that might be of interest and to learn of any site addresses that are
incorrect or no longer function

18
Gassing in Guinea – on and off ship

Feature Extra
Dr Aleksandra Bojarska FCARCSI
Department of Anaesthesia
Diana Princess of Wales Hospital
Grimsby
UK
Email: alexbojar@hotmail.com
ife is full of surprises: when I went to an
L anaesthetic conference in a ski resort in
the French Alps, I didn’t expect to bump into
Dr Keith Thomson who persuaded me to go
to Guinea to spend some time on the ship
MV Anastasis.
Guinea-Conakry is a small West African
state between Guinea-Bissau and Sierra
Leone that has recently provided a safe
haven for thousands of refugees from the
civil war in the latter country. Although
possessing considerable mineral resources, it
remains one of the poorest countries in the
world. Life expectancy for males is 43.5years anaesthetic induction rooms so it was In the theatre, there were two
and 48.5 years for females and infant necessary to collect all the drugs and anaesthetic machines but no way of
mortality is 29 per 1000 live births. equipment one was likely to need from a connecting them to our oxygen source, a
The 522-foot Anastasis (Fig.1) is the central store before heading for the operating large oxygen cylinder with a reducing valve
world’s largest non-governmental hospital theatre. and two manometers, one of which was
ship and is operated by Mercy Ships, the Cancrum oris (Fig 2 Overleaf) was not broken. We were eventually able to
nautical arm of a Christian charity “Youth uncommon and presented a significant connect an old and rusty anaesthetic
with a Mission”. On board are three fully anaesthetic challenge. It is caused by a machine to the cylinder with a variety of
equipped operating theatres, a dental clinic, mixed bacterial infection when there is poor tubes and connectors and add our
laboratory and X-ray facilities and a 35- dental hygiene and results in major facial Humphrey (ADE) circuit rather than use the
bedded ward. Most of the surgery performed ulceration with ankylosis of the temoro- inefficient Mapleson C circuit that the
on board is maxillo-facial, ENT, plastic and mandibular joint and minimal mouth opening. local Guinean anaesthetic technician had
ophthalmic but the all volunteer crew also I was extremely grateful to those consultants to use.
runs out-reach and dental clinics and who had taught me awake fibre-optic Our first anaesthetic proceeded
provides health education. All care is intubation which I performed after sedation uneventfully until our patient developed
provided free of charge. with ketamine and midazolam and a crico- ventricular extra-systoles on a vaporiser
All three theatres are equipped with thyroid block with 2% lignocaine. Surgery setting of 1.5% halothane. They
Drager AV1 anaesthetic machines, which, could be lengthy but we were able to disappeared when the concentration was
although bulky, are efficient allowing low ventilate patients overnight in a High reduced and so I suspect the vaporiser had
flow anaesthesia and the ventilation of Dependency Unit with a Siemens 900 never been serviced and was rather
children weighing 10kg or more. ventilator using midazolam and alfentanil for inaccurate. Our second patient had limited
Comprehensive monitoring equipment was sedation. mouth opening but I was able to perform
also available as were modern anaesthetic After two weeks on board ship, we went intubation using a bougie and midazolam
drugs such as propofol, rocuronium, to Donka, the main state-run hospital in and ketamine sedation. We also had to
sevoflurane and remifentanyl, all donated by Conakry, the capital, to provide general contend with an electrical power failure
their manufacturers. anaesthesia for three maxillo-facial operations but had brought torches and our monitors
My fellow anaesthetists were a that were to be performed jointly by one of our had battery back up. After surgery, our
recently arrived Lithuanian anaesthesiologist surgeons and with his local counterpart. The patents were taken to a recovery area that
and an American nurse anaesthetist. We all latter normally performed his own head and contained only a bed where they had to be
had to spend some time initially getting used neck blocks as there were no facilities for cared for by their relatives.
to unfamiliar equipment and brand names intubation or ventilation in the hospital. We, Whilst we worked in one theatre, we
and planning ahead for our lists. We did not therefore, had to bring everything we were watched the local anaesthetic technician
have trained anaesthetic assistants or likely to need from the ship. anaesthetise an elderly lady with bowel

19
Feature Extra

obstruction for a laparotomy in an hospitals three theatres but none were anaesthesia in particular in developing
adjoining theatre. He used ketamine for functional for lack of tubing and cables. countries and one can but admire the local
induction and maintained anaesthesia with Realistically, modern anaesthetic drugs and surgeons and anaesthetic technicians who
halothane in oxygen with the patient equipment are inappropriate to countries are doing their best to provide a service
breathing spontaneously on a mask. The such as Guinea: patients could never afford with minimal resources. Visits from a ship
blood pressure and pulse were monitored to pay for them. If they are lucky, they may such as ours can have negligible impact on
manually but no records were kept. The be able to afford ketamine and halothane the overall situation in a country such as
technique appeared to work satisfactorily and survive with nursing care provided by Guinea. It can, however, have a dramatic
and was also used for Caesarean sections. their relatives. impact on the lives of individuals and
We discovered a number of fairly It is easy to be pessimistic about the perhaps through them, change the world a
modern anaesthetic machines in the state of medicine in general and little for the better.

The Second All African Anaesthetic Congress


23rd-26th September 2001

at the
International Conference Centre, Durban, South Africa
For further information please contact
Professor Tony Rocke Email: mailiti@med.und.ac.za

20
A Detached Retina in the land of Yaks

Feature Extra
and Yetis
Dr Jay Chapman anaesthesia. All procedures under general competent, my major concern was with
anaesthesia are performed at TUTH the anaesthesia. Obviously, the
Background: The Centre sees and treats many anaesthesiologist is the most important
Monday 30 August 1999, extreme eye problems since patients rarely person in the operating room, responsible
Okalahoma City, USA. Giant floaters and present early in the Third World. Many of for one’s survival from the procedure.
flashes of light develop in my right eye. the staff were interested in examining my How competent would the
eye since they saw few patients with early anaesthesiologist be in this Third World
Friday 3 September 1999, retinal detachments as most present with Country? I have confidence in few of
California. Symptoms continue during extensive or total detachments. I quickly them in the United States.
two day, 2,782 km drove to California. formed the impression that Dr Shrestha As it turned out. My
Seen by ophthalmologist and retinal was a highly skilled and competent doctor anaesthesiologist was a female, Dr
specialist. No treatment recommended. with 20 years experience in his field. His Shumati. I found this reassuring as I
demeanour was mild, reserved and concluded that in this male-dominated
Friday 10 September 1990. straightforward and his approach society, a woman had to be very sharp and
Arrive Kathmandu, Nepal. Bumpy methodical and thorough. good at her studies to win a place in
landing. Peripheral visual field defect A New Zealand optometrist who medical school. Her mentor, who would
develops. had been bringing students to Nepal for a supervise the anaesthesia, was a visiting
month each year for twenty years English professor, a real grandmother type,
Monday 13 September 1999. confirmed this impression. His with whom I instantly fell in love. She
Tribhuvan University, Kathmandu. Deliver pronouncement that Dr Shrestha was oozed confidence with her gentle manner
lecture on Forensic Medicine then go to “excellent” greatly reassured me. and my apprehension instantly
Koirala Centre for Ophthalmic Studies. disappeared. She had retired from
Examined by Dr Koirala. Large superior Wednesday 15 September 1999. administering anaesthesia for maxillo-
temporal retinal tear diagnosed. Laser Admitted to TUTH and comprehensively facial and ophthalmic surgery in Sussex
treatment attempted but unsuccessful due examined. Sneaked out of hospital in the and come to work in Nepal. She kept up a
to fluid beneath retina. Referred to Dr evening to go to Bakery Café with a delightful, reassuring and relaxing
Jeevan Shrestha. Nepalese friend for a “last meal”. I ate monologue until I was on the operating
momos, beer, Thai chicken, beer, vegetable table and had disappeared into the never-
Tuesday 14 September 1999. sizzler and beer. As we were leaving the never land where so expertly and gently
Examined by Dr Shrestha. Further café, we met another friend and returned pushed me.
unsuccessful attempt at laser surgery. for further conversation, jokes and beer.
Decision made that a buckle be placed on Conclusion.
the eye under general anaesthesia to Thursday 16 September 1999. At the time of writing, two days post-
prevent further tear and more retinal Surgery including laser and cryo-therapy surgery, I sit with a swollen right orbit
detachment. performed under general anaesthesia. hoping that the procedure will be entirely
Ophthalmic surgery and general Procedure lasted three hours: longer than successful. Dr Shrestha has just phoned to
anaesthesia in Nepal? You must be crazy! anticipated because of difficulty placing enquire how I am and to book a follow up
buckle beneath ocular muscles. On appointment in Monday.
The Eye Centre awakening, delighted to be alive and free This unexpected foray into medical
The B P Koirala Lions Eye Centre for of nausea. Flowers, cards and visitors treatment in Nepal was both unexpected
Ophthalmic Studies Is situated opposite arrive in the evening. and surprisingly satisfactory. The care I
the Emergency Room of Tribhuvan received was as good as I could have
University Teaching Hospital (TUTH). It Friday 17 September 1999. expected elsewhere. The physicians were
is probably no coincidence that it was Bandages removed from right eye. Fluid attentive and helpful. The B P Koirala
built when Dr Koirala’s uncle, G P Koirala gone from retina. Discharged from Lions Centre for Ophthalmic Studies
was Prime Minister. It is a small, modern hospital. offers quality treatment of which every
building, spotlessly clean, with state-of- Nepalese citizen can be justly proud.
the-art equipment and highly competent Anaesthesia
staff. It has an operating theatre for out- After I had decided that the Reprinted from the Kathmandu Post June
patient procedure performed under local ophthalmologist was qualified and 27, 2000.

21
Pigs Might Fly! Almost all flights take off after the a connection at Nairobi from Ugandan to Kenyan
Feature Extra

advertised time, yet the pigs are rarely told the Airways onward to Lusaka. Our flight was late but
reason why or given any other information. the Nairobi-based herders had not heeded the
Sometimes they will be told, on an inaudible public advance call from our pilot to expedite the transfer.
Prof. Paul Fenton address system operated by someone with a There was no one to herd us into the waiting
Department of Anaesthesia speech impediment or reading difficulty that the Kenyan plane, parked right next to us on the
Queen Elizabeth Central Hospital plane is late because it arrived late. Never, in. my tarmac. (One day, in the far distant future, airport
Blantyre experience, could we be told that there was a herders will wake up to the fact that a pig can
Malawi mechanical failure, staff problem (e.g. laziness, actually trot unaided from one plane to another
People who work in airports are a special breed of incompetence, porciphobia), crash on the runway, without the need for a guided tour through a large
human being: they handle the people who want to etc. Yet there are the common reasons why flights building). There were several transit pigs but it
fly in aeroplanes. Airports are the curious places are delayed. soon became apparent to our panicking herd that
where they work. The Nation prides itself on a new If the pigs start snorting excessively, there was a problem: there were not enough
airport and deplores the state of an old one. Yet, if something may happen. The problem is that not places on the plane for us all. But why, when the
you take away the veneer of fancy entrance halls enough pigs are of the snorting type. They are plane was not full? No, it was not the lack of stalls
and the glitz of over-priced, so-called “duty-free” mostly docile and would happily trot into a bacon but a deficiency of troughs.
shops, all airport are much the same, differing only machine if told to do so. Only one or two will (Now, we had inadvertently broken into an
in the numbers of passengers they handle. stamp or make a bad smell in the departure unauthorised information area: it is a general
An airport resembles a kind of special farm lounge, nibble the furniture or leave droppings on observation that a flying pig is not supposed to
for delinquent humans. The dangerous inmates the floor. The rest just quietly await the know how many seats there are or why you can or
are confined to discrete compartments, fenced or instructions if their herdsman or herdswomen. (Are cannot got on to an aircraft. In fact, it is a
glassed in, or moved under close supervision by women naturally ruder then men or is it just that Standard Part 1 order of All Airlines to give no
trained keepers from one secure enclosure to there are more of them in airports and you notice useful information at all. The only information a
another, like cattle or pigs. As though meekly them more? Please send answers on a postcard, pig con be told is that the plane is travelling at an
waiting for the stun gun, these pigs wait in line for signed with a trotter print). altitude of 37,000 feet, that safety is the number
the airport farmers to conduct security and other Snorting pigs cannot make a plane take off one priority and that he fastens his seat belt by
formalities which, when examined in retrospect are any sooner but often the airport herders may hose putting the little bit into the big bit.)
99.99% pointless. them down with free Coca-Cola to cool off or There are 10 transit, pigs but only 5 packets
Can these pigs also fly? Amazing to relate, throw in some free swill. Perhaps if enough pigs of swill. But, we 5 unfortunates argued we are not
millions do everyday. stamped and snorted and made a mess they would hungry and it was only a 2-hour flight. The herders
Usually there is someone at the airport to get their way. But not in Africa, friend. wore adamant: “You cannot fly! Go in to Nairobi!
tell the mindless porcine herd what to do and Here, pig herders are used to such things. It Come back tomorrow!” One pig started to foam at
where to go. In fact, it is essential to have such a is their stock in trade. A seasoned WHO traveller the mouth. Incontinence was imminent. In the
person: on one occasion, I was in a herd that had (the UN is very politically correct, you know; its confusion, while the herders were distracted with
no one in charge and chaos immediately ensued as employees go Pig-class these days) once told me him, I grabbed a blank boarding pass from a pile on
we pathetically tried to organise ourselves to be in that he was waiting for a plane to escape from the desk and made a rush for the security gate.
the right place. We were waiting to check-in for Brazzaville. The glorious, gleaming, wonder I rejoiced that, at 6.00am that morning in
an early morning flight from of Cape Town; it was machine of the skies was there for all to see on the Kampala, I had decided to wear a tie. Clearly the
so early that we pigs had arrived before the runway. Gin and tonics wore being loaded. security man thought I was an Executive Pig and he
herders. There were numerous, gloriously empty, Suddenly, a guard armed with an AK 47 and a did not bother to look at the card. Squealing
check-in desks to snort at, so, like the obedient baton appeared and herded the pigs back into a triumphantly, I charged through the gate and down
little porcines that we were, we all lined up at one closed waiting area, locked the doors and stared at the steps leaving my lesser porcine brothers still
end. After about 30 minutes, the man wearing the them malevolently through the glass. It transpired waving their tickets and protesting their full bellies.
magic clothes i.e. a shirt with epaulettes, arrived that the plane was overbooked and none of these The lesson is: be a smart pig when flying.
and we all stared fingering our tickets and making pigs would get on. The guard had been posted to The wearing of a tie should not be over-
“I’m-in-a-queue” motions. But the ober-pig-fuehrer head off an expected stampede. rated, however. I once fell into conversation with
went straight to a desk at the other end and Once in the plane, luxury, surely, prevails? Not so. another Executive pig and he was travelling
flipped a sign saying, “closed” to read “open.” He These days, the tall pig ponders a modern Business Class. As we entered the plane’s hushed
then sat down with his chin on his hands and paradox: the porcine race is getting taller yet the interior for our night flight to London, the Club
stared into space looking neither to right nor to left. stalls are getting shorter. In 1999, you cannot snort Class steward smiled warmly and greeted him:
He didn’t see us. Was he visually challenged or around your truffles or slurp noisily from your “Glad to have you with us this evening, sir.”
was it a bad hangover? One pig ventured to ask if trough of orange juice if the pig in front is not Assuming that I was with the gentleman, he
there would he other super-beings coming later, to doing the same thing. If the one in front wants to started on the same routine with me but stopped
sit at nearer desks. No response. Also deaf? recline, then all you can do in look at his seat back. half way through when he saw my economy pass.
There was nothing else for it. Jostling with each About 3 inches from your mucus drooling hooter. His smile faded. “Are you not glad to have me?” I
other past signs announcing “unrivalled excellence Being in transit at an airport can be doubly asked, in my customary pseudo-jovial flying mood.
in customer service” we moved to snort at the right stressful for a pig: he is in-coming and out-going at “Just follow the aisle to your right, sir” came the
desk. the same time. This pig-author was trying to make dry response.

22
The World Federation of Societies of

WA & WFSA News


Anaesthesiologists (WFSA)
The WFSA is a voluntary association of Your national society pays a paediatrics) and South Africa (in
membership subscription for each of its obstetrics). Visiting Professorships are
one hundred and seven national societies
full member of $1.25 per year. This has funded for teaching visits that are
of anaesthesiologists. Its principal not been increased since 1980 but at the expected to include practical teaching in
objective is: “to make available the Montreal Congress it was resolved to theatres as well as formal lectures.
highest standards of anaesthesia and Usually the WFSA provides airfares and
resuscitation to all peoples in the world.” Its principal objective is: the host society provides board and
If you are a member of a National lodging.
Society or Association and your society is “to make available the Recently, Dr Douglas Wilkinson
(Oxford, UK) has developed a Primary
a member, then you are part of the highest standards of Trauma Care course, based on the
WFSA. The WFSA holds a World Congress Advanced Trauma Life Support
every four years, hosted and organised anaesthesia and programme, for use in developing
by a member society. One was held in resuscitation to all countries. It has been run in the Pacific,
June this year in Montreal organised by India and Africa and has been universally
the Canadian Society. The next Congress
peoples in the world”. well received.
The Publications Committee has a
will be held in Paris in 2004 and hosted increase this over the next four years to budget of about $50,000 per year. It
by the French Society. $1.50. The subscription is intended to publishes “Update in Anaesthesia” twice
Much of the business of the WFSA cover the administrative costs of the a year. Update contains articles on
is conducted during the World Federation. Additional income is practical anaesthetic procedures and the
Congress. Policy is laid down by a obtained from WFSA investments. The theory that underlies them. It is aimed at
General Assembly which meets twice capital for these investments has been practitioners (doctors, nurse anaesthetists
during each Congress. All member derived from a share of the surpluses and clinical officers) in countries with
societies of good standing can generated by previous World Congresses limited resources and poor access to
participate, sending delegates in and the income enables the federation to educational material. It is currently
proportion to their size. You are fulfil its educational objectives. published in six languages (English,
therefore, represented and can also The Education Committee has the French, Spanish, Russian, Arabic and
attend as an observer (within the largest budget and spends some Mandarin). As well as the printed
constraints of the available space) if you $150,000 each year. In recent years it has versions, it is available on disc, CD and
so wish. The General Assembly elects a funded Refresher Course in sub-Saharan
President, Secretary and Treasurer and Africa (Uganda, Ghana, Sudan, Burkina
an Executive Committee, reflecting the Faso, Tanzania, Mauritius, Botswana,
The WFSA is posed to
geographical spread of member Nigeria, Mozambique, Benin, Ethiopia, re-launch its website
societies, to manage the Federation for Malawi and Togo), Asia (China and
the succeeding four years. The chairmen Vietnam), the Americas (Paraguay, Costa (www.wfsa.org.uk)
of the Standing Committees on Rica, Honduras and Nicaragua), the
Education, Publications, Finance and Pacific (Fiji and Palau) and Eastern
news, specialist chat
Statutes and Bylaws also sit on the Europe (Russia, the Baltic States and rooms and useful
Executive Committee. Macedonia). A course for anaesthetists
The Executive Committee gives on the technical care of equipment has information
effect to the agreed policies of the been held in Uganda (sponsored by
Federation, meeting in alternative years Penlon) and paediatric fibreoptic can be downloaded from the Internet
but otherwise conducting business by workshops have been held in Chile and (www.nda.ox.ac.uk/wfsa). The site has
email, fax and post. The practical Argentina. It also assists Israel in received over 11,000 hits from over 100
decisions concerning many on-going maintaining an active training countries.
activities are delegated to specialist programme for anaesthetists from Donations of teaching material
committees. The Education and Eastern Europe. including books, journals and videos are
Publications Committees have Regional Training Centres are made on request to centres that lack
substantial budgets that they use to supported in Thailand, Benin, Ghana, educational material. Each package is
undertake their important functions. Vietnam, Nepal, Fiji, Chile (in customised, within a fixed budget, to the

23
individual requirements of the recipients.
WA & WFSA News

About thirty packages are dispatched


each year.
During the past four years, the
The Constitution of
retiring Treasurer, Dr Michael Rosen has
obtained funds from the Soros
Foundation to provide training for
World Anaesthesia
anaesthetists from Eastern Europe in
Palliative Medicine. With Dr Michael
Dobson, the WFSA’s liaison officer with Aims and Objectives The Organising Committee is
the World Health Organisation (WHO), World Anaesthesia is a world-wide society composed of the following members (some of
he has obtained grants from the UK whose aims include: whom perform 2 or more tasks):
Department for International Meetings co-ordinator – organiser of
Development to conduct a trial of the ● Support for colleagues in developing regular World Anaesthesia meetings
Glostavent in Mozambique and Zambia countries, by the development of
and to make Update more widely appropriate training, materials, and Publications member – edits Newsletter
available on CD and via the Internet. and sits on editorial board of Update
equipment, and when requested, by
The WFSA is posed to re-launch its
speaking on their behalf to
web site (www.wfsa.org.uk) with news, Liaison member – liases with Specialist
governments, non-governmental
specialist chat rooms and useful Societies
organisations, pharmaceutical
information. A web editor-in-chief and
companies, equipment manufacturers
regular contributors from throughout the Publicity member – responsible for
and others.
world are being sought. Currently, if you
organising publicity at major meetings
look up WFSA on the Internet you are
● Liaison with the many other agencies
more likely to get information about the
whose activities may impinge on Linkman member – responsible for
Welsh Football Supporters Association
anaesthesia & resuscitation maintaining links between members in
than about anaesthesia!
different countries and organising a database
Collaborations enable the WFSA to
● Provision of a network of of information about different locations
achieve more than it can alone. Many
national societies, for example, support appropriately trained and
experienced people able to assist on WFSA linkman – liases with the WFSA
WFSA initiatives by paying the costs of
lecturers on Refresher Courses. The request.
Association linkman – liases with AAGBI
WFSA has worked with the Australian
Society and the Australian government
The Executive is elected by members Adviser for those planning to work
to develop a Diploma (and subsequently
present at the Annual General Meeting. overseas
a Masters) course in Anaesthesia at Fiji
in the South Pacific and is now in
discussion with the Japanese government Chairman – elected for 3 years, re-electable
to further develop the Bangkok Training for one further term Membership of World Anaesthesia
is open to anyone involved with the provision
Centre. With the WHO, a standard for
Honorary Secretary elected for 3 years, re- of anaesthesia. An annual subscription is set
oxygen concentrators has been set and a
electable for one further term at the AGM but members in developing
textbook “Anaesthesia in the District
countries are exempt from payment.
Hospital” has been published and
revised. Treasurer elected for 3 years, re-electable
The activities of World Anaesthesia are
for one further term
The current officers of the WFSA are: mainly educational and include:
President: ● Annual meeting in UK
The executive will work for the Society
Dr Kester Brown (Australia) through the Organising Committee. The ● Overseas meetings with other Societies
Executive will appoint members to the ● Preparation and distribution of
Secretary: organising committee. The membership of educational materials
Dr Anneke Meursing the committee is listed below but other ● Preparation and publication of Newsletter
(Netherlands/Malawi) members may be co-opted at the discretion ● Advice for those planning to work in
of the Chairman. another country
Treasurer:
Dr Richard Walsh (Australia)

Chairman, Executive Committee:


“to make available the highest standards of anaesthesia
Prof. David Bevan (Canada) and resuscitation to all peoples in the world”.
24
A letter from World Anaesthesia Database

World Anaesthesia Database


Dr Iain Wilson
Name: ......................................................................................................................................................................
Dear World Address: ..................................................................................................................................................................
Anaesthesia Member,
......................................................................................................................................................................................

At the World Anaesthesia meeting on 1


......................................................................................................................................................................................
October 99 I was delighted to be elected
Chairman to follow Mike Dobson who ......................................................................................................................................................................................
started World Anaesthesia (WA) some 12
years ago. Currently the membership of Institution: ..........................................................................................................................................................

World Anaesthesia stands at 1454 of


Telephone: Work: ............................................................................................................................................
whom 744 work in the developing world.
As you are aware, World Anaesthesia Home: ....................................................................................................................................................................
supports colleagues providing anaesthesia
overseas. One of its activities is to send Fax: ............................................................................................................................................................................
(free of charge) the educational journal
“Update in Anaesthesia” to members
E-mail address: ..................................................................................................................................................

working in developing countries. Other Job Title: ................................................................................................................................................................


members can access the electronic version
at http://www.nda.ox.ac.uk/wfsa/. The Speciality: ..............................................................................................................................................................
costs of Update are met by WFSA
(printing and distribution) and WA Grade: ....................................................................................................................................................................

(preparation and typesetting of paper and Age: ..........................................................................................................................................................................


electronic versions).
Our Treasurer (Douglas Wilkinson),
Secretary (Charlie Collins) and I have
Experience overseas:
been bringing our membership and
subscription records up to date. At our last
Please list the countries where you have worked (other than your home country).
AGM it was decided that the Annual Please add: the places in those countries, the dates and the type of work you were
Membership should be increased to £20 or engaged in. (e.g. Disaster Relief, Support for refugees, Area of War/Conflict,
equivalent. Members working in Longer term medical missionary or secular relief agency work). Continue on a
developing countries are exempt. separate sheet if necessary:
If you would like to renew your
membership of World Anaesthesia, please ......................................................................................................................................................................................

complete the new database of members


......................................................................................................................................................................................
and send it to Dr Charlie Collins at the
address below. We shall then contact you ......................................................................................................................................................................................
to arrange collection of your subscription,
depending on where you live. ......................................................................................................................................................................................
If you wish to receive copies of
......................................................................................................................................................................................
Update in Anaesthesia to send overseas
please let me know by email how many ......................................................................................................................................................................................
copies are required and the address for
delivery. We shall mail them on to you or ......................................................................................................................................................................................
to the address you specify for the
......................................................................................................................................................................................
recipients.
Many thanks for your continued ......................................................................................................................................................................................
support for World Anaesthesia – it is
greatly appreciated! ......................................................................................................................................................................................

Dr Iain Wilson ......................................................................................................................................................................................

......................................................................................................................................................................................
Chairman, World Anaesthesia
Email: iain.wilson5@virgin.net ......................................................................................................................................................................................

25

World Anaesthesia Database continued
Particular interests:
(e.g. subspecialities of anaesthesia/care of the critically ill, education, distance learning, appropriate research writing,
disaster relief, conflict situations, medical missionary, long term secular:

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................

Languages spoken: ....................................................................................................................................................

Availability:
Are you happy to answer enquiries relevant to your experience/expertise? ■ Yes ■ No
Are you able to write for WA publications? ■ Yes ■ No

Are you available for working visits abroad? ■ < 1 month ■ 1 to 6 months

How much notice do you require? ■ 2 weeks ■ 2 months ■ 6 months ■ >6

Any comments: ..........................................................................................................................................................

..................................................................................................................................................................................

..................................................................................................................................................................................

..................................................................................................................................................................................

..................................................................................................................................................................................

..................................................................................................................................................................................

Please complete this form as accurately as possible and return to:

Dr. C. Collins, Secretary, World Anaesthesia


Dept. Anaesthesia, Royal Devon and Exeter Hospital (Wonford), Barrack Road, Exeter, Devon EX2 5DW
United Kingdom