Pediatric Anesthesia for Voluntary Services Abroad

Voluntary agencies from developed countries deliver a wide variety of medical services to less developed countries worldwide (1–3). More than 150 programs based in the United States alone send volunteer medical professionals to developing countries for periods ranging from 1 wk to 3 yr to offer medical services or training. 1 Among the direct services provided are visiting surgical programs for elective treatment of congenital and acquired conditions that cause physical impairment or threaten longevity (e.g., congenital heart disease, orthopedic deformities, cleft palate, and burn contractures) or that result in social stigmatization (e.g., cleft lip or urogenital abnormalities). This review article recommends strategies to organize elective surgical teams for voluntary medical services abroad (VMSA), emphasizing issues related to perioperative safety for the pediatric patient. This review draws upon the collective experiences of members of the Society for Pediatric Anesthesia to address logistical considerations, preoperative assessment, anesthetic techniques, monitoring, and postoperative care. (Note: Emergency relief services, large-scale medical emergencies, and programs providing indirect services occur outside the scope of this document.) Why Guidelines for VMSA Programs? Practices for perioperative care in VMSA programs differ from those of the sponsoring and host countries. In sponsoring countries, elective surgery occurs after the patient’s medical condition is optimally stabilized; modern operating rooms (ORs), a postanesthesia care unit (PACU) staffed with well-qualified personnel, access to intensive care, and drugs and equipment, such as monitors, infusion pumps, and specialized regional techniques, are standard. By contrast, in underdeveloped countries, anesthetic drugs, monitors, and ancillary resources are typically limited; surgery for elective correction of congenital deformities is uncommon. Because most patients undergo surgery for trauma, obstetrics, or a few general surgical procedures, surgical subspecialties are sparsely represented. Anesthesia may be provided by a physician or a physician extender such as a nurse, clinical officer, or anesthesia assistant. Because much of the surgery performed in these settings is not wholly elective, the assessment of acceptable perioperative risk may differ from that for elective procedures. VMSA programs providing elective surgery represent a third distinct type of anesthesia practice and has four characteristics. First, many of the patients treated would not ordinarily be encountered in industrialized countries. Common preexisting medical conditions include chronic respiratory symptoms, nutritional deficiencies, and advanced states of the surgical condition. Second, VMSA operating teams are composed of practitioners who usually have not worked together and who arrive with diverse skills, personalities, and expectations of one another. The importance of team cohesion in minimizing oversights and errors is not measurable but has been shown in human factors research to play a significant role in promoting high quality care and safe outcomes (4). Third, VMSA programs seek to treat large numbers of patients in a short time. The newly configured team must achieve efficient patient screening, rapid operating room turnovers, brief recovery, and optimal postoperative stability of patients in a setting of minimally experienced postoperative supervision. Finally, anesthesia providers often must work without their customary equipment and monitors and may find themselves modifying their usual requirements to accomplish a trip’s goals. For example, they may accept some patients at serious risk for perioperative complications while working in a technologically austere environment. Planning and Organizing the Trip A successful voluntary surgical program requires scrupulous planning for more than 1 yr (1–3). Handling difficult physical conditions, working with a multinational team, and learning to use unfamiliar equipment and supplies are challenging for practitioners. The sponsoring agency must energetically communicate with prospective team members to ensure planning concerns are addressed in a timely manner. For example, prospective volunteers should investigate early whether their malpractice insurance covers the volunteer work and if not, decide whether that constitutes an impediment. Most VMSA agencies do not have policies to cover individuals. Team members also need to be given realistic expectations about the site’s protocols and infrastructure, the limits of their own physical and mental endurance, and the expressed and implied cultural agendas of the host country and hospital. Volunteers can expect that difficulties will arise in the form of equipment or supply shortfalls, unanticipated deficiencies in infrastructure (e.g., water or electricity), or shortages of qualified support personnel. Despite these problems, agencies may elect to go forward with their programs if they determine the shortfalls will not preclude the success of the endeavor. Pressures to move ahead may arise from a desire to satisfy a specific commitment to a program, to respond to perceived expectations from donors, or to provide important experience for participants. For such reasons, improvisation and nonstandard approaches to clinical issues characterize VMSA programs. The boundary distinguishing required versus unacceptable improvisations is difficult to define. However, knowingly structuring a trip to require improvisation that borders on unsafe practice is a disservice to everyone involved. Goals Generally, VMSA programs originate with an invitation or request for service from an in-country medical or lay group. It is essential that in-country hosts and the VMSA agency fully understand and agree with the purposes of the program. Consensus among local practitioners, community leaders, and medical supervisory staff in the host community regarding the need for the VMSA services and the anticipated scope of work must be clearly articulated in advance. The VMSA organization should have a clear understanding of the host’s expectations from the visit and the role the host wishes to play in the program. Critical questions include the following: What vested interests are behind the invitation and the program’s success? Is the primary goal to provide direct medical service or educate local staff? Are local practitioners expecting to participate? What types of surgery are anticipated, and what are the limitations to proper medical management in the setting? What types and ages of patients are expected, and how many might be treated (2) ? What equipment (e.g., anesthesia machines) is available? How far will patients have to travel? If required, are there provisions for family members to stay the week of surgery? There are important opportunities to develop bonds and share knowledge and experience with in-country providers. However, when local culture and social structure is ignored, or relationships are not properly cultivated, there can be grave misunderstandings and resentment. Resistance (and even quiet sabotage) may result if local practitioners believe the program has paternalistic undertones, disparages their stature within their own community, or leaves behind unsolicited responsibilities for follow-up (1). Preliminary Site Visit Once a request for service has been accepted, a preliminary site visit is essential. Even for the smallest VMSA projects where there are extensive correspondence and photographs of the facility, a site visit should be strongly considered. Besides a first-hand view of facilities and equipment, the visit allows the cultivation of professional relationships and the identification of one or more specific program advocates who may help in future negotiations and problem solving. The visit should occur far enough in advance so issues can be addressed satisfactorily. A VMSA agency representative knowledgeable about space, facilities, and equipment for perioperative care should be on the visiting team. A follow-up written report with photographs documenting the physical layout and facilities (e.g., anesthesia machines, oxygen supply, and electrical access) should be sent to the team leaders. As part of the site visit, a VMSA agency representative should meet with local civic sponsors, political leaders interested in the project, and medical staff leaders, including the individual clinical department directors. Lack of full support from any of these groups or local rivalries and resentments could impede program success. If individual directors are unavailable, surrogates should be identified so questions regarding facilities and manpower can be answered. Expectations must be clarified, and the desire for formal educational exchanges or clinical participation by local personnel must be discussed. Plans for temporary licenses and hospital privileges also should be made, allowing sufficient time for bureaucratic delays. Arrangements for volunteers. Arrangements for volunteers include in-country transportation, housing, meals, and security. Responsibility for these arrangements and the adequacy of the arrangements must be fully outlined with back-up plans made in advance. In addition, the work schedule, importance of adequate rest, and mutual social obligations should be addressed. To be hospitable, host organizations may want to plan what could turn out to be excessive social obligations for volunteers. Security issues to consider include: Notifying the in-country United States Embassy of the planned program Understanding restricted activities while in the host country Providing escorts where required Furnishing emergency contact information (e.g., embassies or airlines) Formulating contingency plans for medical emergencies, natural disasters, or civil conflicts Reviewing, on a timely basis, travel cautions posted by the United States State Department and health advisories from the Centers for Disease Control and related organizations (Appendix). Hospital facilities. The hospital or clinic facility should be able to accommodate the expected volume of patients (and their family members) for screening, surgery, and recovery. To what extent will the surgical program disrupt normal hospital routines? Will the local providers agree to the disruption? Will management of emergencies be compromised? Do provisions need to be made to redirect other hospital patients? What costs will be incurred in supporting laboratory, radiographs, pharmacy needs, and facility needs? Who will bear these costs? The adequacy and reliability of such basics as electricity (e.g., current type and outlet placements), water, oxygen, suction, and fresh air or air conditioning must be evaluated. Contingency plans for their breakdown should be investigated. Frequency of outages and the availability of back-up generators should be noted. Inconsistent electrical supply is a common problem in many developing countries, and electrical connections adequate for in-country hospital operations may be inadequate for an intense surgical schedule. Even if the facility reports infrequent outages, flashlights may prove useful. Laboratory facilities should be appropriate to the needs of the proposed surgery and able to support management of complications (e.g., blood gases, coagulation studies, and electrolytes). The blood bank should be able to type the expected number of patients and to provide blood products if required. Radiologic facilities must be investigated, including determination of the availability and cost of film for simple studies. The pharmacy should be reviewed to assess its ability to provide backup in the event of shortfalls of analgesics (including controlled substances), anesthetics, and emergency supplies. In some cases, routine drugs are more easily obtained from community pharmacies than the hospital. Communication between team members is often a critical issue. Telephone connections within the hospital among the various patient care areas, as well as plans for contacting the surgical team after hours, should be reviewed. Hand-held two-way radios are a practical means of allowing team leaders to maintain regular contact because many sites do not have alternate means of rapid communication. Plans for how translators will be recruited, oriented, and dispatched during the entire program should be formulated. Screening and registration. The patient screening area should be reviewed for patient flow through screening stations and space required for registration, generation of medical records, and preoperative and follow-up consults. The local facility might not have adequate supplies (e.g., tongue depressors, blood pressure cuffs, otoscopes, and electrocardiograph machines/paper), and plans must be made accordingly. Plans to integrate medical records between the volunteer agency and the local facility should be developed. Patient identification must accommodate local conventions regarding family and personal names. This simple but crucial issue will allow filing records so they can be easily matched with patients. Forms should be standardized and kept in duplicate so that hospital records and laboratory tests can be accessed both locally and at the VMSA agency’s home base. How patients will consent for surgery and whether written forms will be used should also be worked out at this juncture. Operating rooms (ORs). The number of ORs occupied by the VMSA program should take into account the host hospital’s daily and emergency needs. Storage of equipment and supplies should allow for easy daily setup and takedown of the OR. Equipment should be secured nightly because loss or theft may result in the suspension of the entire program and may adversely affect VMSA-host relationships. Because the VMSA distribution of OR tables may differ from the hospital’s usual arrangement, it is important to document the availability of adequate surgical lighting, access to suction devices, and oxygen supplies. In some cases, several OR tables may be set up in a room. This arrangement facilitates teaching, enables circulating nurses to assist several teams, and may permit anesthesia providers to assist other teams in an emergency. Many hospitals have no central oxygen supply and depend on refillable H cylinders. When there is a central supply of oxygen, it is likely piped from large tanks of compressed gas and not refrigerated liquid oxygen reservoirs, as used in developed countries. Although larger quantities of oxygen may be stored in liquid form, liquefying oxygen requires generating high pressures (5–10 atm) and low temperatures (−100°C to −150°C), and these technologies may be unavailable. If a central oxygen supply is not available, each OR table will require a dedicated tank (G or H cylinder), and the PACU should be equipped with a tank for every two beds. G and H cylinders, when fully charged to 2200 psi, hold 5300 and 6900 L, respectively. In general, when using a nonrebreathing system, a full H cylinder will last for 15–20 h or more of anesthesia if properly conserved. Emergency supplies should be close at hand for the OR, PACU, and postoperative areas. An adequate number of tank regulators should be provided for the program’s needs (note that threading may differ among countries). Nitrous oxide is not likely to be available because of cost, but when used, safety devices such as proportioning systems and meters of inspired oxygen concentration should accompany it. Temperature regulation may be a problem in surgical areas when the presence of large numbers of VMSA patients and staff overheat the environment. Provisions for adequate ventilation, fans, or air conditioning are important to help the staff endure long daily schedules. Conversely, in cool climates, availability of warming devices for patients under anesthesia is important. Shipment of supplies. For surgical and anesthesia supplies (discussed below) to arrive intact and in a timely fashion requires substantial advanced planning. For materials that will not be hand carried, shipping arrangements should consider the timing, possible delays, and meticulous documentation for customs agents. Endorsement letters from government agencies or internationally recognized charities may facilitate transit through customs. Materials past their expiration dates should not be shipped because the discovery of even one may provoke confiscation of the entire shipment. Similarly, controlled substances should not be included without proper authorizations. Some organizations have been able to piggyback supplies with the shipments of willing companies that regularly do business in the host country, allowing both economy and efficiency. Expected patient population. Strategies for publicizing the VMSA program and for notifying and transporting potential patients should be developed during the site visit. Steps should be taken so proposed services are described in ways that neither encourage inappropriate candidates nor discourage appropriate ones. Although the screening clinic during the actual program will produce the final surgical list, preliminary screening by local health providers before arrival of the team may be useful. The site visit is the time to orient these field personnel or, at the least, provide materials that should be communicated to them. Preliminary screening can prevent unnecessary hardship and travel for individuals who are not good surgical candidates, as well as keep the VMSA team from being overwhelmed by patients. Team Composition Anesthesiologists traveling to developing countries will face people, cultures, and circumstances that are unfamiliar. Nonetheless, they must provide safe and effective care and use skills used in everyday practice, e.g., adaptability, strict attention to details, cooperation, conservation, conflict resolution, and team building. Team roles should be defined and communicated to the entire team. Although in-country medical personnel may play a vital role, it is important to delineate their responsibilities and time commitments before the trip. A particular challenge is forming a cohesive team among culturally diverse practitioners who may have disparate expectations of each other’s roles. The importance of team cohesion cannot be overemphasized. Team members need to depend upon each other for clinical efficiency as well as for prompt identification and resolution of potentially serious complications (4). Volunteers should be oriented before the actual trip to local customs and expectations (e.g., proper greetings, appropriate dress, and hospital etiquette). Customs regarding introductions, ceremonies and gifts, personal behaviors, use of alcohol, tobacco, or other drugs, and actions perceived as romantic displays should be well understood. Team leadership. There are four principal team managerial responsibilities. The team manager should be experienced in international medical programs, knowledgeable about the site, and familiar with important local contacts. He or she is responsible for all matters related to team mobilization and site preparation and should participate in the site visit. Specific duties include recruitment, credentialing of team members, assuring appropriate housing, transportation, and local facility use, and coordinating with local hospital and community personnel. The surgical and anesthesia team leaders are responsible for patient selection, perioperative care supervision, and professional relations with local physicians. The clinical supervisor (often a nurse) is responsible for managing supplies, equipment, and nonphysician personnel. The leaders must work closely in planning patient screening and selection, range of services provided, and traffic flow. They should also prospectively develop plans to manage adverse events. Team size. Distribution of personnel, given the confines of the local environment, should be as close as possible to perioperative care standards of US-based practices. This means adequate levels of skilled nursing for preoperative, PACU, and postoperative care. Even the most skilled local nurses may have limited experience managing large numbers of children after surgery or in assessing airway and cardiovascular issues in postoperative pediatric patients. Errors in recognizing respiratory complications, dosing analgesics, and adequate hydration in small patients are potential sources of avoidable complications. Therefore, the VMSA team should either include personnel who can provide this care or be prepared to supervise in-country personnel. The number of personnel should be adequate to cover problems and complications arising in postoperative patients while surgeries are underway. For programs handling many patients each day, an intensivist, anesthesiologist, or pediatrician should be available to manage problems arising in preoperative and postoperative areas. An intensivist or anesthesia float should also be available to assist with IV access, airway difficulties, or other problems that arise in the OR. Additional core personnel to consider for the team include logistics assistants, a medical records librarian, respiratory therapist, biomedical technician, and other medical professionals as suited to the program. Anesthesia providers. Selecting skilled anesthesia volunteers is a complex issue. Whereas VMSA agencies may not want to curtail activities for lack of pediatric anesthesia support, we believe that programs treating young children should require anesthesia volunteers with extensive experience dealing with pediatric patients. They should be familiar with various induction techniques, have experience using the anesthetic techniques and drugs to be used on the trip, and have experience dealing with perioperative issues specific to the planned surgical procedures (e.g., bleeding and edema related to palate repair). More important than whether a provider is a certified registered nurse anesthetist, doctor of osteopathy, or doctor of medicine is the provider’s experience and comfort level dealing with pediatric patients in an austere setting. However, some countries do require all anesthesia providers to be physicians. Registered respiratory therapists have been used on some trips as anesthesiology assistants. Because of their familiarity with perioperative issues, airway management, and equipment, they can assist with preoperative evaluation, airway assessment, patient transport, equipment setup, vascular access, management of mechanical ventilation, extubation, and transport to the PACU. On-call team and Trip MD. Arrangements for an on-call schedule to manage postoperative emergencies and clear instructions for communicating with the team after hours should be developed. Plans should allow for an anesthesiologist or intensivist skilled in emergency airway management to be immediately available in the hospital each day until all patients are discharged from the PACU. Also, one team physician should be designated team doctor to deal with the medical problems of team members. On the Ground Communications Team meetings are an essential part of forging a cohesive team (4). Team leaders should meet to agree on program goals, patient selection criteria, scope of surgeries to be performed, and to review the spectrum of clinical skills available to the team. A meeting of the entire team must take place before the beginning of clinical work where team members fully discuss their roles and expectations. Once the program is underway, daily team meetings are essential to air differences, provide updates, and discuss concerns. Some VMSA veterans have found it useful to have each discipline report concerns at the full team meetings while reviewing the activities of the previous day. Although seemingly simple, such a format allows for an exchange of ideas, validates the role of each team member, and makes it possible to address differences in style and experience. For example, some OR nurses are not accustomed to assisting during the anesthesia induction. Similarly, anesthesiologists differ in how accustomed they are to proceeding unassisted. PACU nurses may have varying expectations of how care is transferred or how wakeful children should be on arrival. At the end of each day, the various chiefs should conduct a systematic review of the day’s cases to evaluate problems or concerns. Additional team meetings (both inter- and intradisciplinary) should occur daily for the first few days, if not throughout the trip, to pass on information, problems, and tips. Although it may seem that meetings take up a disproportionate amount of time, in reality much can be accomplished by focused discussions over a meal or on a bus ride. Conflict resolution. Because of the intensity and close working quarters associated with VMSA surgical programs, disagreements over resource allocation, interpersonal strife, and staff illnesses may have a serious impact on the program’s success and safety. Euphoria over initial success in providing good quality care may give way to fatigue from stressful days, sleep deprivation, excessive social commitments, and discontent with unfamiliar foods. Additional stresses may result from the illness of colleagues and the consequent redistribution of workload. Some volunteers may become irritable, confrontational, or even careless in their practice. Recognizing the risk and the symptoms of emotional and physical fatigue and adjusting the pace of the work and social activities is essential not only for enjoying the rewards of the trip, but also for providing high quality and safe patient care in a challenging environment. Screening Clinic The process of selecting patients for surgery is of paramount importance, and criteria for patient selection should be prospectively established. Whereas proper patient selection allows for positive outcomes, ill-considered selections may have negative ramifications far beyond the individual patient or trip. Considerations of patient safety would dictate that patients be selected based on the goals of the program, skills of the team, and availability of facilities. For instance, selection of small infants on the basis of interesting disease, surgeon’s skills, teaching value, or lack of older patients may be inappropriate. One must additionally account for the PACU facilities and the postoperative staff’s familiarity with management of the infant airway, hydration status, respiratory function, and pain management. Thus, whereas the surgical and anesthesia staff may be comfortable managing small infants, if the nursing staff is unfamiliar with postoperative care of small infants, safety may dictate that elective surgery not be offered. A stratification of priorities based on surgical condition, teaching value, distance traveled, or access to alternative facilities will help determine the final OR schedule and prioritize procedures. Despite their emotional appeal to team members, some children may not be appropriate candidates for surgery in these settings because their disease process is too advanced, the complexity of the proposed surgery is too demanding, or appropriate postoperative care is unavailable. Once criteria for patient selection have been established, strategies for managing problems that are likely to be encountered during screening should be developed. The screening clinic should strive to uncover previously undiagnosed congenital anomalies and intercurrent illnesses of concern. For many patients, this will be their first evaluation by a physician. Frequently, preoperative laboratory tests or radiographs are not practical. Language barriers may hinder a thorough medical history. Therefore, it is vital that a competent translator assist the screening physician. Anemia, parasites, reactive airway disease, tuberculosis, otorrhea, rheumatic heart disease, and soft tissue infections are common. In addition, some patients may deliberately conceal underlying medical conditions for fear of not being accepted for surgery (5). The assessment of risk is primarily an anesthetic concern; in equivocal cases, the final decision should rest with the anesthesia team. Surgical schedule. The operating schedule should take into account when the last patients of the day are expected to be discharged from the PACU, as well as potential openings because of cancellations. Younger children and more complex cases are best performed early in the day and early in the trip so that complications can be addressed while full team resources are available. However, cases scheduled for the first day should be uncomplicated and their start times staggered to allow for identifying and managing unforeseen problems. In considering the surgical list, the team should anticipate that local sponsors may request additional special cases be accommodated. Notification. The method of notifying patients as to whether or not they will be offered surgery must be clearly publicized at the screening clinic. Those turned away will likely be upset, disappointed, or frustrated. It is important that team members, translators, and, if available, social workers help explain reasons for the selection and realistic alternatives available. Patients should not be gratuitously invited to return next year if it is unlikely the team will return or the surgery offered. A final station in the screening clinic should provide clear instructions on preoperative preparation and where and when to report for surgery. The information should be available in writing (in the appropriate language) and posted conspicuously at a predesignated location. Besides the frustration of missing a surgical opportunity after long anticipation and extensive waiting in the screening clinic, a vacant OR slot also deprives another potential candidate of surgery. NPO guidelines. NPO guidelines should reflect the standards in use by