International Missions

I attended the recent Global Outreach course in Halifax, Nova Scotia for the last 4 days. This is a timely course as I will be arriving in Rwanda to teach anaesthetic residents next Saturday. Right now I am sitting in the Halifax airport en route to Toronto where I meet my wife and then off to Belgium for a couple of days before our flight to Kigali.

I planned this trip 2 years ago but it is almost on me now. I have been really nervous about this for the last month.

Attending the course made me feel reassured in someways, scared in some ways and depressed in some ways. There were a lot of people there who had been on missions both like the one I am about to go to in Rwanda, MSF missions, Red Cross missions, large and small missions and a fascinating surgeon/anaesthesiologist couple who had lived in Uganda for most of the past 20 years.

Some reflections:

1. I learned (actually I already knew) that we are not going to make any more than a small change at a local level if that. We are not going to make a big change in the way things are done even though we are trying to teach. We will actually only influence a small number of people.

2. If I save someone or improve just one person's life, my trip will have been a success. We are supposed to teach but there will be a time when I will just have to jump in and do things myself and this may be a good thing.

3. International aid may be making people in less developed countries more dependent however there are a lot of people in developed countries making a very good living off maintaining that dependence.

There, I have really set the bar low for my trip.

By the way in my last post I talked about some of the neat equipment I got to use.

At the top is a drawover vaporizer kit. This is portable and with an open circuit could be used in remote locations (like the X-ray department?) This vaporizer can use Halothane or Isoflurane but they make a Sevo vaporizer. You do have to use an open circuit and it would be better to use spontaneous ventilation. You can attach oxygen or just use air. This kit sells for $5000!

Below is the Glostavent machine. It runs off an oxygen concentrator but can run off ambient air. The machine uses 1/7 of of the tidal volume to power the ventilator (meaning it can run for several hours using a small oxygen cylinder). It uses a drawover vaporizer and an open circuit. It can be used without electricity or compressed gas (granted using air). Cost: $5000!

By the way you cannot use either of these devices in Canada or the US as they are not approved for use. This means that the US Navy which uses these devices has to go to Britain to train on them.

We also had a lecture on Halothane which they talked like it was some old drug. Of course when I was a resident we still used Halothane exclusively in children. And it worked pretty good as I remember. We also had a demonstation on the Boyle machine which they actually used when I was a resident (and for the first 4 years I was on staff). Quite frankly I still long for their simplicity. I felt really old when some people asked how you connected them to a ventilator and I was the only person who knew how.

We also had a fascinating lecture on ether. Except for being explosive and making 20-30 % of people nauseated it sounds like a great agent. You do have to take the bad with the good?

I will be posting more on my other blog. If you contact me I may just give you the URL.

What have you been holding out on us?

I have been attending the Global Outreach course in Halifax NS prior to my deployment to Rwanda.

What has really impressed me is how easy it is to give a really good anaesthetic for not much money.

Like for example anaesthetic vapourizers that cost $5000 and last forever with very little mantainance or anaesthetic machines that cost under $20,000 (including the cost of those above vaporizers) which will work without compressed gas or electricity.

And of course using standard monitoring which we have to use anyway capable of giving as good an anaesthetic or better as what we can do with the $100K machines we are told we have to buy. Of course they don't come with a sound system either.

Won't be Bloggin' for a while

Tomorrow I am heading off to eventually end up in Rwanda for 4 weeks to teach with the CAS International Education Fund program before a Kenyan safari.

I will be posting my experiences and pictures on another blog, however as I like to keep my work and life separate, I will also keep my one blog life and my other blog life separate.

I may post a few pictures and posts if I have time.

"See" you in July.

EBL

I have to start thinking of some original topics instead of responding to Great Zs posts.

I am not sure what the importance of the EBL is anymore. It is so much easier just to get a hemoglobin (which we are now able to get again on the blood gas machine since I kicked respiratory's asses).

We never ask at our hospital anymore. At the Centre of Excellence, they asked after total joints. I started giving it to them right down to the nearest 1 cc which the nurse dutifully would write down. Probably why they hated me there.

After one surgeon low balled his blood letting, I looked at him and said, "There's that much on your gown."

IV s

I am only getting around to commenting on this old post by Great Z

I honestly thought I was the only anaesthesiologist who was bothered by IV s.

I think I do most things fairly well. Spinals I get first shot most times; epidurals likewise. I can do a wide range of pain clinic procedures quickly and efficiently. Central lines don't usually cause me grief.

But the difficult IV?

I dread them, the patient who comes to OR covered in bandaids from previous attempts, the heavy smoker, the chemo patient, the scared stiff shut down patient and of course the child. Anaesthesiologists, because we do so many, are better at the easy and moderately difficult IV. When it comes to the above patients we are floundering just like everybody else.

My visceral dislike of IV s possibly stems from my internship where I was used as an IV service. This was a little hard on me and the patients as where I did my student internship, the nurses started the IVs so I was learning on the fly as it was. Fortunately early on during a 4 week anaesthetic rotation, one of the anesthesiologist taught me a technique of starting IVs which I use to this day. Early on however I had a patient who had been on IV antibiotics for weeks and had no veins. I asked the resident if she could go on oral antibiotics and he insisted that she needed the IV and suggested I call anaesthesia. I did so and talked to the resident who passed me on to his staffman. "When your staffman comes in and can't start the IV." said the anaesthesiologist, "I will come down and try to start it."

We do have some aces up our sleeves. We know some places where people usually don't look; the palmar surface of the wrist, the medial forearm just below the elbow and of course the feet. I am never shy about using the antecubital vein. I also will use smaller bore gauge needles such as a 22. We have other aces like central lines, IM ketamine and inhalational inductions (which I occasionally do on adults with poor veins). These last two are of course only useful for patients who are going to get a general anyway. Most of us dread the call to the ward for the patient in whom nobody is able to start an IV.

About a year ago, I had a lady for a C/S under spinal. As it turned out she had a mastectomy with an axillary dissection on her right side and of course chemo which screwed up the veins on her left side. I stared at her left arm for a while and couldn't see anything resembling a vein. Using her foot,assuming there were veins there, is of course out as in the event that the OB gets into the pelvic veins, I am going to be transfusing the suction bottle. After thinking, I told the patient that I was going to have to put a central line in her neck. She was quite cooperative and the line went in smoothly under local. I then proceeded with the spinal and she had her baby. At the end of the case I offered to try to put an IV in her foot so that the central line could come out. "Don't bother," said the OB.

For the rest of the day, I got a phone call about every hour from the post-partum ward. "You know we can't have central lines on this ward," the call would go. I would explain that there was no IV access. There was an attempt to transfer her to the General Surgery ward which could take central lines but they weren't comfortable with an obstetric patient. After a while, I told them to sort it out amongst themselves and think about what was good for the patient and not what was in the policy manual. The phone calls stopped and I started waiting for the letters (which never came.)

A couple of years ago I got a call from the pediatric ward. While we have a large Pediatric Centre of Excellence in our city, our hospital for reasons of pride had insisted on keeping a pediatric ward which thankfully they closed about a year ago. "We have a child with bacterial lymphadenitis here," said the nurse,"who needs IV antibiotics and his IV is gone." Okay I don't like being used as an IV service, but I do have some skills in that area, I wasn't that busy, plus in 30 years (including medical school) I had never seen a case of "bacterial lymphadenitis" so I was pretty excited.

I arrived on the pediatric ward to find a happy child playing with his mother. Happy that is until he saw me approaching with the IV tray. Seeing it was going to be struggle, I looked at the child and thought, "he looks awfully healthy to be needing IV antibiotics". So I examined him. Firstly I felt around his neck where the infected lymph nodes were supposed to be and couldn't really feel any. Not even the "shotty" lymph nodes we used to use to justify giving antibiotics to what we knew was a viral infection. I asked what his temperature was and it was normal. I looked in the chart and the white count was normal. I phoned the pediatrician's office. He was not in but I asked his secretary if he could call me back about the patient and left my cell number. He of course never called back.

It was of course quite possible that the child had a dramatic response to the IV antibiotics and the pediatrician just hadn't made rounds yet. It is unfortunately more probably that the child just had a URTI, the pediatrician took pity on the mother, admitted the child and felt he had to have a treatment to justify the admission, something I saw countless times in medical school and internship.

So I empathize with Great Z and all our brother and sister anaesthesiologists who I now know are as stressed out as we are over this issue.

Bin Laden; Random thoughts

OK....

Bin Laden has been living just outside the capital of Pakistan for who knows how long in a large luxurious fortified compound. Presumably also getting hemodialysis every 2 days.

How much does the US spend on "intelligence"?

Meanwhile we have been taking off our shoes in security, having our shaving cream confiscated and getting to the airport 3 hours early for flights.

Canadian troops have been in Afghanistan for years at a huge financial and worse human cost. We won't even talk about the financial and human cost to the US.

And of course killing Bin Laden is not going to bring back all the people who died in 911 and other related terrorist activities, not to mention the at least 10 fold higher number of innocent people who have died in reprisals in Iraq and Afghanistan. Nor is killing Bin Laden going to end terrorism; by either side.

And with the convenient "burial at sea", conspiracy theorists are going to have a field day.