Shooting Blanks with the Big Guns

During discussions about medical mission work the general approach is to think about how to do more with less; Less equipment, different drugs, fewer monitors.  We have access to one agent that is not available back home- whole blood.  In most developed nations with a modern blood back it is more flexible to separate a blood donation in to three parts: plasma, red cells, platelets.  Most often when someone receives a transfusion in Canada they are receiving only one of those components.  In major transfusions we end up providing all three components but separately.  In resource constrained environments transfusions only come in the form of whole blood.  What comes out of one vein goes into another (after it is tested for malaria, hepatitis and HIV).  Patients really respond well especially when they are bleeding as a unit contains all the clotting factors in addition to the oxygen carrying components.  It is kind of an anesthesia treat to have the availability of whole blood transfusions.

When it comes to vasopressors phenylephrine is the only agent I really miss. We are well stocked with ephedrine, epinephrine and dopamine.  These are agents to raise the blood pressure in very sick patients.  In almost every circumstance these that these special agents were required the patient was gravely ill with a serious infection.  I had a few patients who required resuscitation with these agents.

The first case where I had to pull out the big guns was a case of abdominal sepsis from small bowel perforation where is intestinal contents (poo) were leaking into the abdominal cavity.  After 60mg of ephedrine (a rather large dose) I turned to epinephrine, the big daddy of vasopressors that raises both blood pressure and heart rate.  It was the first time I ever saw a paradoxical slowing of the heart rate associated with this drug, which strongly suggested that his intrinsic supply of fight or flight hormones was depleted- a rather poor foreboding.  I put him on a dopamine infusion (not the best choice for sepsis but it is what I had) filled up his tank with fluids and hoped for the best.  

The limits of our capabilities are rather stark.  He couldn’t stay on the ventilator as we have only two in the hospital and they are needed in the OR.  If the breathing tube can’t be removed someone has to assist his breathing by hand and that is simply beyond the capacity of our resources.  Our nurses in soins intensive (ICU) are not trained to capable of managing vasopressor agents either so his only chance is to make a dramatic turn for the better immediately after surgery.   As it turns out that is exactly what he did.  I was able to take the breathing tube out and over the course of a few hours in the anesthesia recovery room I was able to wean off his blood pressure medications. 

A few days later another patient arrived with a terrible necrotizing fasciitis of the leg and came to the operating room in a terrible state of septic shock.  He also had a decent case of untreated tuberculosis and we got the special N95 masks out for our own protection.  In the OR his blood pressure didn’t respond to aggressive fluid resuscitation including whole blood and the agents I used didn’t make much of a difference either. He got through the brief debridement surgery without further destabilizing but after they released the thigh tourniquet and the infection washout disseminated to the rest of the body.  After maximizing all therapy his blood pressure and oxygen levels remained disastrously low.

The situation seemed to be compounded by the local and expat staff all leaving at the end of the case including the surgeons and nurses.  The surgery was over and the local staff had families to tend to at the end of the day.   The initial sense of helplessness was rather striking.  Eventually I was able to confirm my options for care under such dire circumstances and the decision to withdraw therapy was made.  We were able to reach his family so the were able to be with him before he succumbed to his illness. 

Losing a patient isn’t easy in any context.  The inevitability of death is a part of delivering medical care in general and especially in an environment where access to care is so limited.  It just felt like losing a patient for the first time.  There will always be questions on whether there was something that may have changed the course of events but there isn’t long to linger.  There will always be more patients and we have to provide the best care we can with the resources available.  Considering what is available in the environmental context, MSF is doing all right.

Local Anesthesia for the Bangui Locals

It is nice to have options.  The MSF anesthesia kit is a prepackaged set of equipment and medications required to perform 100 anesthetics.  It was conceived many years ago and modified over hundreds of surgical missions.  On average 50% of surgeries take place under ketamine general anesthesia without a breathing tube, 30% are done under spinal or nerve block regional anesthesia and the remaining are a classic general anesthesia with a breathing tube and ventilator in the same manner back home.

Regional anesthesia is used whenever possible.  This means numbing a part of the body through the use of freezing medication.  The major advantage of regional anesthesia is that it allows the surgery to take place with the fewest medications possible.  The patient can be completely awake during surgery without any sensation.  The most common examples of this practice would be a spinal for caesarian section or knee surgery or an epidural for labour pain.  

Epidurals are not available on MSF missions as they require a small tube to remain in the epidural space for a period of time.  Anytime a tube is left in a body cavity there is the risk of infection.  When placed under sterile conditions in a clean environment with appropriate surveillance the risk of an epidural infection is very small.  In North America they are used routinely for labour pain, chest and abdominal surgery.  Here in Central African Republic, the increased risk of a catastrophic epidural infection outweighs the benefits of the pain relief provided by such techniques.

A spinal anesthetic is very similar to an epidural except the needle is much smaller, it goes one layer deeper to puncture the sac of fluid that bathes the spinal cord and brain but it is a single injection with nothing left behind to track an infection back to the central nervous system.  It has to be performed under very strict sterile conditions in order to prevent a meningitis type infection.  Spinals can be used for most any surgery from the abdomen down.  Ceasarean sections are most commonly performed under spinal anesthesia all over the world as it provides the safest anesthetic with the lowest exposure of medications to mother and baby.  We are not an obstetric hospital, which means that I haven’t had the opportunity to be involved with any obstetric patients in Bangui.

The largest barrier to performing spinal anesthetics is that many of the patients come for the treatment for very severe infections that have been festering for many days or weeks.   There are many barriers for people seeking care in CAR. There is limited availability to healthcare and what can be accessed is often associated with a significant cost.   As a result we often see patients arriving in very advanced states of disease.  On a daily basis we see patients with infections that start after a minor injury but by they present the whole limb is infected swollen and spreading fast.  

Even under the most sterile conditions the small amount of inflammation associated with the needle puncture of a spinal anesthetic could result is a seeding of a distant infection in the area of the spinal cord.   As a result the risk and benefit of performing such technique must be carefully weighed.  Most often if there are any signs that the infection has spread beyond the local tissues such as fever or blood pressure instability a spinal is ruled out as an option.

An individual limb can be anesthetized as well.  Nerves of the arm or leg can be specifically targeted and local anesthesia or freezing medication is placed around the nerves to block all sensation and motor control for a period of time again allowing a surgery to take place without a general anesthetic.  The major advantage of regional anesthesia for limbs that it can be used for pain control following surgery reducing the need for opioid medications like morphine which are significantly inferior and carry significant side effects such as confusion, respiratory depression, nausea, vomiting and constipation.   Regional anesthesia has come a long way since I started medicine just over a decade ago.  The practice has moved from using anatomical landmarks and an electrical nerve stimulator to find nerves to the modern use of ultrasound to identify nerves, guide a needle to the precise location and track the distribution of local anesthetics.  I learned the classic nerve stimulator technique as a junior resident but as the new ultrasound technology became available.

I must declare my bias, I am a regional anesthesiologist.  I took specialized training in the form of a fellowship in ultrasound guided regional anesthesia to increase the scope of my practice for situations exactly like this.  I was very impressed to find a state a high quality ultrasound (Ultrasonix Turbo) in use at Bangui General Hospital.  As a result I have been able to provide a number of arm and legs blocks for various procedures allowing patients to have their procedures without undergoing a general anesthetic and having the benefits of effective pain relieve without narcotics for many hours afterward. 

A major benefit that the ultrasound has allowed me to pass onto my patient is an abdominal block for pain relief following bowel surgery.  On a daily basis we have patients presenting with incarcerated hernias, ruptured spleens or perforated ulcers- all emergencies in the general surgery world.  This means that our general surgeons (another Canadian I might add) uses a large incision from the breastbone to the belly button to gain access to the abdominal cavity and address the issue.  

One of the biggest postoperative issues for these patients is pain control.  The location of the incision just below the lungs makes breathing and especially coughing a very painful activity.   In Canada many of these patients would receive an epidural for several days to address the pain.  As a means to mitigate the problem I have been performing a specialized block at the end of these cases to help with the pain.  So far I have managed to perform this block on every patient with one of these surgeries.  I think it helps but the patients here are so stoic that it is very hard to tell. 

When I chose my path in medicine nearly a decade ago there were many factors to consider.  I was drawn to anesthesia for a long list of reasons and to this day I feel I made the decision that was right for me.  One of the factors was the flexibility in participating in humanitarian activities.  Anesthesia and the surgical specialties allow for more frequent but significantly shorter missions.  That was important to me as I figured one day I might have a family and I wanted to minimize the impact on my loved ones.  The burden of my absence remains to be seen.

When I decided to study a specialty within anesthesia in the form of a fellowship I wanted to acquire a skill set that was universal and applicable and valuable in low resource environments.  Regional anesthesia allows me to provide an enhanced level of care to those who too often don’t have many options. 

Down the “K Hole"

Anesthesia is black box to most people.  The general public and even most medical professionals really don’t understand what truly takes place on our side of the drape in the operating room.  In order to explain the dark magic of “putting one to sleep” and more importantly waking a person up at the end of the case many analogies are employed.  Some describe the anesthetic process as flying an airplane with a stable cruising period in the middle with higher risk periods at take off and landing.  In a general sense this hold true as the beginning and end of anesthesia where the patient is being induced or emerging from anesthetic requires very close attention.  But the autopilot of general anesthesia also requires careful vigilance to the surgical process and changing conditions.  At any moment the anesthesiologist must be ready to adapt and intervene in a turbulent case of bleeding, breathing issues or blood pressure management. 

The soft touch down is achieved through a balanced approach to anesthetic depth, cardiac and respiratory physiology and pain management.  In another sense the anesthesiologist is somewhat like the chef or bartender of the medical world.  Through a variety of medications, monitoring and techniques the anesthesiologist must adapt the management of each the patient’s unique physiology to the surgical conditions.  

On a mission with MSF the ingredients and kitchen are rather different.  The medical conditions that patients present with are outside the usual clinical acumen. Malaria is endemic and is one of the first things to check for when someone spikes a fever.  The HIV rate necessitates suspicion of infection when a patient is losing weight or a wound isn’t healing.  Necrotising fasciitis is alive and well here with cases presenting in clusters every few days.  I’ve seen more gunshot wounds than in all my medical training though luckily they are usually limited to the limbs. 

Part of the motivation to participate in a mission such as this is to leave the comfort zone of my home practice and push the limits a little- to expand my envelope of experience.  In preparation for deployment on missions in austere environments I took a course on global outreach anesthesia as a resident. It was among the best four days of my entire medical training.  The course went through a variety of anesthesia equipment, monitors, medications and techniques that are relevant to working in the field.  As you move away from reliance on technology to support patient care, the basics of human physiology and clinical exam are once again emphasized. 

The primary anesthetic technique we use for most cases involving dressing changes, wounds, infections and burns is a deep intravenous sedation with a combination of medications common to anesthesia worldwide.  Midazolam, a benzodiazepine, is used as a relaxant and fentanyl, a potent opioid, is used for pain.   Both agents are short acting and an antidote to reverse the effects is readily available. 

The mainstay medication to provide general anesthesia is to induce a dissociative state with ketamine.  In plain terms, the patient is awake but unaware of their surroundings.  In some less than professional terms, a ketamine based anesthesia can be referred to as putting a patient into the “K-Hole.”  

Ketamine is undoubtedly the most valuable medication for anesthesia care in the developing world as it is a very affordable, powerful pain medication with a wide safety margin that avoids some of the side effects of other medications commonly used. Unlike many other anesthetic agents patients under the influence of ketamine maintain their respiratory drive to a much greater degree.   This means that is considerably more forgiving and can be administered more readily with less sophisticated monitoring by practitioners with less training.  In short it’s harder to overdose a patient on ketamine.  Back in Canada I use ketamine on a daily basis as part of a balanced anesthetic to treat pain but usually at about one tenth the dose to avoid potential unwanted hallucinatory side effects.

In some circles Ketamine is abused as a street drug.  Earlier this year at an international conference on the control of medications China proposed listing Ketamine as a schedule 1 narcotic on the same level as morphine or heroin.  In certain cultures ketamine has gained some popularity as a drug of abuse due to the hallucinatory effects.

The potential effects of increasing the control over ketamine could have severe implications for anesthesia worldwide.  The cost of this affordable medication would certainly rise and transport restrictions would create delays and shortages.   This may not cause much of a ripple back home but the impact on anesthetic care in low resource environments could be devastating, Canadian involvement in the lobby to prevent increased restrictions and access to this essential medicinewere temporarily successful but the risk of further restrictions remain.     

I am amazed at the effectiveness of a ketamine-based anesthetic but it remains rather challenging to compare the practice here in Central African Republic to home.  The patients here are extremely robust.  They tolerate painful procedures better than anyone back home.  I’m not going to change my home practice and start dropping patients in the “K Hole” at every opportunity but it is nice to know how to handle medications outside the usual Canadian practice.

The Needle and the Damage Done

Last month when my scheduled assignment was Yemen most family, friends and colleagues thought I was crazy for accepting a mission in such an unstable environment.  There were stories of suicide attacks and kidnappings in the midst of an erupting civil war.  The president was in exile, the American and Brit forces had pulled out and the Saudis were in the midst of a bombing campaign.  I was rather relieved when Haiti looked like it was going to be my posting mostly because I had the impression that risk of kidnapping would be significantly lower.  Personal security is always at the forefront when making a decision about accepting a mission and the greatest concern to loved ones at home.

The briefing at the MSF orientation in Toronto provided a security backgrounder based on the latest aid worker security report.  The incidence of attacks on humanitarian workers has been increasing over the last several years with the rate of kidnapping dramatically on the rise.  However it still remains an extremely rare event.  In the most recent report from 2013 set a new record for violence against civilian aid operations with 251 separate attacks affecting 460 aid workers representing a 66% increase in events from the previous year.  Of those 155 were killed, 171 were seriously wounded, and 134 were kidnapped.  To provide some context, the spike in attacks in last year is mainly attributed to escalating conflicts and deterioration of governance in Syria and South Sudan. The top five most active conflicts are rounded out by Afghanistan, Pakistan, and Sudan which account for three quarters of all attacks.  The majority of aid worker victims were national staff working to implement international aid in their own countries which is consistent with staffing levels since local employees makes up over 90% of the MSF workforce. They remain the most exposed and at risk for violence.  The highest risk activity for aid workers remains road travel accounting for more than half of violent incidents.  Thankfully and somewhat selfishly these conditions don’t really apply to my situation.

An anesthesiologist working and living in the hospital does not have the same exposure as a nurse traveling to a remote clinic or a driver who spends their entire day on the road.  In fact the most likely event is a minor case of gastroenteritis while adapting to the change in diet or malaria because complacency in regards to taking the prescribed prophylaxis.  Our physiotherapist was off sick with malaria when I arrived but I don’t think he was taking any preventative medication after 5 months in the field. Thankfully the pharmacist keeps the team well stocked with a healthy supply of doxycycline at the dinner table and I am happy to take my daily dose for the five weeks I’m on mission.

The most serious health risk for the medical staff is a needle stick injury.  In a country where the incidence of HIV is (rather poorly) estimated at 10% the reality of being exposed is rather high.  The hazard is comes with the medical profession no matter where you work but in such an environment the risk increases by an order of magnitude.  This past week one of the surgeons poked himself with a dirty needle in the course of an open patellar tendon repair of the knee.  We drew a blood sample from the patient and sent off HIV and hepatitis tests to the laboratory while everyone held their breath.  It was the most vulnerable and fearful I’ve felt since arrival as I thought about the needle and potential damage done.  The surgeon is on his 15^th mission and has been all over the world.  He is married with three children and just survived a rather risky South Pacific Ocean crossing from New Zealand to Chile in a catamaran. 

The awful tension that hung over the project was lifted shortly with news of the patient’s clear lab results.  Our surgeon described the experience as a slow paced game of Russian roulette.   If patient turns out to be positive for HIV, the risk of becoming infected can be almost be eliminated by taking a harsh course of antiretroviral medications for six months.  Hepatitis C which is much more transmissible is harder to treat.

On reflection, the case had setup for a break in concentration to allow for such an error.  He was doing an urgent case and had a follow up clinic waiting.  I had answered his mobile earlier in the case to tell the waiting clinic that he was still in surgery and would arrive shortly.  The surgical equipment available was very limited and what he had was substandard and barely functional.  His assistant was unfamiliar with the procedure and was having difficulty holding the bone steady to place the pin. He is among the most patient and thoughtful surgeons I’ve seen but over the course of the case his frustration was slowly building.  What should be a very simple repair was complicated by the lack of resources and proper assistance.  Considering the circumstances it is really impressive how rarely needle sticks occur under such conditions.  The surgeons really have to adapt to the conditions a much greater extent than anesthesiologists as we have most everything we need in terms of basic equipment and medications. The experience certainly provided a stark reminder for all to be take the time necessary and take care of yourself before the patient.

I would have to say that MSF does take the safety and security of their personnel very seriously.  It has been clear right from the moment I had my interview, right through the orientation, briefings and day-to-day operations.  We all take the security briefings very seriously and follow the rules even if they are the most strict of all the NGOs in the country.

The situation is currently stable in Bangui but tenuous. It is a time of government transition, which always creates the potential for things to go sideways. As recently as December 2013 Bangui was under attack as the Christian militia took back control of the government.  One of our nurse anesthetists who is on her 30^th mission remembers being sequestered in the hospital while gunfire erupted nearby.  A year ago this week 3 national MSF staff were killed in an attack in the northern part of the country that left 19 dead. It serves as a grim reminder of that despite the best security contingencies there are still many intangibles when delivering care to those who need it most.