Anaesthesia for reconstructive surgery in the asia pacific

Scott Fortey

Gosford Hospital NSW Australia

If you enjoy problem solving, new cultures and routines, work well with a limited vocabulary and thrive on being an integral (even valued) part of a team, then being an anaesthetist on an overseas aid trip is for you. My experiences have all been with Interplast Australia and since 2000 I have been on five trips around the Asia Pacific with two more planned this year. There is no better opportunity to dump some accumulated frustration and return home with a new outlook on anaesthesia and healthcare. There is also no better opportunity to help someone (no, not the surgeon) who otherwise would have no chance of an alternative life. Whether it makes a difference overall is really irrelevant- if we can afford it then on an individual basis the work is priceless.
Interplast Australia is an organization that could play a large part in Australian anaesthetists’ lives. It was formed in 1983 by Rotary and the RACS and since then over 10,000 procedures have been performed, recently sending over twenty teams per year. A team usually comprises two plastic surgeons, two nurses (often with no anaesthetic training), and one or two anaesthetists. Trips typically last two weeks and despite being well organized and researched often require re-thinking when in the country. Customs can be difficult despite all the appropriate papers and phone calls being complete. Once at the Hospital, set up begins and sorting of the patients proceeds until lists of planned surgery are made. We take a day or two in the middle weekend to explore the country. Use of local equipment and personnel is essential; however we can take a portable anaesthesia machine and boxes of surgical equipment. Most procedures are for cleft palate or lip lesions or reconstruction post burns contracture or cancer- not the simplest of procedures even at home. Increasingly, free flaps are being employed in the management of certain deformities and there is always a lot of focus on teaching for surgeons, anaesthetists and nurses. There is a cautious method needed to teach and work with the locals as it is very easy to put them off side if we disrespect their techniques- and there’s not much point teaching techniques to which they have no access.

Challenges include (but are not limited to); language, different skills, techniques and knowledge, malfunctioning equipment, missing equipment, blackouts where there is no light or suction, failed oxygen supply and post op management where panadol is the most that is given for any painful condition. Greater challenges await even when all the equipment is functioning- one look at some of the patient’s airways gets you re- inventing techniques rarely used at home. There is no fibre-optic scope, Glidescope or Air traq but we do take bougies and Laryngeal Masks.
One technique worth mentioning because it is often overlooked at home is topicalisation of the airway followed by sedation/anaesthesia with ketamine. The patient breathes spontaneously but allows direct laryngoscopy. Ketamine is given in boluses of 0.5-1 mg/kg after a small dose of midazolam. Ketamine is then titrated to effect and topicalisation added to if needed. There are a few reports of laryngospasm with ketamine but none that I could find with topicalisation and ketamine. Therefore topicalise first if possible. Since first using this method I now have a small series of nine patients (three abroad), all in either previously difficult intubations or predictable difficult intubations and only one failure in a morbidly obese patient prior to banding whom I baulked at giving large doses of ketamine to and whose gag reflex was too strong. I have not encountered any obese patients in my trips overseas. None of the patients recalled the procedure although most had some type of vivid dream.
Language is usually a challenge with a local translator being essential. I learn five phrases early in the trip; “Hello, Goodbye”, “Excuse me”, “Sorry”, “How much?” and the numbers. Knocking into a local in a narrow Phillipino street could easily lead to an unwanted situation. A simple “sorry” (attempted in their language) is better than travel insurance.
I look forward to each trip, I enjoy each trip and I reflect upon each trip on return. Hopefully more anaesthetists will one day also experience this wonderful opportunity.