The majority of the world's population lacks access to safe, timely, and affordable surgical care. Although there is a health workforce crisis across the board in the poorest countries in the world, anesthesia is disproportionally affected. This article explores some of the key issues that must be tackled to strengthen the anesthesia workforce in low- and lower-middle-income countries. First, we need to increase the overall number of safe anesthesia providers to match a huge burden of disease, particularly in the poorest countries in the world and in remote and rural areas. Through using a task-sharing model, an increase is required in both nonphysician anesthesia providers and anesthesia specialists. Second, there is a need to improve and support the competency of anesthesia providers overall. It is important to include a broad base of knowledge, skills, and attitudes required to manage complex and high-risk patients and to lead improvements in the quality of care. Third, there needs to be a concerted effort to encourage interprofessional skills and the aspects of working and learning together with colleagues in a complex surgical ecosystem. Finally, there has to be a focus on developing a workforce that is resilient to burnout and the challenges of an overwhelming clinical burden and very restricted resources. This is essential for anesthesia providers to stay healthy and effective and necessary to reduce the inevitable loss of human resources through migration and cessation of professional practice. It is vital to realize that all of these issues need to be tackled simultaneously, and none neglected, if a sustainable and scalable solution is to be achieved.
The ZADP and the Zambia Master of Medicine (MMed) Anaesthesia programme provides an example of a cross-cultural peer-directed co-learning model that benefits trainees from developed and developing postgraduate training programmes. This synergistic model is one that could be applied to other educational initiatives supported from overseas. This model not only adds a useful dimension to the educational support provided, but also embodies the principle of co-development that is so important to the sustainability of such projects.
The mean age was 28 yr. The majority of patients, 64/69 (93%), were male. By mechanism of injury, 55 (80%) were assaulted, there were five sports injuries (7%), four road traffic accidents (6%), four trips/falls (6%), and one case where the mechanism was unclear. Fifty-seven patients (83%) suffered isolated injuries; 12 (17%) sustained concomitant injuries, although none required any other operative intervention. No patients suffered a C-spine injury. The most widely used 'primary' laryngoscopy strategy, in 43 cases (62%), was video laryngoscope (C-MAC®, Karl Storz GmbH & Co. KG (Tuttlingen, Germany) in our centre). Direct laryngoscopy with a Macintosh blade was performed in 20 cases (29%). Six cases (9%) were intubated electively with a fibreoptic scope (four awake and two asleep), although the reasons for this choice of technique were not clear. Mouth opening was quantitatively recorded in all 69 cases. There was no intubation difficulty in any of the 69 cases, and none required a 'secondary' intubation strategy. This cohort, most of whom presented with an isolated injury, represents a subset of patients with mandibular fractures. Polytrauma patients are managed at our regional trauma centre. No patients sustained C-spine injuries, similar to a previously published work, 1 showing that isolated mandibular fractures are rarely associated with C-spine injury. Despite the typical presentation with significant trismus, and despite 26% of patients having a condylar fracture, which can be associated with mechanical obstruction to mouth opening, 2 the vast majority of patients in this cohort (91%) were intubated uneventfully using either a videolaryngoscope or a standard Macintosh blade.
The chapter covers pre-op assessment in the context of limited availability to tests and investigations outlining the key considerations that should be made in assessing fitness for and appropriateness of surgery. Key aspects of consent within different cultural contexts are explored as well as important consent considerations for quality improvement and research projects. A practical approach to the assessment and management of pain in the context of limited availability of medications and trained staff is taken including the management of acute pain, non-surgical pain, pain related to cancer, chronic pain, and neuropathic pain. In the last section, key aspects of anaesthesia and resuscitation at high altitude are covered.
The chapter provides the reader with information on the non-clinical background to working as an anaesthetist in a low-resource setting. It concentrates on important concepts that should inform the way you practise and teach, rather than technical aspects of anaesthesia. Although technical aspects of delivering anaesthesia are usually uppermost in the minds of anaesthetists new to working in low-resource settings, it is often the case that adapting successfully to the local context proves the more challenging aspect. Topics covered include humanitarian and developmental principles, teaching anaesthesia, looking after your own health, being a good visitor, and how to adapt your practice.
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