Lena E. Dohlman

Consensus Statements Regarding the Multidisciplinary Care of Limb Amputation Patients in Disasters or Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict

Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systems the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

Best Practice Guidelines on Surgical Response in Disasters and Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space

The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

Obturator neuropathy after multiple genitourinary procedures

Management of neuropathic complications of surgery associated with multiple genitourinary procedures can prove difficult. A case of obturator neuropathy is reported. A rational approach for diagnosis and management is presented as well as possible mechanisms for its presence.

Anesthesia education across borders.

Purpose of review Changing attitudes toward global health are affecting medical education programs at all levels in the sUSA and abroad. This review describes some of these changes, and how these affect the educational aspects of US global health programs and anesthesia training in developing countries. Recent findings Interest in global health has surged in the past decade, and support for programs has increased in medical schools, university hospitals and from the US government. Recognition of the surgical burden of disease as a global public health problem has been slow but is also increasing. Anesthesia involvement in building healthcare education infrastructure and workforce in low-resource countries is needed and important, and benefits can be had on both sides of the border. Summary The past 5 years have brought a new global focus on workforce development and education in anesthesia. Programs need to be supported by all stakeholders and monitored for safety, quality and outcomes.

Compartmental pressure monitoring after arterial reconstruction lacks clinical relevance

Anterior compartmental intramuscular pressure was studied by the continuous-infusion technique during and after arterial reconstruction of the abdominal or lower extremity vessels in 23 patients. Although there were significant differences between the mean pressures in those patients who had proximal or distal arterial reconstruction, the mean pressure did not increase in the sequential preocclusion, occlusion, and postoperative periods during a mean follow-up of 26 hours in proximal reconstructions and 19 hours in distal reconstructions. One patient had pressures consistent with a borderline compartmental syndrome but died of a ruptured left ventricle before complete correlation of the clinical course and pressures could be made. We conclude from this study that although routine measurement of compartmental pressures during arterial reconstruction of the lower extremities yields interesting findings, it makes no important contribution to the clinical management of the patient.

Successful volunteering--matching the anesthesia volunteer and the aid organization.

The past decade has seen a significant increase in the interest and options for global outreach by medical personnel from developed countries. Faced with an array of volunteer possibilities, how does an anesthesia provider go about finding the right program? An important first step is to do a self-assessment of the motivation, needs, and expectations behind the desire to volunteer. Aside from the humanitarian aspect, there can be a multitude of underlying reasons for an anesthesia provider to seek to volunteer in a developing country. A new graduate just out of an anesthesia training program might be looking for a chance to use his/her newly gained skills independently in an international setting and to have a chance to experience meaningful adventure travel. A mid-career anesthesiologist may be in a good practice, but may feel that the routines of daily work and restrictions on autonomy have sapped his/her enthusiasm for medicine. A new environment and a chance to make a difference is sought to renew his/her professional passion. A recently retired or semi-retired

Providing anesthesia in resource-limited settings

Purpose of review The article reviews the reality of anesthetic resource constraints in low and middle-income countries (LMICs). Understanding these limitations is important to volunteers from high-income countries who desire to teach or safely provide anesthesia services in these countries. Recent findings Recently published information on the state of anesthetic resources in LMICs is helping to guide humanitarian outreach efforts from high-income countries. The importance of using context-appropriate anesthesia standards and equipment is now emphasized. Global health experts are encouraging equal partnerships between anesthesia health care providers working together from different countries. The key roles that ketamine and regional anesthesia play in providing well tolerated anesthesia for cesarean sections and other common procedures is increasingly recognized. Summary Anesthesia can be safely given in LMICs with basic supplies and equipment, if the anesthesia provider is trained and vigilant. Neuraxial and regional anesthesia and the use of ketamine as a general anesthetic appear to be the safest alternatives in low-resource countries. Environmentally appropriate equipment should be encouraged and pulse oximeters should be in every anesthetizing location. LMICs will continue to need support from outside sources until capacity building has made more progress.

International Anesthesia Workforce Development

A major barrier to building the anesthesia workforce in low-income and middle-income countries (LMICs) has been the low priority that surgery and safe anesthesia has had for many decades in these countries. Several contributing factors have led to renewed interest in improving access to operative services in low-resource countries. Noncommunicable diseases (NCDs), many of which are amenable to surgical intervention, are now leading contributors to worldwide death and disability. Reports on the available anesthesia workforce and resources in many LMICs have given a clearer picture of the severity of the current anesthesia capacity crisis. This knowledge has resulted in 2015 policy reports from prominent international organizations supporting the feasibility and importance of improving access to global surgery and anesthesia. Results are also starting to come in on several internationally supported educational and training programs geared towards improving anesthesia capacity and quality in LMICs. This review discusses these factors and reports which give guidance and new hope for future anesthesia capacity building where it is most needed globally.