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Title: Turning Back Time: Anesthesia Practices in ThirdWorld Africa, with Board Review of Relevant, but Unf


1
Turning Back Time Anesthesia Practices in
Third-World Africa,with Board Review of
Relevant, but Unfamiliar Gases and Equipment
Ralph C. Bethea, III, MDCA-3 Resident,
Department of AnesthesiologyWake Forest
University School of MedicineWinston-Salem,
North Carolina March 2004
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Serengeti
3
Past WFU Resident Experiences
  • a journey for development of cultural
    awareness, adaptation, independence, and personal
    and professional growth
  • The lessons learnedmost intensive of my
    resident training
  • Those who go never see the world in the same way
    againhelps an individual to grow and become a
    broader person., Dr. James

4
Dr. Frank James 1990
  • I look upon this experience as a most valuable
    one for our residents and believe that it
    represents one of the things which we have been
    able to develop in our department which sets us
    apart from many of our competitors throughout the
    country.
  • an opportunityto grow in a waywhich could not
    occur without such an experience

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Benefits of International Experience
  • Teaches vigilance
  • selection of monitors
  • adjustment to new environments
  • tolerance and cultural sensitivity
  • fostering future professional relationships
  • independence and resourcefulness
  • Get out of CA-3 Call Pool (think again)

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Preparing to Go Overseas
  • Learn the available equipment
  • Teaching Material
  • reinforces material, public speaking practice,
    reflects positively on home institution
  • Represent your department, university, U.S.A.
  • Remain flexible and sensitive to host program -
    open mind
  • forget how its done back home
  • fit into the system
  • laborer not a savior

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Health Volunteers Overseas
Improving Global Health Through Education

Volunteers responsible for travel and living
expenses Assignments 2-4 weeks (or
longer) Pre-departure briefing materials provided
www.hvousa.org info_at_hvousa.org
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HVO a snapshot
  • 25 Countries
  • 50 Programs
  • 2,500 Trainees
  • 150 Domestic
  • Volunteers
  • 375 Annual Overseas Volunteers
  • 7 Full-time and 4 Part-time Staff

11
Beginnings of Ether
  • 1842- Dr. Crawford Long anesthetized James
    Venable (Published after Morton)
  • 1844- Horace Wells (N2O)
  • 1846- William T.G. Morton anesthetized Gilbert
    Abbott at Mass General

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Down-town Mwanza, Tanzania
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Bugando Medical Center
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Sweating it out
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Pharmacy
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Draw Over Vaporizer
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Diethyl Ether
  • Most widely used inhalational
  • safety, availability, inexpensive
  • Strong irritant smell
  • boiling point 35 degree C
  • MAC 2
  • Relatively soluble (B/G 12)
  • 80-90 inhaled is exhaled, 10 met.

42
Diethyl Ether
  • Colorless
  • flammable with air at 2
  • explosive with O2 or N2O
  • electrocautery, static electricity, short
    exhalation exhaust tube, dry atmosphere

43
Ether - Pharmacology
  • Anesthetic and analgesic properties
  • postop analgesia
  • Catecholamine effect
  • adrenal release
  • increased CO (unless stage IV)
  • Safe with epinephrine infiltration
  • muscle relaxation

44
Ether - Clinical
  • Uterine relaxation ext / int uterine version
  • bronchodilation Asthma
  • salivary secretions markedly increased
  • anticholinergic premed (atropine 1.0 mg)
  • PONV - ingested in saliva
  • gastric irritation, PONV
  • no increase with 3, NDNMB, IPPV

45
EMO Vaporizer
  • Epstein-Macintosh-Oxford
  • Thermocompensation and buffering
  • latent heat of vaporization
  • decreased T causes decreased C
  • Thermostatically operated valve to control air
    inflow
  • Buffering- mass of substance with increased
    specific heat capacity that resists change in
    temperature (copper, H2O)

46
Vaporizers
  • EMO
  • OMV

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OMV
  • Oxford Miniature Vaporizer
  • Lacks full thermocompensation
  • thermal buffering H2O / antifreeze
  • Halothane vaporizer

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Draw Over Apparatus
  • Vaporizer and self inflating bellow
  • low resistance
  • gt 1 one way valves
  • accurate C over wide range flows
  • EMO and OMV
  • also useable with continuous flow systems

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Oxygen
  • H Cylinders
  • industrial oxygen frequently used
  • fractional distillation of air
  • Oxygen Concentrators
  • cheaper than H cylinders
  • WHO approved model list
  • 4 L/min low pressure flow
  • 1 minute flow after electricity failure

51
Oxygenation
  • Ether is frequently used with room air
  • stimulates ventilation
  • increases CO
  • Oxygen usage
  • young, old, sick, anemic, halothane
  • 1 L/min 35 - 40 FiO2
  • 5 L/min 80 FiO2
  • fed into reservoir tubing (gt 30 cm)

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O2 Concentrator
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Oxford Self Inflating Bellows
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Self Inflating Bellows
  • Oxford Inflating Bellows
  • 2 one way valves either side of bellows
  • placed between vaporizer and E1 valve
  • internal spring (1/3 capacity at rest)
  • light internal clip for storage
  • easy spontaneous ventilation
  • visible movement

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Self Inflating BellowPPV
  • Open inspiratory valve crisply
  • avoid lifting bellows to maximal capacity
  • VT of 2L
  • Pediatric bellows exist

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End Inhalation
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End Exhalation
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Concepts of Barotrauma
62
OIB valve set up
  • If E1 valve is in function, the downstream one
    way valve must be disabled
  • magnet or removal of valve
  • E1 may stick causing barotrauma
  • Remove magnet with Heidbrink valve (pop-off
    valve) - spontaneous vent.
  • does not prevent expired gas backflow

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Ambu E1 Valve
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Magnet removed valve closed
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Heidbrink Valve
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Heidbrink Valve Set Up
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Letter by Dr. Francis James to Robert Stoelting
MD 1990
  • During the time in Africa, the residents benefit
    in many wayswithout sophisticated monitoring
    equipmentthey have to use their basic senses to
    monitor patientsas was necessary 20-30 years ago
    in this country.

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Anesthetic Practice
  • SAB less fear of death
  • hyperbaric lido 5-7.5 dex (60-75 mg)
  • 45-60 min, ketamine, meperidine IV
  • hypotension - preload gt 1 liter
  • ephedrine not available, epi 25 mcg (abrupt)
  • hyperbaric bupivacaine 0.5 (10-12 mg)
  • PDPH where are they? 22 g quincke
  • cultural, racial, socio-economic reasons

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Bernard Mbeya, Tanzania
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African Efficiency
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