PROVIDING ANESTHESIA BEYOND USA BORDERS

1. PROVIDING ANESTHESIA BEYOND USA BORDERS KATUBIYA BENJAMIN BAKATUBIA SRNA ,RN , BS, MBA ALLEGHENY VALLEY HOSPITAL /LA ROCHE COLLEGE SCHOOL OF ANESTHESIA 2011 SPRING ANESTHESIA CONFERENCE APRIL 02,2011

3. METHODS OF PROVIDING ANESTHESIA SERVICES BEYOND THE USA • Currently they are two main methods a Certified Registered Nurse Anesthetists from the USA can provide anesthesia service to other countries. • Legally working • In certain parts of the world • Any country if working for a USA agency • Volunteerism • Technology may introduce new choices

4. LEGALLY WORKING FOR NON-USA AGENCIES ABROAD • Nurse Anesthetists are practicing all over the world , generally. • However , mobility for nurse anesthetists to practicing in other countries is affected by • Rules and regulations defining conditions for being authorized as a foreigner for practicing. • Economics

5. COUNTRIES WHERE NURSE ANESTHETIST CAN WORK LEGALLY • North AmericaUSAJamaica • AfricaCongo Democratic R Ghana Tunisia • EuropeDenmark FranceUnited Kingdom Switzerland Sweden • AsiaCambodia IndonesiaTaiwan

6. COUNTRY ANNUAL SALARIES (€) COMPARED

7. 1 euro = 1.4234 US dollars EXCHANGE RATE 1 euro = 1.4234 US dollars

8. WHO IS A NURSE ANESTHETIST VOLUNTEER? • A Nurse Anesthetist volunteer is someone ,qualified ,who performs a nursing and anesthesia service for free. • The community, organizations and individuals receive a vital benefit, that otherwise , could not have existed without the assistance of volunteers.

9. BENEFITS OF VOLUNTEERING • Perhaps the first and biggest benefits are the satisfaction of serving and making a difference in the community and country. • The Pride, satisfaction and a sense of accomplishment alone are worthwhile intangible beneficial reason to serve, share time and talents. • CRNA volunteers also: • Transform their own lives • Solve problems • Strengthen communities • Improve lives • Connect to others

10. "Everybody can be great because everybody can serve.“ - Martin Luther King, Jr.

11. VOLUNTEERING AND HEALTH • A review of recent researches, has established a strong relationship between volunteering and health. Those who volunteer have • lower mortality rates • greater functional ability • lower rates of depression later in life than those who do not • Comparisons of the health benefits of volunteering for different age groups have also shown that older volunteers are the most likely to receive greater benefits because • volunteering provides them with physical and social activity • They obtain a sense of purpose at a time when their social roles are changing. • 100 hours in volunteer time per year are most likely to exhibit positive health outcomes

14. GLOBAL HEALTH CRISIS • The above is made up of a populations in crisis of: • longevity • maternal mortality • compromised survival from trauma and other emergencies. • A predicament triad manifests itself as follows : • Limited higher education • Compromised level of care • Lack of expertise and technical anesthesia providers • No availability of safe anesthesia for surgery, labor and delivery and other procedures. • No provision of acute and chronic pain relief strategies. • No existence of highest level of intensive care. • Lack of equipment / technology

16. THE DEGREE OF CRISIS • Anesthesia crisis exist in low-income countries • In the USA, there are 35 anesthesiologists for 300 thousand people • In Cambodia, there 25 anesthesiologist for 13 million people • In Ethiopia, there are 12 practicing anesthesiologists for 85 million people. • In Sierra Leone there is 1 anesthesiologist for 5 million people

17. Ratio Nurse Anesthetist / 100 000 Hbts

18. RATIO OF ANESTHESIA CASES NOT REALIZED BY ANESTHESIOLOGIST

19. LENGTH OF VOLUNTEERING • Two types of time period exist • Short term ( 1 week to three months) • Maybe planned or unplanned • Unplanned Includes : • response to world disasters such as Katrina Hurricane , Earth Quakes in Haiti and Japan, etc • Planned ones marches : • Personal fulfillment • Professional Credits • School programs • Vacation • Long term (6 months to a number of years) • Usually planned • Establishing and running an anesthesia school • Supporting local government with anesthesia policy making • Establishing a hospital

20. SELECTING A VOLUNTEERING ORGANIZATION • Depends on • Personal goals • Locations in crisis • Organizational goals • Quality of information • Internet • Websites • Seminars • Meeting other volunteers • Current affairs and news

21. PLANNING • Passport • Not all countries require U.S citizens to carry a passport to enter • A passport or birth certificate may be needed to return to the United States. • Leave a copy of the face sheet of your passport at home in case of emergencies • Visa • A visa overlooked maybe a denial of entry into a foreign country. • Check this requirement and start procurement process at least several weeks early • Check in with the U.S. Embassy or Consulate on arrival. • Contact you in an emergency. • License • Your licenses e.g nursing , etc must be valid and current

22. PLANNING • Financial and expenses • Plan before you leave • Expenses varies with the sponsoring group • Be ready to spend • Remember to arrange for payment of your own bills at home • Taxes • Direct and documentable expenses can be deducted from individual income tax. • Even for volunteer expenses claimed on tax returns can be audited by the U.S. Internal Revenue Service

23. PLANNING • Anesthesia equipment • Assume a simplest of anesthesia equipment at your destination. • Ask preceding anesthesia provider • A portable pulse oximeter from Walgreen is a good idea • Owning laryngoscope maybe useful • Think outside the box. • Sanitation • Different standards from the United States. • Carry your own toilet paper and packaged towelets. • Okay to bath with water from the faucets or fountains • Use bottled water for drinking and brushing your teeth • Do not eat uncooked foods , unless cleaned with bottled water

24. PLANNING • Prescription drugs and medical devices • Appropriate labels and original container • A letter from the sponsoring agency stating • Purpose of your trip • You will be carrying medical supplies • It is hard to bring them back medical supplies and drugs into the United States. • Oxygen • No

25. PLANNING • Health precautions • You are a tourist but will be working in environment with infection that you are not immune to. • Universal precautions • Malaria prophylaxis recommended if going to endemic to the region. • A gamma globulin shot to protect against infectious hepatitis is recommended in the week before leaving. • Tetanus, polio, and measles boosters • Yellow fever, cholera, and other vaccinations may be required • Consult with a travel clinics and CDC hotline

27. A LITTLE BACKGROUND OF AFRICA • Consists of • 48 countries on the African continent (if Sudan is officially split into two N. Sudan and S. Sudan) • 6 island nations • Is second largest continent , following Asia • Africa population is around 1 billion • Most African countries have annual population growth rates above 2% • In some African states half or more of the population is under 25 years of age

29. A LITTLE BACKGROUND OF AFRICA • Life expectancy is below 60 years in most the African Countries • Other mortality rate: • The infant mortality rate is at 9% • Child mortality under five years at 15%

30. Weather • Tropical: • warm and comparatively dry inland • hot and humid along coast area • Season • Snow is rare during winter • During the rainy season one enjoys both lots of rain and beautiful skies daily.

32. ANESTHESIA VOLUNTEERING IN AFRICA • How does a typical major city look like ?

34. ACCOMODATIONS • Accommodations are usually • quite adequate • include : • dormitories • private homes • occasionally hotels • guesthouses

36. JOURNEY TO AFRICA • How does a providing anesthesia in a typical village looks like ?

38. TYPES ANESTHESIA SERVICES NEEDED • The types of anesthesia services you can get involved are : • Academics • Training SRNA • Operating a volunteer service • Administering Anesthetics • Knowledge of culture , customs and tropical co-exisiting diseases is important

40. COMMON CO-EXISTING DISEASES • The most common co-existing diseases are : • Diabetes • HTN • Malaria • Cholera • Yellow Fever • Tuberculosis • Dengue Fever • Typhoid Fever • Sickle cell anemia

42. DISTRIBUTION OF CO-EXISTING DISEASES • Malaria (Most Common) • Botswana • South Africa • Namibia • Swaziland • Zimbabwe • Dengue Fever • Zimbabwe • South Africa • Swaziland • Typhoid Fever • South African countries. • Most concentrated in the rural areas • Smaller cities. • Yellow Fever • Sudan • Angola • Congo DR. • Cholera • Southern African countries

44. SICKLE CELL DISEASE • Sickle cell disease is an autosomal recessive inheritance hemoglobinopathy. • Beta chain of HgbA has valine substituted for glutamine at position 6 • Homozygote have symptoms secondary to deoxygenated HgbS which undergoes sickling • RBCs become insoluble, rigid and sickle shaped • Onset likely in hypoxia, acidosis, low temperature or cellular dehydration •  Reversible only before H2O and K are lost

45. SCD CLINICAL FEATURES • Hematological. • Acute low Hgb secondary to infection induced hemolysis or an acute sequestration syndrome in the spleen . • multiple organ damage through repeated veno-occlusive episodes . Blood transfusion is essential. • Respiratory. • Acute chest syndrome .S/S include dyspnea, cough , hemoptysis and pleuritic chest pain. • pulmonary hypertension and respiratory failure. • Genitourinary. • Relative hypoxia and hyperosmolarity of the renal medulla creates an environment for sickling in the vasa recta. Hematuria and Priapism

46. SCD CLINICAL FEATURES • Liver. • Jaundice , gallstone and Liver failure • Skeletal. • Sickling and microvascular occlusion causes shortening of the limbs and gross deformity of joints. Osteomyelitis . • Skin. • Leg ulcers • Neurological. • Acute brain syndrome with s/s of confusion with variable neurological defects.

47. SCD PREOP MANAGEMENT • Full blood count. • Sickledex • Urea and electrolyte. • Liver function tests. • ECG • Chest X-ray

48. SCD • Local infarction causes: • Chest pain • Musculoskeletal pain • Abdominal pain • Splenic sequestration • Hematuria • CVA /TIA • Problems • Anemia • Prevention of sickling • Surgical procedure • Infection risk

49. SCD ANESTHETIC MANAGEMENT • Achieve HgbA >40% with total Hgb >10 g/dl via exchange transfusion. Transfuse slowly to avoid an increase in blood viscosity. Aim to achieve HgbA levels of more than 70% to limit sickling crises. • Assess for pre-existing organ damage • Caution with sedation. Anxiolytics are preferable to opiates • Monitor : • SaO2 • Temp • Urine • hydration

50. SCD ANESTHETIC MGT • Replace fluid loss promptly. A central venous pressure line may help monitor fluid replacement. • Adequate oxygenation • Pre-oxygenation, hyperventilation can shift oxy-Hgb curve to the left and O2 is more readily bound • Maintain cardiac output • Avoid vasoconstrictors • May need antibiotics