The Anesthesia Minimum

At the start of this week there was very little direction with concern to what I was actually supposed to be doing. Not terribly wanting to commit to one service for the week and risk being bored to death by a small uneventful patient load or being trapped in an OR, I headed over to the clinic where I could more or less pick and choose what I wanted to do. I started working with this Doctor named Jonathan who I found out was actually a Pathologist. He was functioning as a Family Physician helping out in clinic for the day. If I was in the states and a pathologist was working in a general clinic seeing patients that would be like, well, actually that would be like a pathologist seeing patients, its about as absurd as anything I can come up with. He informed me that he usually works in the clinic for a couple of hours every day and has been for the last 9 years. I asked him about the path lab before we started seeing patients, he told me they ran out of stains and the only thing he can look at are gross specimens. As we started in the clinic I was expecting a train wreck and I would have to bite my tongue so hard it would come off. To my flabbergasted surprise this pathologist was heads and tails the best clinician I have yet worked with in Palau. He was able to take his knowledge in pathology and apply it clinically. Everything he diagnosed he was able to go through the mechanism of how the disease worked and how the patients present. It made me wonder that although pathologists never interact with patients I wonder if most could work a clinic if they really had to, granted they remember which side to listen out of a stethoscope.

That afternoon I was planning on going back to clinic, but was informed that there was an anesthesia conference going on in the library that might be worth checking out, Vanessa was already there. The conference was actually a week long event, it was actually pretty cool. These two Anesthesiologists and Surgeon from Australia were running the thing. The concept was to bring other Anesthesiologists and Nurse anesthetists from other islands in for the week and run through a training seminar. There were about 10 others there from places like Yap, Chuuk, and as far as the Marshall Islands. They represented all of Micronesia. This conference is actually held every other year on different islands. One of the Australian doctors Arthur said he had been doing it for several years, and the faces are usually the same. The main concept of the week was more about establishing a system of professional support for these people rather than truly trying to educate them. Most of them work in these rather remote islands in rather awful medical conditions in complete isolation. They are also under educated and under equipped for the jobs they are doing, this became apparent very quickly. Islands like Yap and Chuuk can’t do simple things like blood gases, nor do they have anything outside the most basic of drugs and gases. Often times the doctors from these first world countries would start talking about a tube or drug that is basically considered standard of care in many other places, they realized that no one in the room had access to what they were referring. They couldn’t really do anything else besides look at each other and move on to another topic. Palau is no exception, and they lack just about as much as the rest, occasionally they have a couple things that no one else has.

I learned that conditions in Chuuk are the worst; they don’t even have running water in the hospital. But, I was shocked to find out that Chuuk has 60,000 people, which is three times more than Palau. While Palau is a fairly safe place where you can walk around at night with no issues, the same night time walk in Chuuk and you might find yourself with what they called a “phillipinni” through your chest. It’s basically a tire iron straightened out and sharpened and then they launch them at each other with these sling shot like contraptions. Now imagine this thing sticking out of you and being rushed into a hospital with no working utilities, and a skeleton staff that has no capabilities to handle such a trauma. The anesthesiologist that never did any official training in the field comes to prep you for surgery. You see him push some drug into your IV which is the only kind they have, in your last image you see what the drug was and knowing a little bit about drugs you think wait I shouldn’t get that drug because… and you pass out. In Manila you might wake up, in Chuuk you just saw your last cockroach scurry across an operating room floor. The World Health Organization is well aware of the health care disaster is this area, and like most areas of the world the problem revolves around corruption and money. The WHO and Federated States of Micronesia pour money into places like Chuuk but the local government is so corrupt that hardly a dime gets to where it’s intended. You just flat lined on the operating room table, but their defibulator broke about a month ago.

I was actually impressed with how the Australians had organized the week. Every modern well proven method of learning module was somehow in play. We did review questions, had problem based learning sessions with fake scenarios, watched DVDs, and of course death by powerpoint. At one point they asked Vanessa and I to act out scenarios and the participants would each take turns working us up like a trauma patient and running through the basic ABCs of trauma (airway, breathing, circulation). It was fun, the Aussies hammed it up and all had a good laugh with some of the scenarios. Although it was a bit scary at times when some of these Anesthesiologists who were MDs did not understand the simple concept of how to access the Airway, Breathing, and Circulation in that order. Arthur told me later that he teaches basically the same course every other year to what is basically the same group of people and little is retained. So these guys do what they can to teach the trade. If nothing gets through at the end of the week they have at least helped the group establish some kind of professional comradely, and at a very minimum give an email address or two so they can ask questions later. But I think Vanessa and I have enjoyed it because we actually are learning a good deal about anesthesia and getting a lot of review at the same time. We are also getting another lesion about the challenges in this region.