To the Editor:—
We read with interest both the article by Fisher et al. 1on assessing pediatric anesthesia practices for volunteer medical services in underdeveloped countries and the accompanying editorial by Warner et al. 2The authors have detailed suggestions for improving outcome. Ours is a small, specialized group: Heart Care International, headquartered in Greenwich, Connecticut. We published our initial report 3on a single trip for a 9-day period to Guatemala City, Guatemala, in 1995.
We have a different approach, and our outcome results support our methodology as detailed below. We visit the same location consecutively over a period of several years for purposes of training the local physicians and to provide follow-up care. We confine ourselves to pediatric cardiac surgery, which for all practical purposes was nonexistent in Guatemala at that time. For each operating room, there was a pediatric cardiac surgeon, a surgical assistant, and a pediatric cardiac anesthesiologist. Another anesthesiologist circulated between two rooms and was present at critical periods, such as induction of anesthesia, separation from bypass, and the end of surgery. An additional anesthesiologist circulated between the operating rooms and the intensive care unit (ICU). One anesthesia technician was also available. There was a scrub nurse and a circulating nurse for each operating room. The ICU was staffed by a nurse for every two patients, a cardiologist, a pediatric intensivist, and a respiratory therapist; 24-h ICU coverage was provided. We had nighttime operating room coverage at the same staffing level for any possible emergencies. Each specialty team of doctors, nurses, and ancillary staff had a leader who helped to coordinate all the activities. A screening team arrived several weeks before the main group to examine the surgical candidates who were presented to us by the local cardiologist and, if necessary, performed cardiac catheterization to arrive at the appropriate diagnosis.
Like others, we were also faced with obsolete anesthesia machines and ventilators. Our group included a biomedical engineer, who made sure that however primitive the equipment, it was functional. We utilized portable uninterruptible power sources for each anesthesia location and the ICU as there are frequent power outages. We stringently followed American Society of Anesthesiologists guidelines for the standard of care. Every anesthetic location, along with the standard electrocardiogram and blood pressure monitors, had a monitor for inspired oxygen concentration, a pulse oximeter, an expired carbon dioxide analyzer, and an anesthetic gas analyzer. All patients, except those undergoing relatively minor procedures, such as correction of patent ductus, had arterial and central venous pressure monitors. All patients were transported with monitors from the operating room to the ICU. The ICU team stayed on for a week after the end of surgery to safely discharge all the patients.
We attribute our success to the following reasons. The group was initially assembled at Columbia Presbyterian Medical Center in New York City. We all knew each other and had no difficulty functioning as a group. Since the early beginning, members have migrated to other institutions, but we still function as a group and understand each other's strengths and weaknesses. The group is dedicated to this endeavor, and our turnover rate is very low. All patients were carefully examined prior to surgery and by the anesthesiologist on the day of surgery. We took absolutely no shortcuts in patient monitoring. Our group was liberally staffed; an understaffed group is false economy. Though we had no formal didactic program, we encouraged local physicians and nurses to participate in all aspects of patient care. We limit ourselves to one trip a year, and always to the same location. Indeed, we feel it is of paramount importance to be invited by the medical practitioners of the host country so that we may learn what their needs are and may effectively transfer our expertise to the local medical establishment. It is important that we are not perceived as surgical raiders who are on a mission to do as many cases as possible in order to gain experience doing a particular procedure that will benefit us upon our return to the United States.
We are pleased to say that Guatemala has now become self-sufficient, and we have moved to a new location, Santo Domingo, in the Dominican Republic. We now staff three operating rooms, and surgery is limited to maximum of 2 weeks. We also fully staff a one-room interventional cardiac catheterization laboratory requiring anesthesia care, once again, with two anesthesiologists. The facility is in the same hospital complex, but a little away from the main operating rooms. We have now treated over 300 children surgically, performed over 100 diagnostic cardiac catheterization procedures, performed over 20 interventional cardiac catheterization procedures, and provided guidance for medical therapy for over 1,000 children in Guatemala and the Dominican Republic. A preliminary report was presented at the American Society of Anesthesiologists annual meeting, 4and our results compare very favorably to the best in our country.
Thus, an experienced, cohesive group, careful planning, adequate staffing, proper patient screening, patient monitoring second to none, and a biomedical engineer who visited the site prior to the group's arrival and made sure that all equipment was functional and remained so throughout the visit reflected the outcome of our patients. We carried all our noncontrolled drugs, supplies, and equipment with us. We take pride in that a team of cardiologists visits the location approximately every 6 months to follow up on all the children we cared for to evaluate their health status and quality of life. We have actually put in practice all along most of the suggestions made by Warner et al. 2
Quality-of-care measurements are moving toward the use of standardized quality of life indicators and away from morbidity and mortality figures as these are becoming less frequent. It is in the follow-up of patients and their health status at a time distant from the surgical intervention that the appropriateness of their management is now being assessed. We strongly believe that good patient outcome is possible during volunteer medical services throughout the world if one follows a stringent set of rules similar to what we have outlined.