The comments of Drs. Mayhew and Burrows are cogent and relevant. We believe that anesthesiologists practicing abroad for elective surgery should strive to apply the standards of care they apply in their home practices as closely as possible. There should be a clear understanding of what are appropriate perioperative risks for elective surgery in the selection of patients, the techniques used, the monitoring applied, and the skill mix of personnel involved. Credentialing of volunteers is an especially complex issue. We agree that it would be advantageous to have fully trained pediatric anesthesiologists available for all missions. This is not always practical. Although agencies may not want to limit their programs because of a lack of pediatric anesthesia expertise, programs treating pediatric patients should require their volunteers to have extensive experience dealing with children and with perioperative issues specific to the planned surgical procedures (e.g. , bleeding and edema related to palate repair). The most important but also most elusive credential is the ability to understand one's limitations in the austere setting, and to exercise what we all understand (but cannot precisely describe) as “good clinical judgment.”

The ultimate goal of many of the short-term voluntary programs is to transfer the ability to provide service to entirely local providers through modeling, training, and perhaps provision of supplies. Dr. Khambatta et al.  describe an excellent and intensive approach to pediatric cardiac anesthesia in a developing country. They are to be congratulated for their devotion to this cause. Many of the concerns of plastic surgical groups who undertake to train interested general surgeons, dentists, or otolaryngologists are quite different than the tertiary level of care of Heart Care International. However, the important themes they reiterate—meticulous planning, team cohesion and continuity, good patient selection, and follow-up assessment—are the foundations for success in all of these endeavors.