Perspectives on Anesthesia at Mulago

By Megan Foureman, CRNA, MSN | September 20-23, 2013

The anesthesia providers here at Mulago Hospital in Kampala, Uganda must everyday overcome barriers to care that simply do not exist in the United States. Anesthesia supplies, equipment, and medications are a hodge-podge of donations from all over the world. Much of this equipment has been used, reused, repaired, and patched far beyond the point of its reasonable lifespan…at least by US standards.

In spite of such obstacles, anesthesia providers here do a remarkable job of combining sound scientific knowledge, stubborn ingenuity, creativity, and persistence of spirit in order to provide sound anesthesia care. What they accomplish is remarkable. While much of their practice and resources would be considered unacceptable by US standards, the fact remains that their outcomes are most often good. This is the bright side of anesthesia care in Uganda.

Just as easily visible is the dark side. The most basic of equipment is so very difficult to find. Reliable measurement of oxygen saturation and blood pressure (bare minimum intra-operative monitoring) is by no means guaranteed. Sophisticated equipment that requires special maintenance and regular calibration receives neither. The ingenuity of the local and volunteer anesthesia providers is evident in every patched blood pressure cuff, every tattered cable covered in tape, every piece of ‘disposable’ equipment that has been used, washed, and reused until holes are worn into them. Even at this point, the local providers tell us, “We discard nothing.” Who knows when perhaps the cables from this torn BP cuff might be used as a small tourniquet for IV insertion? And might it be possible that this stylet is no longer suitable to aid in endotracheal intubations, but could very well be fashioned into an IV pole? Even though there is no machine to test the battery on the theatre’s air conditioner, can one not tell a live battery by simply placing it on the tongue?

As volunteer anesthesia providers at Mulago hospital, my colleague and I have just finished a case: a posterior fusion of cervical vertebrae 2 and 3. For curiosity’s sake, we make a list of the reasons that a prudent anesthesia provider in the US would cancel this case before even rolling back to the operating theatre. That list follows:

  • inability to monitor EtC02
  • erratic power to vital signs monitor
  • inability to mix oxygen with air on anesthesia machine
  • no secondary oxygen source
  • non-functioning BP cuff
  • inadequate EKG reading
  • inability to monitor temperature intra-operatively
  • ventilator continuously alarming ‘low 02 pressure’ in spite of our trouble-shooting

Mulago HospitalBy First World standards, such compromise is unacceptable. I propose, however, that we in the US are simply on opposite ends of the spectrum of unacceptability. Is it acceptable that we have ‘disposable’ laryngoscope blades? Is it acceptable that we are often known to actively warm our patients (again using ‘disposable’ equipment) for a short case with limited exposure? Is it acceptable that we throw away large quantities of drugs because the practice of using multi-dose vials has essentially become obsolete? The list could go on and on. I dare not attempt to provide answers here, but I think it is important to pose the questions.

As I ponder this, I am reminded of a story told by Pulitzer Prize winning author Jared Diamond. He describes a conversation he had in 1972 with a fellow named Yali, a local politician in Papua New Guinea. After much heartfelt communication between the two men about inherent disparities of resources between the two cultures, Yali asks Diamond the poignant and heartbreakingly simple question: “Why is it that you white people developed so much cargo and brought it to New Guinea, but we black people had little cargo of our own?” The word ‘cargo’ here refers to all manner of necessities: equipment, food, tools, shelter, and the like. I have no idea of the answer to Yali’s question and I suspect that it is one of those questions that does not have an answer anyway. Perhaps the important part is just to continue to ask. For whatever reason, we in the US have indeed been gifted with much cargo while others have not. It is not because we are smarter or more deserving and it is not because we are better stewards of our cargo. Why then?

Many times, the weight of all that extra cargo burdens my heart. There is no easy way to redistribute that cargo. Trips like this one are a start though. In addition to bringing much cargo and skills, we have formed relationships. The effects of those relationships can potentially be never-ending. We have made tangible differences in many lives. We ourselves have been touched by many moments, stories, faces, situations, smiles, tears, and embraces. I believe this is the cargo that the Ugandans give as a gift to us.

Chris KeithPerspectives on Anesthesia at Mulago