It's the beginning of our first day at Baguio General Hospital and tensions are a little high. The Canadians wanted to start on time! I half expected that things might be a little more relaxed on the mission, like we might even switch over to “Filipino Time”, meaning whatever happens, happens when it happens, typically around an hour later than you had planned.
I had to put together my anesthesia cart from scratch, picking through the supplies and our own pharmacy shelves for drugs. It was a simple metal rolling cart with three wheels that sometimes worked, and one that was frozen with rust, so it was a struggle to move it through the hallways. It didn’t roll as much as slide, and I would alternately try pulling and pushing to keep it going straight. Of course, I had overpacked it, trying not to forget anything I could possibly need, and things would fall off. Anesthesia is all about anticipating critical events which happen only one in a thousand times. It is best to be prepared for anything.
I performed a checklist on my anesthesia machine, an aged Ohmeda Modulus II Plus, which was literally rusting away. We were lucky to be able to secure the only two machines in the hospital that had working ventilators. Since the electrical system in the Philippines runs at 220 volts, we needed step-down transformers to run some the monitors we brought with us. A nurse told me that the first year she joined the mission, she destroyed a lot of equipment plugging in 110V machines into the 220V wall sockets. We taped over the accessory 220V outlets on the back of my Ohmeda Modulus II Plus to prevent anyone from accidentally plugging the 110V monitors into them.
Another issue was that there wasn’t a scavenging system on my machine. Scavenging vents the expired anesthetic gases into a waste system, rather than directly into the operating room environment. You need to do this because chronic exposure to anesthetic agents could have detrimental effects on the health of operating room personnel. For instance, nitrous oxide suppresses vitamin B12 activity and is linked to bone marrow suppression and reproductive difficulties. They didn’t know about this in bygone days of anesthesia and excess gases were vented directly into the room. Residents exposed to residual gases in their first days of their training would get a little sleepy, but supposedly would develop tolerance to the effects after a couple weeks. In modern hospitals scavenging is accomplished actively through a central vacuum system, but in Baguio we simply attached a hose to the breathing circuit and vented it out the window. Either way, the anesthetics, which are halogenated hydrocarbons, find their way to the upper atmosphere, where they not only contribute to the destruction of the ozone layer but also and act as powerful greenhouse gases.
Since there was no central oxygen pipeline system, our anesthesia machines worked off large oxygen H-cylinders placed in the corner of each room. One of the most critical pieces of equipment was the crescent wrench used to connect the oxygen gas line from the machine to the cylinder. It was always hanging in a prominent place in the hallway. If your oxygen runs out in the middle of the case you are going to need to get this in a hurry to switch over to a new tank. I almost started my first case with an empty tank. We replaced it at the last minute. Normally every machine is equipped with a small backup oxygen tank called an E-cylinder but none of our machines had them, so our margin of safety was significantly decreased.
The challenges I faced were nothing compared to what the BGH anesthesia residents have to deal with on a daily basis. Rachael, a first year resident who accompanied me in my room, told me that they usually work without any electronic monitoring -- no EKG, automated blood pressure cuff, or end-tidal CO2 or anesthetic gas monitors. Blood pressure is measured with a manual cuff and pulses are palpated. If a resident has a pulse oximeter, it is only because she bought it herself! As I mentioned before, only two anesthesia machines in the hospital have working ventilators, so they often ventilate by hand through an entire case.
If that isn’t bad enough, they work crazy hours -- 38 hour shifts on call (what they call “duty”), and are still assigned to work a room the following day. The operating room runs 24 hours a day of course. Common emergency procedures include appendectomies, open gallbladders (the equipment to do laparoscopic gallbladders is lacking), cesarean sections, decompressive craniectomies (for strokes), and laparotomies (usually for penetrating trauma). Saturday night is a big night for stabbings and gun shot wounds. Because of the constant demands of work, residents live at the hospital (thus the term “resident”), which charges them for room and board. That was how medical training used to be in the United States back in the day, before regulations to limit resident work hours were passed.
I definitely worked some long stretches during my training, working all night and catching 30 minute naps before morning rounds on what we lovingly called "The Dog Mat", a thin foam mattress we kept on the floor of a storage room on the cardiology ward. Residency programs justified that kind of treatment by saying that doctors needed to learn how to work effectively under pressure and while sleep deprived, and we weren't going to get the breadth of experience we needed if we didn't put in the hours. Today it all just sounds like an excuse for abusive labor practices to me. I am shocked at the conditions I put up with back then, but you don't bother complaining when you know it's only temporary.
In a way I envy the BGH residents’ training, because as technology continues to advance and make the delivery of anesthesia easier and safer in North America, I think we become so dependent on our machines that we start to lose our clinical skills. There is a relatively new device we use for airway management called the Glidescope, for instance, that uses a video camera for endotracheal intubation. A trained monkey can intubate with this thing, and when that secret gets out no one will need anesthesiologists anymore. But hasn't that always been the central problem with technology? Who needs to develop any skill to memorize anything when you always have access to the internet and Google, for instance. And writing cursive script has become a lost art. Kids these days don't know how to even read it anymore, but they can sure text with their thumbs like crazy!
[Photo credit to Katya Palladina]