and welcome to Style Points. Today, our guest
is going to talk to us about her experience doing
volunteer anesthesia in environments where resources
are particularly scarce. Dr. Erica Alcibiade,
who once told me to pronounce her name using
the letters L, C, B, A, and D, is an assistant
professor of anesthesiology and former chief
resident of our program here at the University
of Cincinnati. After graduation, she did her
fellowship in regional anesthesiology and acute
pain medicine at Johns Hopkins before coming
back to our group at UC. When she isn't practicing
aerial yoga, she's planning her next trip to
some amazing locale where she takes pictures
of herself eating snacks next to a waterfall.
Erica, thank you so much for joining us. Absolutely.
So I've got a question for you, which is pretty
commonplace at this point. I've asked it to many,
many people over time. But it's our dinner question.
So if you could have dinner with anyone in the
world, could be somebody from the past or even
from fiction, who are you having over for dinner
and why? I've always traditionally been really
bad at answering this question. You know, all
of my guests say the exact same thing. So I'm
interested in your bad answer as well. But I
have two and I can't decide which is the more
accurate answer. So I'm going to give you both.
Excellent. The first is my... grandfather on
my dad's side uh he passed away when my dad was
a teenager and came over to the us from italy
so i feel like he would have some really cool
stories both about you know family and some historical
stuff uh so i think that would be really cool
to find out and figure out you know what terrible
things my dad was doing as a teenager so you
could use this blackmail against him exactly
excellent And then my other answer is John Muir,
because I love doing the national parks and outdoorsy
stuff. And I think he would have some really
cool stories about what he saw that used to exist
prior to everything becoming modernized. That
makes a lot of sense. And that sort of plays
into what we're going to talk about today, which
is essentially you being a world traveler and
somehow turning that into something that you
can do at work as well as on your own free time.
Let's talk about that. How did you get into doing
what it is you do? So I wish I had a, you know,
great story, but it's just kind of a culmination
of everything that I love to do. As you mentioned,
I love to travel and I always knew I wanted to
take care of resource limited areas. I went to
medical school in East Tennessee where there
is not a whole lot of rural medicine population
being taken care of. So we used to do clinics
for them and just combining some of the things
that I love. International mission trips have
become something that I am. super passionate
about. It's one of the reasons that I did a regional
and acute pain fellowship. I want to be able
to teach regional in resource -limited areas,
places where general anesthesia is not necessarily
safe, that people can have surgeries with much
less risk. So is regional safer somehow than
general anesthesia? Let's walk through that.
Yeah. A lot of the studies that look at resource
-limited areas in anesthesia show that there's
just not well -trained anesthesia providers and
in some areas, not anesthesia providers at all.
So managing airways and respiratory status is
one of the leading causes of morbidity in these
areas. So if you can avoid needing to manipulate
an airway and knock out someone's arm or leg
or, you know, whatever it is that they can have
surgery comfortably without needing general anesthesia,
it can actually be much safer for them in the
long run. So that's what inspired you to do your
fellowship? It did. How was your fellowship geared
towards that what sorts of techniques things
did you learn did you gain expertise in that
made this easier for you? One of the reasons
I chose to go to Hopkins for fellowship was because
they have a lot of global connections already.
And I had asked during my interview process about
the ability of spending my elective time doing
mission trips and doing global health work. And
they were very supportive of it. Although they
didn't have a program involved for regional at
the time, they were very supportive in figuring
out how I could do that. And I was actually able
to spend two weeks in Ghana. and another week
in Uganda during fellowship, both on regional
-based trips, one through ASRA and another through
another local group that one of the surgeons
that we worked with was involved in. So I got
to go and do and teach blocks and be really involved
in kind of more a regional -focused trip rather
than a generally anesthesia -focused trip. So
it was really cool to see all of that. I had
the privilege of being and attending while you
were here in training, and I remember you as
a trainee. And you were always somebody who was
really steady and good with blocks and good with
your needlework. So I think it surprised some
of us when we thought about you doing a regional
fellowship. But that makes it make a lot more
sense for me, at least in my mind, why you would
want to do a regional fellowship. It wasn't necessarily
that you needed any extra skills with a block
needle, which, again, you were always great at.
But more about... gaining a global perspective
on things yeah yeah and that was a large part
of you know doing the fellowship learning how
to kind of teach these things better um to trainees
that you know have never done a block have never
even seen an ultrasound in some of these locations
so let's talk a little bit more about what you
do as part of your work here in all these different
countries? Do you have some different buckets
that you like to put things into? Yeah, every
trip's a little bit different. You know, there's
teaching trips, there's doing trips, there's,
you know, educational things. So here at UC,
we have two trips that we have gone on multiple
times, one being started by Mike Howershock.
with Partners for Medical Relief in Belize. That
is more of a doing with a slight component of
teaching trip that we regularly take residents
on. That is more of a general anesthesia type
trip. It's mostly with ENT surgeons and general
surgeons. So it just leads to more general anesthesia
happening for those type of procedures. And then
in Uganda, it's kind of a combination of both
doing and teaching, which is another trip that
Josh tried. had gotten involved in with one of
our surgeons, Dr. Zender, with his nonprofit.
So that's a little bit more doing and teaching
simultaneously. They tend to bring trainees from
all over the country to the hospital that we
happen to be at so that their trainees can learn
from us. And they have anesthesiologists as well
as what they call medical officers there, which
kind of function similar to how we think of like
CRNAs and AAs here. But a lot of them practice.
a little more independently just because of lack
of providers throughout the country. Sure, that
makes a lot of sense. So let's talk about sort
of start to finish what one of these trips looks
like, generally speaking. I'm sure that with
these longstanding trips, you have a date in
mind that you're going to go. What does all the
logistics look like between having the idea and
actually going and doing? Uh, there's a lot that
goes into it that, you know, people don't necessarily
think of or recognize. Um, Mike has got me a
lot more involved in the planning stages of the
Belize trip. I'm actually now on the board of
partners for medical relief and I'm involved
in a lot of their planning and logistics and
figuring that out. Um, so, you know, things from
ordering medications, ordering supplies, what
do we think we'll need? Who's coming with us?
How do we get everyone there safely? You know,
Most of these countries, whenever medical trips
come in, go through the supplies that you're
bringing in, make sure they're not expired, make
sure that there are things that are safe that
they would use on their patients, which is totally
appropriate. But it's common questions that I
get here is, hey, we have all this stuff expiring.
Can we just give it to you for a mission trip?
And while I wish we could take it. the answer
isn't always yes um so it's just little things
like that how do you have a big enough team how
do you account for if somebody gets sick making
sure you have you know a backup plan in that
scenario if someone can't go last minute if a
flight gets delayed What medicines do you want
to have with you? What medicines can you readily
obtain and take into places? Obviously, we're
not going to, you know, buy fentanyl off the
street and take it down to a foreign country
with us. So that's something we have to rely
on getting there and knowing, you know, their
health system can help us as well. So making
connections within whatever city hospital system,
even government that you're, you know, going
through can really help safely get your group
there, do the work that you need to do. connect
with the people you want to educate i don't actually
have any personal experience with buying fentanyl
off the street and i have never thought about
the logistics involved with getting controlled
medicines in a foreign country yeah how do you
do you send an email how does how does that work
how do you how do you start to think about obtaining
something like that yeah um in belize which is
where i have like the most experience you know
getting um kind of the medications and the involvement
in that is we actually use the hospital system,
uh, that we work through is, um, narcotics. Um,
so we have what we lovingly call the drug lady,
uh, and she comes every morning with a locked
box, um, that has fentanyl and morphine in it,
as well as, um, usually a couple of pills and
things that they can like coding, uh, Tylenol
number threes that they can send patients home
with, um, if they so desire. Um, and we sign
it out from them. And at the end of the day,
she comes back around and takes whatever vials
are unused and redocuments it in her book and
puts how many milligrams each patient got and
who it went to. And they're all the glass ampoules.
So one of the big things I have to teach trainees
is not to throw that glass ampoule in the sharps
bin because she wants it back. She wants proof
that that is gone. So many times trainees are
digging. With, you know, long forceps or something
to get a fentanyl vial out of the sharps container.
So that's always a learning curve. That sounds
actually like a more intensive wasting process
than I maybe would anticipate for that sort of
environment. In Africa, the experience I've had
is just one of the other providers gets it and
we use it. I don't know what waste process we
go through there. Well, that makes sense. Okay,
so. What other supplies do you need for a trip
like this? And how does one obtain those things?
A lot of it is, you know, things that we think
of as, you know, disposable, reusable things,
endotracheal tubes, needles, syringes, oral airways,
just anything you would think of for it. normal
anesthetic, even IVs and tubing. And typically
we don't take fluids with us because they're
heavy. That's something else we buy from their
hospital system to use just because it's hard
to ship fluids. But we'll often take the medicines
with us and things. There are a couple of places
within the city that do, I guess, donation -based
things that people can donate from hospital systems.
There's Matthew 25 Ministries, and then there's
a place down in Louisville. I can't remember
currently, but they get a lot of medical supplies
and you can send them kind of a wish list or
go dig through some of their bins yourself. And
then they are able to you buy it for a very cheap
price in comparison to what you would buy on
like the medical market to take with you. So
are you packing that all into a checked bag?
How does that work? Checked bags. or duffel bags
or whatever you know you can get um this last
trip to belize that i went on um The first week
where we take down a majority of the supplies,
the second week they bring some more supplies,
but a lot of the stuff goes down the first week
just to make sure we have everything that we
need. I think we had 75 checked bags that were
going with us. Whoa. Are you carting these through
the airport? How does this work? Are you taking
multiple trips from your car? It's a big group.
They have people, you know, there's a couple
houses that do the packing of the supplies, and
then they tell people, hey, start coming to pick
up. checked bags. Um, so people will stop by
all these, you know, different people's houses
and pick up bags and it's your responsibility
to get them to the airport and they check you
in, in one big group and scan them all through.
And somehow I got involved in that process last
year. So I was, you know, handing passports back
to everyone and counting bags and doing all sorts
of crazy stuff. So it was kind of cool to be
on that side of things, but it was definitely
very labor intensive. I would hate to be. behind
you in line oh yeah at the airport they specifically
gave us our own um our own uh ticket counter
and made everyone else go elsewhere wow yeah
i can imagine that is that some is that a situation
where they sort of know that you're coming and
are doing this or is it just you show up and
they're like oh great Probably a little bit of
both. I know Mr. Kirby that organizes the tickets
and that kind of stuff had messaged American
back and forth about some of the logistics and
getting some approvals for free bags just since
it was a mission trip and that kind of stuff.
So they had maybe an idea, but I doubt the ticket
counter realized that that was happening until
we showed up. Okay, so you've packed all of your...
drugs and equipment you've gotten on the plane
i assume that you're massively jet lagged um
you get there then what what happens um well
kind of depends you know which trip it is the
belize trip is about a two hour drive from the
airport to where we're actually going to be working
The Uganda trip, which is my next most frequent
trip, is about an hour from the airport. So you
have to wait for all of those 75 or however many
bags you're checking to come through the terminals,
put them all on the thing, load them up into
vans. You know, 12 passenger vans are typically
what we travel in. Um, so however many of those
you need for however many people are going, Belize,
we often have like six, 12 passenger vans packed
full of people and bags, um, on the way up to
Corozal where we typically are based. Um, so
you, you know, you land, you wait for everyone
to get their stuff, um, personal bags and all
the checked equipment bags. Uh, if somebody goes
and gets the vans, I don't take responsibility
for driving those. That seems like too much for
me. That was going to be my next question. Are
you driving? Someone from the trip is. I have
yet to volunteer for that role. You do all the
other stuff. You don't need to drive the van.
Yen Shay once made me bounce my head off of the
ceiling when I was sitting on the floor of the
back of the van. So that was on purpose, but
you know. Excellent. Well, I imagine when you're
packed in tight with all those 75 bags, it's
probably inevitable. Yeah. Flat tire the last
time we were driving to the hospital in one of
those vans. So that was fun Okay, so tell me
the flat tire story though There's you know,
six van six white vans just following each other
and all of a sudden we see like some smoking
coming From the one really go what's going on
and they pull off and we realize they have a
flat tire So everyone just kind of you know files
off to the side of the road since we're traveling
in a large caravan and I didn't know this, but
apparently there's spare tires like tacked up
to the bottom of a lot of these vans. But between,
I think, four vans, we could only find one tire
that A, we could get off or B, that wasn't also
flat and destroyed. So they sent a bunch of us
on our merry way. They sent another van from
the rental company up to meet them and they eventually
made it to the hotel and the hospital. Excellent.
Okay, so you get there to the area where the
hotel and the hospital is. What does that...
hospital operating room look like? How is it
different from what we have here? So the hospital
that we go to in Belize is the Corazal Hospital.
It is in northern Belize and just across the
Mexico border. The system or the hospital that
we typically do our surgeries in there does not
have functional operating rooms unless a team
is there volunteering. So they are just used
for volunteer teams. About 45 minutes away is
a city called Orange Walk where they do their
um, actual surgeries for that area. Um, which
I actually personally haven't been to, but some
of our other colleagues have, have been there.
They've done surgery there in the past, just
depending on what's going on. Um, so I've never
seen those operating rooms, but the ones in cortisol,
uh, there's two ORs that we use. Um, you know,
they're big white rooms with whatever equipment
that people have left behind. Um, our group has
actually, um, Found I don't remember where they
came from, but had donated and had anesthesia
machines donated in the last couple of years.
So they're actually newer than the ones that
I started going there with. Mike knew very well
how to use the I believe he calls them narco
meds machines that are sitting now in the back
hallway that we use as a display for the residents
when they come down to see what anesthesia machines
used to look like. But now we have. some more
updated equipment um there's you know a hospital
bed uh or our bed and each one um that is not
electronic it does not go up and down most of
the time it has a foot pedal to raise and lower
that that might work sometimes uh so you're kind
of just working with the equipment that is readily
available when you were using those older machines
back back a few years ago what were some of the
biggest differences between those machines and
maybe the slightly more updated machines we have
here um definitely the co2 absorbent was different
it was just one of those ones that you dumped
pellets in rather than had the exchangeable canisters
that we now take down with us for you know the
trips um but it was just a very um saturated
co2 absorbent so you never really knew exactly
when your gas was gonna wear off the gas analyzer
was a little questionable um The machines also
progressively the screen that showed like the
title volume and your minute ventilation and
that kind of stuff throughout the week that I
was there as a resident when Chris and Mary were
there also just progressively kept getting blacker
and blacker up the screen as the week went on.
So at the end of the trip, you could only see
where it said the date and time, which wasn't
accurate anyways. I would imagine that would
be the least helpful thing to know is the date
and time when you're trying to anesthetize somebody.
Yes. So what we're dealing with is doing anesthesia
in this completely resource -limited environment.
What else besides the machine being a little
out of date is different? Yeah. So with Belize,
we take pretty much everything with us. So we're
able to tailor it a little bit better to what
we're more used to here in the U .S. You know,
we take the meds that we can get with us. Some
of the things that are harder to get, obviously,
the controlled substances. For whatever reason,
it's hard to get phenylephrine ordered, but we
can usually get ephedrine ordered, which is wild
to me considering it's a controlled substance
here in Ohio, but it's not everywhere. Just knowing
what meds you have, how much of those meds you
have, because it's a finite resource. However
much propofol you take with you is how much you
have available for that week or two weeks, depending
how long you're going for. Also sizing of things.
We can take a bunch of endotracheal tubes down,
but if we end up doing a bunch of peds and only
have a few peds -sized things, you can't do any
more peds safely. So just different things to
plan for. A colleague down there that has a basement,
which is apparently rare in Belize, but he keeps
a lot of equipment in his basement for us that
he brings up in a trailer every time we come
to visit. So we have a lot of disposable supplies
kind of tucked away in there so that we know
we have some endotracheal tubes and things like
that left there. And we donate a lot of it to
their local teams as well whenever they ask for
certain supplies. That way we can always bring
more the next time. What about monitoring? Are
your monitors significantly different than we
use here? I wouldn't say significantly different,
but intermittently functional might be a correct
wording. In one of the ORs, we use two different
monitor screens to get all of the vitals we are
used to having. I think one of them has the blood
pressure. One of them has the pulse ox and end
tidal. And I don't remember which has the EKG
on it. But we have to use two different monitor
screens and two different sets of cables to get
the appropriate vitals that we would normally
have here during surgery. We also have portable
monitors out in PACU. There's four PACU beds.
But it kind of just depends on, you know, as
a patient is waking up more, sometimes that monitor
shifts to the patient that's just coming out.
That's, you know, someone's awake and talking.
they're probably more fine than the person that's
still just coming out of general. So you have
to kind of allocate your resources and prioritize
your resources as needed. So tell me a story
or two about some different situations that you've
been in while you're there that required a different
plan than you would have maybe done if you had
more unlimited resources like you have here.
Yeah, I think there's definitely different scenarios
where... You just kind of have to be adaptable
and figure out what their norm is. On my trip
to Ghana, which I said was more regional focused,
we spent most of our time in their what they
call their accident and emergency operating theater,
which is a lot of ortho trauma and a lot of kind
of trauma based surgeries that come in through
their ER. Again, it's relatively unsafe to do
general anesthesia in a lot of these places.
So we'll never forget this little eight -year
-old girl who had broken her arm in a motorcycle
accident. And she was tearful, but in good spirits.
And they did a nerve block on her. They did an
infraclav block on her. No sedation, no warning,
just. poking her with a needle and she's crying,
screaming through it. But in the operating room,
she is wide awake, singing along to the music.
And, you know, they let her pick the music. And
in the U .S., an eight year old awake for surgery,
awake for a nerve block is unthinkable in most
places. So just kind of seeing that and realizing,
oh, like this is real different than what I would
see at a children's hospital at home was one
of those moments that I was like, oh, OK. I have
a seven -year -old who I consider to be a reasonably
tough kid, but would he be okay with getting
a completely unsedated infraclav? I don't think
so. Infraclavs are, like, sensitive, too. I mean,
she was small, but, like, you know, you got to
go through some muscle to get there. Yeah, that's
pretty impressive. Absolutely. Another time that
I had to definitely change my anesthesia plan.
Derek Florence and I went on a trip to Uganda
with Chad and his group a couple years ago. And
we actually decided we were going to stay for
a safari. So we flew separately from the rest
of the group. And we happened to get there. We
were supposed to get there 30 minutes before
them. So we were like, great, we'll start grabbing
bags. We'll see you all when you get here. We
aren't going to be the reason for the delay.
I start getting texts as we land from Katrina,
who says, hey. we've been delayed in rwanda it'll
be another hour before we get there okay fair
all right fine keep getting texts from katrina
hey we're getting more and more delayed hey we're
getting more and more delayed okay she's finally
like why don't you go find jeff which is the
local surgeon she was like you've been there
you know him you've met him he will get you guys
out of there you guys don't have to wait for
us our flight's gonna get cancelled um so They
had given Derek and I equipment bags of just
like gauze and some things that they were like,
well, you guys are more likely to get delayed
than us. So you take the, you know, the lighter,
less necessary equipment to have. We'll keep
the surgical equipment, the airway equipment,
that kind of stuff with us. And, you know, we'll
get you there. So we had our bags of gauze and
who knows what else that we didn't really, you
know, necessarily need for anesthesia purposes.
It's midnight and Jeff gets us to the house that
we're staying at. And he says, you guys just
want to come to the hospital with me tomorrow?
Like, you know, everyone else is stuck. We're
like, yeah, sure. That's what we're here to do.
He's like, great. I'll pick you up at eight.
Picks us up the next morning. He's like, I'm
just going to do a couple little surgeries. Do
you guys want to help out? Like, yeah, absolutely.
Like, why not? The local team who I had worked
with there before, Barbara, has become a good
friend to me. She's one of their medical officers.
She was there with some some of her trainees.
Jeff says, I'm just going to do a quick biopsy
of this guy's, you know, oral tumor, figure out
what it is. And, you know, it'll be a quick case.
You say, OK. Whenever I'm hearing these stories.
They always start with, oh, it's just going to
be a quick case. How many times have we heard
that anywhere? Many. Many. Our surgeons say that,
too. Surgeons don't necessarily understand quick
case. I was just in a 15 -minute case that lasted
about an hour and a half yesterday. Right. I
understand. Right. And most of the cases we do
in Uganda are big flap cases. My longest case
there has been 15 and a half hours. Oh, my gosh.
Quite lengthy. Definitely life changing. Wow.
But Jeff says this will be a quick case. He saves
generally his big giant cases for when his colleagues
are there that can help him out and have multiple
surgeons in the case. Sure. And so we induce
this guy has a normal external airway exam, I
should say, as well. Can't see anything of what
we're biopsying. So I'm like, OK, it's probably
something small. We induce this guy goes to sleep.
He's maskable. it's fine their team uh takes
a look uh under do because that's all they have
available and they're not able to get a view
i notice they start suctioning some blood out
of the airway that's a little weird but okay
um so they look again can't get a view uh so
either derek or i don't remember which one of
us first took a look and was like there's also
nothing here now there's 400 of blood in the
the canister oh my gosh just from the airway
just from the airway which we have not secured
at this point. Luckily, Snow Maskable, their
team goes to push a second dose of sucks because
it has been roughly 10 minutes that we are working
on this airway at this point. And I had to stop
them from A, redosing sucks, and B, I was like,
if we can't get this guy's airway, we can't give
him more paralytic. Maybe we need him to start
breathing again. We need him to wake up or, you
know. We have to get his airway. So I looked
at Jeff, the surgeon, and I said, I need you
to take this man right now. And he's like, what?
And I was like, seriously, I need you to take
this man right now. And they open up trach supplies
and we masked this man through a trach. Wow.
And after. His trach was in and Jeff was actually
able to take a look at his his equipment. This
man had a giant molecular tumor. which was the
reason we couldn't get a view and he had a lot
of bleeding. But it was a moment that I was like,
holy crap, like what would have happened if I
wasn't here to say that? And I'm hopeful that
things would have gone differently, but I'm not
100 % sure they were. The volykia, of course,
being the area right where you want to put the
tip of your blade when you're trying to intubate.
Yeah, yeah, which makes sense as to why he had
a normal external airway exam. That is scary.
So it sounds to me like this was a situation
where you made a pretty rapid call that saved
somebody's life. I'm hopeful, yes. And, of course,
we brought a McGrath and a Glidescope with us,
but it was stuck in Rwanda with the rest of the
team. And the other bag, of course. Excellent.
So what is it like collaborating with these people
like Jeff who work there and are used to that
sort of environment? What's the difference? between
your experiences everyone is typically very laid
back in all scenarios like even in that scenario
he did not seem like anything was emergent like
he worked quickly but you know it's just like
everyone is calm at all times i think they deal
with a lot of these emergencies more frequently
than maybe we do and can handle it appropriately
the funny thing is the last time i had been in
that same operating room in uganda with the same
team We left as they were doing an emergency
awake trach on that same bed. Oh, wow. The patient
was wide awake because it was an awake trach
respiratory distress and they anticipated difficulty.
But the very next time I was back, it was a masked
trach, emergency trach on that same bed. So kind
of seeing the flip side of the two scenarios
was kind of wild. So they're very good at handling
those sorts of emergency scenarios, at least
from the psychological perspective, you'd say.
I think so. Yeah. What are some differences where
you notice that maybe our team has a little bit
more expertise in? I think knowing when something
is going to go wrong, that anticipation of. you
know, this could be bad, um, where they were
going to try again and again to DL when it was
clear to me that we weren't getting any sort
of view and we're just getting more blood. And
eventually probably we're not going to be able
to mask this man, um, that either we were going
to have to wake him up or do a trach. And those
were going to be our two options. Um, so I just
think anticipating those definitely our airway
skills are more advanced. Obviously we also have
more advanced equipment. Here in the U .S., we
at UC here have McGraths and, you know, every
OR. So sometimes that's people's default. But
they don't have, you know, any of those video
equipments that could potentially save them in
scenarios such as that. So you are obviously,
to me, an excellent teacher. The residents always
really enjoy working with you, learning from
you, all these different things. What kind of
situations do you get to use your teaching skills
over there? Are you passing on some of the knowledge
that you have to some of the providers that are
over there? Yeah, absolutely. Like I said, in
Belize, it's more of a doing trip, but we regularly
take SRNAs and residents with us on those trips.
So they get to see kind of a different environment,
different thought processes. We do a pre -op
clinic day where, you know. You're screening
these patients, but you don't have lab results
or echoes or any sort of testing. It's how functional
can you be? What do you do for work? Do you get
chest pain with those kind of things? And you
have to make judgment calls based off of that.
So it's a different environment for the residents
and SRNAs that we take with us to learn. So we
don't just get to send them for their cardiology
consult. Unfortunately, no. Get a full million
-dollar workout. Unfortunately, no. But it tends
to work out just fine. And then in Africa, there's
a lot of teaching opportunity. They bring trainees
to the hospitals where they have groups coming
in, knowing that they're going to have that opportunity
for educational learning. And a lot of my teaching,
I like to do just about whatever scenario we're
in, because I think it's the easiest to learn.
in that modality, if you can relate it to something
that you're doing. But we've talked about doing
more formal education programs with the Uganda
curriculum as we get there and topics that they
are interested in with blocks for me and Josh
that frequently goes is critical care trained.
So he has a lot to teach as well. And in Ghana,
which I'm hopeful to go back to at some point
as well with the ASRA trip, I've been talking
to one of the coordinators there. They're very
interested in learning regional pain and even
chronic pain things. They actually have somebody
that's doing a fellowship in just pain, which
is acute and chronic there to learn all the procedural
stuff. And she wants to she's been teaching everyone
things that she learns from everybody else. So
it's really cool to see that kind of do one,
see one, teach one method throughout the process.
They even have a program through the World Society
of. Federation of Anesthesia, I think WSFA, I
think that's the correct acronym, where they
send trainees from other countries in Africa
to this hospital in Ghana to learn regional because
they have so much exposure through ASRA. ASRA
being? The American Society of Regional Anesthesia.
Thank you. Just for my audience who may not be
as aware of the acronym as you and I have gotten
more accustomed to. What about ultrasound availability?
Is that something that you have access to that
they have access to there? Are you bringing something
handheld? How does that all work? It really depends
where you're at. The hospital in Ghana that regularly
does their own regional procedures and is building
this fellowship and has people come train, they
do have an ultrasound. It is one of the, I think
it's a sonocyte. either m turbo or m max which
doesn't mean a lot to a lot of people but it's
one of those ones that like flips open like a
laptop and is kind of old school for a lot of
places here um but they have one of those readily
available um that is the only hospital that i've
ever been to internationally that has their own
ultrasound wow The hospital I went to in Uganda
for my regional trip had told us they were regularly
using ultrasound and regularly doing blocks.
So I thought, great, we'll be able to build on
that. Turns out they were regularly doing blocks
but had never seen an ultrasound before. So they
were doing landmark -based. anatomical blocks,
but had never seen an ultrasound before. So luckily,
Research International, the group that I had
went through, had sent an ultrasound with us
just in case, which was actually the same ultrasound
that I found in Ghana, which I thought was kind
of coincidental. But we had to teach them how
to use an ultrasound and how to find a needle
and all of that kind of stuff. So I went. had
a colleague go down to the market and bought
chicken breast. And we started playing with needles
and ultrasound on the chicken breast before we
started poking on patients. Yeah, it's definitely
good to block a chicken breast before you start
on the patients themselves. Yes. Yeah. So when
you left, though, the ultrasound probably also
went away too, right? Unfortunately, yeah. How
do you make sure when you're doing all this teaching
and telling people how to do the latest and greatest
thing, how do you make sure that your efforts
are having a lasting impact? Yeah, a lot of that
is figuring out what equipment they have available
and how to use the equipment they readily have
access to. Obviously, donations are great, but
they're not necessarily sustainable unless it's
a continuous donation pipeline. From a just resources
standpoint, talking to Obi, the fellow in Ghana,
they didn't have block needles there. She was
like, yeah, sometimes we get them when, you know,
people come through and do this kind of stuff,
but it's not something we can easily and affordably
get. So I asked her, you know, what they typically
use for doing their blocks. And the answer was
an IV needle, an 18 gauge for adults and 20 gauge
for children. Wow. Because that's what they readily
and cheaply have access to, where you and I would
never think of doing a block with an IV needle.
Not only because that's a larger size than we're
used to using. It's not a blunt tip needle, you
know, just different things that from a safety
perspective. But that is their norm and that's
what they train with because that's what they
can reliably get and use. Right. You worry about
things like cutting through nerves and all that
sort of stuff. You'd have to be a lot more careful.
Right. So just I was like, oh, I've never thought
of doing that. But that's, you know, their norm.
So just kind of adapting to teach with the equipment
they can readily and easily use is one of the
things that can be helpful. And then figuring
out, especially if you're going to go back to
somewhere regularly, you can figure out what
they need in. Uganda, one of the local anesthesiologists
has her own like pocket butterfly that she will
use for blocks, but that's her personal equipment.
Sure. So it just kind of depends. Some people
are willing to, you know, spend some of their,
you know, hard earned money for these things
and other places are not. So it just kind of.
kind of depends you know either building a fund
to donate money to get them the equipment that
they need um or bringing things that you can
leave behind i know um josh has actually found
multiple things on ebay um that we have left
in uganda um that he has generously you know
paid for out of his own pocket um an entitled
co2 monitor being one of those things that he
found on ebay uh because we didn't have entitled
monitoring in uganda entitle monitoring is one
of those things that is very important to an
anesthesiologist yeah i can imagine that it probably
makes a big difference to them yeah um so you
know a couple hundred dollars he was you know
able to donate that and leave you know that we
were able to teach them how to appropriately
use it and and what the numbers meant and all
of that kind of stuff where it's something that
they didn't regularly see but here it's one of
our uh standards of monitoring so yeah absolutely
that's something that i guess you more often
think about in the context of the history of
anesthesia is when they started adding things
like pulse ox and then tidal CO2 to make sure
that we can keep our patients safe. But when
you are going somewhere like you've been with
very limited resources, I guess you can't necessarily
take that stuff for granted. So what other memorable
moments do you have from your experience taking
these trips? That's such a broad question, John.
I have many. I know. And I've heard you tell
a lot of these stories before, but I just really
enjoy every time you come back hearing all the
new stories that you have. I think one of my
most just memorable patient stories was my first
trip to Uganda. We had a 17 -year -old who came
in for a head and neck. camp. He had a tumor
on his face. He had told everyone that he was
21 because he was still 17 and could not technically
consent for himself. But he had been largely
disowned by his family because of this tumor.
He had stopped going to school because he had
been made fun of so frequently. And it was very
disfiguring. It was mostly on his maxilla, kind
of in his nose and cheek region. But it's very,
you know, scary looking whenever you just see
it in general um so jeff had saved this case
knowing that the team was coming that it was
going to be a big procedure and he had uh told
this kid that he would you know help him out
as as best we could um so seeing his airway for
the first time i was still a resident on this
trip i was like holy crap this is terrifying
what do we do um and i you know i wish i could
show pictures and things on a podcast but makes
it a little tough, uh, in this modality. Um,
but we did a, you know, very thorough airway
exam and actually found out he had a great mouth
opening. Um, it was just all maxilla. Um, he
was a grade one view whenever you actually took
a look, um, at his Malin potty score or, uh,
yeah. And, um, but he was not going to be maskable.
Um, so we had to come up with a plan where we
could, um, you know, either rapid sequence intubate
or keep him spontaneously breathing and so we
figured out exactly what we needed to do airway
wise and luckily his airway you know wasn't that
terrifying it all ended up going very well he
had a 12 plus hour surgery where they created
a flap and removed this mass and And unfortunately,
his flap failed the first day, so we had to bring
him back to the operating room for a second 12
-hour procedure from a flap for the second day.
So this guy had, you know, two 12 -plus -hour
general anesthetics back -to -back. But his second
flap luckily took. He had a trach for about three
months, and then they were able to decannulate
him as he healed and is now back to living. you
know, a normal life. Um, luckily whenever they
sent the tumor to pathology, it was a non -cancerous,
just rapidly growing, uh, benign tumor. Um, so
he doesn't have to worry about, you know, well,
malignant cancer, um, happening there. Um, but
definitely a life -changing story and something
that I was like, holy crap, how does this even
happen? Um, kind of moment. Those sort of moments,
I imagine, make it all seem worth it when you
can make that big of a difference to somebody
who otherwise would have had a totally different
outcome to their lives. Absolutely. And when
I had talked to him beforehand and even after,
he said he wanted to be a doctor after all of
this. And he was a very smart kid, but he had
stopped going to school because he was being
made fun of and bullied. But now that he was...
back to living a normal life, he can, you know,
go and get the education and that kind of stuff.
So I'm hopeful to one day see him when I'm over
there as a, as a physician. Well, I look forward
to reading his personal statement. He applies
to our program. He can, he can probably name
drop you. Um, if somebody were in the early phases
of their career about to become a resident, or
maybe they're a resident already, and they think
that what you are talking about sounds amazing
incredible and that's a direction they want to
go with their career what recommendations do
you have for them um definitely let people know
you're interested it's one of those things that
a lot of global health stuff happens by word
of mouth i constantly get people reaching out
to me both other you know attendings from other
places that i've worked with saying like hey
what connections you have what do you know what
can i do or what programs can we grow Just letting
people know you're interested. I know when I
interviewed for residency here and Mike had talked
about the Belize trip, I was like, I am interested.
I want to do that. It's part of the reason that
I was interested in this program. And Mike knew
from the day one of me being an intern that I
was going to Belize and I was not going to have
it any other way as a CA3. And then COVID happened
and it almost ruined it, but we got to go. But
just letting people know you're interested, seeing
what opportunities are available. There's a lot
of different groups that go all over the world
that are big groups, both anesthesia as well
as surgical and just even medical wise. A lot
of it's kind of doing your own research or finding
out who knows what in whatever area you're in.
Mike redirects a lot of people to me now, which
is totally fine. But I've made a lot of contacts
through him. And that's also how I got involved
in Uganda. You know, Josh was like, hey, who's
who's interested? And I immediately jumped on
it. And now I've got to go back a couple of times.
So just letting people know you're interested
when those things come up, you know, things get
sent your way and somehow it ends up working
out. That's fantastic. What about. Any societies
that you recommend joining or being a part of
that have maybe been of help to you? What do
you think about that? I joined the ASRA, again,
the Anesthesia Society of Regional Anesthesia.
They have a global health special interest group.
I joined that. So they have a lot of little updates
here and there. They have a couple of different
trips that go various places. throughout the
world um so i'm trying to get a little bit more
involved in one of those and then actually one
of our colleagues here is uh trying to get his
uh brian's trying to get his tanzania trip i
think he actually has it recognized by azra now
oh that's great um so creating more opportunities
out there um and his is primarily a education
-based trip in um one of the hospitals in Tanzania.
So just getting involved like that, even if it's,
you know, doing a virtual lecture at first, trying
to, you know, get involved with that hospital
and then seeing what connections you can make.
If you're willing to do a lot of legwork, there's
definitely a lot of opportunities. If you want
something that's already a little more established,
there's definitely a lot of those things out
there too. So could you briefly talk about the
opportunities that our residents have if they
were doing a residency here? towards one of those
trips yeah absolutely um so here you see um we
take um usually three ca3s every year to belize
with us um that number can be flexed just kind
of depending on um how many trips there are in
different things um the group that we go to belize
with typically goes twice a year um for at least
three weeks among those trips so we definitely
have availability if we have enough staff to
to cover those trips for the residents um but
we There's usually a couple of residents, if
not more, that want to go on those trips. So
we have to figure out who has the time and availability
to spend some of their elective time doing that.
And then we also take residents on the Uganda
trip as well. Usually just one just because it's
a smaller trip overall and it's a lot farther
and more difficult to get to. And oftentimes.
10 to 14 days. So it's a little bit longer of
a time commitment and a little bit more of a
money commitment. But, you know, we help our
residents with some of the funding and the opportunity
and giving them the information that they need
to make those decisions. And it's always a very
positive feedback from the residents that get
to go. So I would love to be able to take all
of them if they all show interest. And it's something
that counts as real rotation time, right? It
does. We have it approved through the ACGME as
a recognized rotation for the CA3s. We just submit
a thing every year for the ones that are going
to get it approved for them. And it's seemingly
a pretty seamless process at this point, but
definitely something that can be done for a lot
of global health trips at other institutions
with a little bit of legwork as well. So what
kind of advice would you give to somebody who's
just about to take their first global trip? Be
ready to be adaptable and troubleshoot and be
prepared for everything. I know that seems silly,
but it's one of those things that you just never
know what's going to happen. I remember the first
trip I ever did. Me and Mary and Chris were in
the white van on the way up to the hospital,
and Mike was going through emergency scenarios
with us and said, if this happens, what are you
going to do? If this happens, what are you going
to do? And one of his scenarios was, if the power
goes out, what are you going to do? You know,
the power goes out here and the generator kicks
on. Right. Power goes out there. It's not a generator
to kick on. And we're all like, oh, that's not
going to happen. Lo and behold, happens to me.
Excellent. So you're already working with unfamiliar
equipment and in a situation where you've never
been in taking care of somebody's life is in
your hands and the power goes out. What are you
feeling in that moment? Oh, crap. But, you know,
a little more explicit, I think. Thank you for
sanitizing it for the podcast audience. Luckily,
you know, Mike had run through this. You know,
I think I would have been able to think through
it just a little slower, probably, if we hadn't
already talked about it. Luckily for me, it was
an ENT surgery where they had some headlights
on. So the room wasn't totally pitch black, but
it is a room without windows. So, you know, if
there were no headlights, it would have been
pitch black. I also popped on the. the light
on my cell phone, my flashlight and just laid
it so that it was flashing up. Luckily, the other
OR had just excavated and was rolling to PACU
when this happened. So at least their patient
was no longer under general, but obviously still
needed monitors. And switched over to an ambu
bag and was drawn up some propofol and Mary ran
in and said, what can I do? So I handed her the
propofol and said, I don't know, start being
an infusion pump. assign assign mary as the infusion
pump and you got to squeeze the bag so you guys
became the anesthesia machine correct um and
then last year uh john latrimoy and i were there
and i briefly ran through said scenario with
him and it happened to him It sounds like this
is actually a pretty high yield scenario to run
through. Yeah, it turns out. I think those are
the only two occurrences that I know for sure
it's happened. And luckily, it wasn't a long
power outage. It felt like it was forever. But
in reality, it was a couple of minutes. OK, so
it's something where the power did come back
on. You're able to turn everything back on and
it resolved. Yes. But you don't know, you know,
when it's when it happens. Apparently, one of
them was a planned power outage that no one had
told us about. You just didn't think to put planned
power outage as part of your anesthesia plan.
Right. Well, next time maybe you can consider
that. So now it's a scenario that is high yield
to run through for the residents going this year.
If you guys are listening, go ahead and plan
for that. Oh, excellent. So let's back up a little.
I'd love to hear some of the style points that
have helped make you more successful in your
life and career. Um, you know, I think just being
able to be adaptable, being able to work with
whoever you're working with in whatever scenarios
you're working with is is important. You know,
there's some people that are very rigid and probably
aren't the right people to to do these kind of
trips. The other thing is just being friendly
and social and communicating can go a long way.
Building relationships and having people trust
you and know who you are and coming into an area
that. you're not necessarily familiar with, um,
is super helpful. Um, I now have, you know, WhatsApp
messages going with, you know, Barbara and patients
and some of the other people in Uganda and I'm
Facebook friends with some of the people in Belize.
So, you know, just kind of keeping that rapport,
um, going, going back to the same locations.
Being willing to help and being adaptable and
doing whatever they need you to do. Sometimes
it's not just doing anesthesia. Sometimes it's
helping with a pre -op IV that they're having
trouble getting. Sometimes it's scrubbing because
they need somebody in the OR to scrub and we
have an extra person. So just kind of being adaptable
and ready to do anything and friendly and willing
to take whatever role you need to take goes a
long way. Well, when I think of. the people on
my short list of having high adaptability and
emotional intelligence and being friendly, you
are close to the top of that list. So thank you
so much for joining us. Absolutely. Anytime.
Thanks for joining us for this month's episode
of Style Points. If you found yourself particularly
interested in the topic of this episode, Erica
has offered to share her email address with anyone
who is interested in global health. For that,
or if you have any other thoughts, please email
me at stylepointspodcast at gmail .com, and I
would be happy to send that to you. I genuinely
appreciate everyone who has taken time out of
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