Author: Dr Mark Catolico, Final Year Specialty Registrar, Great Ormond Street Hospital for Children NHS Foundation Trust
As a UK trainee we have the privilege of plentiful senior input comparative to other specialties. At this point my experience was nine months in general anaesthesia & paediatric anaesthesia with direct supervision only. What was I to do when faced with anaesthetising a paediatric patient in a developing country! This was the challenge that I chose to accept.
How I got involved
It was early December 2005, in the brand new state of the art Theatres at University College Hospital. I was the anaesthetist for the Paediatics Maxillofacial list. Whilst in the anaesthetic room, Mr Peter Ayliffe (Consultant Maxillofacial Surgeon) spoke to me. This can be quite difficult whilst attempting blind nasal intubation, but I proceeded multitasking and Mr Ayliffe started talking in Tagalog (native language of the Philippines). This threw me completely. I failed my blind nasal technique, and tried a more conventional approach.
By this time Mr Ayliffe told me his involvement with PAGES (Philippine American Group of Educators & Surgeons) and its annual medical missions to the Philippines. By the time I had transferred my patient to the operating theatre I had somehow agreed to go on the mission.
The Philippines is the second largest archipelago (to Indonesia) with over 7000 islands. It is a developing country with a population of almost 90 million (compared to the UK just over 60 million).
The country has very close links with Spanish America, and about 90% of Filipinos are Roman Catholics. The country became independent of the USA in 1946, and under the control of President Ferdinand Marcos until the 1980’s.
A revolution came as a result of Marcos’ corruption, which left the Philippines in a state of bankruptcy. Even after several decades of regeneration, about 40% of the population lives below the poverty line1 & huge inequalities in healthcare remain.
The Philippines American Group of Educators and Surgeons (PAGES) was founded in May 1990. An independent group of surgeons, anaesthesiologists, nurses and others, with their primary goal to provide free surgical repair of cleft lips and palates as well as other congenital (mostly facial) deformities. Their secondary goal is to educate the local healthcare practitioners to continue the work once the group leaves. The ongoing mission is Operation HOPE (Helping Other People Excel) which has helped over five thousand patients to date. Apart from the return air fare, most of the expenses are covered by the PAGES group.
Cleft means split or separation; which can occur to the lip, palate or both from the failure of the two maxillary processes to fuse with the fronto-nasal process in the first trimester. The incidence is 1 in 700 which is similar in both the Philippines & UK. Surgical repairs usually occur during infancy, with palatal repair delayed to allow adaptation of oral breathing as surgery causes partial nasal obstruction.
The major problem is that most surgery is delayed too long which leads to language delay and articulation difficulties, affecting interaction between children and adults. Associated problems are difficulty feeding, risks of aspiration and airway obstruction. These lead to repeated ear infections, dental problems and detrimental psychosocial issues.
The welcome home
Being a british born Filipino, it felt like a home from home. As most Filipinos in the UK are trained nurses, I almost feel like a novelty, and wonder if there are any other practising Filipino doctors. Obviously my ignorance and naivety were greeted with an array and magnitude of many American Filipino doctors. I was definitely not alone.
The mission began with all the pizzazz of a West End Musical. We had not one, but two opening ceremonies involving plenty of traditional dancing and food. Even the Director of Surgery sang a romantic tune for valentines.
Finger to the pulse
The monitoring I had become so use to in the UK, was nowhere to be seen. My mouth dropped when I started to realise the actual truth of my living horror – I had to monitor the patients clinically – finger on the pulse, continuously listening to the patient’s breathing and heart beat through a precordial stethoscope, sphygmonometer and an occasional pulse oximeter shared amongst three operating tables.
I had never seen a precordial stethoscope, to which my American anaesthetic colleagues looked at me with dismay. Out of all the monitoring available it became the one I would favour the most.
There were five operating tables, two in one theatre, three in the other, each with its respective anaesthetic machine.
Each Anaesthetist had their own drug box. The one surprising feature was the limited amount of opioids available, an ampoule of fentanyl (100 mcg). I was reassured that opioids were unnecessary; ketamine & regional anaesthetic techniques would be a good alternative.
Luckily my colleagues had been very good in labelling all the boxes & equipment. There was even a Malignant Hyperthermia kit (just in case).
Meanwhile, the surgeons were assessing the preselected patients ready for the week. This gave them an idea of the difficulty of repair, timing and an opportunity to explain to the parents the realistic outcome from surgery.
With so much to do, the anaesthetists delegated pre-assessment to our well abled paediatricians. This excluded any associated syndromes involving difficult airway, such as Pierre Robin. Most patients were ASA I or II with chest radiographs and full blood counts done as required.
A typical day
So a typical day would be waking up at 0530 with a call from reception. Getting ready for breakfast at 0600, then having our morning brief in the reception of the hotel at 0630; we would then commute to the hospital at 0645 arriving by 0715.
At the hospital, the surgeons would review the patients from the day before; whilst the anaesthetists prepare the equipment for the first patient.
Once ready to start (0830), I would go to the corridor where the children would be with their parents. They would already be cannulated with IV fluids performed by the nurses,
Although English is the second language, almost everyone can speak some English. So it was relatively easy to speak to the parents about what was to happen.
IV sedation (mixture of propofol & ketamine) would occur in the corridor; and the parent escorted out. The child would be carried to the operating table where suxamethonium is given. The reliability of suxamethonium was questionable due to its storage at room temperature. I however encountered no problems intubating them with the cuffed south facing RAE tubes.
The anaesthetic was maintained with isoflurane breathing spontaneously on a circle circuit which I was assured by my American seniors would be adequate despite my concerns of dead space & high resistance. With no volatile monitoring, the occasional sniff of the circuit had to suffice. The machine delivers Oxygen, but no air or nitrous mixture. So my safety net of delivering 100% oxygen when encountering a problem was scuppered.
In addition, the cleft lip repairs received an infraorbital nerve block via the intraoral approach. Cleft palate repairs take longer and are more stimulating, requiring a Boyle Davis gag which proved to be a real challenge.
We would typically do between 6-7 cases in a day. The day would end by about 1900-1930 after having cleaned the equipment & restocked for the next day. Throughout we were well fed having a mid morning snack; lunch, tea and dinner before returning home. Most nights consisted of relaxing by the outdoor bar with a San Miguel beer or two.
With guided experience of my American colleagues, they managed to train me to ‘fly solo’ and by the latter half of the week I was anaesthetising patients as young as 7 months. I was most surprised about the ease of intubation, and throughout the week I had not missed one. The most difficult was no opioids being available.
Despite the minor setbacks and adjustments in my practice, the biggest difference was the lack of an ODP (Operating Department Practitioner). Till arriving in the Philippines every anaesthetic I had given was with the experienced assistance of an ODP. Apart from knowing where everything is and being the gatekeeper to the opioids, they are a safety net, a person you can bounce ideas off when stuck.
RSI – Recalling Serious Incident
Of all my memories from that week, the one that remains pertinent is of a child post cleft palate repair earlier that day. I was particularly concerned as it was oozing excess blood earlier; therefore the surgeon reviewed the patient. However after mutual discussion with one of the senior anaesthetists, and our list had some free space; we felt it was fair to bring the child back to theatre for examination under sedation with Propofol and Isoflurane.
This technique didn’t feel right to me at the time, but having only been there a week; I trusted the opinion of my more experienced colleague. It was a very difficult procedure, requiring far more sedation than imagined, and there were occasional episodes of apnoea and desaturation. This was when another of the more senior anaesthetists explained that I had broken one of the cardinal rules – consider this patient as having a full stomach due to digested blood. This child should have been intubated via Rapid Sequence Induction (RSI). Fortunately the child made a complete recovery.
 Bolton P. Anaesthesia for cleft palate surgery. In: Pace N, Peutrell J, Serpell M, eds. Anaesthesia and Intensive Care Medicine 2006; 7:5 157