Are we providing modern anesthetics services in the Kingdom of Saudi Arabia?

Abstract

This illustrated detailed article will describe history of over forty years struggle, of hardship and discrimination to the specialty. I have with my colleagues faced obstacles and disappointments during the development of modern anaesthesia services with its subspecialties in Saudi Arabia. I have all support and encouragement from the top authorities of the university. I have managed to establish a top class anaesthesia department, Saudi Anaesthetic Association and the King Saud Fellowship in anaesthesia and intensive care within one decade. The next decade was assigned for expansion to create the Arab Board of anaesthesia and Intensive Care followed by the Saudi Specialty of anaesthesia and intensive care and its fellowship in different Subspecialties. I always wonder within myself, have I and my colleagues achieved our goal and did we do well.

INTRODUCTION

Recently I had an accident and broke my upper arm that needed surgical intervention under anesthesia. When I was young, I had several anesthesias with no fear, but now due to certain diseases and old age, the anesthetist may encounter some difficulties in providing safe anesthesia. I was confident though, as I knew the physicians who were involved in my case had done the preoperative clinical examination and investigations and education by both surgeon and anesthetist to prepare me for the surgery. I was in safe hands. Thank you all, and above all thanks and blessings to God.

During my convalescence at home, several colleagues’ juniors and seniors visited me and raised various issues about the anesthetist's current situation, reputation, and image of anesthesia in the kingdom. Some colleagues asked me the following questions.

• The father of anesthesia in the Kingdom.

• Former chairman of the department at the college of medicine.

• Founder and member of the Saudi Anesthetic Association.

• Founder of King Saud fellowship of anesthesia and intensive care.

• Former General Secretary and Vice Chairman for the Arab Board of Anesthesia and Intensive Care.

• Chairman and member of the Saudi Council for the Specialty of Anesthesia and Intensive Care.

• Chairman of the CPR National Committee of the Saudi Heart Association and fondly known as Mr. CPR of the Kingdom

They asked me to organize a campaign on readable, visual, and audible media to enlighten and educate the public on the status of our specialty in the Kingdom and the nature of clinical services in anesthesia we provide. The main objective of this campaign is to stop rogue newspaper articles containing sensational statements. The editors of all newspapers should be wise enough to assign a medical consultant to edit such articles before publication regarding medical incidents or liable statements on any medical specialties.

The entire group of colleagues has agreed to a clear strategic approach to a campaign on the specialty of anesthesia and the clinical services provided in the manner to review the history and development on national and international level.

HISTORY OF ANESTHESIA

In the past, anesthesia was primitive. One of the famous occasions when John Snow In 1853, anaesthetized Queen Victoria of England during childbirth to her eighth child, Leopold, with the help of the new anesthetic, chloroform. The Queen was so impressed by the relief it gave from the pain of childbirth that she used it again in 1857 at the birth of her ninth and final child, Beatrice.[1] Through the years the specialty has developed slowly but leaped forward more than any branch of medicine, starting with the development of the mechanical ventilators by The Swedish company Elema to care for the pandemic disease of polio. This led to establishing intensive care units managed by anesthetists who were the only specialty able to manage critical cases as they understood the respiratory, cardiac, renal, and hepatic physiology and pathology. They were masters of the pharmacology and pharmacokinetics. This followed by implementing their skills to open cardiac surgery, pediatrics surgery, neurosurgery, thoracic surgery, neonatal surgery, pain management, relief of pain in obstetrics, resuscitation and recently to the day surgery, distance anesthesia and robotic surgery.

MODERN ANAESTHESIA

The modern advances of various surgeries in the world only became possible because anesthetists were able to put patients into a sleep monitoring them during surgery beat by beat to discover and rectify any changes in the patient conditions that will minimize any mishaps and increase safety of the patient under anesthesia. It was the standard of care implementation of rigid codes of practice for preoperative screening of the patient and selecting the right patients for elective surgery. Optimization of the physical status of the seriously ill patients before submitting them to any surgical procedures. Even in surgical emergency situations, patients are screened carefully and given anesthesia that is appropriate for their conditions. These policies reduced the mortality rate due to state-of-the-art anesthesia in the Western world to a very low rate of 1: 200 000, while four decades ago it was acceptable to be 1: 10 000.[2,3]

The improvement in the anesthetic services are due to the following.

1. Implementation of the standard of care and monitoring. The standard of care and monitoring specify to have:

   • consultant per theatre;
   • junior or resident in training;
   • anesthesia technician as an assistant only;
   • daily cockpit check and before every case on all machines, drugs, monitors, and disposable equipment;
   • regular attendance of continuous medical education in order to upgrading the knowledge and skills and obtaining the necessary credit hours;
   • conducting morbidity, mortality, and other meetings to review incidences, updating the standards and supervising the staff in the department;
   • submitting annual audit with statistics presented to the hospital board.

2. Implementation, enforcement, and updating policies and procedures for the specialty and its branches.

3. Establishing structured residency training programs.

4. All staff members of the specialty working in the Kingdom must obtain their license to practice according to the rules and regulation of the country. The license must be renewed every 3/5 years.

5. The higher authority of health care in the Kingdom should have a review board. The board should have staff members from each health care system. The board objectives are to supervise, review all various documents submitted from all hospitals and able to perform regular and/or random visits.

At present we do not have a collective mortality and morbidity figures in Saudi Arabia, so literally we cannot compare our figures to the international figures. Our efforts were few and far between. Some advanced and specialized hospitals have implemented the standard of care and monitoring plus the policies and procedures that are under constant review and updated continuously. The efforts culminated to establish the following.

1. We managed to establish the residency training programs.

2. Compulsory registration with The SCFHS and obtaining license to practice medicine in the Kingdom.

3. Collecting 90 credit hours of continuous medical education (CME) every 3 years necessary for renewal the license. We are still deficient in several issues and far from being supreme. The highest authority of health care delivery system in the land will prepare complete rules of laws having the following:

   • Establish standards of care and monitoring in each hospital in the Kingdom;
   • Establish and enforce policies and procedures for the specialty and its branches in all hospitals;
   • Conduct regular morbidity, mortality, and incidence reports;
   • Submitting an annual audit on the activities of the department of anesthesia in each hospital;
   • The Ministry of Health should be the supreme council to supervise activities and functions and establish random and regular inspections of all hospitals in cooperation with the Saudi Anaesthetic Association (SAA).

The chairman of the department, the hospital and the regional director will be totally responsible to implement and enforce these measures.

MAL PRACTICE IN THE SPECIALTY OF ANESTHETIC

We are all concerned about the involvement of the newspaper whenever an incidence ending with a death due to alleged fault of anesthetist. Newspapers immediately present sensational articles that may have incorrect or less or no facts, this in turn allows medical professionals from various specialties giving their opinions and pointing fingers at the specialty. The fact that the image of our specialty is low in the eyes of the community is due to being enclosed in the operating rooms without direct rapport with the patient.

We are all sad for the loss of any human being in our medical practice for whatever reasons and particularly when it happens to a colleague and we would like to give our sincere condolences to the family, relatives and friends. I mentioned to my colleagues, I will only be involved when I am asked to give my opinion or be part of the committee.

In this article, I would like to present a clearer picture about modern anesthesia services nationally and internationally. In any professional field medical mistakes happen. When establishing rigid measures nationwide in all hospitals this will ultimately minimize these mistakes. A few articles published on medical litigation in Saudi Arabia each discus the problems and the critical issues from different angles. One focused on the numbers of mal practice cases in all hospitals in the Kingdom. The results were amazing, the ministry of health as the highest followed by private sectors, small clinic, military hospitals, poly clinics, while the specialized hospitals and the university were the lowest. Also the author looked into the medical specialties. Anesthesia specialty came seventh with 4%, while obstetric was the first with 27%.[4–6]

The specialty of anesthesia lacks the funds to establish a wider survey, research on incidents, and mal practice in the field of anesthesia by conducting regular mortality and morbidity meetings. If we succeed in providing the above measures, the proper data can be collected, analyzed, and compared with the international figures. Ultimately the aim is to improve the anesthetic services in the Kingdom.

PATIENT CARE BY THE ANESTHETIST

The anesthesia professionals will treat a patient undergoing anesthesia as a captain of an airplane full of passengers before taking off. The captain has to conduct full cockpit check, maintaining flight, and landing safely with all passengers to the required destination. There is no difference between the anesthetists and the captain of the airplane. The anesthetists perform daily cockpit check and before every case on all machines, drugs, monitors, and disposable equipment.

SAUDI ANAESTHETIC ASSOCIATION

Since its foundation in 1989 G.[7] At the beginning it started with the department of anesthesia at King Khalid University Hospital by implementing and enforcing.

• The standard of care and monitoring.

• Consultant/theatre plus trainee and assistant technician.

• Daily and in between cases the check procedure of all machines, monitors, drugs, and disposable instruments.

• Constant supervision and monitoring during induction, maintenance of anesthesia, recovery of the patient and safe delivery to the recovery room staff with detailed report on the event of anesthesia and the status of the patient condition.

• Holding regular morbidity and mortality meetings.

• Analyze the critical cases in order to find the most probable reasons for the incident and put forward a solution to be adopted so there will be no repetition.

• Submit annual audit on the activities of the department.

Only several major government hospitals established their standards of care according to the GCC rules and regulations. The SAA tried and failed miserably for several reasons to implement such standards in all hospitals in the country, to mention one, SAA does not have the power to legalize any form of improvements on the private or the MOH hospitals.

The higher health authorities in the western nations permits the anesthetic associations to have the upper hand with certain certifying bodies of the specialty to be totally responsible for establishing the-state-of-the-art of anesthesia practice. This is usually achieved by utilizing the top academicians and consultants of the specialty to be in charge. They recommend the latest and most sophisticated equipment, monitors, and the recently developed drugs. The cost is not important as patients safety is the concern. These western associations also have a hand in recognizing centers for anesthesia training.

ANAESTHESIA SERVICES IN THE KINGDOM

The above-mentioned practices are not well established all over the Kingdom. There are various differences between the three main categories of health care systems that care for the patients and allow the qualified staff to practice medicine among them the anesthetists. These are the following.

• Ministry of Health Hospitals.

• Private sector hospitals.

• Other government hospitals:

These include several university hospitals, several military hospitals, three National Guard hospitals, two King Faisal Specialized Hospitals, Security Forces hospitals, and King Khalid specialist eye hospital.

Two articles recently published by the author; the first titled “the status of anesthesia service and the residency training program Saudi Arabia.”[8] The second article titled “Update in anesthesia service and residency training program in KSA”. “How far from the target?” Data published in both articles were obtained from the annual book of statistic issued by the MOH 1423 and 1426 H, respectively.[9]

An updated statistics from 1430 annual book of statistic issued by the MOH.

Saudi Arabia population is approximately 25 373 513 Million (1430H) 2009 G.

Overall power of health care delivery system in the Kingdom is provided by three main categories of health care systems as mentioned before [Table 1].

Table 1.

Statistics concerning the workload of the anaesthetists in SA

The above statistics give clear information that there is huge deficit in the actual working manpower in the specialty of anesthesia in the Kingdom of Saudi Arabia particularly in ministry of health and the private sector hospitals. These two categories have a huge annual workload/anesthetists plus they do not apply a rigid code of conduct and no standard of care and monitoring. I found in my two studies that they use junior anesthetists/theatre instead of consultant; even some hospitals allow technicians to anesthetized patients. This should not be allowed in the twenty first Century. They do not hold any M. and M. Meetings for incidents and do not produce annual audit on the activities of the specialty. When we compare their Figures with the Figures of the other government hospitals in all aspects we find out, there are discrepancies due to none application of the standard of care and monitoring, among other measures responsible for improving the anesthetic services. In order to cover this vast deficit we need to convince both the MOH and the Private sector to alter their attitude and care toward bridging the gap in the anesthetic services in their hospitals by taken the following recommendations more seriously.

1. The higher authority in the ministry of health who is in control of their hospitals and the private sector hospitals has to implement and enforce the standard of care and monitoring issued by WHO 2010.[12] It is stipulated to have consultant/theatre plus other measures. This can only be applied by altering their policy to recruit more expatriates consultant grades instead the existing policy of recruiting juniors who are more likely to be the source of increased law suits case due to malpractice.

2. Future plan of the ministry of health is to make available at least 30 vacant posts. These should be distributed as one post/each of the 16 health regions and to increase the # up to five posts in the three major regions.

3. At the moment the MOH hospitals have only a few Saudi anesthetists, but with this future plan, the ministry of health hospitals will have more Saudi medical graduates joining the residency training program to be graduated and take their place as the future anesthetists.

4. Implementation of the 30% increase in the salary for the rare specialty of anesthesia in order to attract the newly graduates from the increased number of government and private medical colleges.

THE SAUDI RESIDENCY TRAINING PROGRAM

The training program utilized the new methodology in training that became the official and the practical way all over the world, not only for its simplicity but for its wider application in preparing the new candidates to understand, absorb, and digest the amount of cognitive and didactic knowledge given to them in proper doses. The program recently changed from 4 to 5 years. The extra year this year was made to accommodate the expanded services in the field of anesthesia. This is carried out through the junior period of 3 years where the proper teaching of general and local methods of anesthesia for different fields for surgical interferences. The successful resident will continue his/her development in the senior period of two years set for rotation through the different fields of the anesthetic subspecialties training programs.

Legend of Major Picture Image one H. R. Highness Prince Sattam [Figure 1], H.E. Professor Doctor Osamah Al-Shobukshi, Vice Rector of King Saud University, Professors Mohamad Takrouri and Mohamaed Seraj to right and left of VIPs guests. Collections of images of VIP anesthesiologists of the world who appeared in anesthesia practice and academic life with appropriate legends [Figures 2–6].

Figure 1.

His Highness Prince Sattam Bin AbdelAziz, H.E. Professor Doctor Osamah Al-Shobukshi, Vice Rector of King Saud University, Professors Mohamad Takrouri and Mohamaed Seraj to right and left of VIPs guests

Figure 2.

After one of SAA Meeting coinciding with Saudi university Anesthesia Fellowship exam some of the examiners greeting Prof. Seraj in His office Prof. Ameer Channa, beside Prof. M. Seraj and Dr. Dhafer Khudairi and Professor Anis Baraka Channa

Figure 6.

Prof. Mohamed Seraj encircled by non anesthesiologist professors of KSU Profs: Ahmad Metwali, Hazem I Al Kawashki and Khalid Kattan

Figure 3.

At the end of some recent Saudi Association meeting organizers and participants in last shot of the day around Prof. Mohamed Seraj

Figure 4.

(a) Late Dr. Peter Safer in the office of Prof. Mohamed Seraj as welcomed guest and friend. (b) Prof. Viby-Mogenson appeared in the department and in Prof. Mohammed Seraj office as welcomed friend and guest

Figure 5.

In the workshop session of ACLS course among participant Prof. Mohamed Seraj mingles with participants and discusses

BRIEF NOTES

• Total number of Saudi anesthetists almost reach 300 (145 actually practicing anesthetists, the remainder are in local and international residency training programs).

• The program can accommodate up to 200 in five years program (40/year).

• We have 18 tertiary hospitals recognized in three major regions.

• Last year 2010 G we accepted 37 residents.

• Total residents in the program are 98.

• 50 were graduated up till now from the Saudi Specialty of Anaesthesia and Intensive Care

• We have three fellowships in the following subspecialties (Cardiac, Paediatric Anaesthesia and Critical Care).

• Number of trainees in the above fellowships is as follows (4-6-22, respectively).

• Number of graduates from these three fellowships are as follows (4-3-5, respectively).

• Recently the government approved 30% increase in salaries for all rare specialties.

• Pain management the fourth subspecialty created by the council. In process.

CONCLUSION

Without the help of His Royal Highness Prince Naif and His Excellency Professor Doctor Osamah A. Al-Shuboukshi the former Minister of Health, anesthesia may not have reached the advanced level we have achieved. I had the honor to meet his Royal highness Prince Naif personally for almost two hours to discuss his queries, the status of the existing clinical services and finally submit to his Royal Highness full and broad spectrum documents. His Royal Highness forward the document to professor Osamah Al-Shuboukshi who after inspection of the documents acted appropriately and made a committee from three deputies from the ministry of health, general secretary and his assistant of the Saudi Commission for health specialties plus the chairman and the deputy of the Saudi Council of the specialty for anesthesia and intensive care (Dr. D. Al-khedairy and I) to meet, review, discuss and come out with future plans and strategies for the anesthesia specialty in the kingdom of Saudi Arabia.

Further on Professor Osama Al-Shuboukshi decided to established various committees responsible to write guidelines and standards for all medical specialties among them anesthesia in the kingdom. Dr. Walid Al-yafi was in charge of Anesthesia and Intensive Care and I was responsible for Medical Emergency Services. Unfortunately the final efforts achieved by all committees were somewhat frozen in time. The standard of care and monitoring including policy and procedures produced by the Saudi Anaesthetic Association and the special committees of the MOH were implemented in some major hospitals, while was not implemented in the majority of hospitals in the Kingdom of Saudi Arabia.[13]

Legend Figure 2(a) and (b) Prof. M. Seraj. friend late professor Peter Safar in 1995 Prof. M. Seraj and old friend Professor Viby Mogenson

The supreme council for health care system in the Kingdom is responsible for the health care planners, coordination and feedback. The end result is reflected on the citizens and residents. Several issues play crucial roles on our specialty. They are the following.

1. Cost factor is also at work in hiring personnel at a low cost. If you have a policy to recruit with low salary, we will only get low standard of professionals with no chance to attain the standard of care and monitoring.

2. All health care systems in the Kingdom should not make any discrepancy in salaries between medical specialties. All medical personnel work the same hours/week. In fact the duty of anesthetists does not end once the operation is finished but continue until the patient is fully awake in the recovery room and make sure that the patient can be transferred to the ward or continue in the intensive care unit.

3. They may be unable to operate the sophisticated equipment, perform safe anesthesia particularly for difficult cases and acted alone in peripheral hospitals.

4. No senior staff or assistant for support.

5. Lack of drugs with good safety margin as they are expensive.

6. The use of equipment with no biomedical facilities as backup.

7. All medical colleges must introduce a compulsory anesthesia curriculum of 3–4 weeks in the field of anesthesia and intensive care. Lack of exposure of the medical students to our specialty is a major defect as professor A. Grogono found out in his study on the resident training program in the USA and published in ASA journal.[14]

8. The Saudi Council for the specialty of anesthesia and intensive care would like to recommend having (a career day) where top academician and consultant anesthetists will be selected to visit student in the final year of medical colleges in each region to promote the specialty of anesthesia. This day is organized and conducted with cooperation with the medical colleges. The team will provide lectures, discussion with slides and video plus every student will receive the promotion booklet on the specialty.

WHAT WE EXCEPT OF COURSE!! DISASTER

When it come to the anesthetist. He is not well paid, is exploited by system including by the surgical and administrative personals, etc. It is good for the advances of surgical techniques to provide the

• the latest apparatus and equipment;

• provide drugs with good safety margin;

• technical assistant.

All anesthesiologists should have the same privileges as any other branches in medicine even more so as they are working longer hours, under stress, liable to be infected, addiction, etc. A median annual salary of $325 000 makes anesthesiology among the most highly paid specialties among respondents to Medscape's survey. Only radiologists, orthopedic surgeons, and cardiologists earned this much or more. Twenty percent of respondents earned $300 000 to $349 000, and 25% earned $350 000 to $449 000. The highest earners among anesthesiologists are subspecialists, particularly those who focus on pediatrics and cardiology.[15]

Finally a word of wisdom. We may be able to perform all major surgeries successfully, but we fail in some cases of minor surgical intervention outside the appropriate system. We feel that in an ideal society, every person is entitle for safe surgery as WHO says and everybody is entitled to safe anesthesia in the World Like WFSA says.

In conclusion, let us protect the specialty of anesthesia as it was built in this country inch by inch. It was never supported by the highest health authority. The evidences mentioned previously prove beyond any doubts that I am right. I am willing to challenge anyone. But still there miles of the road to walk. Just ask the professionals.