Innovations, improvisations, challenges and constraints: The untold story of anesthesia in developing nations

Anesthesia is a relatively young science, which is hardly a century and a half old ever since its birth in 1845. It began as an improvisation or some may call it “tarkeeb” or “jugaad” (innovation) during the early period. The journey and the success achieved in the earlier period were mainly based on observations, trials and errors.[1] The evolution has been gradual similar to our civilization and now the specialty has graduated to a fully-fledged science with multiple subspecialties.[2] There have been mentions of word anesthesia as a part of surgical specialty mentioned in literary sciences, which pertains to the signs of existence of this specialty much earlier than anesthesia was actually invented.[3] It is a matter of great pride that first lady anesthetist of the world belonged to one of the developing nation.[4]

Ancient anesthesia was administered on few evolving guidelines, which had limited scope for being scientifically tested. Algorithms came into existence as increasing number of difficulties and challenges were encountered during anesthesia in complicated procedures and comorbidities. The strict pattern of these guidelines and algorithms led to gradual but revolutionary changes in evidence based anesthesia. As a result, anesthesia procedures have become more sophisticated and streamlined with progressive developments in these procedural protocols. The development of modern anesthesia services can be attributed both to some individuals and team efforts from developing nations.[5,6]

However, scenario in resource challenged nations is studded with multiple challenges. Most of the anesthesia procedures are being followed on the basis of methodology and techniques described in books. Common challenges faced by anesthesiologists in these nations include but are not limited to financial constraints, non-uniform availability of equipment and drugs, partly trained support staff and a large number of patients, especially in the government health set-ups.[7,8]

To overcome these challenges, there have been sporadic and team efforts which have led to the above mentioned innovations based on the logical empiricism in anesthesia practice.[5,6] These “regional” innovations and improvisations have been largely responsible for the present day anesthesia status in these developing nations. However, one school of thought criticizes this practice and terms it as a failure to follow evidence based medicine while the other school of thought is also prevalent which when confronted with these aspects may hide behind the banner of experience based anesthesia.

Extending our professional journey into the 21^st century, we are still facing challenges in operation theaters daily such as anaesthetizing patients with 3-4% hemoglobin which may not go down well with the scientific world, but lives have to be saved especially during life-threatening surgical emergencies or urgent obstetrical operative indications. In many centers, blood glucose is still controlled with intravenous infusion in fluid bottles instead of scarcely available infusion and syringe pumps. The inadequate infrastructure in the peripheral health set-ups makes the validity of available reports doubtful. Moreover, some interesting facts relate to the guessing and estimation of electrolytes levels from electrocardiogram tracings. The scarcity and limited availability of blood and blood products is covered up by infusing colloids. Even the upper abdominal surgeries like cholecystectomy are carried out under spinal anesthesia. Difficult airway cases are being managed by thiopentone, ketamine or midazolam with face mask ventilation as availability of difficult airway gadgets and anesthesia work stations is considered a luxury. TEC-6 and TEC-7 vaporizers have replaced all the older vaporizers in developed nations, but TEC-3 and Goldman vaporizers are still being used in developing nations.[9,10]

Minimum mandatory monitoring standards have been formulated globally as well as at various national levels of developing nations.[11,12] But still monitoring in majority of health centers in resource challenged nations is carried out by palpating the pulse, estimating the airway compliance and pressures from the feel of the bag, estimating intravascular volume from urinary output and non-invasive blood pressure reading, awareness being guessed from signs of sympathetic stimulation such as tachycardia, hypertension and sweating, saturation being estimated from the color of body and lips and so on.

This may be an exaggerated critical analysis of our limited material and manpower resources but it has got certain merits attached to it. On deeper insight, one can observe that such practices truly help our patients, surgeons, health-care administrators and contribute immensely to economic and health services development though this role is hardly ever being credited or recognized in totality. By exclusively taking the challenges on to his own shoulders, anesthesiologist is able to save so many lives as well as money to the nation though such practices cannot be termed as perfect or ideal. At the same time we must exert extreme vigilance and should qualify all our statements.[13] We the anesthesiologist, should always discourage unethical practices such as condoning the reuse of disposable equipment especially in a scenario where human immunodeficiency virus, hepatitis C virus and hepatitis B surface antigen are rampant.

Authors from developing nations are finding it extremely difficult to publish their research work in western literature. The innovations and improvisations, which are in abundance, are not able to get appropriate coverage in the global anesthesia practice and publishing industry. The irony is that to make the journals of developing nation popular, we still need help from western nations as the research and publication from this part of the world is considered to be of lower quality. In the last two decades, many authors, reviewers and editors from the developing countries have made their name at the global level but such examples can be counted on fingers. It is high time that warrants a high level of co-operation among the literary personalities of these developing nations as well as an increase frequency of cross-talks among the various researchers so as to uplift the standard of our specialty at global level. However, seeing the progress of our specialty, we must feel proud of our innovations in anesthesia. There is a strong need felt to highlight our innovations like other specialties do, so that we can take our specialty to higher realms.