VOLUME 35, ISSUE 1

Many of us may not have realized that, as the world shut down in March of 2020 and international borders closed due to concerns of the spread of the COVID-19 virus, many countries were left without the medical resources for which they were once accustomed. Medical missions, volunteer organizations, and relief efforts were forced to discontinue aid to these developing countries and many people were left without medical care in many areas of the world. As global supply issues changed, many international communities faced a scarcity of medical supplies. In some instances, access to medical equipment was already challenging, only to be worsened by decreased production, limited travel, and the closing of shipping ports.

As academic physicians, we recently traveled to Africa as invited speakers and guests of a hospital that serves a rural population. As with most third world countries, conserving limited resources was a standard practice and crucial to providing patient care. When we disclosed that we use disposable laryngoscopes and LMAs, there were audible gasps in the audience. Working in an environment where everything (i.e., oral airways, stylets, endotracheal tubes) is sterilized and reused, they were incredulous that supplies and equipment were so easily discarded. Even bag valve masks were sterilized and reused, often resulting in difficult mask ventilation due to the sterilizing chemicals saturating the equipment. Ventilators were already a luxury pre-pandemic and the shortage was only made worse with the pandemic. The hospital had one video laryngoscope for difficult intubations, however, the resolution of the screen was so poor that it offered only a mild benefit.

Despite all these hardships, it was amazing to see the resilience exhibited by the medical professionals. During the pandemic, this hospital did not have an anesthesiologist for almost two years, as the previously affiliated U.S. medical organization withdrew the two anesthesiologists before borders closed. A U.S. residency program stopped sending their global health elective resident during this time as well. Some physician volunteers (i.e., pediatricians, internal medicine physicians) remained and, without the benefit of visiting anesthesiologists, they became primary consultants for airway interventions for the last two years. These non-anesthesiologists also became the primary teachers of airway management skills for their trainees during the pandemic.

Unlike the U.S., the physician workforce in some parts of Africa is comprised of many physicians who may have only completed an intern year. Not all physicians enter residencies after their intern year. Many decide to work as independent physicians for a few years before returning to their residency education. Some may end up in rural areas where they become a doc-of-all-trades, performing different types of care ranging from being a critical care doctor, surgeon, and anesthesiologist. Of all the interns we met during our visit, none had ever had simulation airway training…practicing for the first time in vivo. Access to airway education is extremely limited and many enter the workforce without any formal training in airway management.

Throughout our stay, it was apparent that our colleagues were eager to learn so they could provide excellent care. Unfortunately, education is sometimes limited, and at times nonexistent, without the help of volunteers and global health initiatives. As U.S. physicians, we were always aware that we had many luxuries regarding supplies and equipment; however, we realized on this trip that we also take the access to education for granted. In the U.S., it is an expectation that airway management skills are taught by trained professionals. We came to realize that, in many rural parts of Africa, airway management skills are often learned by reading outdated textbooks and being taught by practitioners who have no formal training themselves, perhaps propagating poor or inappropriate ideas on to new learners. Although we have seen and heard many global health organizations asking for donations for supplies, equipment, and doctors to care for patients, we have not seen as much attention being called for physicians to educate. In some ways, education is equally as important for patient care. For example, if endotracheal tubes are donated, it still requires someone with intubation skills to use that endotracheal tube. We may not all have the means to donate physical supplies and equipment but, as anesthesiologists, we are all trained and possess the knowledge and skills to teach others, which are equally as valuable. As physician-educators, we hope that the airway education we provided will not only make an impact in the learners’ education but also translate into improving patient care for the future. Even something as simple as showing how to properly position and pre-oxygenate the patient may make a significant difference in patient care. It may have even more of an impact in a third-world country where video laryngoscopes are not available and patient positioning could be the deciding factor between a successful and unsuccessful intubation.

Overall, this trip was enlightening, as reading about the limited resources in developing countries is not equivalent to witnessing it first-hand. As anesthesiologists, we have much to offer in terms of our versatility and wide range of skills. As international borders have begun to reopen, we encourage others to participate in global health and education at least once in your career. We believe that you will find it to be a very rewarding experience.