VOLUME 36, ISSUE 1
Meesha Khatker, M.D.
Chief Resident
Department of Anesthesiology
Baylor College of Medicine
Houston, TX
Jaime Garcia, M.D.
Chief Resident
Department of Anesthesiology
Baylor College of Medicine
Houston, TX
Raja Palvadi, M.D.
Associate Professor of Anesthesiology
Baylor College of Medicine
Houston, TX
Justo Gonzalez, M.D.
Assistant Professor of Anesthesiology
Baylor College of Medicine
Houston, TX
Advancing Global Orthopedic Anesthesia: Collaborative Regional Anesthesia Training for US and Dominican Anesthesia Residents in Santiago, Dominican Republic
Orthopedic anesthesia mission work in Santiago, Dominican Republic stands at the intersection of medical outreach, cross-cultural collaboration, and advanced perioperative care. This article delves into the multitude of benefits associated with engaging in orthopedic anesthesia missions in Santiago, with a specific emphasis on the utilization of regional anesthesia techniques. Furthermore, it explores the profound impact on anesthesiology residents from both the United States and the Dominican Republic from this unique and enriching experience.
Addressing Orthopedic Healthcare Disparities
Orthopedic trauma is a significant source of disability worldwide, and many regions, including Santiago, grapple with limited access to specialized orthopedic care. The Dominican Republic is known globally for having the worst motor vehicle crash-related mortality rate in the world [1]. Mission work in this area provides a targeted response to orthopedic healthcare disparities by bringing together skilled orthopedic teams to address the unique needs of patients requiring orthopedic interventions. Through Creighton University and its Caribbean branch, Institute for Latin American Concern (ILAC), a Surgical Ambulatory Clinic was built with three working operating rooms to allow outside surgical teams to come and perform surgeries for Dominican Republic citizens for only a nominal fee. Often, the patients have prior chronic orthopedic trauma issues that have not been fully addressed or may have healed inappropriately. At the same time, there is growing interest from US anesthesiology residents to be provided an opportunity during residency for a global health experience. The Baylor College of Medicine Department of Anesthesiology has sponsored residents and faculty by providing time and finances to join the US orthopedic surgical team in the Dominican Republic. The focus on orthopedic anesthesia ensures that individuals with musculoskeletal issues receive optimal perioperative care, addressing a critical gap in the local healthcare landscape.
Regional Anesthesia: Optimizing Orthopedic Surgeries
Orthopedic surgeries often involve intricate procedures and require precise pain management strategies. Regional anesthesia techniques, such as peripheral nerve blocks and spinal anesthesia, emerge as invaluable tools in optimizing pain control for orthopedic patients. By leveraging regional anesthesia during mission work, anesthesia teams can enhance the overall perioperative experience for patients, minimizing postoperative pain and nausea while also avoiding invasive airway management, which would only increase patient risk and simultaneously incur unnecessary equipment and environmental costs [2]. At this site, patients often have sedation throughout and receive a nerve block that will serve as the primary anesthetic and, if needed, may receive an additional spinal anesthetic. Since these are ambulatory cases, shorter acting local anesthetics such as chloroprocaine or mepivacaine are the preferred spinal medications [3]. Moreover, due to lack of immediate access to dantrolene, the avoidance of halogenated volatile anesthetics and succinylcholine by utilizing regional anesthesia mitigates that risk of malignant hyperthermia.
Empowering Anesthesiology Residents Through Hands-On Training
The global health arena serves as a unique training ground for anesthesiology residents from both the United States and the Dominican Republic. The hands-on experience exposes residents to a diverse range of orthopedic cases, providing them with a comprehensive understanding of the nuances associated with this specialized field. The mentorship provided by experienced anesthesiologists creates an environment conducive to skill development, critical thinking, and clinical decision-making, ultimately developing resourceful future anesthesiologists. Often, patients have limited preoperative testing and with a careful history and physical and the use of point of care ultrasound (POCUS) becomes invaluable in performing further evaluation that may impact patient management. During downtime between or after cases, we are able to teach and practice basic POCUS techniques to familiarize trainees with normal anatomy and rule out obvious abnormal findings. Every year ultrasound equipment has become less costly and more portable and, currently, we are able to bring personal probes to use in conjunction with a smart phone or tablet. The Dominican Republic residents have also had access to these portable probes, allowing acquired ultrasound skills to be continued in their practice.
Cross-Cultural Collaboration: Bridging the Gap
Engaging anesthesiology residents from both the United States and the Dominican Republic fosters cross-cultural collaboration, enriching the learning experience for all involved. The exchange of knowledge, perspectives, and best practices creates a dynamic environment that transcends geographical boundaries. Anesthesiology residents gain exposure to different healthcare delivery systems, cultural norms, and patient expectations, thereby broadening their understanding of global healthcare delivery. Learning to work in a limited resource setting fosters creativity and bolsters a sense of camaraderie and problem solving when working together. Often the Dominican resident has already worked through existing equipment problems and is able to share that knowledge with their American counterparts. An example includes lack of infusion pumps for propofol that can be overcome by hanging a reservoir attached to titratable drip infusion, which is now a lost art not commonly seen by our US residents today.
Strengthening Global Anesthesia Capacity
Teaching regional anesthesia to anesthesiology residents in Santiago contributes to strengthening the local providers’ capacity. By imparting skills and knowledge to local practitioners, the mission work leaves a lasting impact on the community. This collaboration is mutually beneficial, as the Dominican Republic anesthesiologists are especially adept at spinal anesthesia as this is usually the most efficient anesthetic approach for their patient population. Their providers have taught us different techniques and uses for neuraxial approaches. The US has focused primarily on general anesthetic approaches and are often deficient in such approaches. For example, spinals tend to still be underutilized despite such robust evidence-based benefits [4]. However, expanding our mission practice to include neuraxial anesthetics aligns with the principles of sustainable healthcare development. This approach empowers local anesthesia providers to continue delivering high-quality care long after the mission team has departed.
Enhancing Patient-Centered Care
Global health places a strong emphasis on patient-centered care. Regional anesthesia not only optimizes pain management but also contributes to reducing the overall perioperative stress experienced by patients. The personalized approach to anesthesia care aligns with the principles of patient-centered medical homes, ensuring that each patient’s unique needs and preferences are taken into account throughout their orthopedic surgical journey. Patients who have had a personal burden due to physical disability are able to recover with the hope of being able to return to work and a higher functional ability. They are very appreciative and grateful for this. The intangible personal satisfaction felt by anesthesia providers during these trips is not easily found in practice in the United States, where anesthesia is often managed simply as an unavoidable requirement of having surgery, and anesthesiologists are expected to accommodate rapid and efficient turnover of patients and cases. This satisfaction helps to mitigate the symptoms of burnout experienced by anesthesiologists and encourages mental wellness of the physician [5].
Fostering Long-Term Collaborative Partnerships
The work in Santiago is not just a one-time intervention, but an opportunity to foster long-term collaborative partnerships. We hope to return annually with junior and senior residents who will provide continuity of the care and education that has been built in previous years. By involving anesthesia residents from both the United States and the Dominican Republic, organizers lay the foundation for ongoing collaboration, knowledge exchange, and shared learning. In the past, we have performed afternoon workshops and presentations where topics are formally discussed, and difficult cases are presented by both American and Dominican residents. These sustained relationships can lead to continued improvements in healthcare delivery and facilitate future mission initiatives. The long-term hope is that trainees who experience medical mission work will be more likely to continue that work once they are done with training.
In summary, orthopedic anesthesia in Santiago, Dominican Republic, presents a unique and impactful avenue for anesthesia professionals and residents to contribute to global health. The focus on regional anesthesia not only optimizes perioperative care for orthopedic patients, but also serves as a platform for cross-cultural collaboration and increases the capacity of patients that can be cared for. The organizers create a rich learning environment that extends beyond clinical skills to encompass cultural competence, empathy, and a shared commitment to advancing orthopedic anesthesia on a global scale. As we continue to navigate the complexities of global healthcare, medical mission work such as this exemplifies the transformative power of collaborative and patient-centered initiatives.
References:
- World Bank. Mortality caused by road traffic injury (per 100,000 population), 2020. https://data.worldbank.org/indicator/SH.STA.TRAF.P5
- Graff, V., Gabutti, L. Treglia, G. Pascale, M., Anselmi, L., Cafarotti, S., La Regina, D., Mongelli, F., Saporito, A. Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature. Braz J Anesthesiol 2023; 73: 316-39
- Gebhardt, V., Zawierucha, V., Schöffski, O., Schwarz, A., Weiss, C., Schmittner, MD. Spinal anaesthesia with chloroprocaine 1% versus total intravenous anaesthesia for outpatient knee arthroscopy: A randomised controlled trial. Eur J Anaesthesiol 2018; 35: 774-81
- Ferreira AC, Hung CW, Ghanta RB, Harrington MA, Halawi MJ. Spinal anesthesia is a grossly underutilized gold standard in primary total joint arthroplasty: propensity‑matched analysis of a national surgical quality database. Arthroplasty 2023; 5:7
- Afonso AM, Cadwell JB, Staffa SJ, Sinskey JL, Vinson AE. U.S. Attending Anesthesiologist Burnout in the Postpandemic Era. Anesthesiology.2024
Dr. Garcia (on right) focuses on performing a lower extremity block with portable ultrasound.
Dr. Almonte (on left), a senior Dominican resident identifies structures to Dr. Palvadi during point of care ultrasound exam.
Dr. Khatker (on left) performs a pre-operative upper extremity anesthetic block with Dr. Eric Kim.
