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The following vignette provides an excellent picture of typical operating room (OR) anesthesia in a resource-poor venue1:
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John, an anaesthetic clinical officer, is administering a general anaesthetic [and] performs a rapid sequence induction with thiopental and suxamethonium and intubates using his own laryngoscope and a tracheal tube that has been used dozens of times before … John carries all his own equipment with him, along with a supply of drugs for the day—anything left in theatre will disappear by tomorrow. Normal saline is running in through an 18G cannula that the patient's family were asked to buy from the local pharmacy.
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John administers 50 mg of pethidine—this may be the last analgesic the patient receives until the unpredictable visit of the night matron to the ward in 9 h time—and turns up the OMV [Oxford Miniature Vaporizer] to deliver 2% halothane. The inspired concentration must be estimated clinically because the halothane "expired" 8 months ago and the clinical effect is unpredictable. The EMO [Epstein-Macintosh-Oxford] vaporiser and a bottle of ether are on stand-by behind the anaesthetic machine, as we are down to our last bottle of halothane…. The modern anaesthesia monitor, looking out of place in these surroundings, was purchased, along with eight others, by the European project. The screen has a psychedelic tinge to it and I suspect it is on its last legs. The capnograph trace is flat, as the last remaining moisture trap has been "borrowed" for use in ICU, where it will be circulated around the four beds. The ECG trace is true, but periodically interrupted as the long out-of-date electrodes require a small drop of thiopental to improve their conductivity. The oximetry probe is a paediatric one and roughly taped with grubby Elastoplast around the man's little finger.
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John ventilates the patient using the Oxford Inflating Bellows as part of a draw-over system, aiming to keep him deeply anaesthetised and apnoeic using a high concentration of halothane. There are no muscle relaxants apart from suxamethonium. Emergency drugs, atropine and adrenaline, are drawn up on a redundant Boyle's machine, which acts as a trolley and equipment store. A lone size H oxygen cylinder is deep in dust in the corner and has been empty for several years.
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John requests a nasogastric tube, so I head to the locked anaesthetic store room where 10 or so years of unsorted donations to the department have piled up. After 15 min, I find one at the bottom of a box of out-of-date NG feed. I can tell by the look on his face that John is torn between using this valued commodity for this patient or saving it for the next.
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Anesthesia in Austere Circumstances
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Anesthesia's three principal functions are to keep the patient alive through surgery, to make surgery painless, and to provide the best possible surgical conditions.
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