Anaesthetist - Good Samaritan

Dan Holmes

Dr Dan Holmes, MIPS member


Short term surgical missions to developing countries are appealing on several levels.  

Helping people who do not have the access to high quality healthcare enjoyed by Australians and providing some education to local doctors are the biggest motivations.  There are also those secondary gains - the chance to experience another country and its culture, meet new people and (let's be honest) that warm personal glow from doing something rewarding.

As an anaesthetist I was asked to travel on an ENT surgical mission to rural Indonesia, to perform head and neck operations at a local charity hospital.  Fortunately the charity that organised the visit, OSSAA (Overseas Surgical Specialist Association of Australia), had been travelling to Indonesia and Timor Leste for over 10 years. Within their mission statement is a promise to provide training locally as well as perform medical procedures.  All OSSAA teams provide reports that are regularly published on the charity’s website. and part Part of the remit for the surgeons on this particular mission was to follow up previous patients, ensuring quality control and accountability.

Island of Flores IndonesiaAnd so began a cycle of paperwork to allow a suitcase of anaesthetic medication to travel with me from Darwin to the small rural town of Cancar on the Indonesian island of Flores.  A shaky and interesting mountain route in a rickety minibus (I was thankful the driver had left enough space between windscreen stickers to see the road) saw us arrive to over 100 patients and their families eager to be seen by the visiting doctors. 

Our two Australian surgeons and nurses were joined by an Indonesian surgeon and three young local GPs. On finishing medical school in Indonesia, doctors must pay up to $50,000 to begin their specialist training, during which time they do not earn any wages.  Unless already wealthy, this means working in clinics or hospitals, often run by the private sector or a charity, until enough is saved to enter the training program.  It was a genuine pleasure to work with such dedicated colleagues who also provided us with an invaluable medical translation service.

Reviewing 120 patients in 6 hours and creating a manageable theatre list was a challenge, with decisions having to be made quickly and decisively.  As this was a trip with a particular focus on head and neck surgery, the majority of patients we listed suffered from struma (Indonesian for goitre).  Cassava root can be a cheap source of carbohydrate in low income areas, but undercooking often causes chronic low level cyanide poisoning and thyroid enlargement. 

Local shops in CancarAs an anaesthetist this meant assessing airways for potential problems in people with a growth resembling the size of a small melon at the front of their neck.  Assessment needed to be brief but thorough, which was usually straightforward as investigations are minimal and most people had never see a doctor.  There are often no known pre-existing medical problems and no known allergies; it doesn’t mean they are not there, just that they have never been diagnosed.

In developing world medicine, difficult ethical decisions are frequently encountered.  For example, we weren’t able to offer a seven year old boy with a nasty airway tumour any treatment.  Similarly an octogenarian with a potentially treatable lesion was not offered surgery as the hospital could not justify operating on an elderly patient with so many young people needing help. As our visit was short, we needed to do the most good for the most people.

Providing anaesthesia in an austere environment is a challenge requiring a large dose of adaptability,a willingness to maintain standards and the ability to be relaxed in an unfamiliar environment and culture.  I regularly reassured myself that my ultimate fallback of getting the oxygen in and waking the patient should any disasters occur would still work.  

Local Theatre Team Cancar FloresA good working relationship with the surgeons was the most important factor in ensuring all tasks were performed safely and proficiently.  I was fortunate to travel with a great team that respected my judgement as I did theirs.  There was never any pressure to perform procedures with which I was uncomfortable and if I had misgivings, cases were openly discussed within the group.  In essence, it is fair to say that if I was uncomfortable, everybody else was too, bearing in mind that mishaps are a catastrophe for the patient, the family, the hospital, the team and the entire charity group.  

Five days of operating and 28 major cases (including two emergencies) later, we said our goodbyes, packed up and left for home.  The days were long and tiring, and there was a certain niggling background stress as I missed my usual cacophony of fancy machines and automated alarms But like every other anaesthetist I have spoken to about such trips, I had done something worthwhile for the patients, provided some education, experienced a new culture, met new people and just maybe arrived home with a certain extra glow.   

Dr Dan Holmes, FANZCA 

Anaesthetic Specialist
Royal Darwin Hospital

Last edited: February 2014

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