Anesthesia for surgical missions

Finding the right NGO

Hundreds of organizations provide short-term surgery to LRCs, making it difficult to choose an affiliation. A primary consideration for many volunteers is the NGO’s safety focus, which includes proper vetting of providers’ credentials, suitable composition of teams, and provision of adequate equipment and supplies ( ). Widely endorsed guidelines for perioperative care during plastic and reconstructive surgical missions, created jointly by anesthesiologists from Society for Pediatric Anesthesia (SPA) Global and surgeons from Volunteers in Plastic Surgery (VIPS), were first published in 2011 ( ; ) and serve as a valuable tool for evaluating an NGO’s safety focus. Those guidelines have been recently updated by the same committees with input from the Paediatric Anaesthesia Community of South Africa ( ). The guidelines once again focus on plastic and reconstructive surgical missions; most of the safety recommendations apply to other types of mission surgery. An NGO’s safety focus can also be evaluated by determining whether they meet the international standards for safe anesthesia practice developed jointly by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO) ( ). Numerous other considerations for finding a compatible NGO are detailed in Box 45.1 . An important decision point for all should be the degree of acceptable personal risk. Bear in mind that some NGOs seek hotbeds of conflict or contagious illness, whereas others exercise considerable caution and avoid those risks.

Few resources exist for finding an NGO that is a good fit. A searchable index created by SPA Global allows searching according to one’s own medical specialty, religion, desired mission location, time commitment, and type of volunteer activity ( http://www3.pedsanesthesia.org/vmsa_search.iphtml ). Once the search is narrowed, one can visit specific NGO websites to find information on history, philosophy, goals, practice locations, mission schedules, and how to get involved. Currently, there is no formal mechanism to evaluate volunteer satisfaction with individual NGOs. Canvasing friends and colleagues who have traveled with various NGOs may be the best option.

Personal risk management: Avoiding and managing illness during a surgical mission

Attention to surgical mission–related health risks should begin at least 2 months prior to the trip. That allows time to visit a travel medicine clinic (when available) or one’s physician in order to obtain vaccines, medicines, and advice. Travel medicine clinics are able to address specific health issues in the region hosting the surgical mission. A checklist of health issues is provided in Box 45.2 . The Centers for Disease Control and Prevention (CDC) has published the CDC Yellow Book: Health Information for International Travel since 1967. That publication serves as a compendium of worldwide travel health recommendations, including health requirements for entering countries and recommendations for vaccination and malaria prophylaxis. Hard copy ( ) and online ( https://wwwnc.cdc.gov/travel/page/yellowbook-home ) versions exist, as well as a smart phone applications for iOS and Android. An additional valuable resource is the CDC’s Traveler’s Health website ( https://wwwnc.cdc.gov/travel/yellowbook/2020/table-of-contents ). It allows input of destination and traveler type and provides general information on topics such as food and water safety and country-specific travel notices, recommendations, and requirements.

Healthcare workers traveling to LRCs should be up to date on routine vaccinations, including hepatitis B, and should strongly consider having up-to-date vaccination for typhoid disease and hepatitis A (requires two shots, 6 months apart). They should follow CDC country-specific recommendations for polio, meningococcal, Japanese encephalitis, rabies, cholera, and yellow fever vaccinations. Up-to-date country-specific requirements for yellow fever vaccination are available from the WHO ( ) and the CDC ( http://wwwnc.cdc.gov/travel ) and must be adhered to because numerous African and South American countries require visitors to produce documentation of yellow fever vaccination on an International Certificate of Vaccination or Prophylaxis (often referred to as the “yellow card”).

Malarial prophylaxis includes both mosquito avoidance and chemoprophylaxis. Specific CDC recommendations for malaria chemoprophylaxis for all destinations should be studied to determine whether chemoprophylaxis is needed and to insure selection of an agent that will be effective for the specific region and suitable for the traveler. Some chemoprophylaxis agents require initiation 2 weeks prior to arrival.

Travel to surgical mission sites usually involves prolonged air travel and risk for deep vein thrombosis. At times, three or four flights and travel times in excess of 24 hours are required. The CDC Traveler’s Health website gives recommendations for deep vein thrombosis prophylaxis for long-distance travel ( https://wwwnc.cdc.gov/travel/page/dvt ). They recommend calf muscle exercises and frequent ambulation for all, and use of aspirin or anticoagulants only for high-risk cases after discussion with one’s physician.

Travel to LRCs invariably involves risk of acquiring travelers’ diarrhea (TD), a clinical syndrome that results from infection by various intestinal organisms. Travelers’ diarrhea is often incapacitating and can be quite severe and protracted if antimicrobial therapy is not started. In addition to the personal inconvenience, surgical team productivity may be dramatically affected when key team members fall ill. Following CDC or other food and water safety tips ( https://wwwnc.cdc.gov/travel/page/food-water-safety ) is highly recommended but is far from a foolproof method for avoiding TD. Water purification tablets or filtration devices may be useful when going to particularly remote settings or providing disaster relief. Fluoroquinolones are effective prophylactic agents for TD, with ciprofloxacin found to be 94% protective against TD ( ). However, antibiotic chemoprophylaxis is generally discouraged because it promotes antibiotic resistance in the individual and the community. Also, it removes normal protective microflora and promotes infection by resistant organisms, including salmonella ( ). Select individuals at high risk of complications from severe TD may be candidates for antibiotic chemoprophylaxis. In that case, rifaximin may be the prophylactic antibiotic of choice ( ). Chemoprophylaxis for TD using probiotics may be somewhat effective and does not appear to produce adverse side effects, whereas bismuth subsalicylate (two tablets four times daily) is 65% preventive but causes discoloration of the tongue, dark stool, and can lead to salicylate toxicity. Antibiotic treatment of moderate TD (diarrhea that is distressing or interferes with planned activities) is clearly indicated. Although a panel of experts recommends no antibiotics for mild TD ( ), many surgical mission team members start antibiotic treatment as soon as symptoms of TD appear because the cost of incapacitation is high. Bacterial pathogens differ substantially according to global region. The most common Latin American pathogens are enterotoxigenic Escherichia coli (33.6%) and enteroaggregative E. coli (24.1%) whereas Southeast Asian TD is most commonly caused by Campylobacter (32.4%) ( ). Mission volunteers should travel with appropriate antibiotics to treat TD. Antibiotic choice differs according to travel location, with ciprofloxacin being the drug of choice for most locations (500 mg orally every 12 hours for 1 day) and macrolide agents such as azithromycin (500 mg orally once daily for 1 to 3 days) indicated in locations where fluoroquinolone-resistant Campylobacter have become endemic (most notably in Asia, and particularly in Thailand). Volunteers should also travel with an antimotility agent such as loperamide or diphenoxylate, which can safely provide TD symptom relief if used in conjunction with an antibiotic but should not be used in the presence of fever or bloody diarrhea ( ). Although bacteria cause the vast majority of TD, keep in mind that viruses and protozoa may also be causative agents, requiring symptomatic treatment or antiprotozoal medication (such as metronidazole), respectively.

Human immunodeficiency virus (HIV) infection is particularly prevalent in LRCs, especially within indigent populations typically cared for by surgical mission teams. NGOs should be prepared to manage a volunteer’s exposure to blood or other body fluids that may contain HIV. Preparation includes the ability to immediately start postexposure prophylaxis (PEP) with an effective antiviral regimen and a plan for how to obtain source patient HIV testing to determine the need to either initiate or continue PEP ( ). Preferably, the organization responsible for the surgical mission can provide on-site rapid HIV testing. The World Health Organization (WHO) has vetted numerous rapid HIV tests with sensitivity and specificity over 99%, and their list may serve as a useful reference for organizations interested in procuring rapid HIV tests ( ). Early initiation of PEP provides best results, preferably within a few hours of exposure. Whenever on-site testing is unavailable, PEP can be initiated and discontinued once the source patient is found to be HIV negative by a reliable test. The most current recommendation of the United States Public Health Service is to administer a combination of raltegravir 400 mg PO twice daily, together with a combination medication Truvada, containing tenofovir DF (300 mg) and emtricitabine (200 mg) orally once daily, or alternatives described in their manuscript ( ). Prior to embarking on a surgical mission, volunteers should determine their organization’s plan for managing possible HIV exposure. Volunteers who experience HIV exposure during a surgical mission must confer with their physician once home so that proper follow-up medical care and counseling can occur ( ).

Medical emergencies involving volunteers can occur while overseas. Medical insurance plans at home often do not include coverage when outside the home country and rarely include costly medical evacuation. Surgical mission volunteers should check with their health insurance providers, including government health plans, to determine whether they will be covered during the mission and should consider purchase of travel insurance to cover gaps. Travel health insurance and medical evacuation policies vary widely, and one should pay attention to details when purchasing them. Important details for evacuation insurance are whether the decision to order evacuation is made by the treating physician or a company consultant or is the insured’s own choice and the details of how the evacuation would take place. Policies that order evacuation by insured’s own choice and transport by specialized air ambulance are unusual and particularly costly. In cases of emergency, travelers should always consult their home country’s consular service for assistance.

Many NGOs supply volunteers with a list of suggested travel items that includes personal health items. Additionally, the CDC has posted recommendations for a travel health kit ( http://wwwnc.cdc.gov/travel/page/pack-smart ). They note the importance of packing all prescription medications, including an epinephrine autoinjector for those who have had severe allergic reactions. Over-the-counter medications are usually easy to find in LRCs but not at remote sites, and decisions regarding these must be individualized according to mission location and personal needs.

Personal risk management: Avoiding physical harm

Most surgical mission volunteers affiliate with NGOs that avoid sites where there is military conflict, political unrest, or frequent terrorist attacks. Nonetheless, they should understand that their risk during a surgical mission would usually be well beyond that at home. The U.S. Department of State Bureau of Consular Affairs regularly posts up-to-date country-specific alerts and warnings, and safety and security information detailing criminal concerns, political unrest, military and terrorist activity, and traffic and other transportation dangers ( http://travel.state.gov/content/passports/english/alertswarnings.html ). Those alerts and warnings provide an opportunity to become informed about the risks one might undertake and to mitigate those risks by following detailed advice provided on their website. It is worth noting that data from the U.S. Department of State shows that the leading cause of injury-related death for U.S. citizens in foreign countries is traffic injury ( , chap. 3). U.S. citizens should consider enrolling their trip with the U.S. Department of State’s Smart Traveler Enrollment Program (STEP; https://step.state.gov/ ). STEP helps U.S. embassies keep travelers abreast of safety conditions and helps contact travelers and their families in an emergency.

Personal risk management: Medical liability

Physicians going on surgical missions rarely think about carrying medical malpractice insurance for the mission, even though they would never consider practicing without it at home. Numerous U.S. federal and state laws protect health practitioners from medical malpractice lawsuits when they are practicing at free clinics or responding to disasters and emergencies within the United States. International Humanitarian Law may protect international medical volunteers from medical liability when serving in an official capacity in areas of armed conflict, occupation, or natural disasters but most likely would not protect volunteers from medical liability during standard surgical missions ( ).

The American Society of Anesthesiology’s (ASA) Committee on Professional Liability looked into the question of whether physicians on surgical missions should carry medical malpractice insurance that covers their volunteer work. They found only a few documented medical malpractice lawsuits against international healthcare volunteers and noted that it was not clear whether those were medical, surgical, or anesthesia related ( ). Although malpractice lawsuits are extremely rare and may be more likely to be directed against an NGO than an individual, some volunteers may prefer to acquire liability coverage and therefore need to know their options. Unfortunately, a minority of NGOs provide medical malpractice coverage for their volunteers, and a minority of U.S.-based medical malpractice insurance companies provide malpractice coverage during humanitarian missions. The ASA’s Committee on Professional Liability’s report lists companies that do extend coverage under specific conditions, with most requiring the lawsuit be filed within the United States ( ). Many large academic medical centers are self-insured, have their own liability trust, and may extend malpractice coverage during surgical missions if formally asked to do so. If none of those options are available, stand-alone malpractice coverage for surgical missions exists but is hard to find. Once located, one should examine policy terms closely, particularly exclusion clauses, liability limits, and policy period.

Finally, one may be able to limit liability by aligning with an organization that focuses on patient safety. That focus can be measured by adherence to guidelines and international standards noted previously ( ; ; ). Providing the proper practice environment, equipment, teammates, practice guidelines including patient exclusion criteria, and a safety culture that includes use of standard checklists and handoffs decreases patient risk and therefore decreases liability. Additionally, some protection may be afforded by working with an organization that obtains and documents basic informed consent for surgery and anesthesia, obtained in the patient’s or legal guardian’s own language. Standard of care during surgical missions in LMICs is a matter of opinion, as it is in HRCs. Maintaining surgical mission practice standards as close as possible to those in HRCs may decrease the chance of lawsuit and is, after all, the right thing to do.