Anaesthesia safety in Pakistan

When I introduce myself as an anaesthetist/anaesthesiologist at social functions, I either get a blank look or a comment “Are anaesthesists doctors?” Or someone comes up with their or their relative’s horror stories regarding anaesthesia.

“My relative went for a simple operation but never woke up; the surgeon said it was the anaesthesist’s fault.”

“My friend had a Caesarian section under general anaesthesia and she was awake and felt pain throughout.”

“I have had several operations, each time I had so much vomiting, it was a horrible experience.”

The complaints are endless. Are these misconceptions or reality? Is it safe to undergo anaesthesia in Pakistan? What is the myth and what is the reality!

Anaesthesia is still a field of medicine which is shrouded in mystery for the patients and their relatives. Even those working in the medical field which includes our surgical colleagues, do not completely understand the specialty and the role of the anaesthetist. For the patient an anaesthetist is someone who approaches them in a hurry first time before surgery, does a quick examination, asks a few questions and then disappears. He/she reappears again in the operating room, wearing a mask, a scrub suit and an injection in hand, who tells them that they will be off to sleep in a few seconds. Few remember the face of this nameless figure. For many of them this person holds the status of a technician working in the operating room. In my opinion the profession itself is to blame as well. If we take a few minutes to explain the importance of this specialty, its role in patient safety and surgical well-being at the time of our preoperative visit, the perceptions will change.

Anaesthesia is actually a medical specialty like any other specialty in Medicine. Anaesthetists/anaesthesiologists today have extensive responsibilities both inside and outside the operating room. Their current role has expanded from inside the operating room to managing patients in critical care areas, painless deliveries, pain management beyond the operation theatre, risk assessment and safety and quality management.

In the operating room and immediate postoperative period they are the specialists in perioperative medicine who look after the medical wellbeing of their patients. The effects of anaesthesia techniques and the mixture of drugs used, have to be assessed and planned for each individual patient undergoing surgery minor or major. They also manage any medical complications that arise during this period.

Modern anaesthesia given by a qualified trained anaesthetist is considered virtually risk-free. Perioperative mortality, ie, risk of death while undergoing surgery is less than one per 10,000 anaesthetics, a risk much less than crossing a busy road in Karachi traffic. However this figure may not hold true in Pakistan as well as many other middle and low income countries (LMIC). In 2012 a publication in Lancet, a reputable international medical journal, showed evidence that in LMIC this risk is much higher than developed countries. Why have developed countries reduced the risk but not us? One reason is by incorporating safety standards and safety guidelines in their everyday clinical practice. Safe anaesthesia requires a trained safe workforce and availability of a range of drugs, gases and equipment. The apparatus and machines used need to conform to International Standards and undergo regular service and maintenance by qualified engineers. Safety also requires safe hospital systems and incident monitoring. In our current environment these may be up to mark in some major centres but lack in many other smaller urban hospitals and in the periphery.

The World Federation of the Societies of Anaesthesiologists represents 135 anaesthesia societies from around the world. They came up with International Standards for the Safe Practice of Anaesthesia in year 2010. These have recently been revised and republished in 2018 and are endorsed by the WHO. The standards apply to all anaesthesia providers around the world, and have been matched with the facilities and infrastructure of rural district or referral hospitals. The standards refer to professional aspects, facility, equipment, medication safety, monitoring and conduct of anaesthesia.

Implementation of these standards by the decision-makers in the government is now the need of the day and will help in improving anaesthesia safety nationally. In addition, the responsibility of putting things right rests on all of us as well. Even a lay person can play their role in asking their surgeon and hospital whether they have provision of proper anaesthesia facility and a trained anaesthesia doctor before they undergo anaesthesia. Safe surgery and anaesthesia is your right and should not be left to chance alone in this day and age.

Published in The Express Tribune, November 11^th, 2018.

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