Page 60 - JSOM Winter 2017

Depending on the size of the item and its importance to the mis- Logistics
sion, consider hand carrying it to and from the mission country. Regular meetings leading up to the mission are extremely impor-
tant for mission success. Every detail possible regarding travel and
The supplies and medications needed for the mission must be tai- lodging arrangements should be evaluated ahead of time. The an-
lored to the surgical services being supported, the duration of the esthesia team lead must ensure that everyone associated with ar-
mission, the case load, and the anticipated patient population. ranging travel knows exactly who is on the team so nobody is left
off any order sets or itineraries. The anesthesia team lead should
We highly recommend planning a medication and supply list also work to have the entire anesthesia team, and preferably the
based on the use of total intravenous anesthetics (TIVAs) to entire mission team, travel and be lodged together. This is very
minimize the possibility of triggering malignant hyperthermia, helpful in getting the entire team in place on time to start the mis-
which has occurred during military support of humanitarian sion and minimizing logistical challenges throughout the mission.
missions. In addition to its safety profile, TIVA is also rec-
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ognized for its unique flexibility that allows tailoring specific In some cases, an advanced team (typically the surgical and an-
agents to the needs of the particular patient as well as the abil- esthesia team leads, an operating room [OR] nurse and a surgi-
ity to continue to provide anesthesia during power or equip- cal technician) will travel a few days in advance of the rest of the
ment failure. If the team decides not to use TIVAs, then it must team to finalize site details before the arrival of the entire team.
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obtain detailed information about the host nation’s particular
anesthesia circuits to determine their functionality and safety. The anesthesia team lead should also inquire about options for
Otherwise, plan for delivering anesthesia circuits to the site. meals, both in and around the hotel, as well at the hospital,
We have had marked success with coordinating the delivery, as well as transportation options for the team to and from the
assembly, and use of the Dräger Fabius Tiro M (Drägerwork hospital. All logistical arrangements must be made with the
AG & Co, https://www.draeger.com) in several limited-resource safety of your team in mind.
environments. If this is the case, then appropriate amounts of
volatile anesthetics will need be to be included on the supply list. Translators
It is vital to mission success to have personnel who speak
A sample supply list and medication list to support a 25-30 case the host-nation language available to the entire mission team
mission, using TIVA, for a mission expected to involve mostly throughout each portion of the mission. Having a reliable point
adults and a few pediatric patients are provided in Figures 2 and of contact at the host-nation hospital can be invaluable for ac-
3, respectively. There lists also assume practicing in a standalone cessing many resources for the mission, including translators.
facility with power and oxygen. Emergency medications are in- Translators can be local nurses, technicians, physicians, or
cluded as well and their presence on all overall mission supply members of the mission team. Translators are needed for nearly
lists should be verified throughout every step of the process. every step of the way during the mission execution phase.

Avoid transporting narcotics to the mission site, if possible. Preoperative Considerations
Make every attempt to arrange shipment and delivery of these Most missions will require time for patient screening by the sur-
controlled items ahead of time to prevent having a team mem- gical service and this is an ideal time for the anesthesia team to
ber transporting them in their luggage or personal belongings. perform its pre-operative assessments for those patients selected
for surgery. Keep in mind that several hundred patients may
Other supplies that may need to be considered include dif- need to be screened by the surgeons to generate a caseload of 40
ficult-airway equipment and adjuncts, neuraxial anesthetic to 50 patients for a 2-week mission trip. If patients are not pre-
kits, an ultrasound machine, regional equipment (e.g., nerve screened by the host nation, then it will likely take several days
stimulators, block needles, intralipid therapy), and additional of patient screening to generate a full surgical schedule, given
pediatric equipment (e.g., supplies necessary for administer- the low surgical rate in a typical mission patient pool of 1:10. 2
ing intravenous fluids or other medications, microdrippers,
airways devices, masks, circuits). Inquire into the ability to obtain basic laboratory tests (e.g.,
complete blood cell counts, chemistry panels, β-human chori-
Do not forget to include routine documentation forms, such as onic gonadotropin testing) and imaging (chest radiographs) at
the preoperative assessments, intraoperative records, postop- the site. Asking about these early in the planning process will let
erative order sets, postoperative assessments, and potentially the anesthesia team know what is available in case something
other forms such as a difficult-airway letter. Bring extra copies is needed during the preoperative assessment period. Consider
or ensure the ability to make copies. bringing over-the-counter pregnancy testing kits if the hospital
cannot support such testing. Also inquire about the availability
Once a list of supplies is developed, the supplies must be or- of consultants such as cardiology and pulmonology who might
dered or acquired, and a plan for either packing or shipping be required to perform adequate preoperative assessment.
them to the mission site must be made. Checking with the sur-
gical team lead periodically is important to ensure no changes The anesthesia team lead should work closely with the surgical
to the surgical plan or site have occurred that would affect the team lead to request clinic space and with a translator to al-
supplies needed. Furthermore, keep in mind that additional low their team to perform preoperative assessments. Request-
time may be required for surgical/anesthetic supplies to clear ing this ahead of time should allow for adequate coordination
host-nation customs once they arrive in country. before the team’s arrival for the mission.

It cannot be overemphasized that failure to plan, acquire, and Last, the anesthesia team lead must work closely with the lead
ensure timely delivery of the proper supplies can severely ham- surgeon to ensure the surgical cases remain within the scope
per the overall goals of the mission. and capabilities of the surgical and anesthesia teams in the

58 | JSOM Volume 17, Edition 4/Winter 2017