Did we really close the gap?

Did we really close the gap?

  • Issue 65

Gabriel M. Gurman
Chief Editor

Many years ago, immediately after the fall of the Iron Curtain, a serious process of closing the professional distances between the two parts of the continent started, and the WFSA promoted a series of programs and projects with the aim of offering our colleagues from Eastern Europe the necessary help to overcome the huge differences in their daily practice.

Soon, ESA started its own projects, and gradually we have witnessed real progress in creating a serious clinical base for offering modern tools to all our patients, in every single country.

Those of us who frequently visit colleagues from the Eastern part of the continent can easily follow the tremendous changes in the way our profession is practiced in many of the hospitals that once upon a time suffered from a continuous lack of means for treating patients.
Now we are more than a quarter of a century after the most important political, economic, and philosophical event that took place in Europe in the second part of the previous century. The time has come to ask a crucial question: did we really close the gap?

From one side, the progress is evident. Our peers from Eastern Europe became an integral part of our organization. They take part not only in the current projects related to our profession, but also significantly contribute to the scientific activity, research, and education.

The level of treatment offered to their patients does not differ from that given to the average West European patient. A quick visit to an operating room or to an intensive care unit in many Eastern Europe hospitals will give the visitor a feeling of being “at home”; most of the procedures are being done in the same conditions as anywhere on the continent.

But, unfortunately, the situation is not homogenous. If, in principle, the differences between West and East have been almost wiped out, the gap is still evident when one speaks about big hospitals versus small ones.

One can conclude that as of today, in general, anaesthetic management is practiced in a very similar way in any hospital, but differences are still here, regarding equipment, drugs, monitors, etc.

Thinking about a car on the road, everybody would agree that both Suzuki and Rolls-Royce will have to have the minimum tools for assuring the safety of the passenger: reliable brakes, an odometer, lights, etc. Take also the example of the work done by a surgeon in the operating room. There would be no surgeon who would accept operating on a patient without minimal conditions to perform the procedure: perfect sterility, gloves, instruments, lights, etc. But what about anaesthesia?!

Would it be possible to anesthetize a patient without a monitoring system that would include the basic parameters such as: ECG, oximetry, capnography, non-invasive blood pressure measurement? Is anybody ready to administer a neuromuscular block agent without having a neurostimulator to measure the intensity of muscle paralysis? And what about having easy access to a blood gas analyser? Is anybody ready to accept the absence of such an important tool in an operating theatre?

The percentage of accidental awareness during general anaesthesia for caesarean section is significantly higher than for any other surgical procedure. Would anyone be ready to administer anaesthesia for this operation without a cerebral function monitor?

We encounter on an almost daily basis cases of pulmonary cripples, who need to be assessed and prepared for surgery and anaesthesia, but in the absence of a laboratory for pulmonary functions tests this cannot be properly done.

The list could go on, and I am sure that many of our readers would be able to extend it. Still, this is the reality in many hospitals in Europe. One can easily offer explanations for this sad situation, but we do not need more explanations. We have to act.

ESA started the Lifebox program, which is intended to purchase pulse oximeters for remote hospitals in those countries where this device is still needed, and here is the place to commend the initiators of this important project. But this is not enough.

This reality is difficult to change but far from being impossible. Money is the first obstacle, but this is not the only one. Healthcare administrators still see anaesthesia as an appendix to the surgical activity and thus principles of patient safety are sometimes neglected. We also are to blame for accepting the situation without strongly asking and fighting for a change.

Since we cannot refuse treatment in an emergent situation and always anaesthetise a trauma patient or an acute abdomen with the tools we have, there are many administrators who would see it as a normal current practice, to be extended to elective surgery, too.

Since the anaesthesia mortality is steadily going down, one could think that patient safety could be assured with less equipment, fewer drugs, or fewer tools than is obviously necessary.

Since in the vast majority of cases the average specialist in anaesthesiology can perform a correct tracheal intubation, it would be rather difficult to convince a hospital director that every single operating room absolutely needs capnography for a quick diagnosis of oesophageal intubation.

It is true, “Monitoring devices play an important role in safe anesthesia as extensions of human senses and clinical skills rather than their replacement” (Can J Anaesth 2010;57:1027), but minimal equipment is vital for the patient’s security. I do suggest that our readers refer to that above mentioned Canadian paper in order to find out the guidelines to infrastructure, supplies, and anaesthesia standards at the level 2 facilities (district/provincial hospital, 100-300 beds) adopted by WFSA, and compare the recommendations in use today to their current situation. A comprehensive paper on patient safety in conjunction with the Helsinki Declaration can be found in Eur J Anaesth 2010;27:592.

I am of an opinion that each of us is completely entitled to start fighting to close the existing gap. During the 2016 Euroanaesthesia Congress last month in London, a world-wide group of experts met and discussed ways to improve anaesthesia patient safety.

We do hope that soon this group will not only issue guidelines and protocols, but will also establish the ways to implement them in those parts of the continent where help is needed for assuring the success of this campaign.

Discussing topics directly related to patient safety in the perioperative period becomes the task of every single society and organization responsible for the program of each scientific event. I invite our National Societies to take the opportunity and initiate lectures and panels on this important issue, with the aim of finding the most appropriate ways to reach the point where the safety of the anaesthetized patient would be the same all over the continent.