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Preparing for a mission trip to El Salvador began months earlier with gathering of supplies and anesthesia equipment and medications for the April 2017 trip. Molly McCormick MD had ordered some Zofran, ketorolac, and rocuronium from the pharmacy, and she initiated a supply and packing list.  Initially we planned on reusing medications left by the last medical mission group, however, we also had shipped some medications by Fed Ex after inventory and completing a customs forms with the lot numbers and expirations. I also hand carried additional airway items such as LMAs, and anesthesia induction and emergency drugs. For ease of getting through customs, Peggy Winter Frisella had written a note to customs officials explaining the mission trip, and I had this note and a copy of the customs medications form. When I got to customs in El Salvador, I was pulled from the line for an inspection of my equipment and medications, which when shown the packing list, note and customs form, they approved without detaining me or keeping the medications.  Upon arrival at the airport, we were informed that some of our boxes that had been shipped were missing, but a team believed they were at an offsite storage facility.  

 After arriving at the hospital, I met with Molly McCormick, lead anesthesiologist and Jim Hennesy CRNA to discuss the patients, schedule, and equipment. We began by inventorying available equipment, unpacking boxes, and setting up rooms. We were able to secure shelves for our airway equipment, LMAs, anesthesia circuits, syringes, and IV supplies, and also began dividing up the available drugs between the 2 ORs. Molly had brought the AED, and a stretcher in the supply room was used for placement of the emergency drugs for quick access. There was plenty of sevoflurane and isoflurane, and the large oxygen and nitrous tanks were full. One of the anesthesia machines was a Narkomed and fully serviceable, with the ability for controlled ventilation. The other anesthesia machine had no reliable end tidal Carbon Dioxide monitoring, and was only capable of hand bagging or spontaneous ventilation. In discussing the schedule, the general cases that needed muscle relaxation and endotracheal tubes would start in and be assigned to the Narkomed machine, Jim Hennesy started in that room.  I staffed the other room, for LMAs only. Additionally, Molly discussed that most patients were healthy except for 2 or 3, including a lady with much shortness of breath and a difficult airway that would be performed as a MAC sedation case.  On Sunday we went to Church in town, and Molly saw the difficult airway lady, which she pointed out for reference. A few days later, I helped the resident walk her into the OR and I asked to have the attending Dr Brent Matthews do a local anesthetic with  sedation for her hernia repair. The resident also noted that she was short of breath, and using propofol  and fentanyl made her blood pressure drop, which I treated with phenylephrine.

 On Monday, the first case that was a general and endotracheal with muscle relaxation, the case went more quickly than planned, and Jim had to wait an additional 15 minutes to let the rocuronium diffuse so he could reverse the patient. My room did not go smoothly initially, the machine made loud noises, and was using oxygen excessively. At the end of the case, Molly and I agreed the machine needed to be replaced and repaired. Another machine was quickly set-up by the anesthesia tech.  By mid afternoon cases were going smooth, however, the end-tidal carbon dioxide monitors were fogging up and not reading results. We monitored ventilation and vital signs, and did not have digital or numerical readouts for anesthetic agents. One pregnancy test was done intraoperatively because it had not been done pre-operatively and the surgeon Dr. Hurley asked if the patient could be pregnant due to a large uterus and abodomen. The lack of monitoring ability was not a patient safety problem, but it goes against standards for anesthesia safety in America and at Barnes-Jewish hospital.  

 The hospital staff were extremely helpful . The nurses had started all the IVs without any infiltrations. All patients were walked back from the rooms to the OR by our staff and sometimes a local nurse. We had an occasional staff member help translate to get the patients on and off the bed, and helped with induction preparation. A nurse was also present to chart the OR events. Anesthesia staff and Dr Carcamo our host checked on us frequently for equipment needs. All took breaks for lunch, and one anesthesia staff member stayed outside the rooms in PACU or checking on the next OR patient. We had no real complications, a few cases of nausea even though they had received ondansetron, and a few patients with pain that ketorolac could not treat. Overall, the patients did well although they had no midazolam to pretreat anxiety, and minimal use of fentanyl, 50-100 mcg.

 As a CRNA I was challenged by the very hot and humid El Salvador spring, and the warm ORs.  We all pushed drinking bottled water to stay hydrated. The kitchen staff did an excellent job preparing our meals with variety, including my favorite pupusas.  On Wednesday I got a case of GI distress with travelers’ diarrhea and vomiting, after having unpasteurized yogurt and fruit at breakfast, and Molly took over my room for several hours until I felt better that afternoon. It is good to have 3 anesthesia personnel for this reason. In the mornings we shared coffee, and in the evenings we discussed our cases at dinner, and relaxed with a beer. The team in El Salvador worked together to provide the patients the best of care for hernia surgery. I firmly believe our El Salvador volunteer mission members from SOFA are the best at working together and taking care of one another. I’m looking forward to the next mission.

Tracy Lanes, CRNA

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