Central Line

Episode Number: 122

Episode Title: Inside the Monitor – Global Critical Care

Recorded: February 2024

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. KIYA LOCKE:

Welcome back. I'm Dr. Keya Locke, your host for today's episode. I'm joined by Doctor Ana Maria Crawford, guest editor of the March Monitor, on the topic of global critical care. We're going to dive into that critical intersection of global health and critical care, and Dr. Crawford is a great person to turn to for this fascinating topic.

Dr. Crawford, could you tell us about yourself and your experience with critical care, medicine and global health and more importantly, how you see those issues coming together?

DR. ANA MARIA CRAWFORD:

Yeah. Thank you for having me. So I practice both anesthesiology and critical care medicine at Stanford University currently, but I've been involved in global health since about 2005. I knew very early in my training that I wanted to engage in global health as part of my career, but I also knew that I wanted to be an intensivist. So years ago, people didn't really see that overlap. And in fact, when I would tell people I wanted to do both critical care and global health, they didn't quite get it. And even one person laughed when I told them that I wanted to do that. But I think now the global health landscape has really evolved and changed. And and now many, probably arguably most academic centers have global health programs for their trainees and have faculty that engage in in global health. And then more importantly, kind of to zoom out, I think we're in a really great time of opportunity to bring global health and critical care together. This past year, in 2023, at the World Health Assembly, they passed a resolution called the echo resolution, which essentially vowed to strengthen health care systems to deliver high quality, emergency critical and operative care. And this is important because it's really the first time that critical care has been mentioned on a global health priority list.

DR. LOCKE:

So thinking about the things that you have mentioned already, um, we understand that critical illness can affect anyone, anywhere. And patients continue to suffer under certain harmful assumptions. Can you talk about the assumptions that may be harming this patient subset? And what do we need to look out for?

DR. CRAWFORD:

Yes, absolutely. And that's such a good question. I think historically critical care has been lower on the priority list because frankly, it's it's overwhelming. It's very resource intensive and and very expensive. And so it has been kind of in last place to really develop critical care services or critical care medicine across the globe. But I think we're making one big assumption that that harms patients, and that is that critical care is ICU level care. In fact, there's some evidence done both in, I believe it was Malawi as well as Sweden, that 90% of critically ill patients are actually found outside of intensive care units. So I think one of the first assumptions is that we assume that critical care means ICU level care. But what we really need to be focusing on is time critical care. And that needs to be wherever the patients are.

Another big assumption that I've noticed over the years when it comes to critically ill patients is that I think many of us, in well-resourced settings, are shocked to learn that a lot of the foundational care is missing when there's resource constraints. And what I mean by that is we assume that when we're sick, we can present to a hospital that will have, you know, our vital signs checked and a physical exam, and someone will come up with a care plan and triage us accordingly. And then, you know, we'll receive care that that gets us better and discharged back home. But a lot of this doesn't actually happen. In fact, some places you may not ever get your vital signs checked. Or if you do, you may have them checked on admission, but the person checking them may not realize that they're consistent with a life threatening or critical illness, and they may not take the appropriate first step actions. And we're talking about things as simple as providing oxygen therapy or giving some fluids. These are really foundational things. And I think as global health professionals, we try to address critical care, assuming that a lot of this foundational care is in place. And unfortunately, it's just not.

I think another big assumption that is made is that if we just can expand access to care, that that will be enough. But much like assuming that the foundational care is there, having access to care doesn't necessarily guarantee a good outcome for patients. So assuming care is enough is a big mistake because we really need to focus on quality improvement of care and making sure that not only do they have access to resources, but that those resources are used by trained workforce and that they function within, you know, clinical processes and systems that are effective for good patient outcomes?

Equipment is a big thing in global health. There's a lot of people that donate equipment, and it is useful sometimes. And I think you probably remember at the beginning of the pandemic, the world flooded low and middle income countries with ventilators. But at that time, a very small percentage of people actually, um, one, needed that advanced level ICU care and, two, benefited from it. So not only were they flooded with ventilators, but these ventilators were placed in locations where there were not trained intensivists, and actually a lot of the places did not even have electricity or oxygen to run those ventilators. So I say this - it sounds a little dramatic, but I think mechanical ventilators can actually do more harm than good or be be more like a weapon than than a treatment if if in the wrong place or in the wrong hands.

And then another big assumption is that we can take our guidelines from developed countries with lots of resources and just kind of copy paste and apply those to these settings, and that's certainly not the case. Um, a good example is, you know, we often focus on fluid resuscitation and early septic shock, but there's a study in, in pediatric patients and in adult patients that using that that strategy of early resuscitation actually led to worse outcomes. So those are a few examples of assumptions that we make. And we try to come up with solutions. But but we're basing them on a gap and resources that simply isn't there.

DR. LOCKE:

Excellent information. And it sounds like the assumptions that you discuss can have real world implications for the care that was delivered. I really like the story about extra ventilators going somewhere where there didn't have a lot of usefulness. Do you have any other sort of real world examples of how subscribing to these assumptions pose a danger to patient care?

DR. CRAWFORD:

Yeah, we have countless examples, and my colleagues who live in these resource constrained settings will tell you story after story after story. Um, so when you speak to colleagues across the globe, they tell you these stories that are really just heartbreaking. So in one of the articles in this issue, we talk about a woman in Lesotho who presented to the emergency ward, and she was hypoxemic and she was hypertensive. She had a fever, and she was clearly in this decompensated deteriorating state. But because the person who was evaluating her in the emergency ward didn't recognize those vital signs as being life threatening, the one was essentially sent back to to line to wait. Um, and they they wanted a doctor to see the patient. But oftentimes doctors are not immediately available. They're oftentimes overworked and covering multiple wards or units at the same time. And so they finally decided to send her home. Um, and just by chance, my colleague who works in Lesotho, who's a trained intensivist, happened to walk by and see her, and she was struggling to breathe, and she was stumbling around. And he immediately recognized how sick she was, and he admitted her and resuscitated her. Um, and he found out that she had p.j.p pneumonia associated with her HIV infection. But this is just one example, and there's countless examples that my colleagues abroad will recount. And they really are heartbreaking. And it's these small assumptions that we make that patients are going to be recognized. So it's really that recognition and that time sensitive response that can rescue patients and reverse their their critical illness. So I think small improvements in quality improvement can really make a huge impact. So it's not just about teaching the knowledge. It's actually working together. And these clinical processes and systems that that also needs to improve.

DR. LOCKE:

Your stories were very focused on sort of the global setting. Do you think that this problem with access, in addition to a global scale, is also in the US and sort of what is the state of global critical care and how are the challenges unique? Um, it's interesting to think about, you know, in other countries, but do you feel like the challenges are shared broadly between international and within our borders?

DR. CRAWFORD:

Yeah, I do, and I've actually witnessed it myself. You know, I have a similar clinical vignette from a place that I worked in an intensive care unit here in the Bay area, and I was the intensivist on call overnight, but was never called. And when I arrived, I happened to arrive to the hospital early because I can't help myself. But I always arrive early and found a patient in extremis and she had altered mental status. Her skin was mottled. They were unable to get, um, a pulse oximetry or blood pressure reading. She had horrible IV access. In fact, she had an intraosseous placed and unfortunately it wasn't recognized that altered mental status and the inability to get an accurate pulse oximetry reading or consistent read on blood pressure were actually signs of poor perfusion and septic shock. And so unfortunately, I wasn't called. And it was, you know, she'd been in the state for four hours by the time I got there. So, you know, she was appropriately resuscitated and lined up and started on vasoactive drips, but she ended up passing away the next day. So this isn't a very high resourced setting, but I think it is demonstrative of some of this failure to recognize when people are critically ill. You know, just because a patient is is able to moan, you know, doesn't mean that they're okay. Um, so I think there are clinical examples and I think this is coupled to, you know, as you know, a national physician shortage. And there's a couple things that I think come into play there. There's there's certainly an urban rural divide where we have more physicians in the urban setting. But sometimes when you go outside of the cities and into these more rural settings, the resources are much, much less, um, and so is perhaps, you know, the refresher training and things like that needed. So I think this is going to become worse and it's going to become exacerbated by our physician shortage.

I think that also reminds us that we have disparities in this country between different populations. Um, it also makes me think about how difficult it is to practice medicine or get a license to practice medicine. If you're an international medical graduate, the United States makes that exceedingly hard. And so we have potential solutions to at least address the workforce shortage. But we're going to need some major changes to make that happen in our in our country, we do have shortages both in the workforce and in resources and and possibly training, even in the United States and certainly across different communities in the United States.

DR. LOCKE:

Understood, understood. So it seems as though all of the things that you have mentioned, such as access to care and equipment problems and improving the quality, you know, really do apply not only on the global stage but across the country, and that's really important, and I'm glad that you pointed that out. Um, what do you feel are the biggest gaps when it comes to critical care?

DR. CRAWFORD:

Yeah, this is such a good question and something I think a lot about. You know, I've chosen to use education and quality improvement and, uh, research and advocacy to try to address some of the disparities in patient outcomes, uh, both at home and across the globe. And so the answer to that question really depends on on where you are. You know, maybe in the situation in the ICU here in the Bay area was, uh, the solution might have been CME training, or maybe it was something to address the culture or fear of calling the physician who's on call, or there's multiple multiple things that that go into a functioning system. But, you know, if you're trying to take care of a critically ill patient in a district hospital, in a rural setting, in a very resource constrained setting, um, you know, maybe there is equipment, maybe the gap is is in the, in the medical training and nursing training.

Looking at at the global health colleagues and professionals that that I work with who are trying to address critical care globally, you know, I see a lot of refresher courses and content addressing resuscitation, triage, escalation of care, um, airway management and those types of things. But again, all of that is part of this resuscitative or triage phase of care. And much like the Lesotho example, that foundational care is not available in many, many places. And so we're building on top of kind of a crumbling foundation, is how I think about it, where, you know, these essentials, which we work with a group called Essential Emergency and Critical Care to address that exact thing. Um, and you can read more about EECC in the issue. But that foundational care is missing. And that's, that's the biggest gap that I see at the beginning of the continuum of care.

Once a patient does make it to the intensive care unit, in resource constrained settings, there's there's not very many trained intensivists. There may be supply chain disruptions all the time. Um, I already mentioned that we have, you know, blackouts and brownouts from the electrical systems. We often will lack oxygen or run out of oxygen. There's a lot of turnover because it's difficult to work in some of these environments. I think the other major gap that I see is on actually the the opposite end of the care continuum, and that is once they're in the intensive care unit, the mortality rates are just exceedingly high. And not a lot of people are trained in ICU care. And so those patients end up passing away. So even though they may have a ventilator and the patient may be placed on the ventilator, if they're not cared for appropriately, then they get ventilator associated pneumonia, they get septic shock and they end up passing away. So I training intensivists. Um, both nurses and physicians to care for people in the intensive care unit is another huge, huge gap in critical care. Um, I do a lot of work in, in Rwanda, and we're currently working now with the Ministry of Health to start, uh, critical care fellowship training programs. And that's, that's a trend that's that I've seen expand and across many countries in, in east, central and southern Africa where I've done most of my work.

DR. LOCKE:

Oh, thank you so much for that. And you're world travel is very impressive. Uh, I could listen to you talk about this all day, frankly. So you, um, talked about sort of that ICU team and what that looks like. And that brings to mind here, you know, we have a team-based model, meaning we have physician anesthesiologists, residents, nurses, nurse anesthetists, um, all caring together for a patient. And conversely, the World Federation of Societies of Anesthesia workforce map suggests that other countries have only physicians providing anesthesia care. Now, if that's correct, and you know, I'd hate to play devil's advocate, but if that's correct, I'm wondering if you see connections between global critical care and scope creep, which is probably on everyone's mind.

DR. CRAWFORD:

Yeah. So again, you're asking really great questions. Um, so first, I'll kind of take us through the the World Federation of Societies of Anesthesiologists did generate this workforce map, and it looked at physician providers for anesthesia. And it did demonstrate that many, many places simply lack, um, anesthesia providers. The limitation of that workforce map is that it was based on survey data. And so whether they did not have a physician or whether they had no data, they entered zero for both of those situations. So if they didn't get a response, it doesn't necessarily mean that nobody in that country is anesthetizing patients. Um, most likely people are being anesthetized everywhere, but it could mean that that they have non-physician providers, but they just didn't have a response for that. That country and that that workforce map is, is really great for demonstrating the shortages that exist across the globe. But there are limitations to that survey data. Also, it's a little bit dated now, and I think they're working on an update. So we might have more updated data but also more accurate, um, descriptive data from that survey. So I would not assume, frankly, that there's only physicians providing anesthesia. And there are lots of different models across the globe, and most of them do have physicians that are leading their anesthesia care teams. And some places only have physicians. That's that's true in some places.

You know, I think anyone who went to the anesthesiology meeting this past year and in San Francisco, if you listen to the Rovenstine lecture, Doctor Sessler talked about scope creep and talked about non-physician providers in the United States. And and at the end of his lecture, he said, you know, this is primarily a United States problem. And I actually went up to him at the end and I, I said, it's not a United States problem. It's a problem everywhere. Because if you don't have enough physicians or you don't have strong physician leadership, somebody will anesthetize the patient. So that's typically a non-physician. And that training across the globe of non-physicians varies dramatically. So, you know, we're lucky in the United States that we have very highly trained CRNAs that can offer safe anesthesia to patients. Um, I still am very much so for a team-based physician led model. But you could compare that to a non-physician anesthetist or anesthesia provider, for example, in Rwanda. And things do change. It has gotten somewhat better, but that's a high school student plus 2 or 3 years of training for anesthesia. So the breadth and depth of knowledge of those providers is vastly different depending on where you are.

When we think about training, either anesthesia providers and especially critical care providers for patients across the globe, it's really important to recognize that if we don't have strong physician leadership that are taking care of patients across the entire care continuum, somebody else will do it. So I think it's really important to have physicians lead the way.

Another thing that I've noticed is specific to critical care. And that is, unlike in the United States across most of the globe, anesthesiology is synonymous with critical care. Anesthesiologists are the intensivists in most places. The United States is actually the exception in this, where we have pulmonologists and surgeons and internal medicine and neurologists and emergency medicine. We have a very multidisciplinary approach to, uh, fellowship, training and critical care. But across most of the globe, anesthesia is critical care. So I think it's really important for us to realize that if we don't lead in all of these other countries when it comes to critical care, um, other people will. And so I think it's important for advocating for our patients. And I think anesthesiologists need to be there. You know, I've never really understood why somebody from internal medicine or cardiology or some other specialty is recommending the type of anesthesia that we do for a patient, or why anesthesia gets blamed for every single complication that occurs. And it's simply because people don't actually really understand what anesthesia is and how it works. So I think if we're not there, other people will do our job and other people will come up with what they think are the answers to whatever questions being asked. So I think it's really, really important for us to lead in critical care as well across the globe.

DR. LOCKE:

That sounds amazing. And I want to talk more about your solutions and what you think is the best way forward and and what's working. But we need to take a short break, so stay with me.

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DR. DEBORAH SCHWENGEL:

Hi, this is Doctor Deborah Schwengel. I'm chair of the ASA patient Safety Editorial board. Anesthesiologists need to be prepared to handle mass casualty incidents that we call MCIs. But many anesthesiologists are not familiar with the protocols in place to deal with MCIs. Every hospital should have incident command systems that are activated to manage the dynamic and usually novel circumstances of MCI. Every MCI is different. Incident command organizes teams into subteams with clear and manageable scopes of responsibilities. The incident command structure is designed to optimize communication to maximize patient and staff safety. It's very important to remember that certain patient populations are at higher risk during MCIs, namely children, pregnant patients, the elderly, and cognitively impaired patients, who require careful triage and appropriate referral. Care should also be taken to prevent inequities that affect people with disabilities and people of color. Ongoing education on hospital policies and procedures, as well as disaster preparedness exercises, rehearsals, and simulations are needed to ensure that anesthesiology teams are ready. The time to prepare is now.

VOICE OVER:

For more patient safety content, visit asahq.org/patientsafety.

DR. LOCKE:

If we're to stop assuming and start advocating, where does that start. Specifically, are there lessons that we can take away from the global community?

DR. CRAWFORD:

You know, I think the pandemic was a really great lens through which we can view health care and our systems and how we're all connected, but also how we're all vulnerable. You know, Los Angeles ran out of oxygen. And if you think about it, that's remarkable. You know, oxygen is this really scarce resource. And so many other parts of the globe, and many of us are working really hard to bring attention to that essential medication. The fact that that Los Angeles ran out of oxygen during the pandemic is really eye opening. You know, no system, no country, no health care facilities is really invincible.

You know, I think also the fact that infectious diseases are still spreading across the globe and. even in a highly resourced health system, it just shows that we're really connected globally and we must collaborate. We have to collaborate at a governmental level, at a systems level, and that's the only way we're going to benefit, you know, most of our patients across the globe. System issues that affect patients and physicians, we should certainly advocate for essential medications, but also for essential quality of care that is, you know, as timely as when patients need it. So whether it's in Rwanda or Lesotho or California, I think it's important for us to take care of critically ill patients. And I think when we collaborate across these systems and countries and institutions, we actually understand our weaknesses and our strengths of all the systems, and we start to learn from each other, and it really does benefit all of us.

You know, I think another thing that people assume when they hear global health is, you know, you're flying around the country and yes, travel is involved and we've certainly traveled quite a bit, but we also have an opportunity to learn from our colleagues abroad. So it's not always that we're the ones bringing the lessons. If we stop and we look and we listen to our colleagues that are working with resource constraints, we really have a lot to learn from them. So some of the examples that I've seen is, you know, when we finish a surgery or a procedure in the ICU or the operating theatres, we leave with five huge bags of trash. In Rwanda after a surgery, they have a kick bucket. It's this tiny little kick bucket that has all of their waste in it. So, you know, everybody's trying these green initiatives and trying to optimize our resource utilization. But they've they've already been doing that. And they have really creative ways of using and reusing equipment and things like that. The pendulum has swung a little bit too far when we are looking at making everything into a kit where we use one thing out of it and throw the rest of it away, you know, I understand the infection concerns and the safety concerns, but I think we could reevaluate a lot of those things. So I think green practices and resource utilization are huge lessons that that we can take away from our colleagues across the globe.

And then similarly, when you are forced to practice with resource constraints, you really become a master innovator. You know, they are very, very clever on how they use or don't use equipment, and they come up with really great solutions when they run out of things. You know, sometimes we have a lot of stress because we run out of rocuronium because we forgot how to use Vecuronium and reverse it. And, you know, they navigate supply chain disruptions really seamlessly. And so I think what we've learned at Stanford is when we do bring our colleagues from abroad, these are the kinds of conversations and learning that that comes out of those exchanges. And it's a global health opportunity for our colleagues coming from abroad. But it's also kind of creating a global health opportunity for all of the trainees and faculty that work at Stanford that may not be able to travel. So we've worked hard to get these rotations established, but also to demonstrate their value. And they are incredibly valuable. For our global colleagues, you know, they can read about something in a book or hear me tell them about something in the intensive care unit, but they've never seen it come together in an effective health care system. But when they come to Stanford or any other institution that's that's well resourced and organized, it's eye opening. You know, they really start to see how they can make their own quality improvements in their setting, and they're much more able at determining what will and won't work than I am. So I think we have a lot to learn from our colleagues abroad, just as much as they have to learn from us in our systems.

DR. LOCKE:

And that really resonated with me. I mean, it's always interesting to me that organizations and businesses outside of medicine really understand what globalization does for their customer base, talent pool and all of those things. So when you talk about, um, sort of collaborating and thinking about new ways to, to address supply chain issues, I sometimes I feel like in medicine, we tend to be a couple steps behind when it comes to the business of things. So thank you so much for highlighting that.

Talk a little bit about the concept of essential emergency and critical care, or this EECC. Myself, I'm not familiar, and I'm sure a lot of our listeners may not be familiar with it. Um, so I'm hoping you can educate us a little bit around that.

DR. CRAWFORD:

Yeah. EECC is is essentially a global consortium of providers that are dedicated to providing what they call the care that all critically ill patients should receive in every hospital in the world. So it started out out of Tanzania. Um, and it really is a group of people from all over the globe. It's it's really fun to to know and work with all of them. But the founders saw an experienced that foundational gap that I mentioned earlier. You know, they saw children with altered mental status that that had unrecognized hypoglycemia, for example. And so they realized that it's these really foundational forms of assessment and identification that that were needed. So they noticed that big gap. So EECC is an organization who are working to address that.

And so they they basically pulled together a global consortium of people that they did a modified Delphi and identified 40 clinical processes that are coupled to what they call hospital readiness. So they had 67 hospital readiness requirements, clinical processes and hospital readiness requirements. It really means that somebody, for example, is going to use a pulse oximeter to assess a patient. They're going to recognize whether the result is normal or not. If it's not normal, then they're going to have a clinical process to either address it directly by giving oxygen therapy. Um a hospital readiness requirement would be they have oxygen, they have a nasal cannula or a mask, but also the processes could be they gave oxygen and the patient didn't improve. So they have a process for escalating the care to the next level up, whether it's a physician provider or otherwise.

And so this is what I was alluding to earlier, is that a lot of us in high resource settings are are almost shocked to realize that somebody may not have a pulse oximeter or they may not understand how to interpret that. And so the patient essentially decompensated unrecognized.

Another great study that the EECC group did is, is they actually looked at all of these clinics and facilities across Tanzania. And they found that a remarkable number, I believe it's over way over 80%, actually did have a lot of this essential equipment such as pulse oximetry. But because it's not as widely available, oftentimes it was locked up in the matron's closet or it was otherwise inaccessible by the bedside provider. So even though the resources are there, they may not be available for use.

So EECC is a package of clinical processes and hospital readiness items that that really should be in every single hospital across the globe. And so this network, it's called the EECC network, is really working kind of a multi-pronged approach. There's researchers, educators, um, they work closely with stakeholders, including governments and ministries of health, to make sure that EECC is implemented everywhere across the whole globe. And so there's a lot of us and it's a really great group of people. And so EECCnetwork.org is how you can find out more information about it. But it's a really great organization.

DR. LOCKE:

Well thank you so much for that. Sounds so. And thinking about education, do you feel that our institutions are properly preparing trainees for impactful global health and critical care work? Um, and if so, if perhaps they're doing it at your place, do you feel like there are key areas that anesthesiology programs across the country could focus on?

DR. CRAWFORD:

Yeah, I think we were doing a great job in that global health programs really have expanded across almost every academic center. I actually just recently looked at the American Association of Medical Colleges. They have these exit surveys that they do of medical students who graduate, and they keep tallies on how many had a global health experience in their medical school training. So that's an interesting to look at those trends over time. But anesthesia programs have certainly started to have global health programs for trainees everywhere. I think we're doing a great job of recognizing the importance of global health.

I think we have some opportunities for improvement when we think about how we do global health. You know, you mentioned about companies recognizing the importance and value when of globalization. But I feel like in global health we still have these really great intentions of going out and helping others, but we are less inclined to actually measure our impact. And if we start to look at the impact that we're having, we would really reconsider how we are addressing some of these gaps. So I think the us helping them mentality, kind of this unidirectional charity mindset, although well-intentioned, doesn't necessarily provide the best benefit to these partnerships. And I have had the opportunity and really privilege to to go to Rwanda every year for about 15 years now. And, and you learn more and more and more every, every time you go back to a place. And, and I've seen others come and go in Rwanda and I've really realized that if you don't stop and listen to your colleagues and you come in with preconceived notions about the solutions that you think are needed, you'll really be ineffective. And so if we don't listen to our colleagues and let them lead--they know what what their solutions are, they just need, you know, additional resources or processes or advocacy. So I really think that global health professionals from high resource settings should take on the role of facilitator and really listen to our colleagues. And so I try to impart that in the education and training of, you know, anyone who listen, basically. But I do think the days of good intentions are in our past, and we really should be more systematic about how we approach these and what's needed and what the solutions are. And I don't think we have the answers. I think our colleagues abroad have the answers and we just need to listen.

DR. LOCKE:

Understood, understood. And thinking about that, you know, you know, these guys and, and other girls and guys in other places may be better equipped to not only solve, but to define what their problems actually are. Because, you know, far too often we end up in situations where we're shooting out solutions and we haven't taken the time to really understand what the problem is and what it entails. So again, thank you for pointing that out. Um, and thinking along those lines, what do medical associations like the ASA do to contribute? Sort of what should our role be? Um, and how can we contribute to solutions and better patient care?

DR. CRAWFORD:

Yeah. The role of professional societies is is huge. The ASA has done a fantastic job, and that's really how I first got involved in global health. You know, that program in Rwanda is one of the ASA's overseas training sites. And that program started in 2006. And there was one anesthesiologist, maybe two anesthesiologists in Rwanda. And the Canadian Anesthesiologists Society, International Education Foundation and the ASA Global Health Committee started to send volunteer teachers. Now we've graduated somewhere between 40 and 50 physician anesthesiologists or physicians in Rwanda, which is remarkable. So now our colleagues in Rwanda are the faculty. They are the teachers. They are the mentors. Um, we still need some intensivists. There's a couple trained intensivists, but we certainly need more of those. But to see a country go from 1 or 2 anesthesiologists to to 40 or more is is really a huge improvement. Um, and it would make that WFSA workforce map look much, much better if we could do that across the globe. But I think the ASA has done a really, really good job.

One area of opportunity I think that professional societies have is that many countries are trying to also have professional societies, such as the Rwanda Society of Anesthesia and Critical Care. And so I think the ASA and other societies like it could really mentor at that society level. And I've been asked this question specifically, what role do professional societies play? Having some understanding and collaboration across professional societies could be very, very helpful. And then similarly we play a role in education. And they also need help with accreditation systems and and things like that. So the ACGME is actually has a new effort called Global Services that's working on that in helping other countries develop their basically their board certification and accreditation systems. Professional societies and and similar have have a huge role to play to support countries that have more burgeoning societies.

DR. LOCKE:

Wow. Well, thank you for highlighting that the ASA is, you know, heavily involved in this effort and that this is an opportunity for listeners interested in getting involved in this work, because I had no idea that that was actually happening.

DR. CRAWFORD:

Oh yeah. So the ASA is fantastic for this. So we have the program in Rwanda. There's also a program in Guyana. There's an ASA Global Health committee that I was on for well over probably a decade. The ASA Charitable Foundation--I sit on that board as well. And very amazing group of people working to to keep these global health programs going. We also every year at the ASA, we host Global scholars from all over the world. And that's really a lot of fun. It really brings to the ASA and the ASA membership, that global health opportunity that I mentioned, where you can still have a really great learning exchange without traveling to another country. So the ASA Global Scholars are remarkable. They all do poster presentations and you can learn a lot from them. So the ASA does a really great job.

DR. LOCKE:

Excellent, excellent. So you gave us a lot of great information. What would you say your key takeaways from this episode should be, and what should readers look for when it comes out?

DR. CRAWFORD:

Yeah. One is recognizing that we're we're all connected. The pandemic, you know, it was a horrible thing, obviously, but it did have a lot of lessons hidden in it. And for all of us, it's we're stronger when we collaborate. The, uh, scope creep is something that everybody's really, really concerned about. And we have, you know, a rising physician shortage. And there's lots of people discussing, you know, the types of solutions. But, you know, I think myself and many others who work in resource constrained settings can can attest - if strong physician leadership is not there, other people will fill those gaps. So that goes for anesthesiology as well as critical care. And I think we need to recapture the entire care continuum for our patients. So that's, you know, pre-op, intra op post-op, including pain management and including critical care medicine.

And then I think, you know, we didn't talk about it too, too much, but there's an article on this issue from some global health ICU fellows and trainees. And I think the interest in global critical care makes me very happy, but has really, really gone up. And I have people reaching out to me almost every day. And many of our ICU colleagues are now interested in how they can can work to improve these patient outcomes across the globe. And with all this interest from trainees and younger faculty members comes a lot of really, really great ideas and insights. So I think as we move ahead, it's important for us to obviously make sure our trainees are culturally informed and and ethically considerate when they start to learn about global health. But also we need to listen to them because they bring really unique perspectives and valuable insight into into how we can address these things, both here across disparities in the United States, but certainly in other countries as well.

DR. LOCKE:

Well, Dr. Crawford, you have been a wealth of knowledge. And thanks so much for joining us and sharing so much great information. I personally learned from this conversation, and we hope our listeners got something out of it too. For listeners ready to learn more, please visit asamonitor.org to read the March issue and learn more about Global Critical Care. Be sure to join us for more Central Line very soon.

DR. CRAWFORD:

Thank you.

DR. LOCKE:

Thank you.

VOICE OVER:

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