Anaesthetists: Unsung heroes keeping death at bay

It was in the early 1970s. Hunched over a patient at the Chittagong Medical College Hospital, anesthesiologist Khalilur Rahman was frantically trying to remove liquid from the man's breathing track, which had leaked out of his stomach.

Three to four minutes went by before the fluid suction could be completed, but by then, the patient's lungs had suffered significant damage, turning Khalilur's fears into a grim reality.

The anesthesiologist was trying to insert a breathing tube through the patient's windpipe – a procedure known as endotracheal intubation. It is done on people who cannot breathe on their own, for example, when one has been put to sleep during an operation.

The incident occurred because Khalilur Rahman had to use a relaxant that took 90-120 seconds to prepare a patient for intubation. There was another type of relaxant which takes only 30 seconds to work, but the hospital did not have it at the time.

The patient died only a week after the operation due to complications he suffered at the operating table.

However, the situation has improved drastically over the last five decades. Anaesthesia care has evolved into a much safer medical specialty through advances in medication and equipment, both globally and locally.

Doctors no longer have to clinically examine the patients' heart rate, blood pressure and other health parameters because electronic monitoring equipment has taken over the job of raising the alarm.

Even so, healthcare is being compromised in the country by a lack of logistics and trained anaesthetists. Anaesthesia care, an integral part of medical interventions, has failed to get due attention from the authorities despite its need growing with the times.

World Anaesthesia Day 2020, being observed on Friday in Bangladesh as elsewhere across the globe, aims at celebrating the leading role that anaesthetists play during critical and non-critical medical procedures.

While many health indicators have gained, according to The Lancet, "The development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed."

Bangladesh is one of these countries, and the absence of anaesthesia care has been impacting its health and the economy.

The crisis is felt more acutely against the backdrop of the pandemic when a dearth of trained aneesthetists, who have the responsibility of taking care of unconscious patients, was identified as the main factor in the struggle to provide intensive care at government-designated Covid-19 hospitals.

To address the imminent issue at hand, the government hired 50 anaesthetists for a six-month period until December under special arrangements funded by the World Bank and the UNFPA.

For a lasting solution, however, at least 2,500 anaesthetists should be recruited in the public hospitals up to the upazila level, said Dr Debabrata Banik, former chairman of the Department of Anaesthesia, Analgesia and Intensive Care Medicine at Bangabandhu Sheikh Mujib Medical University.

At present, 900-950 anaesthetists are posted at public hospitals across the country, with most of them based in Dhaka and other big cities. The irony is that more than a thousand anaesthetists around the same time are sitting idle or serving in private healthcare facilities.

The Dhaka Medical College Hospital, a facility that deals with 3,500 patients every day, has only 40 anaesthetists, whereas at least 80 people are necessary only for the morning shift to run its operating theatres and intensive care units. The gap is filled by students who are pursuing post-graduation education at different levels.

The regular and supporting staff feel overburdened with work and suffer from stress, said Debabrata, who is also president of the Bangladesh Society of Anaesthesiologists.

Anaesthetists have been working under such work pressure in other hospitals as well. Many a time, hospitals rely on technicians rather than fully trained anaesthetists for surgical procedures, which might lead to the unexpected death of a patient.

"When we suspect that something like that has happened, we call for an investigation. Unfortunately, there is no documentation on incidents like this," Debabrata said.

The role of an anaesthetist is not limited to putting a patient to sleep during operations. When the patient cannot breathe, he looks after the functioning of mechanical breathing. Alongside, he has to keep all health parameters of the patient steady throughout the process.

Anaesthetic drugs have influence over the whole body, and their impacts– if not monitored carefully – can cause death or brain damage in a matter of a few minutes to hours.

Without such intense supervision, many infectious, maternal, neonatal and non-communicable diseases and injuries become untreatable.

The Lancet, in an article published in 2015, said globally 5 billion people do not have access to safe, affordable, surgical and anaesthesia care when needed.

"Access is worse in low-income and lower-middle-income countries, where nine out of ten people cannot access basic surgical care." As many as 143 million additional surgical procedures are needed in lower and middle-income nations each year to save lives and prevent disabilities.

If urgent investment was not made, the journal pointed out, in strengthening healthcare facilities to provide surgical and anaesthesia care, these countries will incur losses reaching $12.3 trillion between 2015 and 2030.

In a recent interview at his Moghbazar residence, Prof Khalilur Rahman – who now serves as senior consultant anesthesiologist of Birdem General Hospital – said patients hardly recognise the role played by anaesthetists in their crucial hours. "They always remain in the background."

Khalilur Rahman recalled a gynaecology operation on a 60-year-old in the late 1990s when he suddenly noticed that the patient's heart had stopped beating. He promptly performed cardiopulmonary resuscitation (CPR), an emergency life-saving procedure after cardiac arrest, on the patient. It seemed like "a miracle that she survived," he said.

In critical intensive procedures, a life, unconscious, is an existence in the shadow of death. An anaesthetist can save it from slipping into the darkness.

This realisation about the importance of the job might be the first step in bringing about essential changes, said Khalilur Rahman, who has been in the profession for nearly 50 years.