Since our return to Burundi, I have been slowly coming to terms with another one of my phobias. I have a fear of children. Not all children. I am not afraid of my children, or really most children. But as a child is brought into the operating room, my perspective on them changes immediately from “cute and cuddly” to “instrument of terror”. Why is this?
For the past 10 years, as an anesthesiologist in private practice in the U.S., I have become quite comfortable taking care of adult patients in the operating room, even very sick ones. But my time spent taking care of children in the OR has grown more and more sparse. There is a growing movement in the US to stop taking care of pediatric surgical needs at community hospitals and instead to transfer them to a children’s hospital, where they can be taken care of by a pediatric surgeon, a pediatric anesthesiologist, nurses and techs who take care of children every day. In fact, research has now demonstrated that children, especially those under the age of 2, have better outcomes at hospitals that specialize in pediatric care. The result has been that in the US, I rarely anesthetize children, and almost NEVER children under the age of 2.
It turns out there are a lot of ways you can damage or even kill a very small child during surgery and anesthesia. These include medication errors, dosing errors, airway mismanagement, even temperature management. And so you can imagine my, let's just say discomfort upon my return to Kibuye, where I am presented almost daily with children who need to be anesthetized. There is no pediatric hospital in Burundi. My suggestion on day one to transfer a sick child to a “tertiary care center” (specialty hospital) was met with stares of confusion and awkward silence.
On Monday this week, I entered the OR to find that we had scheduled a 2 day old, followed by a 3 day old, followed by a 21 day old, all needing emergent bowel surgery under general anesthesia. Pretty much a full on nightmare from my point of view.
Some people with whom I have spoken over the past several years have suggested that if you are not qualified to do something in Africa, you should not do it. I understand their perspective from a theoretical standpoint. However, from a practical standpoint, if we do not offer surgery to these children at Kibuye, they will most certainly die. So, when does one go from being “underqualified” to “disqualified”? Is it simply a numbers game? If half of your patients are surviving, should you keep going? I can tell you that this week has led me to seriously consider going back to the US to do a year long fellowship in pediatric anesthesia. But even that would likely mean hundreds of kids left without an anesthesiologist for a year.