As part of its effort to create a truly international and inclusive 2018 World Congress on Regional Anesthesia and Pain Medicine, ASRA provided awards for 10 international attendees from low-resource countries. The feedback from these attendees was very positive. Here, we provide feedback from two of the recipients.

World Congress 2018 Provides Invaluable Experience for Ukranian Anesthesiologist

Maryna Freigofer, MD
ASRA 2018 Travel Scholar
Anesthesiologist
Dnipro Regional Cancer Center
Dnipro, Ukraine 

Ukraine is a lower-middle–income European country that has a free of charge public health care system inherited from the Soviet era. Since becoming an independent democratic republic, Ukraine's turbulent economy has negatively affected health care. In 25 years of independence, inadequate efforts have been made to maintain appropriate levels of medical care. State guarantees of free health care are not supported with funding. Currently, Ukraine is lagging behind its European counterparts in medical science, medical services, and technology and is suffering from medical migration and deficiencies in the health care workforce. As a result, care outcomes are not as positive as they should be, given the existing resources. Primary medical care is experiencing widespread dissatisfaction and agrees on the need for reform

The ASRA World Congress provided me with a great opportunity to acquire invaluable experience with ultrasound-guided regional anesthesia and acute and chronic pain management.

As a physician-anesthesiologist at one of the biggest Ukrainian regional cancer centers (Dnipro Cancer Center) that provides comprehensive cancer care with multidisciplinary cancer teams, I provide perioperative management for breast, colorectal, gastric, urologic, and more complex cancers, including thoracic, hepatobiliary, and pancreatic cancer. Although my work is primarily in anesthesia/analgesia for surgical tumor removal, I also deliver analgesic care for both acute and chronic cancer pain.

Figure 1. International scholarship recipients received special recognition at a ceremony held April 20.

In Ukrainian medicine, incurable cancer patients with chronic cancer pain have limited access to adequate opioid analgesia because of imperfect legislation intended to control drug trafficking.

The main reasons for opioid overprescription for perioperative pain control are significant financial constraints and a shortage of modern equipment. This prevents Ukrainian anesthesiologists from using opioid-reduction techniques such as patient-controlled analgesia or multimodal perioperative pain regimens employing regional anesthesia in conjunction with other known protective measures including nonsteroidal anti-inflammatory drugs and gabapentin. With regional anesthesia, we are limited to blindly performed spinal or thoracic epidural analgesia. The use of other regional anesthesia techniques (eg, transverse abdominis plane block, pectoral nerve block) employing anatomical landmarks carries the risk of adverse reactions such as nerve damage and vascular perforation and can’t be provided without sonographic guidance. Ultrasound-guided regional anesthesia is a vital necessity but unavailable option in the cancer center at the present time.

No full-fledged home-based palliative care services are available in Ukraine to assist in the treatment of patients with chronic cancer pain. Until recently, only an injectable form of morphine was available in Ukraine’s public health care system. Since 2013, a Ukrainian pharmaceutical company has produced oral morphine. However, patients must pay for it out of pocket and it is cost prohibitive for most. Analgesic patches are completely unavailable. 

Ukrainian hospitals are encouraged to not admit patients with cancer who are no longer receiving curative treatment, and Dnipro Cancer Center is not exempt from this recommendation. The anesthesia and critical care medicine department has launched a round-the-clock chronic pain management service, but we can cover only patients with advanced cancer and associated pain who are still curable and admitted for chemotherapy or radiotherapy. Secondary to access issues with opioid-related cancer pain relief, anesthesiologists in Ukraine may offer invasive techniques (eg, epidural analgesia, neurolysis) for pain control much earlier than what is recommended by guidelines.

Despite the many challenges Ukranian anesthesiologists face, we are enthusiastic about the care and services we provide. We try to stay up to date with the latest news in anesthesiology technology and research and use every chance to gain new knowledge. The ASRA World Congress provided me with a great opportunity to acquire invaluable experience with ultrasound-guided regional anesthesia and acute and chronic pain management. My intentions were to learn opioid-reduction techniques and integrate multimodal analgesia into our anesthetic plan from the preoperative period and through the recovery period to improve patient outcomes and reduce disability following surgery. The enhanced recovery after surgery (ERAS) pathways highlighted during the World Congress fantastically addressed many of the challenges that we are currently facing. ERAS protocols are now being implemented in Dnipro Cancer Center and have resulted in a change in culture and the way care is delivered. 

I remain hopeful that health care reform and improving technologic capabilities in my country will allow us to follow the paths laid by American and European colleagues and improve the care and health of patients.

Travel Scholarship Transforms Care in Philippines

Lily Roxas-Jingco, MD
Anesthesiologist
Philippine Society of Anesthesiology
Philippines

I am an anesthesiologist working in Negros, one of the 7,107 islands of my country, the Philippines. The island has two provinces and a population of 6 million people. I work in a tertiary government hospital that serves as the main treatment center for difficult cases from all over the island.

The knowledge I got during the debate sessions, the panel discussion, and lecture series was so overwhelming.

Almost 10 years ago I became interested in learning about peripheral nerve blocks because of the volume of high-risk patients that were referred to our institution. I wanted to have an additional option in my armamentarium as an anesthesiologist—one that may offer lower anesthetic risks. But starting out was very difficult: I had no mentors who know about peripheral nerve blocks well enough to teach me, and our country had no program that offers training in regional or peripheral nerve blocks—even in the capital, Manila. A few of my senior consultants even dissuaded me, because nerve blocks were considered too difficult. 

Figure 2. Scholarship recipients were invited to choose from a number of donated texts to take home and share with colleagues.

Still, the need remained, and so I mustered enough courage to at least try. I started to do it using anatomic landmark techniques, reading textbooks, and looking at YouTube videos. It was not easy, but my early successes encouraged me to continue. Because my husband is an orthopedic surgeon, I had ample opportunities to hone my skills, and the continued successes (and cost-effectiveness) of my blocks told me that I was on the right path. 

Eventually I saved enough funds to buy a nerve stimulator, and it helped considerably. At the same time, I was teaching anesthesia residents in our hospital about nerve blocks, instructing them in both anatomic and stimulator-guided techniques. During that time I was introduced to someone in Singapore doing nerve blocks. I helped organize postgraduate events where he and his colleagues taught anesthesiologists on our island (and adjacent islands) about blocks, especially use of ultrasound-guided blocks. They became my first mentors, as I used general-purpose ultrasound machines to perform nerve blocks.

To further hone my skills and enable myself to better impart my learning to my anesthesiology residents, I usually attend workshops and conferences. During those meetings, I met people who are well versed in the field and they became my friends and personal mentors. Networking with colleagues really helped me harness my skills and knowledge and enabled me to manage my patients even better because I could ask colleagues about difficult cases. But attending international conferences cost a great deal, especially coming from a low-income country. Travel scholarships are a great blessing to not only widen my knowledge base but also provide a network of colleagues and friends.

Being awarded a full travel scholarship for the Regional Anesthesia World Congress in New York on April 2018 was an honor and great blessing from the Lord. The knowledge I got during the debate sessions, the panel discussion, and lecture series was so overwhelming that I still review the online feeds from ASRA. It impacted my practice in managing my joint replacement surgeries, and I really advocated more for the use of neural blockade in cancer surgeries based on the debate sessions I attended. The scholarship recipients were also given books, which I donated to my department library. Our training officer and residents were so grateful for the vital reference materials. ASRA did not just grant the scholarship to me, but to my whole department, because I shared my learning with colleagues, residents, and even our local surgeons.

At present I am organizing a postgraduate course in regional anesthesia with my colleagues who are also advocates of peripheral nerve blocks in other parts of our country, along with friends from Singapore (Dr. Joselo Macachor) and from India (Dr. Amjad Maniar). The whole region, not just my island, will soon benefit from the learnings we have because of the grants provided by your gracious benefactors.