To Have and Have Not: The Ultrasound Revolution Reaches Cuban Shores

By Andres Missair, MD; Alexandru Visan, MD; Brian Osman, MD; Oscar De Leon Casasola, MD    Mar 28, 2016

On January 29th, a small team of anesthesiologists from the United States conducted the 2016 Regional Anesthesia and Acute Pain Workshop for local physicians in Havana, Cuba.  The date marked not only the first acute pain medical mission by American anesthesiologists since the Cuban Revolution, but also the rebirth of a friendship with our close neighbors and medical colleagues. This is an excerpt of an article that will appear in the August issue of the ASRA News recounting this amazing and challenging experience.

Cuba is an island nation in the Caribbean with a population of approximately 11.2 million. It boasts one of the most comprehensive and accessible healthcare infrastructures in the world, with 70,594 physicians and 99.4% primary care coverage of the population.[1] In total, 152 hospitals, 451 primary care clinics, and 45,462 beds comprise the nation’s health system.[1]

Thanks to this infrastructure, Cuba can lay claim to various significant health achievements, including the first country to eliminate Polio (1962), the first country to eliminate measles (1996), and the lowest AIDS rate in the Americas.[2] It would seem highly unlikely, therefore, that a country with such medical development would benefit from an international educational mission on acute pain medicine for its own anesthesia specialists.  Yet, while Cuba was the first country in Latin America to have radio and color TV, it was also the last to have internet. Five decades of economic embargo and the disappearance of Soviet economic support have left the Cuban medical infrastructure with limited access to expensive medical technology, in particular perioperative ultrasonography. Ultrasound guidance for venous access or neural blockade is inexistent. The majority of Cuban anesthesiologists rely on paresthesia technique, and only a handful has access to neurostimulation. Despite these obstacles, many have a working knowledge of anatomic landmarks for neural blockade, and some even use surgical nerve blocks in their daily clinical practice.


"while Cuba was the first country in Latin America to have radio and color TV, it was also the last to have internet."


While the concept of an acute pain workshop is simple enough, its ultimate success lies in the sustainability of its program once the faculty have returned home. The academic exercise of teaching and learning is subordinate to the application of the educational material in daily clinical practice. For this reason, the program curriculum was designed to not only teach nerve block techniques but also how to establish and manage an acute pain service. Once the framework was established, session topics defined, and volunteer faculty identified, the work (paperwork) began.

One month prior to the design of the program, a meeting was held with the Cuban Ministry of Health in Havana to determine the feasibility of the mission. Three days of meetings with a veritable alphabet-soup of supervisory departments from the Cuban government would dishearten even the most naïve or obstinately resolute. The Ministry of Health (MINSAP), Ministry of Commerce (MINCEX), Ministry of Foreign Affairs (MINREX), Cuban Association of Anesthesiology (SCAR), and United Nations Emergency Children’s Fund (UNICEF) were all seated at the proverbial table. The timeline was very tight, by any bureaucratic standard, but miraculously all parties agreed to a January 29th launch. Blinded by optimism, we began the daunting task of securing official Cuban visas for the American faculty, customs entry authorizations for over $200,000 of ultrasound equipment (for which I was kindly informed to be personally liable), travel authorizations from our employer universities, and liability agreements with the ultrasound equipment manufacturer. After signing the equivalent of a variable-rate home mortgage in paperwork, we set out to secure the necessary supplies.

For those who have never visited Cuba, the romanticism of history and an idyllic Caribbean setting can obscure a stark reality: everything in Cuba can be difficult. Compounded by years of embargo, even simple household items like toothpaste and toilet paper can be difficult to source. Furthermore, Cuban physicians earn around $40 per month, and most Cuban organizations operate on a shoe-string budget. There would be no financial or material support for our venture. The inevitable conclusion was that the conference would have to be free to all attendees and all supplies provided and transported from the U.S. by the volunteer faculty themselves. There went our luggage carry-on allowance.

The ultrasound equipment for the workshops was generously provided by Sonosite’s Global Health Department, which supports educational missions around the world. Two EDGE ultrasound laptops and two M-TURBO ultrasound systems were delivered with 12 probes of various sizes and frequency ranges. Given the very real risk of having equipment impounded or lost once in the field, the decision was made to take only one high-frequency linear probe (HFL38xp) with each machine and a single back up. In addition, echogenic nerve block needles, gel bottles, paper towels, marking pens, extension cords, AV cables, batteries, and inflatable pool mattresses (for the live scanning models) were also packed for the trip. The only locally sourced item was a piece of pork shoulder for the phantom meat model.

U.S. Medical team (from left): Gregg Kowalzcyk (Sonosite Territory Manager, South FL), Oscar De Leon Casasola, MD; Alexandru Visan, MD; Brian Osman, MD; Andres Missair, MD. Photo taken at the UNICEF headquarters in Havana, Cuba.

“The best made plans are laid to waste.” The proverb was never more true than the night before the 10:00am flight to Havana. Despite weeks of preparation and more paperwork than the Affordable Care Act, the mission hung in the balance just hours before boarding when our travel visas from the Cuban Consulate in Washington, DC failed to arrive. The January blizzard that paralyzed the mid-Atlantic coast had also stranded the FEDEX truck carrying our paperwork. Neither history nor “snowmageddon” was going to stop us, however. At 8:00pm that Sunday night, a call from the Cuban Consul, himself, gave us hope. On Monday morning, with the personal guarantee of a diplomat we had never met, the team drove to Miami International Airport, checked in to Havana Air flight EA3141, and boarded the plane with a myriad other tourists carrying more luggage than a trans-Saharan camel caravan. Forty-five minutes and two bags of banana chips later, we landed in the Jose Marti International Airport of Havana, Cuba.

Stay tuned for part two of this story and plans for future programs in Cuba in the August edition of the ASRA News.

References

  1. Cuba National Health Statistics Bureau, “2014 Annual Health Statistics Report,” http://files.sld.cu/bvscuba/files/2015/04/anuario-estadistico-de-salud-2014.pdf, accessed Feb 12th, 2016.
  2. United Nations Population Fund, “The State of the World Population 2014,” UNPF Pub, NY, NY; 2014

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