Kybele

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Kybele

• Brittany Bergin Clyne
• Wake Forest University
• February 9, 2005

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A Turkish History Lesson

• Population
• Nation wide 70 Million
• 85 live in urban areas
• 3 Europe 97 Asia
• Division of West East
• Ataturk
• 1922 Defeated the Ottoman Empire
• Turkish Republic
• Multi-party democracy
• Secular nation
• Muslim 95-99
• Official Goal Belong to the EU

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A Turkish History Lesson

• Istanbul
• Population 12 million
• 100 miles
• Straddles 2 continents
• Bosphorous separates the city continents

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A Bit of a Turkish Medical Information

• High School Test Score Determines What University
  /- Medical School
• Medical Education
• 6 years (College Medical School)
• Anesthesiology Residency 5 years thesis
• State Hospital
• 800 q month plus performance bonus-up to 2000 q
  month
• University Hospital
• 1500 q month
• If do private patients may supplement up to 1500
  q month

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Scary Facts

• 585,000 maternal deaths occur each year
• 99 occur in developing countries
• 1,600 pregnancy related deaths a day
• In developing countries
• Pregnancy childbirth represent the leading
  causes of death, disease, disability among
  women
• 25 of adult women suffer from illness or injury
  related to pregnancy or childbirth

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Kybele
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Kybele

• Purpose
• Promote Safe Child Birth in Developing Countries
• Promote Regional Analgesia Obstetric Anesthesia
• Inaugural Trip
• Purpose Evaluate whether a focused, short term
  teaching exchange works
• Who
• 7 Renowned O.B. Anesthesiologists Me
• 4 Countries
• USA Canada England Ireland
• 10 University Hospitals in different regions of
  Turkey

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Kybele

• Why Turkey?
• Can We Make a Difference?

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Turkish Childbirth Demographics1998
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Influence of Region on Childbirth in Turkey
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Mode of Delivery by Turkish Hospital
Owen Sahin, Turkish Hospital Survey1998
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Turkey C/S Epidemic

• C/S rate Private 75, Univ 42
• Every year 80,000 unnecessary C/S !

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Turkey C/S EpidemicObstetric Factors

• Convenience
• Increased revenue
• Afraid to perform vaginal delivery
• No VBAC
• Minimal forceps, vacuum
• Inadequate fetal monitoring
• No fetal scalp pH
• Medical system accepts practice

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Turkey C/S Epidemic Cultural Indication

• Inconvenience
• Fear of Labor Pain
• Perception of Safety

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Turkey C/S EpidemicConsequences

• ? Cost of health care
• Disproportionate use of resources
• ? Maternal morbidity mortality
• ? Fetal risk (iatrogenic prematurity)
• Human rights issue?
• Women lose childbirth experience

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Anesthesia for C/S in Turkey
Percent ()
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GA for C/S in TurkeyMaternal Mortality

• Turkish Univ Hosp - 10 y study maternal mortality
• Maternal mortality 471 deaths/100,000 LB
• In US 12 deaths/100,000 live births
• Anesthesia related deaths 6
• Therefore, 28 anesthesia related maternal
  deaths/100,000 live births
• 280 anesthesia deaths/million LB in Turkey
• US 1.1 anesthesia deaths/million LB

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Anesthesia maternal death in TurkeyAnother
perspective

• University hospitals have sicker patients
• Big improvement in 10 years
• 1991 - MMR 132 deaths/100,00 LB
• 2nd Highest MMR in Europe after Romania
• 2004 - MMR 49 deaths/100,000 LB
• IN US MMR 8-15 deaths/100,000 LB

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Kybele Plan

• Observe the system
• Learn some language
• Identify cultural perspectives
• Patient and physician education
• Organize research projects

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Outcome Goals

• Patient acceptance satisfaction
• ? obstetrician nursing fear of RA techniques
• ? anesthesia staff experience in RA placement
  management
• Abstracts publications

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The Little Town of Bursa

• First Ottoman capital
• Population 1.8 million
• Spans 30 miles
• Base of Mt. Uludag
• Uludag University
• Medge Owen Fullbright Scholarship
• Shukran Sahin Professor

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Uludag University

• 23 Operating Room
• 17 Rooms Routinely Used
• 14,000 Surgeries a year
• 10 Multiple Traumas a week
• 2 CABGs a day
• gt90 off pump
• 3 Intracranial aneurysms a week
• 5 Intracranial tumor removals a week
• 50 are awake

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Uludag University

• 6 Intensive Care Units
• Pediatrics
• General Surgery
• Neurosurgery
• Cardiac Surgery
• 2 Internal Medicine
• Anesthesia runs the surgical ICUs

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Uludag University

• Pain Clinic
• 5 Room admitting facility
• Fluoroscopy
• Machine Broken X 3 months

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Uludag UniversityOB Anesthesia 1997

• Labor Analgesia - lt 1
• C/S Rate - 50
• General gt 80 Regional lt 20
• Attitude everything is normal, nothing needs to
  change

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Uludag University OB Anesthesia Stats

• 1,200 Deliveries a year
• 40 C/S 60 Vaginal

• Central oxygen in the labor rooms
• Neonatal resuscitation program

Dr. Owen present
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Uludag University OB Anesthesia Stats

• C/S Increase in RA
• ? 25 27 gauge spinal needles
• No dextrose-containing IV fluid bolus

Dr. Owen present
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My General Anesthesia C/S
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Scared this Guy
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Some Things Dont Change
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Me Talking/Teaching
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Grand Rounds
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Everyone Needs to Chart
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Narcotic Accountablity
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PEDIATRIC ROOM
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Ploss Cart
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Everyone Eats
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Drug Rep Meetings
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Some Little Differences
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Wheres the ETCO2?
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InductionWhat is Preoxygenation?
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Need A Refill?
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Sterilized Gauze
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Holding Hall
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Patient Transport into the OR
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WARM YET?
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Blood Warmer
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Does Anyone Have A Key?
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Is it a MAC or Miller?
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PACU

MONITORING
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• Specialized Tea Coffee Room

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Smoking in the OR
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Gaziantep

• Largest City in Southeast Turkey
• Borders Syria Iraq
• Large Kurdish Population
• 2nd Educational Meeting of the Turkish Society of
  Regional Anesthesia

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Circumcision Outfit
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Question Answer Session
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Regional Teaching Session
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After Meeting Dinner-Dance
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Im Trying
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(Terry I) Still Trying
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I Think Ive Got It!
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Kybele Results

• Host Hospital evaluations
• Experience with Guest Anesthesiologist
• 8/10 Excellent
• 2/10 Good
• 10/10 Judged anesthesiologists as flexible
  knowledgeable
• 7/10 made changes to their clinical practice
• 6/10 reposted help with research manuscript
  writing
• 10/10 have maintained contact with their guests
• Success with the Local Hospitals

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Kybele Results

• Newspaper Articles
• Front Page of a major national newspaper
• Several Articles throughout the country
• Television
• 1 News Segment in Istanbul
• 2 One Hour Talk Shows on the Merits of Vaginal
  Deliveries and the importance of regional
  anesthesia
• Both Featuring Sukran Sahin Myself
• 1 One Hour News Talk Show a week after we left
• Success with Educating the Public

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Kybele Results

• Success For ParticipantsLike the Mastercard
  CommercialOur Experience was Priceless

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