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MOST RECENT TRIP NEWS
A Kybele team of five participants, including three anesthesiologists, one obstetrician, and one neonatologist, led by Dr. Virgil Manica, returned to Romania in May 2009. The team concentrated efforts in Iași, the second largest city in Romania and home to Cuza Voda Maternity, the busiest maternity in Romania, boasting over 7,000 deliveries annually. A hands-on workshop was extremely successful with over 20 anesthesiologists and obstetricians attending from Iași and surrounding towns. The four days were spent demonstrating regional anesthesia techniques for labor analgesia and cesarean section, educating obstetricians and neonatologists on safer practices, and emphasizing the importance of interdepartmental communication for optimal patient outcomes. An educational question and answer session was organized for patients to attend and numerous press conferences were held throughout the week. A book launch of Easy Labor, written by William Camann, MD and translated into Romanian, was accomplished and accepted with enthusiasm by our Romanian colleagues. Overall, the trip was extremely successful and Kybele has been invited to return to Iași for further collaborative educational endeavors.
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Country Details
Romania is one of central-eastern European’s largest nations and has a population of approximately 23 million people. Its capital, Bucharest, has a population of 2.2 million. Romania joined the European Union in 2007. Romania is a country made up of a wide variety of terrain, from the Danube Delta and the plains of Wallachia in the south, to the mountainous regions toward the north. Still recovering from the regime of Nicolae Ceauseascu, Romania is striving to improve its economy, and evidence of improvement is widespread today.
The Site Visit
In April 2007, a team of two physicians, Virgil Manica (Tufts Medical Center, Boston, MA) and Lisa Councilman (Texas A&M HSC-COM, Temple, TX), visited four hospitals in the city of Bucharest and observed regional anesthesia and general anesthesia for cesarean sections, met with the medical directors of each hospital, and met with physicians from other hospitals in regards to future collaboration with Kybele. The team members conducted a conference attended by approximately 60 physicians and presented an informative lecture about Kybele and a lecture on the updated ASA Obstetric Anesthesia Practice Guidelines.
Team members were interviewed for two television programs, two radio programs (one a 45-minute radio program entirely dedicated to Kybele), and two newspaper articles, all aimed to raise public awareness about regional anesthesia for childbirth. In addition, Kybele was asked to assist with writing national protocols/guidelines for obstetric anesthesia and post-operative pain management, a much needed resource for ensuring uniformly safe obstetric anesthesia practices throughout Romania. Plans were made to return with a larger team in May 2008 for teaching and Kybele was invited to participate in the SRATI (Romanian Society of Anesthesia and Intensive Care) Congress.
The Kybele Team Arrives
A team of 13 participants made up of 12 physicians and 1 midwife spent May 10-24, 2008 in Romania, including Virgil Manica (Tufts Medical Center, Boston, MA), Lisa Councilman (Texas A&M HSC-COM, Temple, TX), Brittany Clyne (Charlotte, NC), Amanda Baric (Australia), Thao Thieu (Tufts Medical Center, Boston, MA), Michelle Spears (Texas A&M HSC-COM, Temple, TX), Ellen Harrison (NYC, NY), Paul Nelson (Austin, TX), Janet Fields (Duke, Winston-Salem, NC), Edward Bryan IV (Texas A&M HSC-COM, Temple, TX), Danielle Roncari (Tufts Medical Center, Boston, MA), Dulce Anunciacion (Tufts Medical Center, Boston, MA), Claire Barker (Scotland). Six hospitals were visited in Bucharest, Sibiu, Targu-Mures, Ploiesti, and Brasov, Romania. The team also attended and five members participated as Refresher Course lecturers at SRATI 2008, the Romanian Society of Anesthesia and Intensive Care Annual Congress.
The first week was spent with the group divided between two hospitals, Municipal Hospital, the large teaching hospital in Bucharest, and Polizu, a smaller hospital that provides obstetric services. Several key meetings were set up and attended during the week. Virgil, Lisa, Thao, and Dr. Elena Copaciu (our Romanian host in Bucharest) met with Professor Dr. Dan Sabau, Romanian senator and chairman of the committee on Health, Ecology, and Sports of the Romanian Senate. He was very receptive to the Kybele plan and offered assistance at the Parliament level for legislative help. He also agreed with the need for implementation of national protocols and guidelines for obstetric anesthesia and suggested a meeting with the president of the Romanian College of Physicians. He also agreed to assist in approving much-needed medications for mainstay use in obstetrics (labetalol, magnesium sulfate, hydralazine). Dr. Copaciu and Virgil also met with Dr. Vlad Anton Iliescu, CT surgeon and secretary of state at the Romanian Health Ministry. He was also very receptive to the Kybele project and is willing to assist with approving much-needed medications. He, also, would like to see improved conditions in obstetric anesthesia. Brittany, Thao, and Danielle gave a conference for the obstetricians at the Municipal hospital, with attendees including Dr. Alexandru Anca, vice-president of the Romanian Society of OB-Gyn. The topic of discussion was the effect of regional anesthesia on the progress of labor, from both anesthesiologist’s and obstetrician’s points of view. The lectures were followed by a very lively interactive discussion. The last strategic meeting in Bucharest was with Dr. Vasile Astarastoae, president of the Romanian College of Physicians, who met with Virgil and Dr. Copaciu to discuss ways to approve and implement national standards and guidelines for obstetric anesthesia, to talk about the approval of much-needed medications, and to discuss next year’s projected visit to Moldova and Iasi, Dr. Astarastoae’s hometown. Ed, Dulce, and Danielle presented a conference for residents at Municipal Hospital, discussing resident-relevent topics. This conference was well-attended with standing-room only seating.
The team attended the SRATI Congress in Sinaia where five team members, Virgil, Lisa, Brittany, Amanda, and Janet, were invited speakers for seven Refresher Course lectures. These lectures were very well received and the team was treated as honored guests for the entire length of the congress by Prof. Dr. Dan Tulbure.
The second week began with the team splitting into four groups of three team members each, departing to the cities of Sibiu, Targu-Mures, Ploiesti, and Brasov. These were site visits to determine if future Kybele efforts would be of benefit in any of these cities. Virgil, Michelle, and Lisa visited Sibiu and met with Dr. Ilie Vonica, owner and general director of a private hospital which will start providing maternity services in the near future. Dr. Vonica is very interested in educating his anesthesiologists and obstetricians on labor analgesia and regional anesthesia for cesarean sections and has offered to assist future teams with planning and coordinating visits to Sibiu. One challenge in the public hospital in Sibiu is the reluctance of the obstetricians to allow expansion of anesthesia services to their patients. There is also a shortage of anesthesiologists willing to provide obstetric anesthesia services to women in labor. This seemed to be a problem in all of the cities we visited. There has been an outflux of trained anesthesiologists, leaving the country in a state of physician shortage, therefore there are not enough anesthesiologists to provide consistent anesthesia coverage for laboring women. Danielle, Janet, and Amanda visited Zbarcea Hospital in Brasov and noted the labor epidural rate of < 5%. The major obstructions to performance of labor epidurals are lack of staffing and the need for patients to buy their own epidural kits. Of note, the regional anesthesia rate for cesarean section is 98%. Thao, Claire, and Dulce visited Maternitate Spitlaul in Ploiesti and noted much the same as the other teams. The labor epidural rate was 10%, and an 80% spinal anesthesia rate for cesarean sections. Resistance to labor epidurals appeared to be due to several factors including: 1) patient’s ability to pay for the epidural kit and medications, 2) patient’s education level (whether she knows to ask for one), 3) obstetrician’s advocacy or resistance of/to regional anesthesia, and 4) manpower. Ellen, Paul, and Ed visited Spitalul Clinic Judeatan de Urgenta in Targu-Mures, a major referral center for that part of the country so they have a disproportionate high number of high-risk cases. The labor epidural rate is very low, 0.28%, with only 7 labor epidurals in the previous year. About 90% of cesarean sections are done under spinal anesthesia. Shortage of supplies and manpower shortage are two of the impediments to providing labor analgesia for women. A general negative attitude towards labor epidurals was noted in both the anesthesia and obstetric departments, with only one anesthesiologist in the hospital willing to perform them. Overall, the majority of the team felt that overcoming the obstacles of the manpower shortage in anesthesiology would be a challenge beyond the scope of Kybele, and would make future visits with large teams to these cities, with the exception of possibly Sibiu, not very fruitful.
At the end of the second week the team met back in Bucharest and attended a meeting of the Romanian Society of Midwives. Janet presented an informative lecture and a lively discussion ensued regarding the institution of national protocols for obstetric anesthesia. The meeting was well-attended by midwives from all regions of Romania.
Throughout our visit, the team was treated wonderfully by our Romanian hosts who went out of their way to provide us with an unforgettable experience, and continued collaboration for writing and implementing national standards and protocols is planned, as well as possible future education through Refresher Course lectures and conferences. Future efforts will be aimed at possible trips to the northern region, visiting Iasi, on invitation by the chief of anesthesiology at the large maternity hospital there, and possibly assisting in Sibiu with training of anesthesiologists in labor analgesia techniques to be utilized in the new maternity ward.
