Physician training requires the highest intelligence quotient of all professions to assimilate the vast amounts of complex knowledge required. The most critical decision-making medical specialty is anesthesiology, which requires much art of practicing medicine. That art is acquired via experience from years of medical practice.

Clinical experience can also be gleaned from studying these 90 case reports in Brock-Utne’s book, Anesthesia in Low-Resourced Settings. These cases are from third-world countries, but any of these situations could also occur in American Ivy League University hospitals.

Limited hospital night staff can be overwhelmed by a sudden influx of gunshot trauma cases and force one to care for emergency patients outside one’s regular working expertise. Another time one could be working remote from the hospital’s fully equipped main operating room complex in a small-case specialty single operating room. Then a crisis arises needing additional drugs and devices taking 20 min to be transported to that remote venue. Innovative temporary medical measures will be required. Power failures can occur without backup electricity. Suction systems can fail. Gas delivery can fail. An anesthesia machine can fail. A device may develop a problem not foreseen by its designers. Low-resourced settings can occur in a flash moment anywhere in the world, even in rich countries.

This book’s cases challenge anesthesiologists’ training, intellect, and resourcefulness. This book is rich in wisdom. Before doing “mission medical work,” all anesthesiologists should read this book. There is a summarizing list of pearls of wisdom in the book. Reading that list may save one patient’s life in your career. I read the book in 2 days. Reading this book should be mandatory for anesthesia trainees nearing graduation. Anesthesiologists at any career point will read lessons echoing some anesthesia mishap they have experienced and wish they had read this book earlier in their careers.

The deficient resources can be:

  1. anesthesia delivery equipment
  2. monitoring devices for patient physiology and vapor and gas concentrations
  3. anesthesiologist expertise
  4. surgeon skills: that said, many third-world surgeons are incredibly dexterous and experienced
  5. no intensive care facility for postoperative patient ventilation
  6. limited nursing expertise in the postoperative and general ward
  7. drug and device shortages
  8. lack of commonality of languages spoken with patients and coworkers
  9. failed electrical supplies and core services such as gasses and suction

This is the most valuable case in the book.

A 29-yr-old woman fell off a moving train. When she arrived at a midsize Somali hospital, she was hypotensive, in pain, and tachycardic. She had fractures of the T10 vertebra, right humerus, the pelvis, and five right-side ribs with a right-side hemopneumothorax. A large-bore right subclavian multi-lumen access cordis venous cannula and an intercostal chest drain were immediately inserted. The pleural cavity drained 1,500 ml of blood. Additional peripheral venous access catheters were inserted.

The anesthesiologist administered 4 units of blood. The blood pressure improved, but the centralized venous pressure measured via the subclavian cannula stayed at zero. Intercostal blood continued to drain and worried the thoracic surgeon, who urgently wanted to operate to stop the bleeding. The international normalized ratio (INR) test for clotting, of a sample withdrawn for the right-subclavian vein cannula, measured 2.3 (N = less than 1.1 when not on warfarin).

The anesthesiologist worried about the darkness of the ongoing draining chest blood and the inexplicable high INR test result. The thoracotomy found no active bleeding source. A repeat INR test sample drawn from the femoral vein revealed a normal INR test of 1.1. The right subclavian cannula was intrapleural, and the persistent draining dark blood was subclavian catheter transfused blood. The first INR test had been done on the trauma intrapleural blood.


  • Never trust aspiration of blood as evidence of correct placement of subclavian cannula on the side of a hemopneumothorax.
    • oIt is correct to place a subclavian cannula on the same side as a hemopneumothorax, because the danger of an additional iatrogenic pneumothorax on the opposite healthy side could be fatal very swiftly.


  • Inject methylene blue via the subclavian cannula and observe the intercostal drainage for a color change.
  • Another simple test for correct subclavian catheter placement on the same side as the hemopneumothorax is to inject a catheter blood sample into a glass sample tube and observe for clotting within 15 min. The absence of clotting indicates that the cannula tip is in the blood-filled intrapleural space. Intrapleural blood after trauma does not clot due to becoming defibrinated; hence, it produced the first abnormal INR result.1 
  • The diagnosis of an ongoing iatrogenic hemothorax is easily made with the clinical signs of dullness to digital percussion comparing the two sides of the chest if immediate x-rays cannot be taken.

A patient underwent general anesthesia with intubation using a wire-reinforced flexible endotracheal tube. On awakening, the patient bit firmly on the tube and occluded it, bending the reinforcing wire. After the biting relaxed, the tube was still entirely blocked from the crimping of the reinforcing wire. The patient’s chest started to heave as he struggled to breathe past the sustained endotracheal tube obstruction.


Fully deflate the endotracheal tube cuff. That frees up about 40% of the cross-sectional area of the trachea for the patient to breathe past the outside of the endotracheal tube.

Soon this patient woke up and was safely extubated. The problem is preventable by initially placing a bite-block or a Guedel airway in the mouth beside the endotracheal tube.

After reading this book, many will recall many forgotten pearls of wisdom. Dr. Brock-Utne is a rare and superbly trained physician anesthesiologist who has worked extensively in third-world circumstances. He is an Emeritus full clinical professor from Stanford University in California. He is the epitome of a clinically expert scientist. His book is recommended to read.

1. Melick DW et al Experimental hemothorax J Thorac Surg 1945 ; 14:461–79