Bridging the Gap With Your Mobile Phone

The mobile phone revolution has resulted in more people with access to cell phones than clean water and electricity. Now, 104 per 100 people have access to mobile phones in developing countries (Figure) (asamonitor.pub/462PUVd). In collaboration with tech companies, global health organizations such as the World Health Organization (WHO) and United States Agency for International Development (USAID) have already employed mHealth (or mobile health) to communicate with patients, support health care workers, and collect data in primary health care, immunization, tuberculosis (TB), and acquired immune deficiency syndrome (AIDS) projects (BMC Public Health 2020;20:49). Increasingly, anesthesiologists in resource-poor countries use mobile phones for communication, clinical care, and teaching.

In a case illustrating the utility of cell phones, a teenager undergoing a redo thoracotomy became suddenly hypotensive following antibiotic administration. The only available consultant anesthesiologist had just started a case with a difficult airway in a 5-year-old in another OR. The team opened up the Pedi Crisis App^®, the consultant communicated the management plan, the resident drew up epinephrine infusion using a dose-calculating app on his phone, and this inexperienced team managed the anaphylaxis reaction successfully using the Pedi Crisis App. Cognitive aids allow anesthesiologists to perform critical tasks in a crisis quickly (Anesth Analg 2013;117:1162-71). They are particularly invaluable in parts of the world where care must be provided despite limited trained human resources.

The mobile phone is a readily available, portable monitor with many functions for the anesthesiologist in a resource-poor setting. Wireless and wired ultrasound probes cost about $3,000 each. Using a cell phone as the monitor is a much cheaper alternative to fully functional ultrasound machines that can cost over $30,000. Anesthesiologists in developing countries often work at many different hospitals, and these pocket ultrasound probes allow safe performance of line placement, peripheral nerve blocks, and rapid evaluation of deteriorating patients in unfamiliar ORs with variable resources. Videolaryngoscopes using the mobile phone as a display allow more comprehensive access to the most commonly used difficult airway modality after a failed direct laryngoscopy (Anesth Analg 2018;126:1527-34). Pulse oximeter probes attached to mobile phones are another low-cost solution for enhancing safer anesthesia care in austere environments.

When hospitals do not have the means to afford paid subscriptions to journals and books, lack of ready access to medical knowledge and the ability to read around cases due to paywalls is a barrier to safe anesthesia care and a source of ongoing debate (asamonitor.pub/3Npp2rn). Global education outreach programs by many anesthesiology societies, donors, and academic centers strive to fill this gap. The tutorial of the week by the World Federation of Societies of Anaesthesiologists offers topics relevant to anesthesiologists in resource-poor settings and can be accessed online or delivered to registered users via email. The Society for Pediatric Anesthesia also offers free peer-reviewed lectures online. Open access websites like OpenAnesthesia and OpenPediatrics and academic and professional organizations offer free resources on Twitter accounts and YouTube channels, particularly for ultrasound-guided nerve blocks, perioperative ultrasound, and echocardiography. The ubiquitous cell phone is the device most used to access these resources.

Mobile phones have also evolved as a virtual teaching tool for anesthesiologists. Critical skills like flexible scope-assisted intubations are often challenging to teach without clinical skills and simulation labs. Anesthesiology departments have a limited number of flexible intubating scopes and minimize the risk of damage by limiting access to a handful of providers. Apps like Airway Ex^® are a low-tech solution that allow trainees to have the virtual experience of using a flexible intubating scope and managing different difficult airway scenarios.

Mobile phones are essential for communication within the hospital in resource-limited countries, and WhatsApp, with over 2 billion users, has emerged as the most widely used messaging app (asamonitor.pub/3qIhYgI). Without hospital-managed email or beepers, hospital administration depends on WhatsApp groups to communicate administrative and academic tasks and updates. Departmental groups share and manage work schedules through the app. Daily OR lists, assignments, and cases discussed in interdisciplinary conferences are shared with the group. Night coverage depends heavily on communication using mobile phones. Vital signs, EKG, and wound pictures are shared between team members, allowing a limited number of consultants to help junior physicians on call from out-of-hospital locations. WhatsApp groups of regional anesthesiologists offer a forum to communicate their needs and share resources whenever possible. A 4-year-old undergoing hernia repair at the author’s hospital in Pakistan developed malignant hyperthermia. Dantrolene is only available at a handful of centers. An SOS call on a WhatsApp group of local anesthesia professionals connected us with a nearby hospital that had dantrolene left behind after a mission trip, and our team was able to save this child. As a result of our experience, a missionary organization always leaves their leftover dantrolene with our center, and this helped us administer dantrolene promptly when another child developed malignant hyperthermia.

In another case, a call came from a father several hundred miles away, close to the Afghanistan-Pakistan border. A pediatric cardiologist at a nearby hospital had recommended surgery for his 2-year-old with ventricular septal defect. The pediatric cardiac surgeon requested a WhatsApp screenshot of his cardiologist’s note for review and shared it with the rest of his team. The family traveled to the pediatric surgery center for further evaluation and returned to their rural area following surgery funded by a local charity organization. Mobile phone ownership and the availability of internet services have allowed patients in remote and rural areas to connect with physicians in tertiary care centers and minimize the number of trips and expenses associated with planning and care, a barrier to care for some families. Once discharged, patients can communicate concerns, such as wound infection, via WhatsApp chat and be instructed as needed.

The mobile phone offers an economic tool for data capture in grim ORs. One of the biggest challenges to improving the quality of care in low- and middle-income countries is the need for more credible data on health care outcomes. The scarcity of resources for an electronic medical record system, robust medical record keeping, and monitoring of key quality indicators are barriers to continuously evolving into a safer health care system. External donors primarily fund research and data gathering in low- and middle-income countries and focus on infectious diseases, vaccination, TB, AIDS, and malaria. There must be more representation of data from anesthesia professionals in low- and middle-income countries to multicenter, multinational registries related to anesthesia outcomes. Open-source mobile data collection platforms like Omicron Delta Kappa and EpiCollect allow the development and use of customizable forms to capture clinical data. Mobile phone cameras can capture paper medical records, and data can be entered on a mobile phone offline for subsequent audit and analysis.

In conclusion, the mobile phone is a lifeline that offers families and anesthesiologists a low-cost means of communication and aids clinical decision-making, monitoring, education, record keeping, and audits in resource-limited health care systems. Just as we expect perioperative anesthesia care to be enhanced by the ever-evolving and innovative world of technology, universal access to technology in resource-limited countries will help our fellow anesthesiologists to develop their own patient- and quality-centered perioperative care models (Anesth Analg 2023;136:623-6).