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Anesthesia in
Low-Resourced
Settings
Near Misses and Lessons

Learned
John G. Brock-Utne
123
Anesthesia in Low-Resourced Settings
John G. Brock-Utne
Anesthesia
in Low-Resourced
Settings
Near Misses and Lessons Learned
John G. Brock-Utne
Professor of Anesthesia (Emeritus)
Department of Anesthesiology
Perioperative & Pain Medicine
Stanford University School of Medicine
Stanford, CA
USA
ISBN 978-3-030-77653-4 ISBN 978-3-030-77654-1 (eBook)

https://doi.org/10.1007/978-3-030-77654-1
© Springer Nature Switzerland AG 2021

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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
For the next generation
Matthew B. Brock-Utne
Tobias J. Brock-Utne
Anders C. Brock-Utne
Jasper L. Brock-Utne
Stefan S. Brock-Utne
Charlotte E. Brock-Utne
Foreword
Historically, the medical mission trip was the most common form of engagement in
Global Health by anesthesiologists. In generations past, “mission” had a different
meaning. Albert Schweitzer, a humanitarian and physician, won the Nobel Peace
Prize in 1952 largely for his philosophy, “Reverence for Life”. His most notable
work was the foundation of a hospital in Gabon in 1913, a hospital that has been
rebuilt twice, but still provides service and sees patients today.
Over time, Global Health has evolved into its own field of study and has largely
shifted focus towards building local capacity to strengthen healthcare systems
through education and research. Many Global Health experts have even called into
question the value and motivations of short-term, service-based “mission” work,
citing ethical considerations and neocolonialism.
However, if you ask the countless patients whose lives have been changed from
recto-vaginal fistula repairs when local surgeons do not exist, or the babies delivered
safely by foreign physicians, or the child who no longer suffers from malnutrition
after his cleft palate repair, then these mission trips receive resounding support. If
you ask the 50,000 patients seen each year at Albert Schweitzer hospital, one could
assume they support his mission.
Only when you work in a setting where resources are more constrained than your
own do you realize the vast amounts one can take for granted. We cancel cases if the
temperature and humidity are not perfect, while many operating rooms have open
windows, unreliable electricity and lack running water. Individual tourniquets used
for each and every patient can be substituted by tying the same latex glove around
the arms of the day’s patients. Disposable gowns, drapes and masks are reusable
cloth in other settings. Some anesthesia providers have never seen an end-tidal car-
bon dioxide waveform, and some EKG monitors use tiny needle electrodes. Oxygen,
air and suction are not piped through the walls of most facilities. In fact, medical air
is largely unavailable. Astonishingly, so is medical oxygen.
Using industrial oxygen instead of medical-grade oxygen for hypoxemic patients,
using tap water instead of distilled water for ventilator humidification systems,
using an adult blood pressure cuff on a paediatric patient – these are real dilemmas
faced daily by those working without the basic resources required for patient care.
vii
viii Foreword
Providers are forced to make choices between the ideal, the less than ideal and the
unthinkable, to get patients through surgery and critical illness. Although tough
choices often inspire innovation from which we all should learn, there are many
occasions where patient safety is compromised. Learning to maintain a narrow bal-
ance is the goal for any anesthesiologist working when resources are constrained.
The accounts in this book give historical context, exploring equipment most have
never seen, medications no longer available, and a time before vigilance for patient
safety with standard monitoring. In addition to practical learning points, this book
poses common ethical dilemmas still relevant in today’s global health practice. How
do you obtain informed consent with cultural awareness? What should be done to
prevent the donated equipment graveyards? What can we learn from traditional
medicine providers? Through thoughtful case discussions, readers are given fair
warning that challenges always arise when working in new settings, but solutions
are usually local. In rural practice, these dilemmas continue to arise, not only
abroad, but in our own backyards. For the anesthesiologists working in remote areas
with fewer resources, for the anesthesiologists providing clinical service in foreign
environments, for any anesthesiologist about to embark on a mission trip, this book
will provoke considerations you did not have previously. You will be more prepared.
Ana Maria Crawford, MD, MSc, FASA

Founder of the Division of Global Health Equity at Stanford University
Stanford, CA, USA
anacrawford@stanford.edu
Map of Africa
AFRICA
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Cabinda Tanganyika Dodoma
(ANGOLA) Zanzibar
A T L A N T I C UNITED REPUBLIC OF SEYCHELLES
Ascension
Luanda
TANZANIA Providence Is.
(UK) Aldabra Is.
Farquhar Is.
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Nyasa Moroni Agalega Is.
ANGOLA COMOROS (MAURITIUS)
Lilongwe Mayotte Is.

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ZIMBABWE
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Bloemfontein
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SOUTH LESOTHO
AFRICA
Cape Town
The boundaries and names shown and the designations used

on this map do not imply official endorsement or acceptance
by the United Nations.
0 500 1000 km
Final boundary between the Republic of the Sudan and the
Republic of South Sudan has not yet been determined.
0 500 mi
Based on UN map Department of Field Support

Geospatial Information Section (formerly Cartographic Section)
ix
African Countries Are Mentioned
in Alphabetical Order in the Text
I am sure you will be surprised that there are 54 independent countries in Africa.
There are also other countries outside of Africa that are mentioned in the case stud-
ies. They are included separately at the end. The information about all these coun-
tries includes its population, language and religion.
Africa
Algeria
Algeria is a North African country with a Mediterranean coastline and a Saharan

desert interior. Many empires have left legacies here, such as the ancient Roman
ruins in seaside Tipaza. In the capital. Algiers, Ottoman landmarks are seen from
circa 1612. Population: 42 million. Official language Arabic. Religion: Islam.
Angola
Angola is a Southern African nation whose varied terrain encompasses tropical

Atlantic beaches, a labyrinthine system of rivers and a Sub-Saharan desert that
extends across its southern border into Namibia. The country’s colonial history is
reflected in its Portuguese-influenced cuisine and its landmarks including Fortaleza
de São Miguel, a fortress built by the Portuguese in 1576 to defend the capital,
Luanda. Population: 31 million. Official language: Portuguese – spoken by 80% of
the population, but there are six other African languages spoken. Religion: Christian.
xi
xii African Countries Are Mentioned in Alphabetical Order in the Text
Benin
Benin is a French-speaking West African nation. It is a birthplace of the vodun (or

“voodoo”) religion and home to the former Dahomey Kingdom from circa
1600–1900. In Abomey, Dahomey’s former capital, the Historical Museum occu-
pies two royal palaces with bas-reliefs recounting the kingdom’s past and a throne
mounted on human skulls. To the north, Pendjari National Park offers safaris with
elephants, hippos and lions. Population: 12 million. Official language: French, but
there are 55 national languages. Religion: 27.7% Muslim, 25.5% Roman Catholic,
13.5% Protestant, 11.6% Vodun, 9.5% of other Christian denominations and 12.2%
of others or none.
Botswana
Botswana, a landlocked country in Southern Africa, has a landscape defined by the

Kalahari Desert and the world-famous Okavango Delta. The latter becomes a lush
animal habitat during the seasonal floods. The massive Central Kalahari Game
Reserve, with its fossilized river valleys and undulating grasslands, is home to
numerous animals including giraffes, cheetahs, hyenas and wild dogs. The capital is
Gaborone. Population: 2.2 million. Official language: English. There are, however,
20 other languages spoken. Religion: Officially, Botswana is said to be a Christian
country, although the number of practicing Christians is estimated at only around
20% of the population. Many people still maintain dual religious practices between
Christianity and traditional religious worship.
Burkina Faso
Burkina Faso, officially the People’s Democratic Republic of Burkina Faso, is a

small landlocked country in West Africa. A former French colony, it gained indepen-
dence as Upper Volta in 1960. The name Burkina Faso, which means “Land of
Incorruptible People,” was adopted in 1984. The capital Ouagadougou is in the cen-
tre of the country and lies about 500 miles (800 km) from the Atlantic Ocean.
Population: 21 million. Religion: 50% of the population is Muslim. Official language
is French but most people speak Mòoré and Fula as well as the African language.
Burundi
Burundi is a country in east-central Africa, south of the Equator. This landlocked coun-
try is one of the few countries in Africa whose borders were not determined by colonial
rulers. The vast majority of Burundi’s population is Hutu, traditionally a farming
African Countries Are Mentioned in Alphabetical Order in the Text xiii
people. Power, however, has long rested with the Tutsi minority, which historically has
controlled the army and most of the economy, particularly the lucrative international
export of coffee. Few real cultural differences are distinguishable between the two
peoples, and both speak Rundi (Kirundi). Population 11 million; 60% of the population
is Roman Catholic; Official language is Rundi (Kirundi), a Bantu language that is the
standard medium of communication throughout the country and French.
Cape Verde
Cabo Verde, also called Cape Verde, country comprises a group of islands that lie
385 miles (620 km) off the west coast of Africa. Praia on Santiago is the capital. The
largest port in the islands is located at Mindelo on Sao Vicente. Its deepwater har-
bour accommodates sizable vessels and has been used as a fuelling station since the
19th century. Population: 550,000. Official language: Portuguese. Religion: 80%
Roman Catholic
Cameroon
Cameroon, on the Atlantic, is a Central-West African country of varied terrain and

wildlife. Its inland capital, Yaoundé, and its biggest city, the seaport Douala, are
transit points to ecotourism sites as well as beach resorts like Kribi – near the Chutes
de la Lobé waterfalls, which plunge directly into the sea. Population: 26.5 million.
Official language: both English and French. Religion: 80% Christian.
Central African Republic (CAR)
The Central African Republic is a landlocked country in Central Africa. Armed

groups continued to commit serious human rights abuses, expanding their control to
an estimated 70% of the country, while the central government, led by President
Faustin-Archange Touadéra, controlled the capital, Bangui. Population: 4.6 million.
Official language: French and Sango. There are over 72 African languages. Religion:
Christion 90%; Muslim 10%.
Chad
A largely semi-desert country, Chad is rich in gold and uranium and stands to ben-
efit from its recently acquired status as an oil-exporting state. In 2003, it completion
of a $4bn pipeline linking its oilfields to terminals on the Atlantic coast. Chad’s
xiv African Countries Are Mentioned in Alphabetical Order in the Text
post-independence history has been marked by instability and violence, stemming

mostly from tension between the mainly Arab-Muslim and the predominantly
Christian. Poverty is rife, and health and social conditions are poor. Population: 15.5
million. Official language: French and Arabic. Religion: 51.8% practicing Islam,
43.8% practicing some form of Christianity, and the remaining 4.4% being atheist.
Within the Muslim community, 58% are Sunni, 11% are Shia, 4% are Ahmadi and
23% are nondenominational.
Comoros
The Comoros is a volcanic archipelago off Africa’s east coast, in the warm Indian
Ocean waters of the Mozambique Channel. The nation state’s largest island, Grande
Comore (Ngazidja), is ringed by beaches and old lava from the active Mt. Karthala
volcano. Around the port and medina in the capital, Moroni, are carved doors and a
white colonnaded mosque, the Ancienne Mosquée du Vendredi, recalling the
islands’ Arab heritage. Population: 850,000. Official Language: Comorian, French
and Arabic. Religion: 98% are Sunni Muslims.
Congo, Democratic Republic of the Congo
The Democratic Republic of the Congo, also known as DR Congo, the DRC, DROC,
Congo-Kinshasa or simply the Congo, is a country located in Central Africa. It was
formerly called Zaire. It is, by area, the largest country in sub-Saharan Africa, the
second-largest in all of Africa, and the 11th largest in the world. Population: 84 mil-
lion. Official Language: French. Religion: Some three-fourths of the population is
Christian. Adherents of Roman Catholicism account for about one-third of the
country's Christians. The Protestant community includes members of the Evangelical
Church of the Congo.
Congo, Republic of the Congo
The Republic of the Congo, also called Congo-Brazzaville, is a central African

nation with rainforest reserves that are habitats for gorillas. Its capital city,
Brazzaville, lies across the Congo River from Kinshasa, the capital of neighbouring
Democratic Republic of the Congo. Brazzaville’s highlights include traditional craft
markets and the mid-20th-century Basilique Sainte-Anne, with a green-tiled roof
and spire. Population: 5.6 million. Official language: French. Religion: Christian
with 12% Muslims.
African Countries Are Mentioned in Alphabetical Order in the Text xv
Cote d'Ivoire (Ivory Coast)
Côte d'Ivoire is a West African country with beach resorts, rainforests and a French-
colonial legacy. Abidjan, on the Atlantic coast, is the country’s major urban centre.
Its modern landmarks include La Pyramide and St. Paul's Cathedral, a swooping
structure tethered to a massive cross. North of the central business district is the
Banco National Park, a rainforest preserve with hiking trails. Population: 25 mil-
lion. Official Language: French. Religion: Islam 44 % and Christian 34 %. The rest
follows traditional African religions.
Dijbouti
Djibouti, on the Horn of Africa, is a mostly French- and Arabic-speaking country of

dry scrublands, volcanic formations and Gulf of Aden beaches. It’s home to one of
the saltiest bodies of water in the world, the low-lying Lake Assal, in the Danakil
Desert. The nomadic Afar people have settlements along Lake Abbe, a body of salt-
water featuring chimney-like mineral formations. Population: 1 million. Official
language: Arabic and French. Religion: 94% Sunni Muslims.
Egypt
Egypt, a country linking northeast Africa with the Middle East, dates to the time of
the pharaohs. Millennia-old monuments sit along the fertile Nile River Valley,
including Giza's colossal Pyramids and Great Sphinx as well as Luxor's hieroglyph-
lined Karnak Temple and Valley of the Kings tombs. The capital, Cairo, is home to
Ottoman landmarks like Muhammad Ali Mosque and the Egyptian Museum, a trove
of antiquities. Population: 99 Million. Official language: Egypt-Arabic. Religion:
Islam (Shia).
Equatorial Guinea
Equatorial Guinea is a Central African country comprising the Rio Muni mainland
and 5 volcanic offshore islands. Capital Malabo, on Bioko Island, has Spanish colo-
nial architecture and is a hub for the country’s prosperous oil industry. Its Arena
Blanca beach draws dry-season butterflies. The tropical forest of the mainland’s
Monte Alen National Park is home to gorillas, chimpanzees and elephants.
Population: 1.4 million. Official language: French, Spanish and Portuguese Religion:
Christian (90 %).
xvi African Countries Are Mentioned in Alphabetical Order in the Text
Eritrea
The Italians created the colony of Eritrea in the 19th century around Asmara and
named it with its current name. After World War II, Eritrea was annexed to Ethiopia.
In 1991, the Eritrean People’s Liberation Front defeated the Ethiopian government.
Population: 3.5 million. There is NO official language. English and Italian are also
widely understood, but there are many Eritrea languages, like Tigrinya. Arabic and
English predominate in commerce and national business. Religion: 60% Christian
and 35% Islam.
Eswatini (formerly Swaziland)
Eswatini is a landlocked monarchy in Southern Africa. It is bordered by Mozambique

to its northeast and South Africa to its north, west and south. It is one of the smallest
countries in Africa. The population is 1.1 million and is composed primarily of
ethnic Swazis. The language is Swazi, but most speak English. Religion: Traditional
and Christian.
Ethiopia
Ethiopia, in the Horn of Africa, is a rugged, landlocked country split by the Great
Rift Valley. Ethiopia is a predominantly agricultural country – more than 80% of the
population lives in rural areas. With archaeological finds dating back more than 3
million years, it’s a place of ancient culture. Among its important sites are Lalibela
with its rock-cut Christian churches from the 12th to 13th centuries. Population: 115
million. Official language: Ethiopia has 83 different languages with up to 200 dif-
ferent dialects spoken. The largest ethnic and linguistic groups are the Oromos,
Amharas and Tigrayans. Religion: Orthodox 43.5%, Muslim 33.9% and
Protestant 18.5%.
Gabon
Gabon, a country along the Atlantic coast of Central Africa, has significant areas of
protected parkland. The forested coastal terrain of its famed Loango National Park
shelters a diversity of wildlife, from gorillas and hippos to whales. Lopé National
Park consists of mostly rainforest. Akanda National Park is known for its man-
groves and tidal beaches. It was to this country Dr. Albert Schweitzer settled in
1913. He wrote the book called: “Reverence for life”, for which he received the
African Countries Are Mentioned in Alphabetical Order in the Text xvii
1952 Nobel Peace Prize. Actually, I (JGBU) was a little boy seeing him, in on the
balcony of the City Hall, in Oslo when he got the Peace Prize. What an example he
was to us all. Population: 2.1 million. Official language: French. Religion: Roman
Catholics account for about two-fifths.
Gambia
Gambia is a small West African country, bounded by Senegal, with a narrow Atlantic
coastline. It’s known for its diverse ecosystems around the central Gambia River.
Abundant wildlife in its Kiang West National Park and Bao Bolong Wetland Reserve
includes monkeys, leopards, hippos, hyenas and rare birds. The capital, Banjul, and
nearby Serrekunda offer access to beaches. Population: 2.2 million. Official lan-
guage: English. Religion: Muslim 90%.
Ghana
Ghana (Warrior King) is a country located along the Gulf of Guinea an Atlantic
Ocean in West Africa. The first permanent state in the territory of present-day Ghana
dates back to the 11th century. Beginning in the 15th century, the Portuguese
Empire, followed by numerous other European powers, before the British ultimately
established control of the coast by the late 19th century. Ghana became independent
in 1957, Population: 30 million. Official language: English. Religion: Christian 70%.
Guinea-Bissau
Guinea-Bissau is a tropical country on West Africa’s Atlantic coast that’s known for
national parks and wildlife. The forested, sparsely populated Bijagós archipelago is
a protected biosphere reserve. Its main island, Bubaque, forms part of the Orango
Islands National Park, a habitat for saltwater hippos. On the mainland, the capital,
Bissau, is a port with Portuguese colonial buildings in its old city centre. Population:
1.8 million. Official language: Portuguese. Religion: Christian.
Ivory Coast
In 1960 France granted independence under President Felix Houphouet-Boigny. He

held power until he died in 1993. From 2002 to 2007, Civil war effectively splits the
country into Muslim rebel-held north and government-controlled Christian south.
xviii African Countries Are Mentioned in Alphabetical Order in the Text
Post-election 2010, left 3,000 people dead and 500,000 displaced. In 2016 Al-Qaeda
jihadists attack the beach resort of Grand Bassam, near Abidjan, killing 18 people.
Population: 25 million. Official language: French. Religion: Islam, Christian and
indigenes beliefs.
Kenya
Kenya is a country in East Africa with coastline on the Indian Ocean. It encom-
passes savannah, lakelands, the dramatic Great Rift Valley and mountain highlands.
It’s also home to wildlife like lions, elephants and rhinos. From Nairobi, the capital,
many National Parks can be accessed. From many, you can view Tanzania's 5,895
metre Mt. Kilimanjaro. Population: 51 million. Official language: Swahili and
English. Religion: Christian 85% and Islam 10%.
Lesotho
Lesotho, a high-altitude, landlocked kingdom encircled by South Africa, is criss-

crossed by a network of rivers and mountain ranges including the 3,482 metre high
peak of Thabana Ntlenyana. On the Thaba Bosiu plateau, near Lesotho’s capital,
Maseru, are ruins dating from the 19th-century reign of King Moshoeshoe I. Thaba
Bosiu overlooks iconic Mount Qiloane, an enduring symbol of the nation’s Basotho
people. Population: 2.1 million. Official language: Sesotho and English. Religion:
Christian 90%.
Liberia
Liberia is a country in West Africa, bordering Sierra Leone, Guinea and Côte
d'Ivoire. To the west is the Atlantic coast. Here you find the capital city of Monrovia
(named after the US President Monroe). In the city is the Liberia National Museum,
with its exhibits on national culture and history Liberia was founded by free people
of colour from the United States. They created the American Colonization Society
(ACS). In 1847, the ACS encouraged Liberia to declare independence, as the orga-
nization could no longer support the colony against territorial incursions by the
neighboring British and French. The United States declined to act on requests from
the ACS to make Liberia an American colony or to establish a formal protectorate
over Liberia, but it did exercise a “moral protectorate” over Liberia, intervening
when European powers threatened its territory or sovereignty. The Republic of
African Countries Are Mentioned in Alphabetical Order in the Text xix
Liberia was created on July 26, 1847. The Virginia-born Joseph Jenkins Roberts
was the nation’s first president. Population: 4.8 million. Official language: English.
Religion: Christian 85%.
Libya
Libya, officially the State of Libya, is a country in the Maghreb region in North
Africa, bordered by the Mediterranean Sea to the north, Egypt to the east, Sudan to
the southeast, Chad to the south. Since 2015 a second civil broke out, with parts of
Libya split between the Tobruk and Tripoli-based governments, as well as various
tribal and Islamist militias. Population: 6.7 million. Official language: Arabic.
Religion: Islam with 97% Sunni.
Madagascar
Madagascar is the world second largest island in the world in the Indian Ocean. It is
the biggest producer of vanilla in the world. It is approximately 400 km off the coast
of East Africa. Population: 27 million. Official language: Malagasy and French.
Religion: Christian 41% and Islam 7%.
Malawi
Malawi, a landlocked country in southeastern Africa, is defined by its topography of

highlands split by the Great Rift Valley and enormous Lake Malawi. The lake’s
southern end falls within Lake Malawi National Park – sheltering diverse wildlife
from colourful fish to baboons – and its clear waters are popular for diving and boat-
ing. Population: 18.1 million. Official language: English. Religion Christian: 77%
and Islam 15%.
Mali
Mali, officially the Republic of Mali, is a landlocked country in West Africa. Mali
is the eighth-largest country in Africa, with an area of just over 1,240,000 square
kilometres. The population of Mali is 19.1 million. 67% of its population was esti-
mated to be under the age of 25 in 2017. Its capital is Bamako. Official language:
French. Religion: Islam 95%.
xx African Countries Are Mentioned in Alphabetical Order in the Text
Mauritania
Mauritania is an Islamic in Northwest Africa. It is the eleventh largest sovereign

state in Africa and is bordered by the Atlantic Ocean to the west. Population: 4.4
million. Official language: French. Religion: Islam 100%.
Mauritius
Mauritius, an Indian Ocean island nation, is known for its beaches, lagoons and
reefs. The mountainous interior includes Black River Gorges National Park, with
rainforests, waterfalls, hiking trails and wildlife like the flying fox. Population: 1.2
million. Official language: Creole 84%. Religion: Hindu 50%, Christian 33% and
Islam 16%.
Morocco
Morocco is a North African country bordering the Atlantic Ocean and the
Mediterranean Sea. It is distinguished by its Berber, Arabian and European cultural
influences. Casablanca is the largest city. Population: 36 million. Official language:
Arabic. Religion: Islam 73 %.
Mozambique
Mozambique is a southern African nation whose long Indian Ocean coastline is dot-
ted with beaches and offshore marine parks. The fishing is incredible as landmines
have prevented fishing from the beaches. In the Quirimbas Archipelago, a 250 km
stretch of coral islands, mangrove-covered Ibo Island has colonial-era ruins surviv-
ing from a period of Portuguese rule. Population: 29.5 million. Official language:
Portuguese. Religion: Christian 58% and Islam 19%.
Namibia
Namibia is a country in southwest Africa and is distinguished by the Namib Desert

along its Atlantic Ocean coast. The country is home to diverse wildlife, including a
significant cheetah population. The capital, Windhoek, and coastal town Swakopmund
African Countries Are Mentioned in Alphabetical Order in the Text xxi
contain German colonial-era buildings such as Windhoek’s Christuskirche, built in

1907. In the north, Etosha National Park’s salt pan draws game including rhinos and
giraffes. Population: 2.5 million. Official language: English. Religion: Christian 90%.
Niger
Niger is a landlocked country in West Africa named after the Niger River. Population:
22.4 million. Official language: French. Religion: Islam.
Nigeria
Nigeria is an African country on the Gulf of Guinea and has many natural land-
marks and wildlife reserves. Protected areas such as Cross River National Park and
Yankari National Park have waterfalls, dense rainforest, savanna and rare primate
habitats. One of the most recognizable sites is Zuma Rock, a 725 m-tall monolith
outside the capital of Abuja that’s pictured on the national currency. Population: 195
million. Official language: English. Religion: Christianity, Islam and African
Traditional Religion (ATR).
Rwanda
Rwanda, formerly Ruanda, officially the Republic of Rwanda, is a landlocked coun-

try in the Great Rift Valley where the African Great Lakes region and East Africa
converge. One of the smallest countries on the African mainland, its capital city is
Kigali. Population: 12 million. Official languages: Kinyarwanda, French, English
and Swahili. Religion: Christian 95%.
Sao Tome and Principe
São Tomé and Príncipe, an African island nation, close to the equator in the Atlantic.
It is part of a volcano chain featuring striking rock and coral formations, rainforests
and beaches. On the larger island, São Tomé, is the Lagoa Azul lagoon. Ôbo Natural
Park, a biodiverse jungle preserve, covers much of São Tomé and is distinguished
by Pico Cão Grande, a skyscraperlike volcanic rock. Population: 211,000. Official
language: Portuguese. Religion: Christian 95%.
xxii African Countries Are Mentioned in Alphabetical Order in the Text
Senegal
Senegal, officially the Republic of Senegal, is a country in West Africa which is on

the Atlantic Ocean. Senegal is bordered by Mauritania in the north, Mali to the east,
Guinea to the southeast and Guinea-Bissau to the southwest. Population: 15.1 mil-
lion. Official language: French. Religion: Islam 96%.
Seychelles
The Seychelles is an archipelago of 115 islands in the Indian Ocean, off East Africa.
It is home to numerous beaches, coral reefs and nature reserves, as well as rare ani-
mals such as giant Aldabra tortoises. Mahé, a hub for visiting the other islands, is
home to capital Victoria. It also has the mountain rainforests of Morne Seychellois
National Park and beaches. Population: 97,000. Official language: French, Seselwa
and English. Religion: Christian 82%.
Sierra Leone
Sierra Leone is a country in West Africa, on the Atlantic Ocean. It’s known for the
white-sand beaches lining the Freetown Peninsula. The capital city, Freetown, com-
memorates the nation’s slave-trade history with the Cotton Tree landmark and
King’s Yard Gate. Both were known as places of refuge for returned slaves in the
18th and 19th centuries. Nearby Bunce Island was a key departure point during the
slave trade. Population: 7.6 million. Official language: English. Religion: Islam
77% and Christian 21%.
Somalia
Somalia, officially the Federal Republic of Somalia, is a sovereign country located

in the Horn of Africa. It is bordered by Ethiopia to the west, the Gulf of Aden to the
north, the Guardafui Channel and Somali Sea to the east, and Kenya to the south-
west. Population: 15 million. Official language: Somali. Religion: Islam
South Africa
South Africa is a country on the southernmost tip of the African continent, marked
by several distinct ecosystems. Inland safari destination Kruger National Park (the
first designated National park in the world) is populated by big game. The Western
African Countries Are Mentioned in Alphabetical Order in the Text xxiii
Cape offers beaches, lush winelands around Stellenbosch and Paarl, craggy cliffs at
the Cape of Good Hope, forest and lagoons along the Garden Route, and the city of
Cape Town, beneath flat-topped Table Mountain. Natal in the east along the Indian
Ocean with the largest city Durban is the home to 12 million Zulus. Population: 58
million. Official language: Afrikaans, English, Zulu, Xhosa, Venda, Southern Sotho,
Tswana, Tsonga, Northern Sotho, Swati and Ndebele. Religion: Christian 80%.
South Sudan
South Sudan is known as the Republic of South Sudan and is a landlocked country
in East-Central Africa. It is bordered to the east by Ethiopia to the north by Sudan,
to the west by the Central African Republic, to the south-west by the Democratic
Republic of Congo, to the south by Uganda and to the south east by Kenya. It gained
independence from the Republic of Sudan in 2011, Population: 11 million. Official
language: English. Religion: No official religion but the majority are Christian.
Sudan
Sudan, officially the Republic of Sudan, is a country in Northeast Africa. Bordered

by Egypt to the north, Libya to the northwest, Chad to the west and the Red Sea to
the northeast. Population: 42 million. Official language: Arabic and English.
Religion: Islam (majority Sunni).
Tanzania
Tanzania is an East African country known for its vast wilderness areas. They
include the plains of Serengeti National Park, a safari mecca populated by the “big
five” game (elephant, lion, leopard, buffalo and rhino) and Kilimanjaro National
Park, home to Africa’s highest mountain. Offshore lie the tropical islands of
Zanzibar, with Arabic influences, and Mafia, with a marine park home to whale
sharks and coral reefs. Population 56: million. Official language: Swahili and
English. Religion: Majority is Islam.
Togo
Togo, a West African nation on the Gulf of Guinea, is known for its palm-lined
beaches and hilltop villages. Koutammakou, inhabited by the Batammariba people,
is a traditional settlement of fortress-like clay huts dating to the 17th century. In the
xxiv African Countries Are Mentioned in Alphabetical Order in the Text
capital, Lomé, are the multistory Grand Marché bazaar and the Fetish Market, offer-
ing traditional talismans and remedies relating to the vodun (voodoo) religion. Togo
is one of the smallest country in Africa. Population: 8 million. Official language:
Non, but 44 languages are recorded. Religion: Christian 44%, Traditional 37 % and
Islam 14%.
Tunisia
Tunisia is a North African country bordering the Mediterranean Sea to the north and
the Sahara Desert to the south. In the capital, Tunis, the Bardo Museum has archaeo-
logical exhibits from Roman mosaics to Islamic art. The city’s medina quarter
encompasses the massive Al-Zaytuna Mosque and a thriving souk. To the east, the
site of ancient Carthage features the Antonine Baths. Population: 12 million. Official
language: Arabic. Religion: Islam (majority is Sunni).
Uganda
Uganda is a landlocked country in East Africa whose diverse landscape encom-

passes the snow-capped Rwenzori Mountains and immense Lake Victoria. Its abun-
dant wildlife includes chimpanzees as well as rare birds. Remote Bwindi
Impenetrable National Park is a renowned mountain gorilla sanctuary. Murchison
Falls National Park in the northwest is known for its tall waterfalls and wildlife such
as hippos. Population: 43 million. Official language: Swahili and English. Religion:
Christian 75%.
Western Sahara
Western Sahara is a disputed territory on the northwest coast and in the Maghreb
region of North and West Africa. About 20% of the territory is controlled by the
self-proclaimed Sahrawi Arab Democratic Republic, while the remaining 80% of
the territory is occupied and administered by neighboring Morocco. Population:
273,000. Official language: Arabic Religion: Islam.
Zambia
Zambia, in southern Africa, is a landlocked country of rugged terrain and diverse

wildlife, with many parks and safari areas. On its border with Zimbabwe is the
famed Victoria Falls – indigenously called Mosi-oa-Tunya, or “Smoke That
Thunders” – plunging a misty 108 m into a narrow Batoka Gorge. Spanning the
African Countries Are Mentioned in Alphabetical Order in the Text xxv
Zambezi River just below the falls is Victoria Falls Bridge, a spectacular viewpoint.
Population: 17 million. Official language: English. Religion: Christian.
Zimbabwe
Zimbabwe is a landlocked country in southern Africa known for its dramatic land-
scape and diverse wildlife, much of it within parks, reserves and safari areas. On the
Zambezi River, Victoria Falls make a thundering 108 m drop into narrow Batoka
Gorge, where there’s white-water rafting and bungee-jumping. Downstream are
Matusadona and Mana Pools national parks, home to hippos, rhinos and birdlife.
Population: 15 million. Official languages: English, Shona, Xhosa, Tsonga and sev-
eral others. Religion: Christian.
Other Countries Outside of Africa Mentioned Are Follows
Bangladesh
Bangladesh, to the east of India on the Bay of Bengal, is a South Asian country
marked by lush greenery and many waterways. Its Padma (Ganges), Meghna and
Jamuna rivers create fertile plains, and travel by boat is common. On the southern
coast, the Sundarbans, an enormous mangrove forest shared with Eastern India, is
the home to the royal Bengal tiger. Population: 161 million. Official language:
Bengali. Religion: Islam 90%.
Borneo
Borneo, a giant, rugged island in Southeast Asia’s Malay Archipelago, is shared by

the Malaysian states of Sabah and Sarawak, Indonesian Kalimantan and the tiny
nation of Brunei. It’s known for its beaches and ancient, biodiverse rainforest, home
to wildlife including orangutans and clouded leopards. In Sabah is 4,095 m tall
Mount Kinabalu, the island’s highest peak, and, offshore, the famed dive site
Sipadan Island. Population: 21 million. Official language: Bahasa Malaysia.
Religion: Islam 60%, Buddhist 19%, Christian 9% and Hindu 6%.
Columbia
Colombia has significant natural resources and its culture reflects the indigenous
Indian, Spanish and African origins of its people. It has been ravaged by a decades-
long violent conflict involving outlawed armed groups, drug cartels and gross
xxvi African Countries Are Mentioned in Alphabetical Order in the Text
violations of human rights. It is the fourth largest country in South America and one
of the continent's most populous nations. Colombia has substantial oil reserves and
is a major producer of gold, silver, emeralds, platinum and coal. Population: 50 mil-
lion. Official language: Spanish. Religion: Roman Catholic.
Costa Rica
Costa Rica is a rugged, rain-forested Central American country with coastlines on

the Caribbean and Pacific. Though its capital, San Jose, is home to cultural institu-
tions like the Pre-Columbian Gold Museum, Costa Rica is known for its beaches,
volcanoes and biodiversity. Roughly a quarter of its area is made up of protected
jungle, teeming with wildlife including spider monkeys and quetzal birds.
Population: 5 million. Official Language: Spanish. Religion: Christian.
Guyana
Guyana, officially the Co-operative Republic of Guyana, is a country on the north-

ern mainland of South America. It is considered part of the Caribbean region
because of its strong cultural, historical and political ties with other Anglo-Caribbean
countries. Guyana is bordered by the Atlantic Ocean to the north, Brazil to the south
and southwest, Venezuela to the west and Suriname to the east. Guyana is the third-
smallest sovereign state on mainland South America after Uruguay and Suriname.
Guyana is the only South American nation in which English is the official language.
The majority of the population, however, speak Guyanese Creole, an English-based
creole language as a first language. Guyana was settled by the Dutch before coming
under British control in the late 18th century. It was governed as British Guiana with
a mostly plantation-style economy until the 1950s. However, in 2015 Exxon-Mobile
found a large amount of oil and gas in the sea outside of Georgetown, the capital.
Population: 780,000. Official language: English. Religion: Christian 64 %, Hindu
24.8 %, Muslim 6.8% and Jehovah’s Witness 1.3%.
India
India, officially the Republic of India, is a country in South Asia. The Mughal
Empire, in 1526, provided two centuries of relative peace, leaving a legacy of lumi-
nous architecture like the Taj Mahal. Gradually expanding the rule of the British
East India Company followed, turning India into a colonial economy. British Crown
rule commenced in 1858. Indians were granted sovereignty in 1950 with the
African Countries Are Mentioned in Alphabetical Order in the Text xxvii
division of India and Pakistan. India is the second-most populous country in the
world and the seventh-largest country by area. It is also the most populous democ-
racy in the world with a population 1.4 billion. Official language: Hindi and English.
Religion: Hindi 80%, Islam 14%, Christian 2.3% and Sikhism 1.7%.
Nepal
Nepal, officially the Federal Democratic Republic of Nepal, is a country in South

Asia. It is located mainly in the Himalayas but also includes parts of the Indo-
Gangetic Plain. It is landlocked and borders China in the north and India in the south,
east and west. Population: 33 million. Official language: Nepali. Religion: Hindi.
Peru
Peru is a country in South America that is home to a section of Amazon rainforest

and Machu Picchu, an ancient Incan city high in the Andes mountains. The region
around Machu Picchu, including the Sacred Valley, Inca Trail and colonial city of
Cusco, is rich in archaeological sites. On Peru’s arid Pacific coast is Lima, the capi-
tal, with a preserved colonial centre and important collections of pre-Columbian art.
Population: 33 million. Official language: Spanish. Religion: Christian.
Sri Lanka
Sri Lanka, formerly Ceylon, is a country on an island in the Indian Ocean and sepa-
rated from peninsular India by the Palk Strait. It has a maximum length of 268 miles
(432 km) and a maximum width of 139 miles (224 km). Population: 22 million.
Official language: Sinhala, while Tamil shall also be an official language. English is
a link language. Religion: 70.2% Theravada Buddhists, Hindus 12.6%, Islam 9.7%
(mainly Sunni) and Roman Catholic 6.1%.
Syria
Syria, officially the Syrian Arab Republic, is a country in Western Asia, bordering
Lebanon to the southwest, the Mediterranean Sea to the west, Turkey to the north,
Iraq to the east. Population: 16 million. Language: Arabic. Religion: Islam 87%
(majority Sunni (74%).
xxviii African Countries Are Mentioned in Alphabetical Order in the Text
Turkey
Turkey, officially the Republic of Turkey, is a transcontinental country located

mainly on the Anatolian peninsula in Western Asia, with a smaller portion on the
Balkan peninsula in Southeastern Europe. Population: 88 million. Official language:
Turkish. Religion: Islam 60%.
Acknowledgements
To my wife, Sue, for her constant encouragement and understanding as a physi-

cian’s wife. Without her I doubt very much I would have spent 17 wonderful years
in Africa. Her help with proofreading has been invaluable.
To Jon Gjessing, MD, PhD (originally from Sundsvall, Sweden); Arne Oesterud,
MD, PhD; and Lorents Gran, MD, PhD, all of Rikshospitalet, Oslo, Norway for
starting me on my academic path.
To John W. Downing, MD, Professor and Head of Department of Anesthetics,
University Natal Medical School, Durban, South Africa for his guidance, friendship
and wisdom during my time in Durban and beyond.
To Ana Crawford, MD, for being so gracious in agreeing to write the foreword
for this book.
To my secretary Carolyn, the best secretary anyone can have. Her willingness
and her attention to detail are of the highest order.
To Greg Sutorius and Eugenia Judson of Springer, for always being available for
questions and concerns.
I am indebted to the following, whom I have worked with during my sojourn in
Africa and the Far East. I thank them for their camaraderie and outstanding contri-
bution to the population they served.
Miriam Adhikari, Peter John Allan, John Atchison, Andrew Andrews, Nasima
Badsha, Brian Baker, Andy J. Barclay, Rosie Barclay, Jeff Barwise, Gordon Blake,
David Blight, Paul Blignaut, Adrian (Bosie) Bosenberg, Erin Botha, Robert Buley,
Ross Bullock, Richard (Dick) Burrows, Pat Callander, Jerry Coovadia, Chris
Cuerden, Peter Desmaris, George Dimopoulos, Tom Dow, John W. Downing,
Richard Dunning, Johan DuPreez, Inga Elson, Herbert Engelbrecht, Paul
Fairbrother, Vladimir Firago, Louise Fourie, Stephen L. Gaffin, Premjith Gathiram,
Alexandro Gavaze, Jon Gjessing, Michael Grant, Christopher Good, Allan Gorven,
Neal Goodwin, Lorentz Gran, Ronald Green-Thompson, Mike Gregory, Gordon
Haddow, Ariff Ahmed Haffejee, John Hamilton, Rex Henderson, Bruce Henderson,
John Hicks, Allan Hold, Alison Holloway, William Huizinga, David Humphrey,
Mike James, David Jeal, Brother John, Derek G. Jordaan, John Jordaan, Ahmed
(Mahmood) Kadwa, Soromini Kallichurum, Sunder Roopsun Kambaran, Komal
xxix
xxx Acknowledgements
Kamra, Mary Khaing, Muhammad Fazl-Ur Rahman Khan, Harry Kingston,

Yvonne Koen, Ben Le Roux, Andrew Logan, Andrew Love, Paul G. Lukin, Robin
MacGillvray, Rob MacKenzie, TA MacPherson, Rajend Maharaj, Nisha Malhotra,
Emmanuel (“Mannie”) Mankowitz, Masizane Marivate, Maurice Mars, Aileen
Marszalek, Nasim Mayat, Robin McAravey, Larry McFadden, Ashley Micks,
Robert (Bob) Mickel, Jack Moodley, David Morrell, Mike Moshal, Ali Mossa, Don
Moyes, Glen Moffett, Khobi Msimang, Radha Muthukumarasamy, Rai Naidu,
Clint Naiker, Sim Naicker, Birgit Niestroj, James Nixon, Andy Norbury, John
Odell, Stephen O’Keefe, Alicja Orkiszewski, Tim Pavy, Sherman Ripley, Dennis
Pudifin, Deshandra Raidoo, Jerry Readie, John Redpath, John Robbs, Tony Rocke,
Mike Rogers, Chris Rout, Joe Rubin, Tom Ruttman, Robert Salisbury, Inga
Schwegmann, Nigel Schodel, Soraya Seedat, Dione Somerville, Julian Somerville,
Ted Sommerville, Jean Marie Spitaels, Robin Stiebel, Marie Strassburg, James Van
Dellen, Johan Van den Ende, Herman van der Heyden, Hoosen M. Vawda, BJ
Vorster, Hendrik J. Vreman, Michelle Wells, Steve Welman, Nigel Welsh, Brian
Wessels, Ron Williamson, Gail Wilmot, Tim Winning, and Amadeo Zanotti.
Prologue
Two roads diverged in a wood, and I –

I took the one less traveled by,
And that has made all the difference
Robert Frost (1874–1963)
From as far back as I can remember, I have wanted to travel. Perhaps that desire
was sparked by my Norwegian Viking blood. When I was considering a medical
specialty, one of the deciding factors for choosing anesthesiology was that it would
allow me the opportunity to travel and to work throughout the world. Fortunately for
me, my desire to see the world became a reality and I ended up working on three
continents, including 17 years in South Africa.
Many anesthesiologists find that going on a 1–2 weeks medical missions to low-
resource settings is very rewarding. The trip organizers recruit their own team and
send all the required surgical and anesthesia equipment. The only resources pro-
vided by the small hospital you work at are the operating room(s), oxygen, electric-
ity and perhaps nitrous oxide. Modern equipment and monitors that are brought in
ensure safe surgery and anesthesia. This makes the anesthesia experience similar to
the standards set at home.
The case studies in this book do not describe 1–2-week sojourns. They describe
the life of an anesthesiologist when he/she immerses himself/herself for a long
period of time, months, even years, in low-resource settings. It’s an entirely differ-
ent experience from a short medical mission. A few modern machines or equipment
are available. Instead, you will find hospitals that are sorely underfunded. They
consist of low cinder-block buildings which are often surrounded by a tall security
wall. Within the compound are neatly spaced barracks, and inside each you will find
row after row of metal-framed beds spaced about two feet apart. If the hospital is
busy and overcrowded, you may even find patients being housed underneath the
beds. There are no private rooms and usually no curtains for privacy. The electricity
will be intermittent at best since the hospitals often do not have money to pay for
fuel to keep their generators running 24/7. Rarely is there air-conditioning. If you
are lucky there may be ceiling fans, which will stop working when the power cuts
xxxi
xxxii Prologue
out. The heat can be oppressive, and it exaggerates the ever-present odor of sweat
and antiseptic. In addition to these challenges, the anesthesiologist often works
alone with old and/or foreign equipment and manages patients with strange unfa-
miliar diseases, often using outdated drugs.
When you arrive for the first time at one of these low-resource settings, you may
have little practical knowledge of the exotic illnesses among the local inhabitants or
their culture and beliefs. Adding to the challenge, you probably won’t speak the
local language and the patients and nurses probably will not speak your language.
Hence, administrating an anesthetic can be tricky for anyone who has not been
trained in such an environment. I discovered all this when I first arrived in South
Africa in 1971.
In this book, please note that I have named the country where the described case
occurred. It may be in Africa, Asia, Latin or South America. To be clear, I have not
been nor have I worked in many of the countries that are mentioned. The stories do
represent actual cases/problems I collected from my own experiences and from
those of my friends. I have included them to show the variety of different challenges
(diseases, drugs, etc.) that may be encountered when working in these locations.
In front of the book, you will find a map of Africa. There is also, in alphabetical
order, a list of each country mentioned and a short description of these countries, the
population size, major religions practiced and the languages that are spoken. You
may be surprised to learn that there are 54 independent and separate countries
located on the African continent.
The medical staff that provide care at the hospitals/clinics are outstanding peo-
ple, who work under the most difficult conditions, with little or no funding. We can
only admire them for their fortitude and empathy for their fellow men. To me, these
hospitals are like a beacon of hope in an otherwise difficult/dangerous world.
The book tries to outline problems, through case studies that you may encounter
in low-resource settings, even for a short visit. My hope is that the book will prepare
you with a better understanding of the types of problems you can expect to face.
The work may sound daunting. However, should you embark on such an adven-
ture, I can guarantee it will be a most memorable, rewarding experience. In fact, I
would be very surprised if it did not turn out to be one of the happiest periods of
your working life.
It certainly was for me.
I don’t know what your destiny will be,
but the one thing I know:
the ones among you who will be really happy are those who have
sought and found how to serve.
Albert Schweitzer 1875–1965
John G. Brock-Utne, MA, MD, PhD, FCMSA

Department of Anesthesiology, Peri-operative & Pain Medicine
Stanford University Medical Center
Stanford, CA, USA
Contents
Case 1: Now What Will You Do?�� 1

Case 2: What Is Wrong with This Picture? �� 7
Case 3: No Train of Four Neuromuscular Monitor. No Problem�� 9
Case 4: An Old Anesthetic Machine and It’s the Only One �� 11
Case 5: Ether Is the Only Anesthetic and You Have Never Given One�� 13
Case 6: Transporting a Critically Ill Patient Without Monitors�� 15
Case 7: Severe Dehydration and No IV Solution�� 17
Case 8: Thinking Outside the Box�� 19
Case 9: This Is a Serious Problem�� 23
Case 10: Always Check Your Facts�� 27
Case 11: An Impossible Situation? �� 31
Case 12: No Blood Bank. Now What?�� 35
Case 13: What Can the Problem Be? �� 37
Case 14: Living on the Equator�� 39
Case 15: A Word of Caution�� 43
Case 16: A Draw-Over Vaporizer with a Non-rebreathing
Circuit. Be Aware�� 47
Case 17: A Near Tragedy�� 51
Case 18: A Tracheostomy Is Urgently Needed and You Have
Never Done One�� 53
Case 19: A Prolapsed Umbilical Cord�� 57
xxxiii
xxxiv Contents
Case 20: The One-Eyed Patient�� 59

Case 21: Postoperatively You Can’t Communicate
with the Patient�� 61
Case 22: Traumatic Hemothorax and Same Side Central
Venous Access�� 65
Case 23: A Patient with a Difficult Airway and You Have Minimal
Airway Equipment �� 69
Case 24: MRI Suite. What Can the Problem Be? �� 71
Case 25: How Should You Fill CO2 Absorbent in a Canister?�� 75
Case 26: An Old Anesthetic Machine. Look Carefully �� 79
Case 27: A Single Abdominal Knife Wound. Easy Case?�� 83
Case 28: An Endobronchial Foreign Body�� 87
Case 29: Lead Apron�� 89
Case 30: A Tip for Nasal Intubation�� 93
Case 31: A Seriously Ill Patient�� 97
Case 32: Malignant Hyperpyrexia�� 101
Case 33: An Adjuvant to the Cuff-Leak Test�� 105
Case 34: A Bronchoscopy Surprise�� 109
Case 35: Doing Research in Low-Resource Environments.
What to Watch Out for�� 111
Case 36: An Epidural Pump in Labor in a Low-Resource
Environment. Watch Out �� 115
Case 37: This Could Be Serious�� 117
Case 38: A Case of Intraoperative Hyperthermia�� 121
Case 39: A Case of Myasthenia Gravis�� 125
Case 40: A Tragic Case�� 129
Case 41: Essential Equipment�� 133
Case 42: A Potentially Life-Threatening Problem�� 137
Case 43: A Straightforward Case or What?�� 139
Case 44: A Signed Consent. Any Problem �� 143
Case 45: A Cesarean Section with Twins �� 147
Case 46: A Child Bitten by a Rabid Dog�� 149
Contents xxxv
Case 47: What an Airway Surprise�� 153

Case 48: A Case of a Ruptured Ectopic �� 157
Case 49: A Glass Blood Bottle. Any Concern?�� 163
Case 50: An Old EKG Machine�� 167
Case 51: A Bird Ventilator�� 169
Case 52: Intraoperative “Oozing”�� 173
Case 53: Defibrillator. Watch Out�� 177
Case 54: A Case of Trismus �� 179
Case 55: A Diagnostic Dilemma�� 183
Case 56: An Anesthetic Equipment Graveyard�� 187
Case 57: A Motor Vehicle Accident�� 191
Case 58: My Wife Is Dead, Doctor �� 195
Case 59: Disposal of Soda Lime�� 199
Case 60: Compressed Gas Containers �� 203
Case 61: A Neck Abscess�� 207
Case 62: An Emergency Cesarean Section in Togo�� 211
Case 63: An Overdose with Witch Doctor Medicine�� 215
Case 64: A Request from a Family Member�� 219
Case 65: A New Electronic Anesthetic Machine�� 223
Case 66: Hiccups After Induction of Anesthesia �� 225
Case 67: What Is Going On? Was Geht Ab? �� 227
Case 68: A Trans-Indian Ocean Flight�� 231
Case 69: Reinforced (Armored) Endotracheal Tube. Watch Out�� 233
Case 70: A Soda Lime Dilemma �� 237
Case 71: Bain Circuit (Mapleson D). What Is the Problem? �� 239
Case 72: Suxamethonium. Never Forget�� 241
Case 73: What a Lesson�� 243
Case 74: How Much Oxygen Is Left in an E-cylinder?�� 245
Case 75: A Case of Lost in Translation�� 249
Case 76: A Sudden Intraoperative Change in EKG
Amplitude. Any Concern? �� 253
xxxvi Contents
Case 77: Technical Staff must be Well Trained �� 257

Case 78: What Can Go Wrong with This Anesthetic?�� 263
Case 79: A Military Conflict �� 267
Case 80: A Dying Patient�� 271
Case 81: A New Breathing System�� 275
Case 82: A Small Child in a War Zone�� 279
Case 83: A Gangrene Leg�� 283
Case 84: Facial Trauma �� 285
Case 85: Always Check Your Facts�� 289
Case 86: An Acute Appendix �� 293
Case 87: Hospital Administrator. You Have Been Warned�� 297
Case 88: A Tribal Conflict �� 299
Case 89: Intermittent Electrical Power Failure to an
Anesthesia Machine�� 301
Case 90: Bonus Question �� 305
Introduction to Three Stories�� 307

1.Doing Everything with Nothing by Paul Luckin�� 309
2.A Sojourn in a Rural Hospital by Gordon Haddow �� 315
3.A Sojourn in a Warzone by Andrew Love�� 319
A Zulu Wedding �� 325
A Recap �� 327
Index�� 329
Case 1: Now What Will You Do?
You are in Northern Zambia. You are the sole anesthesiologist for the next 3 months
in a mission hospital. This is your first day. Your own anesthetic equipment has not
yet arrived and is not expected for another 2 weeks.
An anesthesia technician shows you a cardboard box with various tubes, etc. (see
below). He tells you:
This is the anesthetic system/circuit that we use for spontaneously breathing patients. The first
few cases are urological and do not require any paralysis. Here is the face mask. (Not shown)
He stands back and expects you to assemble the system.
Can you do that and what is this system called? On the next page you will see it
assembled.
Photo by JGBU
© Springer Nature Switzerland AG 2021 1

J. G. Brock-Utne, Anesthesia in Low-Resourced Settings,
https://doi.org/10.1007/978-3-030-77654-1_1
2 Case 1: Now What Will You Do?
Solution
The assembled system. It should look like this:
Photo by JGBU
Sir Ivan Magill was the first doctor to design this anesthesia system. The object
was to get the face mask away from the patient’s face during faciomaxillary surgery.
He was therefore able to operate on disfigured faces of British soldiers returning
from World War I. This system is also called a Mapleson A system/circuit after
Professor WW Mapleson PhD from Cardiff. I had the pleasure of meeting him in
1980. He has the most charismatic character. In essence, in this system the fresh gas
flow (FGF) enters far away from the patient’s airway. (near the reservoir bag). At the
airway end (mask end), there is a Heidbrink one-way pop-off valve. This is where
you place your face mask.
The Mapleson systems are breathing circuits, also known as (a) flow-controlled
breathing systems or (b) carbon dioxide washout circuits, because they depend upon
fresh gas flow for washing out CO2. Mapleson systems are classified into five basic
types as Mapleson A, B, C, D, and E. Later, Mapleson F was also added.
Mapleson A system is:
1. Simple, safe, and inexpensive
2. Able to deliver the intended inspired gas mixture
3. Able to permit spontaneous breathing in adults
4. Sturdy, compact, and lightweight
5. Effective in eliminating the CO2 if you have at FGF of 70–85 ml/kg/min. (FGF
is increased should the patient have pyrexia)
6. Low in airflow resistance
7. A breathing circuit with minimal dead space
Solution 3
The components of Mapleson A are:

A. Breathing tubes which are:
1. Large bore, usually corrugated tubes, made of rubber or plastic. (Corrugations
increase flexibility and resistance to kinking)
2. Lightweight and with low resistance
3. Have some distensibility but not enough to prevent excessive pressures from
developing in the circuit
B. The adjustable pressure limiting valve (Heidbrink) is also called either a pop-off
valve, exhaust valve, scavenger valve, relief valve, expiratory valve, or an over-
spill valve.
1. This valve allows exhaled waste gases and fresh gas flows to leave the breath-
ing system when the pressure within the breathing system exceeds the valve’s
opening pressure.
2. It is a one-way, adjustable, spring-loaded valve
3. The manual spring adjusts the pressure required to open the valve.
C. Reservoir bag
1. The reservoir bag is an important component of most breathing systems.
2. Made of antistatic rubber or plastic.
3. Are either black, which are antistatic, or green bags that are made of low
charging material which will not create harmful charges.
4. Accommodates fresh gas flow during expiration, acting as a reservoir avail-
able for use in next inspiration.
5. Acts as a monitor of the patient’s ventilatory pattern.
6. Can be used to assist or control the ventilation. Only Mapleson D should be
used for controlled ventilation either by hand or with a ventilator.
7. Because the bag is the most distensible part of the breathing system, it pro-
tects the patient from excessive pressure in the system.
D. Connectors and adaptors
1. Connect various parts of the breathing system.
2. Extend the distance between the patient and the breathing system.
3. Allow more flexibility for maneuvering.
4. Increase dead space and resistance.
5. Increase chances of disconnection.
In Mapleson A system, fresh gas enters the circuit near the reservoir bag, away
from the patient’s airway (Fig. 1.1). A corrugated tubing connects the reservoir bag
near the machine end to the adjustable pressure limiting Heidbrink valve at the
patient’s end of the system. The length of tubing is 110 cm. The valve is near the
patient end for the exhaust of gases during expiration. The reservoir bag is used for
monitoring respiration as well as ventilating the patient. It also acts as a reservoir of
gas and protects the patient from excessive pressure within the breathing system.
Mapleson A is used in spontaneous breathing anesthetized patients (Fig. 1.1).
4 Case 1: Now What Will You Do?
1 2
End-expiration End-inspiration
(high flow)
3 4
Early End-expiration
Expiration (low flow)
Fresh Gas Dead Space Gas Alveolar Gas
Fig. 1.1 As soon as the reservoir bag is full, the expiratory valve opens and the alveolar gas is
vented into the atmosphere. During expiratory pause, the alveolar gas that had come into the cor-
rugated tube is also pushed out through the valve, depending on the fresh gas flow (1). If fresh gas
flow is equal to or more than minute ventilation (70–100 ml/kg/min), it will force the expired
alveolar gas out. If flow is less than minute ventilation, some alveolar gas is retained in the system,
and rebreathing will occur. If fresh gas flow is very low, more alveolar gas will be retained. When
fresh gas flow is equal to the minute ventilation, the system functions at maximum efficiency.
Mapleson A is the circuit of choice for spontaneous respiration, because there is negligible
rebreathing. Flow of fresh gas required is 70–85 ml/kg/min, i.e., approximately 5–6 lit./min fresh
gas flow for an average adult. (Figure Reproduced with permission from Kain ML, Nunn
JF. Functional analysis of Mapleson A system during spontaneous respiration. Fresh gas econom-
ics of the Magill Circuit. Anesthesiology. 1968;29:964–974)
Photo by JGBU. Shows distal end of the Mapleson A circuit with the Heidbrink valve and the
face mask
Suggested Reading 5
Recommendation
It is imperative that you know your Mapleson circuits when embarking on working
in low-resource settings. You will be surprised how often you will use it.
Note that the Mapleson A should not be used for controlled ventilation. If you
must, then EtCO2 monitoring is mandatory.
Suggested Reading
Dorsch JA, Dorsch SE. Understanding anesthesia equipment. 2nd ed. Philadelphia: Williams &
Wilkins; 1984.
Ehrenwerth J, Eisenkraft J, Berry J. Anesthesia equipment. 2nd ed. St. Louis: Elsevier; 2017.
Humphrey D, Brock-Utne JG, Downing JW. Single and dual lever Humphrey A.D.E. low flow
multipurpose anaesthetic breathing systems. Part 1. Clinical comparisons with the Magill
and Bain systems in anaesthetized spontaneously breathing adult patients. Can Anaesth Soc
J. 1986a;33:698–709.
Humphrey D, Brock-Utne JG, Downing JW. Single and dual lever Humphrey A.D.E. low flow
multipurpose anaesthetic breathing systems. Part 1. Its use in controlled ventilation. Can
Anaesth Soc J. 1986b;33:710–8.
Lin Y-C, Brock-Utne JG. Paediatric anesthetic breathing systems. Paediatr Anaesth. 1996;6:1–5.
Schreiber P. Anesthesia equipment, performance, classification and safety. Berlin: Springer-
Verlag; 1972.
You may want to look at this link to see the function of the Mapleson A: https://www.frca.co.uk/
article.aspx?articleid=100138#.
Case 2: What Is Wrong with This Picture?
This is your operating room in eastern Turkey. You have just arrived. An anesthesia
technician shows you how to check the machine and all seems to be working well.
Oxygen is provided by the large H-cylinders. When full it contains approximately
7100 l of oxygen and a pressure of 2200 psi. You see that there is no ventilator but you
can obviously attach a Mapleson A circuit to the fresh gas outlet at the front right of
your anesthesia machine. (See Case 1.) If the technician can provide you with a Bain
circuit (Mapleson D) then you can remove the Mapleson A and use the Bain to hand
ventilate. If you had a pressure cycled ventilator like a Penlon, then you could use that.
However, is there something you should definitely have corrected prior to start-
ing your anesthetic?
Photo courtesy of Dr. Alicja Orkiszewski MD

https://doi.org/10.1007/978-3-030-77654-1_2
8 Case 2: What Is Wrong with This Picture?
Solution
You must secure the large H-cylinders to the wall so that they do not fall down [1].
This is especially true since you are in an earthquake zone.
Discussion
Many years ago, in a laboratory in the Medical School at the University of Natal,
Durban, South Africa, a large H-cylinder containing helium fell down and the valve
on top broke off. This resulted in the cylinder becoming a projectile. It flew through
the wall of the laboratory, entered the hallway and went through the outside wall at
floor level. Leaving the outside wall, it landed in the parking lot. It avoided people
and cars in its wild 100-m dash. At the end of the parking lot, it smashed through a
fence, flew over the pavement, and at ground level, raced across a very busy Congella
Road. It eventually stopped at the wall of a Dutch Reformed Church on the other
side of the road. Miraculously nobody was injured and no cars were hit. The cylin-
der travelled approximately 400 ft.
Recommendation
All large cylinders must be secured.
Reference
1. Brock-Utne JG. A word of warning when working in the Third World. Acta Anaesthesiol
Scand. 2014;58:128.
Case 3: No Train of Four Neuromuscular
Monitor. No Problem
You have just arrived at a mission hospital in northern Zululand, South Africa. All
your anesthetic equipment has not arrived, like an airway bougie and a train of four
neuromuscular monitors. You are told they will arrive in a week.
The next day you are in the operating room and have just concluded an ASA 1
male patient for an open appendectomy. Since the patient is seen to hold his head up
for 3–4 s, the endotracheal tube is removed. The patient is breathing spontaneously
with vital signs normal. Since you have no knowledge of Zulu, you turn to your
anesthesia resident, who is a native Zulu, and ask her how she says:
Stick out your tongue.
She replies:
Khipa ulimi lwakho.
With her help, you tell the patient to stick his tongue out and he does. The resi-
dent then asks you:
Why don’t you just ask the patient to squeeze your hand?
There are several reasons why you would want a patient to stick out their tongue at
the end of a general anesthetic, especially if you do not have neuromuscular monitoring:
1. The patient shows that he/she can follow a command. Of course, you could get
the same answer with the patient squeezing your hand, but there are more reasons.
2. The patient indicates that he/she can protect their airway. This is something hand
squeezing can’t do.
3. Early studies on clinical monitoring of the neuromuscular function have sug-
gested that protruding the tongue is a good assessment of return of neuromuscu-
lar function [1].
4. Sticking out your tongue is a very unusual request. It would be highly unlikely for
someone to stick out their tongue unless asked to do so. Furthermore, squeezing
your hand is more likely to happen by chance than protruding the tongue would.
5. The 12th cranial nerve is intact (a minor point).
6. There is another reason, which is probably the most important one of all. What is that?

https://doi.org/10.1007/978-3-030-77654-1_3
10 Case 3: No Train of Four Neuromuscular Monitor. No Problem
Solution
When the patient sticks his/her tongue out, at your request, at the end of an anes-
thetic this is something you and everyone in the room can see. Hence, in a court of
law or in hospital review board, everyone in the operating room can confirm that the
patient is awake and is following command at the end of the surgery. Remember if
the patient squeezes your hand, ONLY you can feel it.
Discussion
Asking your patient to stick the tongue out is a quick way to establish if the patient
is awake and is following commands. It may also be a good measure of return of
adequate muscle strength [2, 3]. But the most important reason is related to the fact
that everyone can concur that this patient was awake at the end of the anesthetic.
Recommendation
In my anesthetic practice, I always ask my patients to stick their tongue out. When
the patient complies, it gives me great comfort. Maybe it will for you too.
References
1. Ali HH, Savarese JJ. Monitoring of neuromuscular function. Anesthesiology. 1976;45:216–49.

2. Kopman AF. Neuromuscular monitoring: old issues, new controversies. J Crit Care.
2009;24:11–20.
3. Murphy GS, Szokol JW, Marymont JH, Franklin M, Avram MJ, Vender JS. Residual paralysis
at the time of tracheal extubation. Anesth Analg. 2005;100:1840–5.
Case 4: An Old Anesthetic Machine and It’s
the Only One
You have just arrived in a mission hospital in Kenya in East Africa. Below is the
only anesthesia machine available. An emergency has been booked. You have no
opportunity to administrate a safe total intravenous anesthesia (TIVA) as you have
no working infusion pumps.
You look at the machine (see picture below) and decide that you must identify
what is different from the one that you normally use? This is so you can identify the
limitations and then take precautions.
What are the differences?
Photo by JGBU

https://doi.org/10.1007/978-3-030-77654-1_4
12 Case 4: An Old Anesthetic Machine and It’s the Only One
Solution (In No Particular Order)
1. No piped oxygen.
2. No CO2 canisters
3. A Mapleson A circuit.
4. Red rubber endotracheal tube. Check cuff, etc. Always use a stylet.
5. Air cylinder (US color, yellow; international, white and black) is on the left side
on the rotameter.
6. Two air cylinders. Are they full?
7. Two nitrous oxide cylinders. (US color and international color – blue.) Are
they full?
8. No monitors for oxygen saturation, carbon dioxide, oxygen analyzer, and
temperature.
9. No suction. Very important.
10. No oxygen cylinder (US color, green; international, white).
Recommendation
Having identified the machines limitations, then you should correct as much as you
can and check that the machine actually works.
Another random document with
no related content on Scribd:
army might be looked for. Maucune reported from Frias, not long
after his arrival there, that hostile cavalry were across the Ebro in the
direction of Puente Arenas, and that other troops in uncertain
strength were behind them. It was clearly necessary to take new
measures, in view of the fact that the enemy was beyond the Ebro,
in a place where he had not been expected. How much did the move
imply? After consideration Joseph and Jourdan concluded, quite
correctly, that since the main body of Wellington’s army had been
invisible for so many days—it had last been seen on the Hormaza on
June 12th—it was probably continuing its old policy of circular
marches to turn the French right. This was correct, but they credited
Wellington with intending to get round them not by the shorter routes
Osma-Vittoria, but by the much longer route by Valmaseda and
Bilbao, which would cut into the high road to France at Bergara, far
behind Vittoria.
With this idea in their heads the King and the Marshal issued
orders of a lamentably unpractical scope, considering the position
occupied by Wellington’s leading divisions on June 17th. Reille was
ordered to collect his three infantry divisions at Osma, and to hurry
across the mountains by Valmaseda, to cover Bilbao from the west,
by taking up a position somewhere about Miravalles. He would find
the Biscayan capital already held by St. Pol’s Italians, and Rouget’s
brigade of the Army of the North. Foy, who was believed to be at
Tolosa, was instructed to bring up his division to the same point.
Thus a force of some 25,000 men would be collected at Bilbao.
Meanwhile Reille’s original positions at Frias and the Puente Lara
would be taken over by Gazan, who would march up the Ebro from
Arminion with two divisions of infantry and one of cavalry, to watch
the north bank of the Ebro. ‘These dispositions,’ remarks Jourdan,
‘were intended to retard the advance of the enemy in this
mountainous region, and so to gain time for the arrival of the
reinforcements we were expecting [i.e. Clausel]. But it was too
late![523]’
No worse orders could have been given. If Wellington had struck
twenty-four hours later than he did, and Reille had been able to carry
out his first day’s appointed move, and to get forward towards
Bilbao, the result would have been to split the French army in two,
with the main range of the Cantabrian sierras between them: since
Reille and Foy would have joined at Bilbao—three days’ forced
marches away from the King. Meanwhile Joseph, deprived of the
whole Army of Portugal, would have had Wellington striking in on his
flank by Osma, and would have been forced to fight something
resembling the battle of Vittoria with 10,000 men less in hand than
he actually owned on June 21. Either he would have suffered an
even worse defeat than was his lot at Vittoria, or he would have been
compelled to retreat without fighting, down the Ebro, or towards
Pampeluna. In either case he would have lost the line of
communication with France; and while he was driven far east, Foy
and Reille would have had to hurry back on Bayonne, with some risk
of being intercepted and cut off on the way.
As a matter of fact, Reille was checked and turned back upon the
first day of his northward march. He had sent orders to Maucune to
join him from Frias, either by the road along the Ebro by Puente
Lara, or by the mountain track which goes directly from Frias to
Espejo. Then, without waiting for Maucune, he started from Espejo
to march on Osma. He had gone only a few miles when he
discovered a British column debouching on Osma, by the road from
Berberena[524] and the north-west, which he had been intending to
take himself. Seeing his path blocked, but being loth to give way
before what might be no more than a detachment, he drew up his
two divisions on the hillside a mile south of Osma and appeared
ready to offer battle. Moreover, he was expecting the arrival of
Maucune, and judged that if he made off without delaying the enemy
in front of him, the column from Frias might be intercepted and
encircled.
The troops which Reille had met were Graham’s main column—
the 1st and 5th divisions with Bradford’s Portuguese and Anson’s
Light Dragoons, on their march towards Orduña. Graham prepared
to attack, sent forward the German Legion light battalions of the 1st
Division, and pushed out Norman Ramsay’s horse artillery, with a
cavalry escort, to the right of Osma, forming the rest of his force for a
general advance across the Bilbao road. After estimating the
strength of the British, Reille appeared at first inclined to fight, or at
least to show an intention of fighting. But a new enemy suddenly
came up—the 4th Division appeared on a side road, descending
from the hills on the right of Graham’s line. It had just time to throw
out its light companies to skirmish[525] when Reille, seeing himself
obviously outnumbered and outflanked, retreated hastily on Espejo;
the 5th Division followed him on the left, with some tiraillade, the 4th
Division on the right, but he was not caught. ‘Considerable fire on
both sides but little done,’ remarked an observer on the hillside[526].
Reille’s loss was probably about 120 men, nearly all in Sarrut’s
division[527]: that of the British some 50 or 60.
Meanwhile there had been a much more lively fight, with heavier
casualties, a few miles farther south among the mountains nearer
the Ebro. Maucune had started before dawn from Frias, intending to
join Reille by a short cut through the hills, instead of sticking to the
better road along the river-bank by the Puente Lara. He only sent his
guns with a cavalry escort by that route. He was marching with his
two brigades at a considerable distance from each other, the rear
one being hampered by the charge of the divisional transport and
baggage.
The leading brigade had reached the hamlet of San Millan and
was resting there by a brook, when British cavalry scouts came in
upon them—these were German Legion Hussars, at the head of the
Light Division, which Wellington had sent by the cross-path over the
hills by La Boveda. The approaching column had been marching
along a narrow road, shrouded by overhanging rocks and high
banks, in which it could neither see nor be seen. On getting the
alarm the four French battalions formed up to fight, in the small open
space about the village, while the head of the British column,
Vandeleur’s brigade, deployed as fast as it could opposite them, and
attacked; the 2/95th and 3rd Caçadores in front line, the 52nd in
support. Maucune was forced to make a stand, because his rear
brigade was coming up, unseen by his enemies, and would have
been cut off from him if he had retreated at once. But when the head
of Kempt’s brigade of the Light Division appeared, and began to
deploy to the left of Vandeleur’s, he saw that he was outnumbered,
and gave ground perforce. He had been driven through the village,
and was making off along the road, with the Rifle battalions in hot
pursuit, when his second brigade, with the baggage in its rear, came
on the scene—most unexpected by the British, for the track by which
it emerged issued out between two perpendicular rocks and had not
been noticed. Perceiving the trap into which they had fallen, the
belated French turned off the road, and made for the hillside to their
right, while Kempt’s brigade started in pursuit, scrambling over the
rocky slopes to catch them up. The line of flight of the French took
them past the ground over which Vandeleur’s men were chasing
their comrades of the leading brigade, and the odd result followed
that they came in upon the rear of the 52nd, and, though pursued,
seemed to be themselves pursuing. The Oxfordshire battalion
thereupon performed the extraordinary feat of bringing up its left
shoulder, forming line facing to the rear at a run, and charging
backward. They encountered the enemy at the top of a slope, but the
French, seeing themselves between two fires, for Kempt’s men were
following hotly behind them, avoided the collision, struck off
diagonally, and scattering and throwing away their packs went off in
disorder eastward, still keeping up a running fight. The large majority
escaped, and joined Gazan’s troops at Miranda. Meanwhile the first
brigade, pursued by the Rifles and Caçadores, got away in much
better order, and reached Reille’s main body at Espejo. The
transport which had come out of the narrow road too late to follow
the regiments, was captured whole, after a desperate resistance by
the baggage-guard. Maucune got off easily, all things considered,
with the loss of three hundred prisoners, many of them wounded,
and all his impedimenta[528]. The fight was no discredit to the general
or to his men, who saved themselves by presence of mind, when
caught at every disadvantage—inferior troops would have laid down
their arms en masse when they found themselves between two fires
in rough and unknown ground[529]. The total British loss in the two
simultaneous combats of Osma and San Millan was 27 killed and
153 wounded.
Reille, having picked up Maucune’s first brigade at Espejo,
continued his retreat, and got behind the Bayas river at Subijana that
night. The report which he had to send to head-quarters upset all the
plans of Jourdan and the King, and forced them to reconsider their
position, which was obviously most uncomfortable, as their line of
defence along the Ebro was taken in flank, and the proposed
succour to Bilbao made impossible. At least four British divisions had
been detected by Reille, but where were the rest, and where were
the Spaniards, who were known to be in some strength with
Wellington? Was the whole Allied host behind the force which had
driven in the Army of Portugal, or was there some great unseen
column executing some further inscrutable movement?
There was hot discussion at Miranda that night. Reille repeated
the proposition which had already been made at Burgos six days
back, that in consideration of the fact that the army was hopelessly
outflanked, and that its retreat by the high road to Vittoria and
Bayonne was threatened by the presence of Wellington on the
Bayas, it should abandon that line of communication altogether,
march down the Ebro, and take up the line of Pampeluna and
Saragossa, rallying Clausel and, if possible, Suchet, for a general
concentration, by which the British army could be driven back as it
had been from Burgos in 1812. Foy and the Biscay garrisons would
have to take care of themselves—it was unlikely that Wellington
would be able to fall upon them, when the whole of the rest of the
French armies of Spain were on his flank, and taking the offensive
against him.
Joseph, for the third time, refused to consider this scheme,
alleging, as before, the Emperor’s strict orders to keep to the
Bayonne base, and to hold on to the great royal chaussée. But, as is
clear, his refusal was affected by another consideration which in his
eyes had almost equally decisive weight. Vittoria was crammed with
the great convoys of French and Spanish refugees which had
accumulated there, along with all the plunder of Madrid, and the
military material representing the ‘grand train’ of the whole army of
Spain—not to speak of his own immense private baggage. There
had also arrived, within the last few days, a large consignment of
hard cash—the belated arrears of the allowance which the Emperor
had consented to give to the Army of Spain. One of Foy’s brigades
had escorted these fourgons of treasure to Vittoria, and dropped
them there, returning to Bergara with a section of the refugees in
charge, to be passed on to Bayonne.[530] The amount delivered was
not less than five million francs—bitterly needed by the troops, who
were in long arrears. All this accumulation at Vittoria was in large
measure due to the King’s reluctance during the retreat to order a
general shift of all his officials and impedimenta over the border into
France. As long as his ministers, and all the plant of royalty,
remained on the south side of the Pyrenees, he still seemed a king.
And he had hoped to maintain himself first on the Douro, then about
Burgos, then on the Ebro. It was only when this last line was forced
that he made up his mind to surrender his theoretical status, and
think of military considerations alone. The lateness of his decision
was to prove most fatal to his adherents.
Having resolved to order a general retreat on Vittoria, Joseph and
Jourdan took such precautions as seemed possible. Reiterated
orders for haste were sent to Foy and Clausel: the latter was told to
march on Vittoria not on Miranda. Unfortunately he had received the
dispatch sent from Burgos on June 15th, which gave him Miranda as
the concentration-point, and had already gathered his divisions at
Pampeluna on June 18, and started to march by Estella and Logroño
and along the north bank of the Ebro. This gave him two sides of a
triangle to cover, while if he had been assigned the route
Pampeluna-Salvatierra-Vittoria, he would have been saved eighty
miles of road. But on June 9th, when the original orders were issued,
no one could have foreseen, save Wellington, that the critical day of
the campaign would have found the French army far north of the
Ebro. And the new dispatch, sent off on the night of the 18th-19th,
started far too late to reach Pampeluna in time to stop Clausel’s
departure southward. Indeed, it did not catch him up till the battle of
Vittoria had been fought, and the King was a fugitive on the way to
France. Foy received orders a little earlier, though not apparently
those sent directly by the King, but a copy of a dispatch to
Thouvenot, governor of Vittoria, in which the latter was instructed
‘that if General Foy and his division are in your neighbourhood, you
are to bid him give up his march on Bilbao, and draw in towards
Vittoria, unless his presence is absolutely necessary at the point
where he may be at present[531].’ This unhappy piece of wording
gave Foy a choice, which he interpreted as authorizing him to remain
at Bergara, so as to cover the high road to France, a task which he
held to be ‘absolutely necessary.’
As to the troops already on the spot, Reille was ordered to
defend the line of the Bayas river, until the armies of the South and
Centre should have had time to get past his rear and reach Vittoria.
Gazan was ordered to collect the whole of the Army of the South at
Arminion, behind Miranda, drawing in at once the considerable
detachment which he had left beyond the Ebro. In this position he
was to wait till D’Erlon, with the Army of the Centre, who had to
move up from Haro, ten miles to the south, should have arrived and
have got on to the great chaussée. He was then to follow him, acting
as rearguard of the whole force. Between Arminion and Vittoria the
road passes for two miles through the very narrow defile of Puebla,
the bottle-neck through which the Zadorra river cuts its way from the
upland plain of Vittoria to the lower level of the Ebro valley.
D’Erlon, starting at dawn from Haro, reached Arminion at 10
o’clock in the morning of the 19th, and pushed up the defile: the
head of his column was just emerging from its northern end when a
heavy cannonade began to be heard in the west. It continued all the
time that the Army of the South was pressing up the defile, and grew
nearer. This, of course, marked the approach of Wellington, driving
the covering force under Reille before him toward the Zadorra. The
British commander-in-chief had slept the night at Berberena near
Osma, and had there drafted a set of orders which considerably
modified his original scheme: probably the change was due to
topographical information, newly garnered up from the countryside.
Instead of sending Graham’s column via Orduña, to cut in on the
flank of the chaussée behind Vittoria, he had resolved to send it by a
shorter route, a mere country road which goes by Luna, Santa
Eulalia, and Jocano to Murguia—the village which it had been
ordered on the previous day to reach via Orduña and the high road.
Presumably it had been discovered that this would save time,—the
advantage of using a first-rate track being more than
counterbalanced by the fact that the Orduña road was not only ten
miles longer but crossed and recrossed by steep slopes the main
sierra, which forms the watershed between Biscay and Alava. Or
possibly it was only the discovery that the Luna-Jocano route could
be taken by artillery that settled the matter: if it had been reported
useless for wheeled traffic the old orders might have stood. At any
rate, the turning movement, which was to take Graham into the rear
of Vittoria, was made south of the main mountain chain, and not
north of it[532].
Meanwhile, though Graham diverged north-eastward, the rest of
the Army moved straight forward from the valley of the Omecillo to
that of the Bayas in four columns, all parallel to each other, and all
moving by country roads. The 3rd Division was ordered from
Berberena to Carcamo—the 7th followed behind it. The 4th Division
with D’Urban’s cavalry in front, and the Light Division with V. Alten’s
hussars in front, were directed on Subijana and Pobes, keeping in
close and constant communication with each other. Behind them
came the cavalry reserve—R. Hill’s, Grant’s, and Ponsonby’s
brigades—also the heavy artillery. Hill’s column, which had now
come up into touch with the leading divisions, kept to the high road
from Osma and Espejo towards the Puente Lara and the Ebro. But
only cavalry reconnaissances went as far as the river—the mass of
the corps turned off eastward when it had passed Espejo, and
moved by Salinas de Añana, so as to come out into the valley of the
Bayas south of the route of the Light Division. It thus became the
right wing of the army which was deploying for the frontal attack.
It has been mentioned above that a local Spanish force from the
Cantabrian mountains had joined Wellington at Medina de Pomar;
this was the so-called ‘division’, some 3,500 bayonets, of the great
guerrillero of the coast-land, Longa, now no more an irregular but a
titular colonel, while his partida had been reorganized as four
battalions of light infantry. Longa was a tough and persistent fighter
—a case of the ‘survival of the fittest’ among many insurgent chiefs
who had perished. His men were veteran mountaineers,
indefatigable marchers, and skilled skirmishers, if rudimentary in
their drill and equipment. Wellington during the ensuing campaign
gave more work to them than to any other Spanish troops that were
at his disposal—save the Estremaduran division of Morillo, old
comrades of Hill’s corps, to which they had always been attached
since 1811. The use which Wellington now made of Longa’s men
was to employ them as a light covering shield for Graham’s turning
force. They had been sent across the hills from Quincoces[533] on the
17th to occupy Orduña—from thence they descended on the 19th on
to Murguia, thus placing themselves at the head of the turning
column. The object of the arrangement was that, if the enemy should
detect the column, he would imagine it to be a Spanish
demonstration, and not suspect that a heavy British force lay hid
behind the familiar guerrilleros. While Longa was thus brought in
sideways, to form the head of Graham’s column, the other Spanish
force which Wellington was employing was also deflected to join the
main army. Giron’s Galicians, as has been mentioned above, had
been sent by a long sweep through the sierras to demonstrate
against Bilbao. They had reached Valmaseda on the 18th, and their
approach had alarmed all the French garrisons of Biscay. Now,
having put themselves in evidence in the north, they were suddenly
recalled, ordered to march by Amurrio on Orduña and Murguia, and
so to fall into the rear of Graham’s column. The distances were
considerable, the roads steep, and Giron only came up with the
Anglo-Portuguese army on the afternoon of the battle of Vittoria, in
which (unlike Longa) he was too late to take any part. Somewhere
on his march from Aguilar to Valmaseda he picked up a
reinforcement, the very small Asturian division of Porlier—three
battalions or 2,400 men—which Mendizabal had sent to join him
from the blockade of Santoña. This raised the Galician Army to a
total of some 14,000 bayonets.
The 19th June was a very critical day, as no one knew better than
Wellington. The problem was whether, starting with the heads of his
column facing the line of the Bayas, where Reille had rallied his
three divisions and was standing at bay, he could drive in the
detaining force, and cross the Zadorra in pursuit of it, fast enough to
surprise some part of the French army still in its march up from the
south. And, as an equally important problem, there was the question
whether Graham, marching on Murguia, could reach the upper
Zadorra and cut the great road north of Vittoria, before the French
were in position to cover it. If these operations could be carried out,
there would be a scrambling fight scattered over much ground,
rather than a regular pitched battle. If they could not, there would be
a formal general action on the 20th or 21st against an enemy
established in position—unless indeed King Joseph should choose
to continue his retreat without fighting, which Wellington thought
quite possible[534].
Wellington is censured by some critics, including Napier[535], for
not making a swifter advance on the 19th. It is said that a little more
haste would have enabled him to get to Vittoria as soon as the
enemy, and to force him to fight in dislocated disorder on ground
which he had not chosen. This seems unjustifiable. The distance
between the camps of the Allied Army, in front of Osma and Espejo,
and Vittoria is some twenty miles—difficult ground, with the Bayas
river flowing through the midst of it and a formidable position held by
15,000 French behind that stream. As Reille, conscious how much
depended on his gaining time for the King to retreat from Miranda,
was determined to detain the Allied Army as long as he could, it
would have been useless to try to drive him away by a light attack.
The rear of each of Wellington’s columns was trailing many miles
behind the leading brigade. It was necessary to bring up against
Reille a force sufficient to make serious resistance impossible, and
this Wellington did, pushing forward not only the 4th and Light
Divisions, but Hill’s column in support, on the southern flank. It took
time to get them deployed, and the attack was opened by a
cannonade. By the time that a general advance was ordered Reille
had begun to retire—he did so very neatly, and crossed the Zadorra
by the four nearest bridges without any appreciable loss. By this time
the afternoon had arrived, the rest of the French army had passed
the defile of Puebla, and Wellington judged the hour too late for the
commencement of a pitched battle[536]. Moreover, he did not intend to
fight without the co-operation of Graham’s column, and the latter was
not where he would have wished it to be. The day had been very
rainy, the cross roads were bad, and by some error of staff-work the
head of the column had not received the countermarching orders
directing it to march direct on Murguia, but had started in accordance
with the earlier plan on to the Orduña road; the 1st and 5th Divisions
had gone some way upon it before they were recalled and counter-
marched into the right path[537]. Owing to blocks and bad weather
they only reached Jocano, some six or eight miles east of Osma, by
six in the evening. Murguia was still nine miles ahead, the rain was
still falling in torrents, and Graham ordered the divisions to halt and
encamp for the night. The fate of the campaign was not to be fought
out that day, nor on the next, but on the third morning—that of June
21st, 1813.
SECTION XXXVI: CHAPTER VII
THE BATTLE OF VITTORIA. JUNE 21, 1813
(A) The First Stage
The plain of Vittoria, into which the French army debouched on

the afternoon of June 19th, is a plain only by comparison with the
high hills which surround it on all sides, being an oval expanse of
rolling ground drained by the swift and narrow Zadorra river, which
runs on its north-eastern side. Only in its northern section, near the
city, does it show really flat ground. It is about twelve miles long from
north-east to south-west, and varies from six to eight miles in
breadth. The Zadorra is one of those mountain streams which twist
in numberless loops and bends of alternate shallows and deep
pools, in order to get round rocks or spurs which stand in the way of
their direct course[538]. At one point seven miles down-stream from
Vittoria it indulges in a complete ‘hairpin-bend’ in which are the
bridges of Tres Puentes and Villodas, as it circles round a
precipitous knoll. At several other spots it executes minor loops in its
tortuous course. The little city of Vittoria stands on an isolated rising
ground at its northern end, very visible from all directions, and
dominating the whole upland with two prominent church spires at its
highest point. The great road from France enters the plain of Vittoria
and the valley of the Zadorra three miles north-east of the city,
descending from the defile of Salinas, a long and difficult pass in
which Mina and other guerrilleros had executed some of their most
daring raids on French convoys. After passing Vittoria the road
keeps to the middle of the upland in a westerly direction, and issues
from it by the defile of La Puebla, where the Zadorra cuts its way
through the Sierra de Andia in order to join the Ebro. There is not
much more than room for road and river in the gorge, which is
dominated by the heights of La Puebla, a spur of the Andia, on the
east, and by a corresponding but lower range, the end of the heights
of Morillas on the west.
But the Bayonne chaussée is by no means the only road in the
Vittoria upland. The city is the meeting point of a number of second-
class and third-class routes, debouching from various subsidiary
valleys of the Pyrenees and leading to various towns in Navarre or
Biscay. Of these the chief were (1) the Salvatierra-Pampeluna road,
running due east, and then crossing from the valley of the Zadorra to
the upper waters of the Araquil, by which it descends into Navarre.
This was a route practicable for artillery or transport, but narrow, ill
repaired, and steep—eminently not a line to be taken by a large
force in a hurry; (2) the main road to Bilbao by Villareal and Durango,
a coach road, but very tortuous, and ascending high mountains by
long curves and twists; (3) the alternative coach route to Bilbao by
Murguia and Orduña, easier than the Villareal road in its first section,
but forced to cross the main chain of the Pyrenees by difficult
gradients before descending into Biscay; (4) a bad side road to the
central Ebro, going due south by Trevino and La Guardia to Logroño;
(5) a similar route, running due east from Subijana on the Bayas to
the bridges of Nanclares three miles up-stream from the defile of
Puebla. At the opening of the battle of Vittoria Graham’s column was
already across the Murguia-Bilbao road, and in its earliest advance
blocked the Durango-Bilbao road also. Thus the only route beside
the great chaussée available for the French was that to Salvatierra
and Pampeluna. The road to Trevino and Logroño was useless, as
leading in an undesired direction.
In addition to these five coach roads there were several country
tracks running from various points on the Bayas river to minor
bridges on the Zadorra, across the lofty Monte Arrato, the watershed
between the two streams. It was these fifth-rate tracks which
Wellington used on the battle-day for the advance of some of his
central columns, while Hill on the right was forcing the defile of La
Puebla, and Graham on the left was descending from Murguia on to
the bridges of the upper Zadorra north-east of Vittoria.
Having their troops safely concentrated east of the Zadorra on
the evening of June 19, Joseph and Jourdan made up their minds to
stand on the position behind that river, even though Clausel had not
yet come up, nor sent any intelligence as to the route by which he
was arriving. Aides-de-camp were searching for him in all directions
—but nothing had yet been ascertained, beyond the fact that he had
started from Pampeluna on June 15th, marching on Logroño[539].
There was a high chance that some one of many missives would
reach him, and turn him on to Vittoria. But the idea that Clausel must
now be very near at hand was less operative in compelling Joseph to
fight than the idea that he must at all cost save the vast convoys
accumulated around him, his treasure, his military train, his
ministers, and his refugees. He was getting them off northward by
the high road as fast as he could: one convoy marched on the 20th,
under the charge of the troops of the Army of the North who had
formed the garrison of Vittoria, another and a larger at dawn on the
21st, escorted by the whole of Maucune’s division. It had with it
many of the Old Masters stolen from the royal palace at Madrid—the
pictures of Titian, Rafael, and Velasquez, which had been the pride
of the old dynasty—with the pick of the royal armoury and cabinet of
Natural History[540]. It is almost as difficult to make out how Joseph,
already unequal in numbers to his enemy, dared to deprive himself
of Maucune’s division of the Army of Portugal, as to discover why
Wellington left the 6th Division at Medina de Pomar. It does not
seem that the morale of the unit had been shaken by its rude
experience at San Millan on the 18th, for it fought excellently in
subsequent operations: nor had it suffered any disabling losses in
that fight. A more obvious escort might have been found in
Casapalacios’ Spanish auxiliaries, who had already been utilized for
similar purposes between Madrid and Vittoria, or in the scraps of the
Army of the North which had lately joined the retreating host. But
they remained for the battle, while Maucune marched north, with the
cannon sounding behind him all day.
When Jourdan and Joseph first arrayed their host for the
expected battle, it would seem, from the line which they took up, that
they imagined that Wellington would attack them only from the
direction of the Bayas, and paid no attention to Graham’s flanking
movement, though afterwards they wrote dispatches to prove that
they had not ignored it. For they drew up the Army of the South on a
short front, from the exit of the defile of Puebla on the south to the
bridge of Villodas on the north, a front of three miles, with D’Erlon’s
two divisions in second line on each side of the village of Gomecha,
two miles farther back, and the Army of Portugal and the King’s
Guards as a third line in reserve about Zuazo, not far in front of
Vittoria, along with the bulk of the cavalry. This order of battle, as a
glance at the map shows, presupposed a frontal attack from the line
of the Bayas, where Wellington was known to be. It was ill-suited to
face an attack from the north-west on the line of the Zadorra above
Villodas, and still more so an attack from the due north by the roads
from Orduña and Murguia. On the morning of the 20th cavalry
reconnaissances went out to look for the Allied Army—they reported
that the camps along the Bayas above Subijana Morillos did not
seem very large, and that on the Murguia road they had fallen in with
and pushed back Longa’s irregulars, obviously a Spanish
demonstration[541]. ‘No indication being available of the details of a
projected attack, and further information being unprocurable, only
conjectures could be made[542].’
It is interesting to know from the narrative of Jourdan himself
what these conjectures were. ‘Wellington,’ he writes, ‘had shown
himself since the start of the campaign more disposed to manœuvre
his opponents out of their positions, by constantly turning their right
wing, than to attack them frontally and force on a battle. It was
thought probable that, pursuing this system, he would march on
Bilbao by Orduña, and from thence on Durango, so as to force them
to fall back promptly on Mondragon[543], in order to retain their
communications with France. He might even hope to force them to
evacuate Spain by this move, because it would be impossible to feed
a great army on that section of the Pyrenees. The King, knowing that
Clausel was on the move, had little fear of the results of a march on
Bilbao, for on receiving Clausel’s corps he would be strong enough
to take the offensive himself, and would strike at Wellington’s
communications. It did not escape him that if the enemy, instead of
wasting more time on flank movements, should attack him before the
arrival of Clausel, he was in a perilous position. For there was little
chance of getting the better of an adversary who had about double
numbers, and a lost battle would cut off the army from the road to
France, and force it to retire on Pampeluna by a road difficult, if not
impracticable, for the train and artillery of a great host. To avoid the
risk of an instant attack from Wellington, ought we to fall back and
take up the position above the pass of Salinas?[544] But to do this was
to sacrifice the junction with Clausel, who was expected on the 21st
at latest. And how could the army have been fed in the passes? The
greater part of the cavalry and the artillery horses would have had to
be sent back to France at once—famine would have forced the
infantry to follow. Then the King would have been accused of
cowardice, for evacuating Spain without trying the fortune of battle.
To justify such a retreat we should have had to be certain that we
were to be attacked before the 22nd, and we considered that, if
Wellington did decide to fight, it would be unlikely that he could do so
before the 22nd, because of the difficulty of the roads which he had
taken. After mature consideration of the circumstance the King
resolved to stand fast at Vittoria.’
Putting aside the gross over-estimate of Wellington’s strength—
he fought with a superiority of 75,000[545] to 57,000, not with two to
one—the main point to note in this curious and interesting argument
is its defective psychology. Because Wellington had hitherto avoided
frontal attacks, when flank movements suited him better, was it safe
to conclude that he would do so ad infinitum? That he was capable
of a sudden onslaught was obvious to every one who remembered
the battle of Salamanca. Why, if he were about to repeat his previous
encircling policy, should he go by Orduña, Bilbao, and Durango,
rather than by the shorter turn Osma-Murguia-Vittoria? Apparently
the French staff underrated the possibilities of that road, and took the
presence of Longa upon it as a sign that it was only to be used for a
Spanish demonstration[546]. Should not the speed with which
Wellington had traversed the detestable country paths between the
Arlanzon and the Ebro have served as a warning that, if he chose to
push hard, he could cover at a very rapid rate the rather less
formidable tracks north of the Zadorra? In short, the old marshal
committed the not uncommon fault of making false deductions from
an imperfect set of premises. It is much more difficult to say what
should have been his actual course under the existing circumstances
of June 20. Napier holds that he might still have adopted Reille’s old
plan of June 12 and June 18, i.e. that he should have thrown up the
line of communication with France by the high road, have made
ready to retreat on Pampeluna instead of on Bayonne, and have
looked forward to making Saragossa his base. After having picked
up first Clausel and then so much of the Army of Aragon as could be
collected, he might have got 100,000 men together and have started
an offensive campaign[547]. This overlooks the impossibility of getting
the convoys and train safely along the bad road from Vittoria to
Pampeluna, and the difficulty of making Saragossa, where there
were no great accumulations of stores and munitions, the base of an
army of the size projected. All communication with France would
have been thrown on the hopelessly long and circuitous route from
Saragossa to Perpignan, for the pass by Jaca was impracticable for
wheeled traffic. Certainly Joseph would have had to destroy, as a
preliminary measure to a retreat via Salvatierra or Pampeluna, the
greater part of his train. And what would have become of his
wretched horde of refugees?
Another school of critics—among them Belmas—urge that while
it was perfectly correct to cling as a primary necessity to the great
road to France, Vittoria was not the right point at which to defend it,
but the pass of Salinas. Jourdan’s objection that the cavalry would
be useless in the mountains is declared to have little weight, and his
dread of famine to be groundless. For Wellington could not have
remained for many days in front of the passes—he must have
attacked at once a very formidable position, or Foy and the other
troops in Biscay would have had time to join the King; and with
15,000 extra bayonets the French would have been hard to dislodge.
The danger to Clausel would have been not very great, since
Wellington would not have dared to detach a force sufficient to crush
him, while the main French army was in his front, intact and ready to
resume the offensive. And on the other flank Biscay, no doubt, would
have been exposed to an invasion by Giron’s Galicians, when Foy
had withdrawn its garrisons to join the main army. But it is
improbable that this movement would have been backed by any
large section of the Anglo-Portuguese force; for Wellington, as his
previous action showed, was intending to keep all his own old
divisions in one body. He would not have risked any of his own
troops between the Pyrenees and the sea, by trying to thrust them in
on the back of the French position, to Durango or Mondragon. And if
Giron alone went to Bilbao and Durango, his presence in that
direction, and any threats which he might make on the King’s rear,
would be tiresome rather than dangerous.
Be this as it may, whatever the general policy of Jourdan and
Joseph should have been, their particular dispositions for occupying
the Vittoria position were very faulty. It was as well known to every
practical soldier then as it is now, that a normal river-position cannot
be held by a continuous line of troops placed at the water’s edge.
For there will be loops and bends at which the ground on one’s own
side is commanded and enfiladed by higher ground on the enemy’s
side. If troops are pushed forward into such bends, they will be
crushed by artillery fire, or run danger of being cut off by attacks on
the neck of the loop in their rear[548]. Unless the general who has to
defend a river front is favoured with a stream in front of him
absolutely straight, and with all the commanding ground on his own
side (an unusual chance), he must rather look to arranging his army
in such a fashion as to hold as strong points all the favourable
sections of the front, while the unfavourable ones must be watched
from suitable positions drawn back from the water’s edge. By
judicious disposition of artillery, the occupation and preparation of
villages, woods, or other cover, and (if necessary) the throwing up of
trenches, the enemy, though he cannot be prevented from crossing
the river at certain points, can be kept from debouching out of the
sections of the hither bank which he has mastered. And if he loads
up the captured ground with heavy masses of troops which cannot
get forward, he will suffer terribly from artillery fire, while if he does
not hold them strongly, he will be liable to counter-attacks, which will
throw the troops who have crossed back into the river. The most
elementary precaution for the general on the defensive to take is, of
course, to blow up all bridges, and to place artillery to command all
fords, also to have local reserves ready at a proper distance behind
every section where a passage is likely to be tried[549].
We may excuse Joseph and Jourdan for not entrenching all the
weak sections of their front—hasty field works were little used in the
Peninsular War; indeed the trenches which Wellington threw up on
the second day of Fuentes de Oñoro were an almost unique
instance of such an expedient. But the other precautions to be taken
were commonplaces of contemporary tactics. And they were entirely
neglected. The front liable to attack was very long for the size of the
defending army: whole sections of it were neglected. Bridges and
fords were numerous on the Zadorra: incredible as it may seem, not
one of eleven bridges between Durana to the north and Nanclares to
the south was blown up. The numerous fords seem not to have been
known accurately to either the attacking or the defending generals,
but some of the most obvious of them were ignored in Joseph’s
original disposition of his troops. Several alike of bridges and fords
were lightly watched by cavalry only, with no further precaution
taken. What is most astonishing is to find that bridges which were
actually used by French exploring parties on June 20th, so that their
existence was thoroughly realized, were found intact and in some
cases unguarded on the 21st[550]. The fact would seem to be that the
King’s head-quarters staff was dominated by a false idea: that
Wellington’s attack would be delivered on the south part of the river
front, from the defile of Puebla to the bridge of Villodas; and that the
troops discovered on the Murguia road were Longa’s irregulars only,
bound on a demonstration. An acute British observer remarked that
the French position had two main defects—the more important one
was that it faced the wrong way[551]: this was quite true.
The final arrangement, as taken up on the morning of June 20
was that the Army of the South arrayed itself so as to block the
debouches from the defile of La Puebla and the bridges immediately
up-stream from it—those of Nanclares and Villodas. Gazan did not
occupy the entrance of the defile of La Puebla—to do so he must
have stretched his line farther south and east than his numbers
permitted. But he held its exits, with some voltigeur companies from
Maransin’s brigade, perched high up on the culminating ground
immediately above the river.
From this lofty point on the heights of Puebla his first line
stretched north-eastward along a line of low hills, past the villages of
Subijana (low down and not far from the Puebla heights) and Ariñez
(on the high road, at the spot where it crosses the position), a
dominating point on the sky-line. The right wing nearly reached to
the Zadorra at the spot where it makes the ‘hairpin bend’ alluded to
above. But the solid occupation by formed troops did not extend so
far: there were only a cavalry regiment and three guns watching the
bridge of Mendoza[552], and a single company of voltigeurs watching
that of Villodas. The disposition of the units was, counting from the
French left, first Maransin’s brigade occupying Subijana, next
Conroux’s division in a single line on the slopes to the north of the
village of Zumelzu, with a battalion holding a wood in front on lower
ground. Then came Daricau’s division, one brigade in front line
across the high road, the other brigade (St. Pol’s) in reserve north of
the road, and in rear of Leval’s division, which was deployed on the
prominent height in front of the village of Ariñez, which formed the
end of the main position. Between Leval and the Zadorra there was
only Avy’s few squadrons of light horse, watching the bridge of
Mendoza. Nearly a mile to the rear of the main line Villatte’s division
stood in reserve, on the heights on the other side of Ariñez, and with
it Pierre Soult’s cavalry. The position was heavily gunned, as artillery
support went in those days. Each of the three front-line divisions had
its battery with it—a fourth belonging to Pierre Soult’s cavalry was
placed on a knoll in front of the position, from which it could sweep
the approaches from the bridge of Nanclares. In reserve behind
Ariñez was not only Villatte’s battery, but two others drawn from the
general artillery park, and during the early stage of the battle another
pair of batteries, belonging to the Army of Portugal, were sent to join
Leval’s divisional guns on the north end of the position. Gazan had
therefore some 54 pieces in hand, without counting the half-battery
of horse artillery belonging to Digeon’s dragoons, which was absent
far to his extreme right, by the banks of the upper Zadorra.
Three-quarters of a mile behind Gazan’s reserves, the whole
Army of the Centre was deployed on each side of the high road,
Darmagnac’s division north of it in front of Zuazo, Cassagne’s
division south of it, level with Gomecha. Treillard’s dragoons were
behind Cassagne; Avy’s chasseurs (as has been mentioned above)
were watching the Zadorra on the right.
In the original order of battle of the 20th the Army of Portugal had
been in third line, a mile behind the Army of the Centre, on a level
with the villages of Ali and Armentia. But when Digeon’s dragoons

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Health Crisis Management in Acute Care Hospitals:

Leadership and Governance in Primary Healthcare: An

Mauled Lessons Learned from a Grizzly Bear Attack 1st

Near Misses and Lessons

ISBN 978-3-030-77653-4 ISBN 978-3-030-77654-1 (eBook)

© Springer Nature Switzerland AG 2021

Ana Maria Crawford, MD, MSc, FASA

Canary Is. Cairo

CABO VERDE Nouakchott

SIERRA D'IVOIRE Addis Ababa

LEONE Yamoussoukro Accra

LIBERIA Novo CAMEROON Bangui Juba

Lilongwe Mayotte Is.

Lake Harare Carajos

Kariba Antananarivo MAURITIUS

The boundaries and names shown and the designations used

Based on UN map Department of Field Support

Algeria is a North African country with a Mediterranean coastline and a Saharan

Angola is a Southern African nation whose varied terrain encompasses tropical

Benin is a French-speaking West African nation. It is a birthplace of the vodun (or

Botswana, a landlocked country in Southern Africa, has a landscape defined by the

Burkina Faso, officially the People’s Democratic Republic of Burkina Faso, is a

Cameroon, on the Atlantic, is a Central-West African country of varied terrain and

Central African Republic (CAR)

The Central African Republic is a landlocked country in Central Africa. Armed

post-independence history has been marked by instability and violence, stemming

Congo, Democratic Republic of the Congo

Congo, Republic of the Congo

The Republic of the Congo, also called Congo-Brazzaville, is a central African

Cote d'Ivoire (Ivory Coast)

Djibouti, on the Horn of Africa, is a mostly French- and Arabic-speaking country of

Eswatini (formerly Swaziland)

Eswatini is a landlocked monarchy in Southern Africa. It is bordered by Mozambique

In 1960 France granted independence under President Felix Houphouet-Boigny. He

Lesotho, a high-altitude, landlocked kingdom encircled by South Africa, is criss-

Malawi, a landlocked country in southeastern Africa, is defined by its topography of

Mauritania is an Islamic in Northwest Africa. It is the eleventh largest sovereign

Namibia is a country in southwest Africa and is distinguished by the Namib Desert

contain German colonial-era buildings such as Windhoek’s Christuskirche, built in

Rwanda, formerly Ruanda, officially the Republic of Rwanda, is a landlocked coun-

Sao Tome and Principe

Senegal, officially the Republic of Senegal, is a country in West Africa which is on

Somalia, officially the Federal Republic of Somalia, is a sovereign country located

Sudan, officially the Republic of Sudan, is a country in Northeast Africa. Bordered

Uganda is a landlocked country in East Africa whose diverse landscape encom-

Zambia, in southern Africa, is a landlocked country of rugged terrain and diverse

Other Countries Outside of Africa Mentioned Are Follows

Borneo, a giant, rugged island in Southeast Asia’s Malay Archipelago, is shared by

Costa Rica is a rugged, rain-forested Central American country with coastlines on

Guyana, officially the Co-operative Republic of Guyana, is a country on the north-

Nepal, officially the Federal Democratic Republic of Nepal, is a country in South

Central African Republic (CAR)

Congo, Democratic Republic of the Congo

Congo, Republic of the Congo

Cote d'Ivoire (Ivory Coast)

Eswatini (formerly Swaziland)

Sao Tome and Principe

Other Countries Outside of Africa Mentioned Are Follows

Case 1: Now What Will You Do?�� 1

Case 20: The One-Eyed Patient�� 59

Case 47: What an Airway Surprise�� 153

Case 77: Technical Staff must be Well Trained �� 257

Introduction to Three Stories�� 307

Solution (In No Particular Order)