HISTORY AND DEVELOPMENT OF ANESTHESIOLOGY (WITH RESUSCITATION AND INTENSIVE MEDICINE) IN REPUBLIC OF MACEDONIA

Vladimir Andonov¹, Marija Sholjakova¹, Jordan Nojkov¹, Zorka Nikolova-Todorova², Mirjana Shosholcheva², Andrijan Kartalov²,  Biljana Kuzmanovska²

¹Professor pensioner, independent researcher

²Clinic of Anesthesiology, Reanimation and Intensive Care, Faculty of Medicine Ss Cyril and Methodius University, Skopje, Republic of Macedonia

Corresponding author:

Abstract

Aim: To present a chronological overview of the most important events and actors that marked the history of anesthesiology and intensive treatment in R. Macedonia since its beginnings in 1950s.

Method: Retrospective study based on archive materials, published literature and jubilee publications, as well as the memories of individuals who worked in the field of anesthesiology in the past period.

Results: Between the two World Wars the first anesthesia procedures were handled by surgeons. After the World War II, the development of anesthesia in R. Macedonia could be divided in two periods: before 1965 and after 1965. Before 1965 anesthesia was mainly given by technicians trained on courses, and after this year anesthesiology was taken over by anesthesiologists who specialized at the Faculty of Medicine in Skopje. The number of anesthesiologists was 100 in 1985, and today it exceeds 250. The most important figures in the history of the Macedonian anesthesiology are: Dr. Risto Ivanovski, who worked from 1954-1978, and Prof. Dr. Vladimir Andonov, who worked as anesthesiologist from 1965-1999. Both of them are doyens who contributed a lot to the development of anesthesiology service and education of anesthesiologists in R. Macedonia. The intensive treatment had started in 1955, but in real terms it has been performed since 1966, when artificial ventilators have been introduced. Modern Intensive Care Department was opened at the Surgical Clinic in 1995 and it was followed in other hospitals in the state. The Department of Anesthesiology has existed since 1975, and it has made a huge contribution to the education of professionals who apply modern principles in emergency medicine and intensive care.

Conclusion: From modest beginnings in the 1950s, anesthesiology today in Macedonia has developed well organized activity that successfully follow the trends of modern medicine in the field of anesthesiology, resuscitation, intensive care and pain treatment.

Keywords: anesthesiology, resuscitation, intensive care, pain treatment, Republic of  Macedonia, history.

Introduction:

Anesthesiology is a young medical discipline and has become as a practical need of modern surgery [1]. Its origins are linked with the name of the ingenious American dentist William Morton, who performed the first demonstration of anesthesia in the world by inhaled ether as a surgical anesthetic, in Boston, USA, in 1846. According to a verified documentation there is an interesting datum that Croatian anesthesiologists performed the first anesthesia with ether on the Balkans [2, 3] in the region of Zadar 6 months later, namely on March 13, 1847. Anesthesia was given for a long period of time by medical technicians (anesthetists) under the control of surgeons everywhere in the world. As far as in 1947 anesthesiology was introduced as an autonomous medical specialty in Europe. However, during the following decades, the enormous development of surgery, the increasing number of invasive procedures, and the development of artificial ventilation have placed this discipline in the center of modern medicine, without which no modern hospital could be imagined. So, today anesthesia is a constituent part of the healthcare mission of each high-technology medical institution and represents an irreplaceable part in the delivery of modern medical practice in surgery, intensive care, and pain treatment in patients.

The main aim of this article is to present a chronological overview of the most important events and activities in the history of anesthesiology together with intensive treatment in R. Macedonia since its beginnings in 1950s. The second aim is to emphasize the role of the main persons that marked the development of anesthesiology and resuscitation in our country.

Method:

Retrospective study based on archive materials, published literature, University bulletins and jubilee publications, as well as the memories of individuals who worked in the field of anesthesiology in the past period in R. Macedonia.

Results and discussion:

Initial historical data related to health care and anesthesiology in R. Macedonia

Concerning the past, it deserves attention to dedicate a few words to the fresco drawing in the church St. Spas in Skopje where it is shown how God breathes air into the mouth of Adam, the first human. Xylographers worked on this fresco drawing according to the data from the Bible - the first book of Moses 1.2.7. This historical fact is applied in the contemporary approach of resuscitation by the method of breathing (inhaling) air to the victim/patient “mouth to mouth”.

Data for the use of general ether anesthesia on the territory of Serbia originated from 1896 [3]. It might be connected with the situation on the territory of the present Republic of Macedonia, which was a constituent part of the Ottoman Empire, and later of the Kingdom of Yugoslavia. We could not find written documents, but we received indirect verbal information about the types of anesthesia that were used in the 1920s and the period which followed up to the end of the Second World War. By oral history method, Prof. V. Andonov provided important information about the type of anesthesia in Skopje in that period. He was told from Prof. A. Stavridis about the personal experience with anesthesia of his mother Vera Stavridis. When she read an article in the weekly magazine “Ilustrirana Politika”, in mid 1970s, about the spinal anesthesia administered by Prof. Dr L. Shendov for the artificial hip operation performed in Skopje by the orthopedic surgeon Acad. Dr Lj. Serafimov, she reminded herself that as a young girl she had an attack of acute appendicitis in 1940. The operative intervention was done by her future husband, Dr. Sotir Stavridis. But, she remembered that before the intervention, the surgeon had administered one injection in the spine and one injection in the region of the operative field. It might be concluded that the injection administered into the spine was spinal (sub-arachnoid) anesthesia in addition to the local anesthetic administered in the region of the operative intervention.

In any case, this period of development of anesthesia, in general, remains unresolved and it is necessary to search for data and information in historical and private archives about the ways surgeons at that time gave anesthesia. There are some data that solutions of cocaine (cocaine sol.), percaine and novocain were used as local anesthetics for infiltrative local anesthesia and regional spinal anesthesia. Certainly, at that period general anesthesia, in the first instance with ether and later chloroform, pentothal and chlorethyl started to be used. It should be noted that anesthesiology procedures were performed by younger surgeons, as well as by trained secondary educated medical staff.

Anesthesiology development in R. Macedonia after the Second World War

Anesthesiology with resuscitation and intensive care, as a specialty in medicine in the world and in our country, experienced expansive development after the World War II, thus achieving great progress [3]. The events that are important for the history of the Macedonian anesthesiology will be enumerated in chronological order.

In the first years after the World War II, when there was a need for an increased number of operative interventions, anesthesia predominantly was given by trained secondary educated medical staff (we would say very skillful).  From 1960 an organized approach for education of technicians started through longer courses with practical training which lasted for six months. The education took place at the department of anesthesia and resuscitation at the Surgical Clinic in Skopje. For the needs of the military sanitation service, similar education was performed at the Military Hospital in Skopje, too. Later on, around 1965 and onward, the duration of the courses lasted for a year. Such an approach was imposed because the number of doctors in R. Macedonia was very small and insufficient for the complex health needs of the population. Even the suggestions of the World Health Organization at that time supported this approach recommending that anesthesia should be given by medical technicians (anesthetist) under the control of surgeons.

 For this period of the history of anesthesia, when anesthetists performed this work, the choice of ether as an inhalation anesthetic was crucial even in the hands of incompletely trained individuals because ether has a wide range of anesthetic effect until it provokes severe complications. It is simple to use ether as it can be applied only by using the “Schimelbuch's” mask. This method of anesthesia was called “pocket” anesthesia (the bottle with ether in one pocket and the mask in the other one). Certainly, the most inconvenient side effect of it was irritable inhalation, causing a patient’s feeling of suffocation. It was not pleasant and safe even for the anesthetists who applied ether anesthesia, because they breathed a certain amount of ether and slept for hours after duty. Besides ether, chlorethyl (as a local anesthetic) was used, and rarely chloroform, too. Also this period was marked for the use of pentothal (barbiturate with fast and short effect).”

Some of the anesthetists who worked for decades at the surgical hospitals in R. Macedonia in 1960s and 1970s, and Prof. Dr. Vladimir Andonov personally worked with them and mentioned their names are: Marche Drakulevska (later graduated medicine and specialized anesthesiology), Vojo Siljanovski, Stojan Brzakov, Duska Arsova and many others.

In Europe, the specialization for a physician-anesthesiologist was firstly introduced in 1947. As far as to 1947 anesthesiology was considered an "easy learning" branch that could be learned in a few months, "in a course". In R. Macedonia, it was so by the end of 1960s when the doctors, specialists in anesthesiology, finally took full responsibility in the area of anesthesiology, reanimation and intensive care.

From the earliest beginnings of the contemporary anesthesiology in R. Macedonia, in mid 1950s, the central figure is Dr. Risto Ivanovski (Box 1).

Box 1

Dr. Risto Ivanovski was born on Apr 15, 1914 in Prilep, R. Macedonia. He completed High School in Bitola and graduated at the FM-Belgrade in 1942. After the liberation he applied to be a volunteer in the Yugoslav People’s Army. He completed two-year specialization in 1947 and became anesthesiologist for the needs of the Army in Belgrade. A few months later he moved to Zagreb to work i na few hospitals up to 1954 when he came back to Skopje. He was employed at the Military Hospital-Skopje which was the teaching base of the FM-Skopje at that time. Dr. Risto Ivanovski was elected as an Assistant Professor at the FM-Skopje in 1959 and participated in the teaching process of anesthesiology in the framework of the subject of surgery. He was also a visiting professor for anesthesiology in Prishtina. His contribution to the development of anesthesiology in R. Macedonia is enormous. He was one of the three educated anesthesiologists in Yugoslavia, since 1948.  From 1954, when he came in Skopje, he developed the anesthesiology as an independent medical field. In 1955 together with Dr. Djurgja Klajic performed the first endo-tracheal intubation in Macedonia at the Surgical Clinic. He was teacher of the first generations of anesthetists and later the teacher of the doctors-anesthesiologists, too. - He stayed at the Military Hospital up to 1978, when he was retired as a colonel. Dr. Risto Ivanovski died in Skopje in 2013 at the age of 99.

In 1946, Yugoslavia as a part of the antifascist coalition, received aid in medical personnel and equipment (anesthesiology machines from American origin - Forreger) through  United Nations Relief and Rehabilitation Administration (UNRRA) in order to be able to help to the numerous and badly treated war injuries that led to disabilities of different kinds in many young people.

Dr. Patric Shackleton and Dr. Rasel Davis from Great Britain were among the well-known anesthesiologists who came to Yugoslavia from the western countries. So, the education of the first group of Yugoslav doctors in the field of anesthesiology started at Prof. Arneri’s Clinic for Plastic Surgery in Belgrade [8-10]. Dr. Risto Ivanovski was in this group and he is considered to be the founder of anesthesiology in R. Macedonia and Croatia [2, 4, 11].

From 1954, Dr. Ivanovski and Dr. Gindzberg, a well-known thoracic surgeon, were sent together to the Military Hospital in Skopje to organize the modern surgical and anesthesiology service in Macedonia. For this period of his life Dr. Ivanovski said in his memories: "Then the Military Hospital in Skopje gathered several good surgeons (Dr. Pakik, Dr. Pishat, and Dr. Bedekovic) so thoracic and abdominal surgery started. The patients for thoracic surgery were mainly with tuberculosis of the lungs, so thoracoplasty, lobectomy and pulmectomy were performed. All of them were "high risk" patients, so I had to use some new methods for that time, for example "emphasized narcosis" with Laboret’s cocktail and (or) immersion hypothermia. In those years we applied the highest number of anesthesia procedures in hypothermia in Yugoslavia ... ".

Dr. Gjurgja Klajic has an important role in the beginnings of modern anesthesia in R. Macedonia. She was a part of the team of surgeons lead by Prof. B. Oberhofer, who were send to Skopje in 1954 from Croatia and other republics of Yugoslavia, with the purpose to develop surgery and improve the health care in the country [12]. She was educated for anesthesia in Zagreb and gave the first general anesthesia in the operative theater at the Surgical Clinic in Skopje. She also, with Dr. R. Ivanovski, performed the first endo-tracheal intubation for general anesthesia. 

Certainly, the most important person in the development of anesthesiology as a science in R. Macedonia is Prof. Dr. Vladimir Andonov (Box 2), [13-16].

Box  2

The first specialists in anesthesiology in Macedonia who served for the needs of the Surgical Clinic in Skopje in 1965 were Dr. Vladimir Andonov and Dr. Vujica Stojanovic. At the same year Dr. Pavle Mitrevski was employed at the Medical Center in Bitola. The program for specialization lasted for three years. Doctors who became specialists in anesthesiology in the subsequent years until 1974 are presented in Tab. 1.

Table 1. The first group of anesthesiologists who completed specialization at the Faculty of Medicine in Skopje in the period from 1965-74 [17]

Until 1985, the number of doctors - anesthesiologists exceeds 100, while today in Macedonia there are more than 250 anesthesiologists [17].

The role of WHO in development of anesthesiology in R. Macedonia

It is important to mark that in 1960s WHO organized courses of anesthesia for doctors from Member States, with scholarships for with professional stays in Denmark. During this time in Denmark, a great number of patients remained with bulbous paralysis after the great epidemic of poliomyelitis in the late 1950s. In order to treat them, the first artificial ventilation techniques were developed there and later, these techniques became the basis of modern intensive care. Several doctors from Macedonia were sent and took one-year course in anesthesiology in Copenhagen, Denmark: Dr. Spasko Guchev (a surgeon), Dr. Pavle Mitrevski, Dr. Ljupcho Vasilev, and Dr. Nikola Serafimovski.

Dr. Spasko Guchev was later the first Head of the department of anesthesia at the Surgical Clinic, Dr. Pavle Mitrevski continued to work and develop anesthesiology in Bitola, Dr Ljupcho Vasilev remained as urologist, and Dr. Nikola Serafimovski served as anesthesiologist in the City Surgical Hospital in Skopje, from where he went to work in Denmark. This period was also marked by the professional stays of a few specialists in the UK. Dr. Risto Ivanovski was awarded a British Council scholarship for specialization in Edinburgh. Dr Vladimir Andonov spent one-year specialization in St George's Hospital in London. Later in 1983, Dr. Lazar Shendov stayed in St Thomas Hospital and Dr. Marija Sholjakova spent one year at the Department of Anesthesiology of the Royal Postgraduate Medical School, Hammersmith Hospital.

The beginnings of modern anesthesia in R. Macedonia

Modern anesthesia in R. Macedonia began in 1965 when new, modern drugs for anesthesia were introduced in everyday practice by the first doctors specialists in anesthesiology. Besides ether, some new inhaling anesthetics were introduced, i.e. Halothane (Fluothane) and Trilene. Pentothal - a barbiturate with quick and short effect and succinyl choline (Leptosuccin), as depolarized relaxant agent started to be used. For a certain period the gas anesthetic, cyclopropane (C3H6), was used. Cyclopropane was an anesthetic with good characteristics, but because of its potential explosiveness in conditions of sparkling, its period of use was limited. Curare (D-tubocurare) started to be used during this period, and it was later replaced by another non-depolarized relaxant, namely Flaksedil.  The so-called "azeotropic mixture" was also present with volumes of ether (2/3) and Halothane (1/3). Nitric oxide started to be used routinely in early 1970s, when it became easy available because its production started in Slovenia. Ketamine (Ketalar) and Viadril (Viadril-G) appeared then. In early 1970s neurolept anesthesia (NLA) started to be used as a combination of the analgesic Fentanyl and the neurolepetic component Dehydrobenzperidol.

The use of non-depolarized relaxant pancuronium bromide (Pavulone) took dominant place in improving the quality of anesthetics in late 1970s, and even in 1990s the palette of miorelaxants was extended with other drugs (Vecuronium, Atrakurium, Cisatrakurium etc.). These years were also characterized by the modification of neurolept anesthesia in balanced anesthesia when the neuroleptic component was replaced by benzodiazepines. In the 1990s, for the introduction to anesthesia Propofol was introduced instead of barbiturates. In many Macedonian hospitals combinations of opioid analgesics with volatile anesthetics were implemented. In 1992 Isoflurane was introduced for routine use and it became dominant together with Halothane up to the early years in two thousand, when the use of Sevoflurane started.

After introducing the NLA the monitoring in the operating rooms slowly began to improve, first at the University Clinics, and then in the Medical Centers. ECG monitoring became obligatory and later pulse oximetry, and soon it started to be expanded monitoring (capnography etc.). The year 1997 is significant for improving of patient safety because in Bitola, Dr. Dimitar Sekulovski opened the first Anesthesiology Out-patient clinic for preoperative assessment. In the next ten years such organizational unit has become an obligatory part of each Anesthesiology Department.

The use of local/regional anesthesia in R. Macedonia is in accordance with the global trends in this area. From modest beginnings before the World War II, the era of expansion of new drugs and equipment for general anesthesia came in the 1960s, and the regional anesthesia techniques were put on the second place.

Modern regional anesthesia started by performing central neuroaxial blocks, mostly spinal anesthesia. The Clinic for Orthopedic Surgey in Skopje is important concerning its large scale use, where Prof. Dr. Lazar Shendov introduced spinal anesthesia in daily use in 1975 [18]. Later the group of orthopedic anesthetists (P. Georgiev, J. Nojkov, J. Nancheva) improved the quality of spinal anesthesia and expanded its use in pediatric patients. The first epidural blocks for painless childbirth have been given by Dr. Srboljub Mitrovic at the Clinic of Gyneacology and Obstetrics in Skopje in the late 1980s, but the obstetricians opposed this use because of continuation of deliveries and complications. Eventhough, in the second half of 1990s, these interventions, as well as performing Cesarean section in spinal anesthesia, became a routine, firstly at the Clinic of Gynecology and Obstetrics - (Prim. Dr. Lidija Grbevska and Prim. Dr. Atanas Sivevski), and then inland. The first epidural catheter was placed in 1983 by Prof. Dr. V. Andonov, and since then this technique has been used mostly in combination with general anesthesia for extensive surgery or in the treatment of pain in patients. Later on in the same year (1983), Prof. Dr. M. Sholjakova applied morphine in the epidural space for postoperative analgesia. In the recent years, the use of regional anesthesia and analgesia have been expanded particularly the peripheral blocks.

The anesthesia for kidney transplantation was introduced in 1980s by Dr. Rose Bashevska-Ivanovska together with Dr. Vera Shikova. Cadaver transplantation has been developed later and Dr. Petar Duljanov, as an anesthesiologist, gave his unselfish contribution.

Cardio-anesthesia in R. Macedonia dated back to 1973, when the so-called "stress free anesthesia" (high doses of morphine or fentanyl) was applied. The first anesthesia for open heart surgery was given by Prof. Dr. V. Andonov and later until 1990s Prof. Dr. Trajanka Trajkovska gave 74 anesthesia procedures in a series. Also, her particular contribution was the introduction of anesthesia techniques for operations of the trachea and esophagus.

The period from 1992-2014 is characterized with very fast development of modern anesthesiology in R. Macedonia. Many new and innovative methods in the field of anesthesiology and intensive care were introduced in support of surgical and other procedures at various university clinics at the Faculty of Medicine in Skopje and other institutions in Skopje and in R. Macedonia (Tab. 2).

Table 2 [18-24]

Table 2. Innovations in the field of anesthesiology and intensive care introduced in R. Macedonia in the period from 1992-2014 [18-24]

In 1992, the first laparoscopic cholecystectomy was performed at the Clinic for digestive surgery and the anesthetic support was provided by Dr. Vera Shikova.

The first block of the brachial plexus was applied in 1994. If we exclude the old beginnings, when Novocaine, procaine, tropocaine (Prilep, 1953) [25] were used as local anesthetics, the new era of local/regional anesthesia began with the use of lidocaine and from the 1990s with the use of bupivacaine, too. Caudal block was first applied by the pediatric anesthetists (Dr. V. Milosheva, Dr. B. Velkovski, Dr. B. Popovska Dr. A. Kartalov, and Dr. Lj. Donev) in the late 1990s.

The first Center for Treatment of Chronic Pain, as a separate unit, was opened at the Clinic for Orthopedic Surgery by Prof. Dr. L. Shendov in 1997. Today the treatment of pain has been realized in many institutions, including private hospitals, but generally it is still insufficient compared to global trends.

After 2000, several private hospital complexes ("Philip II", "Remedika", "Sistina" etc.) have been established successively. It caused “brain drain” of experienced anesthesiologists of the middle generation from many public health institutions, but primarily from the University Clinic for Anesthesia, Reanimation and Intensive Care (KARIL). This didn’t reflect remarkably on the quality and quantity of anesthesia and intensive care. Although there was drain of half of the specialists in anesthesiology it should be noted that in this period the scope of work increased, so Prof. Z. Nikolova Todorova supported the specialists who stayed in KARIL. These circumstances are certainly an important part in the history of anesthesiology.  Generations who followed deserve special appreciation because they overcame this artificially created personnel deficit, and in a short period of time the situation improved. On the other hand, private health care facilities with investments in equipment, combined with highly professional medical staff attracted by higher incomes, led to a qualitatively new level of development of modern anesthesia departments and levels of services in the field of intensive treatment.

In the last decade, a series of innovations in the field of anesthesiology and intensive care has also happened, especially in the field of transplantation and cardiac surgery. Today, the Macedonian cardio-anesthesiologists successfully perform anesthesia in the private cardio-surgery hospitals - "Filip II" and "Sistina".

Development of intensive care in Macedonia

The first intensive care unit (or "shock room" - as it was called at the time) was established in 1955 as a part of the Surgical Clinic in Skopje for the needs of intensive monitoring of patients with heart operations that were performed at that time.

Beginnings in the true sense of the term "intensive care" dated back in 1966 when an Intensive Care Ward was established at the Surgical Clinic. Then a modern approach to critical patients started. Prof. Dr. Vladimir Andonov, for the first time, introduced the artificial ventilation in critical patients with ventilator (type Mainly). Later, several types of ventilators (Bird, Dragger) were provided. In the first years of artificial ventilation used on patients there were different opinions about their utility. There were loud remarks that death will take its turn for sure in these patients. A year or two should have passed while the surgeons themselves began to demand certain patients to be placed on artificial mechanical ventilation. We should point out the fact that Prof. Dr. V. Andonov in cooperation with grad. eng. J. Andonov invented two prototypes of the so-called transistorized respirator (2xA). This respirator was patented on a federal level. In the subsequent years, intensive care wards were opened in other surgical institutions (first in Bitola and in the surgical hospital of the city of Skopje), as well as in many non-surgical wards (cardiology, neonatology, pulmology, internal wards in medical centers, etc.). There was lack of specialists with experience in intensive care at the non-surgical wards, so the first generations of anesthesiologists were daily engaged in performing invasive procedures.

Establishment of the Clinic for Anesthesiology, Reanimation and Intensive Care

Intensive treatment experienced its real bloom with the establishment of the Clinic for Anesthesiology, Reanimation and Intensive Care (KARIL) in 1989. Prof. Dr. V. Andonov was the first director of KARIL. In January 1993 the new Intensive Care Unit (ICU) was established as part of the newly built facility of the Surgical Clinics. Conditions for enormous progress in the care of critically ill patients receiving mechanical ventilation were created there with the new facilities, new ventilators and monitoring of the brand Siemens. Some contemporary methods in the treatment of critically ill patients and to intensive care were introduced by Prof. Dr. Zorka Nikolova Todorova who served as Director of the ICU from 2006-2013.

Since 1993 the Clinic of Cardiology has had new ventilators for intensive care and has collaborated with anesthesiologists from KARIL in order to develop skills in the application of mechanical ventilation (Dr. Vladimir Janakievski etc.). In 1996 the City Hospital in Skopje and the Medical Centers in Bitola and Shtip equipped their intensive care wards with equipment from the company Acoma donated by the Japanese government. In the following years the intensive care wards in other hospitals in Macedonia were more or less equipped.

The Clinic for Infectious Diseases, historically had the first “tank ventilator” in the 1960s, but the introduction of mechanical ventilation as a synonym for ventilation under positive pressure was initiated by Prof. Dr. Milenkovic and his team nominated to work in the new intensive care ward. Doctors, specialists in infectious diseases were sent to ICU-KARIL (Dr. Krste Grozdanovski, Dr. Marija Cvetanovska, Dr. Valerija Kirovska, and Dr. Sanja Marinkovic) in order to learn the basic principles and procedures of intensive care and start to work independently in their new intensive care unit. During the H1N1 virus outbreak (2009-2010), this cooperation has achieved its top and gave positive results in improving the skills for performing mechanical ventilation at the Clinic for Infectious Diseases.

In October 1994, the President of R. Macedonia, Mr. Kiro Gligorov was admitted for treatment after the attempt on his life at the new facilities of the newly opened ICU of KARIL. The entire anesthesia team (10 doctors and 10 nurses) gave their professional contribution in saving the life of the President. They were continually present by his side for 24 hours and Prim. Dr. Jovan Janchulev remained his personal physician until the end of the President's life.

Patients with respiratory failure from many clinics (Neurology, Pulmology, Gastroenterology, Nephrology, Toxicology, and Pediatrics) were treated in the central unit for intensive care - KARIL besides the surgical patients. Concerning this, there were different opinions, whether in ICU only surgical patients to be treated or patients with different etiologies who need therapy with artificial ventilator to be treated also. The mutual cooperation between ICU – KARIL and the newly opened ICU at the Clinic for Pediatric Diseases should be also noted. The anesthesiologists from KARIL gave strong support to overcome the basic difficulties that the pediatricians-intensive care doctors encountered in that period.

In September 2000, a section for intensive care of neurosurgical patients (Head Prof. Dr. M. Sholjakova) has been established. That same year, by the establishment of the private cardiac surgery hospital "Filip II", the intensive treatment obtained new quality because for the first time several contemporary invasive procedures have been introduced there. For a certain period of time this hospital has served as a training base for postgraduate studies for cardio- anesthesia (2001-2007).

In 2011, the Clinic for Pediatric Surgery led by Dr. Risto Simeonov and active collaboration with Dr. Vladimir Chadikovski, opened a specialized pediatric ICU with 4 ventilators. It was a new challenge for anesthesiologists in the area of anesthesiology and intensive treatment (first liver transplantation was performed to a child, on September 12, 2011). Transplantation of kidneys in children has also become a regular practice, and since April 8, 2013 the project for State Children's cardiac surgery has started.

Special event in the development of this area of medicine is the formation of the Association for Treating of Critical Patients in the framework of the Macedonian Medical Association (MMA) in 2005. Initiated by Prof. Dr. Zorka Nikolova Todorova this Association gathers physicians dealing with this branch of medicine in several areas (surgery, neonatology, cardiology, transfusiology, etc.) in order to analyze interdisciplinary all the challenges of the specific medical fields.

Besides Prof. Dr. V. Andonov, there are other doctors who made significant contribution for the development of the intensive care in the country: Prof. Dr. Maria Sholjakova, Prof. Dr. Zorka Nikolova Todorova, and Prof. Dr. Trajanka Trajkovska who were Heads of this Department at the Surgical Clinics, then Dr. Slavko Krstevski, Dr. Mirjana Shosholcheva, Ph.D., (City Hospital Surgery) as well as Dr. Dimitar Sekulovski and Dr. Vlado Ristovski (Clinical Hospital, Bitola), and Dr. Sime Janevski (in Military Hospital, Skopje).

Professional and educational activities of anesthesiologists from Macedonia

Continuous medical education for anesthesiologists started very early, namely in the period when anesthesiology procedures started to be in the hands of doctors. Since Macedonia was one of the republics of the Former Yugoslavia then, it was normal that the beginnings were mutual for all republics. Thus, the First Congress of Yugoslav Anesthesiologists was held in Belgrade in 1969. The Association of Anesthesiologists from Yugoslavia (JUARIL) was formed then from the existing sections in the Republics. The Association decided that every second year intersection meetings (mini congress) should be held and every four years a congress should be organized and a new President of JUARIL should be elected.

During this period from 1969 to present three intersection meetings and one Congress were held in Macedonia. Inter sectional meetings were held in 1971 (in Ohrid, Prof. Dr. V. Andonov), in 1979 (Skopje, Dr. B. Mickovski) and in 1988 (Bitola, Dr. Sekulovski). In 1981 the IV-th Congress of Yugoslav Anesthesiologists was held in Ohrid when Prof. Andonov was elected as President of JUARIL for a four-year term.

The continuity of having professional congresses has been retained after the independence in 1990, when R. Macedonia became an independent state. The existing Section developed into the Society of Doctors of Anesthesiology, Reanimation and Intensive Care – Macedonian society of anesthesiologists (MSA). Prof. Dr. Jordan Nojkov was elected as the first President of the Society for a period of two four-year terms (1990-1998). Immediately after the independence (1990), MSA has been admitted as a full member of the World Federation of Anesthesiology Associations (WFSA) during the presidency of Johan Zorab, on a meeting in London, and in the next year MSA became a member of the World Federation of Societies for Intensive Medicine (WFSICCM ) [26, 27].

The 1st Congress of Macedonian anesthesiologists with international participation was held in Ohrid in 1995 and the President of the Organizing Committee was Prof. Dr. Jordan Nojkov. The subsequent Macedonian congresses with international participation and other international gathering and educational courses of anesthesiologists in R. Macedonia till 2014 are presented in Table 3.

Table 3. Main professional gatherings and educational courses of anesthesiologists in R. Macedonia in the period from 1995-2014

* Europaen fondation for education in anaesthesiology

The following anesthesiologists were presidents of the Macedonian society of anesthesiologists since its foundation in 1962: Prof. Dr. Risto Ivanovski, Prof. Dr. Vladimir Andonov, Dr Milorad Janevski, Ass. Prof. Lazar Shendov, Dr. Petar Duljanov, Prim. Dr. Borche Micevski, Prim.  Dr. Sime Janevski, Prim. Dr. Dimitar Sekulovski, Dr. Vujica Stojanovic, Prof. Dr. Jordan Nojkov, Ass. Prof. Dr. Violeta Miloshevska, Prof. Dr. Marija Sholjakova, Dr. Zvonko Krstevski, Prof. Dr. Mirjana Shosholcheva and Ass. Prof. Dr. Andrijan Kartalov.

MSA has managed to raise the level of education of Macedonian anesthesiologists through organizing Sectional meetings and workshops where besides lecturers from our country there were regular participation of foreign lecturers from different areas of anesthesiology and intensive care.

Specialization and continuing medical education in anesthesiology development in R. Macedonia

Anesthesiology, reanimation and intensive care are young branches of medical science which are relatively late involved in medical studies everywhere in the world. In Macedonia the scientific and educational activities concerning these branches went through the Department of Anesthesiology at the Faculty of Medicine (FM) in Skopje, which has begun its activities in 1975. This Department was responsible for postgraduate studies and training for specialists, while teaching of students was realized in the framework of the subject of Surgery at the Department of Surgery. In 1998, Prof. Dr. M. Sholjakova was elected Vice Dean of the Medical Faculty in Skopje. Two years later, the Department became independent, and according to the Curriculum for undergraduate studies in medicine the students audit the subject of Anesthesiology with Resuscitation as a separate one. The teaching activities of the Department in the beginning consisted in teaching the subject of anesthesiology with resuscitation for the students of medicine and dentistry. Additionally, in the last several years, teaching has been organized for students at the High Nursing School within the FM-Skopje. The Chair of anesthesiology also organizes lectures for first medical aid, lecturing for postgraduate studies for specialists, Masters degrees and doctoral studies. The tendency of the Chair in performing of these educational activities is to give the students as much practical knowledge as possible in order to enable them to help all critically ill and injured patients in all phases of prehospital care in future.

Specializations in anesthesiology for doctors started in 1963 and lasted for three years in the beginning. In 1974 the duration was extended to 4 years, until 2007, when the Curriculum was adjusted according to European directives and it was extended to 5 years. Based on the inspected licensing in 1999 (again in 2004) by the special Committee of the Board of Anesthesiology of the European Union for medical specializations, KARIL has received a Certificate that it fully meets the European standards for training of specializing doctors and received Accreditation as a European Center for Education in Anesthesiology.

Since 1998 the Chair of anesthesiology has organized three-day courses (postgraduate school) every year for Continuing Medical Education and refreshing the knowledge in anesthesiology, resuscitation, intensive care and pain therapy under the auspices of the European Foundation for Education in Anesthesiology (FEEA, now CEEA). This educational program was created by the European Board of Anesthesiology. The program is equally designed either for young specialists or specializing doctors. Having completed six courses the participants acquire European Diploma in Anesthesiology. Also, since the beginning of its existence (1994) the Chair has organized courses in reanimation for practitioners from different profiles, and lately other activities for the implementation of modern algorithms of the European Council  for Resuscitation [28].

Retired and currently employed lecturers in anesthesiology in R. Macedonia

Since its foundation, the following teachers were and some of them still are members of the Chair of Anesthesiology with reanimation at the FM-Skopje: Prof. Dr. V. Andonov, Prof. Dr. M. Sholjakova, Prof. Dr. J. Nojkov, Ass. Prof. Dr. V. Milosheva, Prof. Dr. Z. Nikolova-Todorova, Prof. Dr. T. Trajkovska, Ass. Prof. Dr. L. Shendov, Prof. Dr. M. Shosholcheva, Ass. Prof. Dr.  J. Nancheva, Ass. Prof. Dr. B. Shirgovska, Ass. Prof. Dr. Andrijan Kartalov and Ass. Prof. Dr. B. Kuzmanovska. At the University “Ss Kliment Ohridski in Bitola, Ass. Prof. Dr. Vlado Dameski is teaching anesthesiology while at the Faculty of Medical Sciences and High Nursing School at the University “Goce Delcev” in Stip  Dr. B. Eftimova and Dr. J. Jovanovska are lecturers in anesthesiology.

The scientific activity of the Department from 1998 has been realized through three domestic and one international project, and numerous other investigations which resulted in 14 doctorates, dozens of Master’s degrees and many professional and scientific papers. The members of the Department have published 11 books in anesthesiology and reanimation, 6 collections of lectures as well as a textbook for medical students.

Limitation of the study

This study used published papers and other materials related to the area of anesthesiology, as well as oral recollections of participants who worked in the field of anesthesiology in the past period. Unfortunately, the number of such studies is very small. Archive materials are missing, especially for the period between the two world wars and immediately after. The authors tried to find documents from that period in historical archives (published papers, operational protocols, lists), but unfortunately with limited success. It remains for the future generations to elucidate this period in more details.

Conclusion

The development of anesthesiology in R. Macedonia has had a trend of permanent improvement since its early beginnings in the 1950's. Starting from a helping tool in the hands of a surgeon, today it has grown into a high technological and independent medical branch, necessary in everyday work in any modern hospital. As in no other discipline, anesthesiology involves contemporary knowledge of pathological physiology and advanced forms of high medical technology in order to support the vital functions of the patient during an operation or in patients with critical illness.

Macedonian anesthesiology has common roots with the anesthesiology in the states emerging from the former Yugoslavia. The pioneer of Macedonian anesthesiology, Dr. Risto Ivanovski, was one of three doyens – the founders of anesthesiology in this area. His arrival in Macedonia in 1954 enabled early introduction of this science modern principles into practice.

In the further development of anesthesiology, the activity of the Surgical Clinic at the FM-Skopje has taken the crucial place, as well as the Military Hospital and City Hospital in Skopje. The first generations of medical technicians - anestheticians for Macedonia and Kosovo have been educated there. In later years (since 1965) more than 250 doctors - anesthesiologists completed specialization and today they successfully perform this activity throughout hospitals in the country. These trained professionals from the Department of Anesthesiology successfully face the challenges posed by modern development of surgery and intensive medicine and give their contribution to the development of anesthesiology as a science. Concerning the educational and scientific activities of the Department the name of Prof. Vladimir Andonov should be mentioned, as well as his numerous successors who contributed to the development of this activity.

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