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
Box 1. Dr. Risto
Ivanovski, Associate Professor in Anesthesiology [4-7]
|
|
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
Box
2. Dr. Vladimir Andonov, Professor
in Anesthesiology [13-16]
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|
Dr. Vladimir Andonov was born on Apr 17, 1934 in Skopje. He
started medical studies at the FM-Skopje in1953 and graduated in 1959. In
1961 he started to work at the Clinic of Surgery and then completed
specialisation in anesthesiology in 1965.
He
was appointed as Head of the Department
of Anesthesiology and Resuscitation within the Surgical Clinic in 1967, and
became Director of the newly established Clinic for Anesthesiology,
Reanimation and Intensive Care (KARIL) at FM-Skopje in 1989, serving till his retirement in
1999.
Dr. V. Andonov realized professional visits
and stays in Belgrade and Zagreb, and then nine months in UK during the
1964/65.
His scientific work was focused to the field
of perfusion in shock sate (habilitation in 1973), and later on to
endo-tracheal application of epinephrine (1986) and to autologue
normovolemic haemodilution (1993-1996). He was elected as Assist. Professor
in 1977, Assoc. Professor in 1983 and Professor in 1990.
Prof. Andonov introduced numerous new
methods and innovations in the field of anesthesiology and intensive care.
He got several recognitions of merit and awards, among them the highest
honors – medal with silver star in 1963 and the government award “Ss. Kliment Ohridski” in 2003. He is author of 76
scientific articles and 5 books.
Prof. Dr. Vladimir Andonov lives in Skopje at the age of 80
years.
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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]
Name
and Surname
|
Year of
specialization
|
Institution
of employment
|
Vladimir
Andonov
|
1965
|
Clinic
for Surgery, Skopje
|
Vujica
Stojanovic
|
1965
|
Clinic
for Surgery, Skopje
|
Pavle
Mitrevski
|
1965
|
General
Hospital, Bitola
|
Ilija
Dubrovski
|
1967
|
Clinic
for Surgery, Skopje
|
Nikola Serafimovski
|
1967
|
City
Hospital, Skopje
|
Avram
Balabanov
|
1967
|
City
Hospital, Skopje
|
Petar
Nikolov
|
1968
|
City
Hospital, Skopje
|
Milorad
Janevski
|
1968
|
Clinic
for Gynecology and Obstetrics, Skopje
|
Sime
Simovski
|
1969
|
General
Hospital, Prilep
|
Agica
Stankova
|
1969
|
Clinic
for Gynecology and Obstetrics, Skopje
|
Roza
Ivanova
|
1970
|
Clinic
for Surgery, Skopje
|
Slavko
Bakrachevski
|
1970
|
General
Hospital, Ohrid
|
Kudjan
Hamporcum
|
1970
|
City
Hospital, Skopje
|
Ljiljana
Lazarevska
|
1970
|
Clinic
for Surgery, Skopje
|
Boris
Micevski
|
1970
|
Clinic
for ORL, Skopje
|
Nikola
Mishkovski
|
1971
|
Clinic
for Gynecology and Obstetrics, Skopje
|
Zika
Urdarevic
|
1971
|
City
Hospital, Skopje
|
Ilinka
Trajkovic
|
1972
|
General
Hospital, Kumanovo
|
Radislav
Kalenikov
|
1972
|
City
Hospital, Skopje
|
Atanas
Stevkov
|
1972
|
General
Hospital, Strumica
|
Stojan
Nichevski
|
1972
|
General
Hospital, Stip
|
Dimitar
Sekulovski
|
1972
|
General
Hospital, Bitola
|
Srboljub
Mitrovic
|
1973
|
Clinic
for Gynecology and Obstetrics, Skopje
|
Simeon
Janevski
|
1974
|
General
Hospital, Veles
|
Lazar
Shendov
|
1974
|
Clinic
for Orthopedic Surgery, Skopje
|
Marija
Sholjakova
|
1975
|
Clinic
for Surgery, Skopje
|
Pantelej
Donev
|
1975
|
General
Hospital, Bitola
|
Trajanka
Trajkovska
|
1975
|
Clinic
for Surgery, Skopje
|
Vera
Shikova
|
1975
|
Clinic
for Surgery, Skopje
|
Milica
Spasova
|
1974
|
Clinic
for Surgery, Skopje
|
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]
Anesthetic
technique
|
Surgical
procedure
|
Year of
introduction
|
Anesthesiologist/s
|
University
Clinic/ Hospital facility
|
New generation of halogen inhalation anesthetics
|
Isoflurane in major surgery
|
1992
|
M. Sholjakova and colleagues at KARIL, UCMF, Skopje
|
KARIL, UCMF, Skopje
|
Epidural anesthesia and
(Lidocain, cystocaine)
|
Painless childbirth
|
1993
|
Srbo Mitrovich
|
Clinic of Ob&G Skopje
|
Basic monitoring in
anesthesia
|
ECG, NBP, PR
|
1994
|
All specialists in anesthesiology
|
All clinical
centers in RM
|
Anesthesia in difficult
position
|
Spinal surgery
|
2004
|
Petar Achkovski
Marina Temelkovska
Mirjana Petrovska
|
Clinic of Trauma and bone
reconstruction
|
Neuro-anesthesia
|
Coiling
procedures in aneurysm surgery
|
...
|
Zlate
Shuplinovski
Vesna
Durnev
Ljupka
Momirovska
|
Clinic
of Neurosurgery
|
Management of brain death
|
Cadaveric transplantation
|
1988
2006
|
Petar
Duljanov
Jovan
Janchulev
Maja
Mojsova
|
Clinic of Urology
|
Controlled and monitored
sedation and analgesia
|
Orthopaedic, plastic and
reconstructive surgery
|
2007
|
Jordan
Nojkov
Jasminka
Nancheva
Anton
Damevski
Danica Pendovska
|
Orthopedic Clinic and
Plastic and Re-constructive Surgery Clinic
|
Euthermia, preoperative
active compression-decompression of limbs
|
Digestive surgery
|
2008
|
Biljana Kuzmanovska
Andrijan Kartalov
Tanja Spirovska
|
Clinic of Digestive Surgery
|
Paediatric anesthesia with
servofluorane
|
Liver transplantation
|
2011
|
Ljupcho Donev
Vesna Durnev
|
Clinic of pediatric surgery
|
Cardiac perfusion
in child
|
Paediatric cardio-surgery
|
2013
|
Ljupcho Donev
Albert Leshi
|
Clinic of pediatric surgery
|
Bariatric surgery and
ultrasound TAP Block
|
Digestive surgery
|
2013
|
Darko Sazdov
Andrijan Kartalov
|
Clinic of Digestive Surgery
|
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
|
Professional event
|
Time (year)
when it was held
|
Venue
|
President of the
Organizational board
|
Output document/s
|
|
|
The 1st Congress
|
1995
|
Ohrid
|
Prof.
dr. Jordan Nojkov
|
Book of abstracts
|
|
|
The 2nd Congress
|
2000
|
Ohrid
|
Ass.
prof. dr. Violeta Milosheva
|
Book of abstracts
|
|
|
The 3rd Congress
|
2005
|
Ohrid
|
Prof.
dr. Mirjana Shosholcheva
|
Book of abstracts
|
|
|
The 4th Congress
|
2010
|
Ohrid
|
Ass.
prof. dr. Jasmina Nancheva
|
Book of abstracts
|
|
|
The 5th Congress
|
2014
|
Ohrid
|
Ass.
prof. dr.Biljana Shirgovska
|
Book of abstracts
|
|
|
Regional Meeting of ESRA
|
1997
|
Ohrid
|
Prof.
dr.Jordan Nojkov
|
Book of abstracts
|
|
|
1st Balkan Congress of Young Anesthesiologists
|
2003
|
Ohrid
|
Prof.
dr.Marija Sholjakova
|
Book of abstracts
|
|
|
FEEA, now CEEA* courses
|
1998-2016
|
Dojran
|
Prof.
dr. Marija Sholjakova,
Ass.
prof. dr. Jasmina Nancheva
|
I,II, III Cycle's book in 6 courses
|
|
|
School of Intensive Critical care
courses
|
2000-2014
|
Skopje
|
Prof. dr. Zorka Nikolova Todorova
|
Book
of refresher courses
|
|
|
School of anesthesia courses
|
2004-2006
|
Mavrovo
|
Prof dr. Mirjana Shosholcheva
|
Book
of refresher courses
|
|
|
Difficult airway courses
|
2010-2014
|
Skopje
|
Ass. prof. dr. Biljana Shirgoska
|
Book of refresher courses
|
|
* 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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