Safely towards the third millennium

Safely towards the third millennium

Excerpted from the Presidential address delivered by Dr. Swinitha Ranasinghe of the College of Anaesthesiologists of Sri Lanka on January 22nd 1999 at the Sri Lnka Foundation Institute.

'Gentlemen, this, is no humbug

With these immortal words spoken 150 years ago, on October 16th 1846, Dr. John Collin Warren, Surgeon, proclaimed that, Thomas Green Morton's, 'new' medication ether, truly provided, adequate and acceptable surgical conditions, while the patient, was apparently insensitive to pain.

Oliver Wendell Holmes, described this ironical comment, as the greatest understatement in the history of medicine and proposed the appellation 'anaesthesia' to this new branch of medicine that evolved.

Dr S. Ranasinghe Arguably, anaesthesia, remains one of the greatest discoveries of all time, not only in the field of medicine, but for all mankind.
Born was the era of painless surgery. No more attendants holding the patient down, no more screaming and no more rushing for the surgeon.

The practice of surgery has been revolutionised.

THIN: EVOLUTION
In the early formative years, practically all of the Anaesthesiologists' time was spent in the operating theatre. The infra-operative care of the surgical patient being the only role of the anaesthesiologist.

Modern anaesthesiology on the other hand, differs widely, from what it was, 50 years ago, not only because of what anaesthesiology involves in the operating room, but also because, we have now expanded our horizons and activities, above and beyond, the provision of mere surgical anaesthesia.

An overview dealing not with individual facets of anaesthesiology, but dwelling in the totality of the many vast changes in physiology, pharmacology, techniques and technology provides the opportunity to consider the progress of anaesthesiology as an identifiable, intellectual and professional component of modern medical practice.

To do so also provides the opportunity to consider, some of the problems and challenges faced in the speciality of anaesthesiology.

Anaesthesiologists are unique among the medical profession, in having the information, training and expertise to co-relate all aspects of the per-operative period, with pre-operative assessment, assessment of risk and optimisation, infra-operative management, post-operative management of pain and fluid balance and weighing all these functions against the cost of anaesthetic care. This unique expertise increases the value of the anaesthesiologist, to patients, colleagues and health care facilities

In fact, it has been recommended that the name of the speciality be changed to include 'perioperative medicine' so as to better describe the medical contributions and responsibilities of the Anaesthesiologist both within and outside the operating room.

It seems imminently clear that the discipline of Anaesthesiology, has evolved from an art, to a sophisticated practice of medicine.

PATIENT SAFETY
Predicting and preparation for the unexpected, which is the theme of this year's scientific sessions is the hallmark of good anaesthesia.

Enormous strides have been taken, to improve the patient safety at operations. However, there are ever more complex operations, in increasingly poor risk patients and professional and public expectations and demands for perfection have arisen greatly.

At the 10th World Congress of Anaesthesiologists, held in 1992, the World Federation of Societies of Anaesthesiologists, of which, the College of Anaesthesiologists of Sri Lanka is a Member Society, adopted the international task force's, international standards document, called, the International Standard For A Safe Practice in Anaesthesiology and recommended it to member societies worldwide.

The most important standard relates to the individual Anaesthetist.

"Alert, Active, Attentive" is the theme of the 4th Congress of the South Asian Confederation of Anaesthesiologists to be held in September this year in Chennai India and this aptly describes the ideal anaesthetist.

The professional status of the individual anaesthetist is important. It is highly recommended that the anaesthetist be appropriately trained and certified as medical specialists and when anaesthetics are provided by junior doctors, that they, be appropriately trained.

AIRWAY MANAGEMENT
Airway Management is the scaffolding upon which the whole practice of anaesthesiology is built. It is within the realms of respiratory management that the penalties of misadventure are greatest.

Instead of learning the use of the simple face mask and tracheal tube, today's trainee is faced with an ever increasing number of airway devices and techniques. Not only must the trainee be taught how to use new equipment but when and where not to use it.

Airway safety may be compromised easily by performing a good technique badly or by using it in inappropriate circumstances.

Facts and theory can be learned from books and the classroom.

Individual manual skills can be taught in isolation.

However, it is only in the workplace that the trainee can learn to combine these, together with the indefinable philosophies of judgement, experience, humanity and ethics into the total process of giving an anaesthetic.

The most important place for anaesthetic training is the ward, the operating theatre and the intensive care unit. Not the classroom and the library.

The influence of clinical teachers as role models for students cannot be under-estimated. Good anaesthesia teachers combine enthusiasm, willingness to teach and an 'inquiry' approach.

The worth of such clinicians must be recognised formally and time and facilities made available to avoid frustration and 'burn out'

Ideally a training room must be available within the anaesthetic department. The use of the manikins is now essential for several reasons. The patient must be protected from the total novice. Some of the new airway procedures are relatively complex. Therefore the trainee must be given the opportunity to practice manoeuvres in an unstressful way.

The protocols we have, for dealing with difficult intubation, and the failed intubation drill that adorn our walls should be simplified into a number of logical steps.

Professional organisations must be set up for setting standards of practice, supervisor of training and for continuing medical education with appropriate certification and accreditation and for the promotion of the field of anaesthesia.

These tasks are carried out by the Board of Study Anaesthesiology and the College of Anaesthesiologists of Sri Lanka. These two professional bodies functioning interdependently, ensures a firm commitment, towards upgrading, all aspects in the field of anaesthesiology in this country.

Basically, at the outset, a proper selection must be made. The College is making every effort to take the best possible selection of doctors.

Ideally, those wishing to embark on a career in anaesthesia, should display the following talents; Aptitude as a doctor, academic ability, enthusiasm, and humanity. Team membership concept, mental stability, sense of humour and should be conscientious.

Where training is concerned, doctors are initially given a 6 months basic training under the supervision of a fully qualified anaesthetist and accredited. To ensure the adequacy of training, at the end of 6 months, he/she sits for the Part 1A examination, on the basic practice of anaesthesia. This Part 1A Examination is not compulsory if the house officer does not want to proceed towards full specialist qualification, but, combined with the examination, Certificate of Competence, it enables them to be placed in Grade 1 of the Public Service. However, nearly all house officers sit for this examination as they, have begun to realise the importance of this examination, to update their knowledge in their, day to day work.

The College is making every effort to make a 2 year compulsory service after this 6 months intensive training period. Losing doctors to other fields of medicine after 6 months of effort and time on teaching and training is of no benefit to the Ministry where even service requirement is not met with. It is a disaster in cost benefit management.

Success at the Part 1A qualifies them for training towards full specialist qualifications.

The full specialist education thereafter is a four and half year structured learning programme inclusive of 2 examinations. Part 1B and Part II MD Anaesthesiology final examination, the submission of a case hook of 10 patients managed' with the relevant discussions, and a scientific paper, based on their personal research work.

RESEARCH
Research is the key to the future.

The importance of anaesthesiology research as part of the training cannot be over- emphasized. We, cannot be leaders in education or practice, if we simply apply the findings of others. Kingmen Brewster, the then President of Yale said it best in 1971.

"If teaching is to be more than the retailing of knowledge, and if research is to seek real breakthrough in the exploration of man and the cosmos then teachers must be scholars and scholarships must be more than refinement of the inherited store of knowledge."

If we limit our research now, then, we will be unable to document, our contributions to health care, in the future.

Postgraduates in Sri Lanka need to submit a scientific paper on their own observations as a pre-requisite for board certification as a specialist in anaesthesiology. Members, juniors and colleagues are free to present their research at the Annual Scientific Sessions of the College.

HUMAN ERROR
Human error was a key factor in most mishaps. Several remedial measures need to be considered.

WORK LOAD
Sufficient number of trained anaesthetists should be available so that individuals may practice to a high standard. Fatigue, hurry, carelessness and inattention affect performance. They should not work more than 12 consecutive hours and a maximum of 80 hours per week, averaged over 4 weeks, should only be allowed. A junior anaesthetist's hours of work, are much longer, than an airline pilot's. Both professions entail considerable periods of monitoring, interposed with high demands on physical congnitive skills. Errors induced by fatigue by pilots and anaesthetists could result in nothing but death.

STRESS
The individual can usefully retain much responsibility for assessing his or her current stress level and make a judgement as to current competency. Aviators are encouraged to use I'M SAFE' before each flight and this approach is readily transferable to anaesthetic practice.

I-Illness? M-Medication? S-Stress? A-Alcohol, F-Fatigue?, E-Eating?

Forces of stress, complacency, boredom, burnout and chronic fatigue can alter, the usual good judgement, of the competent anaesthetist. The known circadian variation in physiological and behavioural rythm is an important issue in shift work performance, and safety, and hence, it is advised, that "routine surgery should not be attempted in the night." Semi casualties can easily be cleared during day time if a second or ever a third casualty theatre is opened up.

FACILITIES AND EQUIPMENT
Appropriate equipment and facilities adequate both in quantity and quality should be present wherever anaesthesia and recovery is undertaken. Equipment should conform to international standards.

As technology is advancing so fast, the useful life of an anaesthetic machine is considered to be only about 10 years.

Sometimes, to declare an anaesthetic machine obsolete, requires an act from God. Anaesthetic machines must be updated with safety devices and alarms.

MAINTENANCE & SERVICE
A large majority of equipment related problems in anaesthesia could be prevented by correct maintenance and servicing. The technician must be qualified and competent. Failure to realise this important aspect, exposes the anaesthetist, to increased liability, in the event, of an untoward outcome, associated with improper maintenance and servicing. Inadequate service in this area truly creates "an accident waiting to happen"

Thorough understanding of the machine is mandatory for safe anaesthetic practice. Machines are equipped with dozens of safety features. Yet, none of these are foolproof. The anaesthetist must check the machine preoperatively using appropriate check out procedures. Anaesthetist's are required to rely heavily, on memory, for essential facts. In contrast, airline pilots use standard checklists. Check lists for checking an anaesthetic machine have been published by Acoma Medical Industry Co. Ltd. and were distributed by the college, a few years back, to all hospitals.

QUALIFIED ASSISTANTS
Provision of qualified assistants is important. The College in consultation with the Ministry is working out a scheme for recruiting and training theatre orderlies as has already been done for the Sri Lanka Army.

MONITORS
The best and only indispensable monitor is the continuous presence of an appropriately trained vigilant anaesthetist. Ideally, he should be the person who assessed the patient pre-operatively, pre-medicated the patient and checked the equipment and the anaesthetic machine. Monitors are the "unsleeping eyes" that allow us to "see the invisible" especially early hypoxaemia and desaturation. They make the hands of the anaesthetist free for other tasks, and give additional information which are beyond our range and enable an objective record to be made. Monitors are not likely to be of value unless the user can recognise and appropriately act, on what he sees. Hence the need, to select the right doctors for training in the speciality, and for them to possess, the right personality characteristics.

There is solid evidence from mortality and morbidity studies conducted, that the combination of pulse oximetry and capnometry can be expected to help reduce anaesthetic related mortality and morbidity.

RECORD KEEPING
Monitoring charts should be freely available to every house officer in every operating theatre in the island so that proper record of events could be made. In the event of a mishap, what solid proof can the defence present? The old dictum "if you did not write it down it did not happen" is still very much applicable in a medico legal sense.

For some unexplained reason, the Ministry has stopped printing monitoring charts.

PRE ANAESTHETIC CARE
The patient must be evaluated by the Anaesthetist, prior to induction of anaesthesia, and informed consent obtained.

Risk factors must be identified, and this can alter care in two ways, whether or how to proceed with surgery, modify the process, of patient care.

Traditionally, anaesthetists in Sri Lanka, have no opportunity to see their patients before hospital admission. The problem of assessment by the anaesthetist after admission may lead to prolonged stay in hospital specially if optimisation of the patient's medical status is required. This, incurs additional expenditure to the state health services, inappropriate use of hospital beds, inefficient use of operating theatre time and causing much inconvenience to the patient and the relatives.

This problem can be resolved, if anaesthetists are able to assess high risk patients on an out-patient pre-admission basis before surgery requiring the establishment of anaesthetic pre-operative evaluation clinics. The establishment of such clinics require the co-operation of consultants of other disciplines such as surgeons, physicians, cardiologists, pathologists, and radiologists.

This is specially important in teaching and general hospitals where there is an acute shortage of beds. This concept should be given encouragement by the Ministry.

POST ANAESTHETIC CARE
Neither medical nor legal responsibility ends at the operating theatre door. Many problems associated with anaesthesia and surgery have known to occur in the immediate post operative period, and it is essential, that supervisor by adequately trained, and experienced, personnel is continued during the recovery, for, this is the time the patient is at the highest risk. This fact, is not appreciated by most surgical and nursing staff, and the most junior nurse is assigned the task of recovery. Sometimes, they have never recovered a patient in their lives. Continuous individual nursing on a one to one basis is recommend until the patient is able to maintain his own airway and the nurse should have no other duties at this time.

Recommended equipment is as listed on the slide.

Thus, we see that the recovery facilities available in our hospitals fall far short of expected standards. The existence of satisfactory recovery facilities is now regarded as essential for the recognition of a hospital for the general professional training of anaesthetists in UK.

OUTPATIENT ANAESTHESIA
When this free standing ambulatory movement was initiated, there was a need to establish a strong safety profile. Consequently only 'healthy' patients, were acceptable candidates, for ambulatory surgery. Today, the subspeciality of ambulatory anaesthesia, has progressed to the total complex care, of a broad spectrum of surgical patients undergoing thousands of different procedures under all types of anaesthetics.

A multitude of factors have led to the advances made in this speciality.

Several reasons limit the use of ambulatory anaesthesia in our government hospitals. In the private sector however, a fair percentage of patients are operated on, on an outpatient basis.

RISK ASSESSMENT
Risk may be defined as the chance of harm. Risk assessment is a complex task and involves not only identifying risk but estimating both their chance of occurrence and the magnitude and severity.

There is abundant evidence that the way friends, relations, colleagues,, the lay press, the legal system, responds to a disaster is related more to the perception of risk, than the actual risk. It is not surprising, that, patients who perceive that they have to have an anaesthetic for a disease they did not want and, those who are unfamiliar with hospitals and know little about the whole diagnostic therapeutic process may be very angry when they are harmed. There may be much benefit in education about anaesthesia, informed consent and discussion of options.

Risk is an inevitable consequence of almost any action and should be weighed against the positive outcome of the action. Thus, one anaesthetic death should be weighed against the problem that would arise, if 20,000 patients either went without surgery altogether or had the surgery without anaesthesia.

In reality however, there is an expectation that anaesthesia should be entirely safe, unrealistic though this may be, and its manifest benefits are essentially ignored.

The patient and his or her relations are not the only ones at risk. The anaesthetist suffers substantially after a disaster. Apart from the mental trauma he goes through, he is placed at risk of litigation. Post traumatic stress disorder is now a well recognised clinical entity. Those who have experienced anaesthetic mishaps need to undergo critical incident stress debriefing.

MORTALITY IN ANAESTHESIA
Complications associated with anaesthesia and surgery have been a primary concern of the medical speciality since the first anaesthetic related death was reported in 1847.

In this report, a young woman, Ann Parkinson had been anaesthetised with ether, and a tumour of her thigh was removed. 40 hours after the procedure, she was found dead. During the Coroner's inquest 3 broad categories of factors were articulated to have contributed to her perioperative death. These categories are still used today. Patient disease, surgery and anaesthesia. The difficulty then, and today, is separating these 3 factors that contribute to adverse outcomes. This difficulty can be confounding since factors are usually inter-related.

Review of mortality studies over the last few decades show that mortality has dropped to almost 0.5 or less per 10,000 anaesthetics which carries a lower risk than travelling in a motor car.

Several explanations have been given for improved outcomes -

(1) Significant increase in the number of anaesthesiologists, (2) Better quality of anaesthesia training, (3) Emergence of safer drugs, (4) Use of better anaesthetic techniques, (5) Heightened awareness of anaesthetic risk including pre-operative anaesthetic risk assessment, (6) Introduction of formal promulgated safety standards in anaesthetic practice, (7) Better monitoring, (8) Improvement in post-anaesthetic care facilities, (9) Critical incident reporting as in the field of aviation, who, for many years, have learnt detailed lessons from its disasters, to make flying safer., (10) Anaesthetic audits

OBSTETRICS
In the first national study of anaesthesia related maternal mortality in the United States presented by Hawkins, it was interesting to note that maternal mortality figures showed, that the case fatality rate for general anaesthesia was 2.3 times that for regional anaesthesia in the 1979-1984 period increasing to 16.7 times that for regional anaesthesia in the 1985 to 1990 period.

This report, together with the report on the confidential enquiry into maternal deaths in the United Kingdom, resonate the views of most anaesthesiologists and logically provoke the following recommendations;

(1) Early consultant involvement
(2) Encourage greater use of regional anaesthesia
(3) Improve safety for those patients who still require general anaesthesia.
(4) Availability of trained assistants
(5) Availability of high dependency care units
(6) Mandatory monitoring

The College of Anaesthesiologists is making every effort to fill the existing vacancies in consultant posts in the country, avoid junior anaesthetists administering obstetric anaesthesia, and if not a contra indication, regional anaesthesia has been recommended. The College also has specified the mandatory use of the pulseoximeter and the capnometer in obstetrics and efforts are being made with the Ministry to obtain trained assistants.

Where adequate trained staff for the delivery of obstetric anaesthesia is concerned, it is interesting to note, the following observation.

The removal of a brain tumour from an elderly patient calls for a surgeon, 2 assistant surgeons, assisting nurse, 2 running nurses, a consultant anaesthetist, a registrar in anaesthesia and a couple of junior anaesthetists. Patient's prognosis is only 18 months and the hospital investiture is tremendous. In contrast, birth of a baby at 4 am is more often attended by one registrar obstetrics, one interne house officer, one house officer anaesthesia, and two nurses.

ACCOUNTABILITY AND AUDIT
In the United Kingdom medical audit is now the "buzz" word. The term audit can cover most of the usual implications including Peer Review which as David quoted in 1991 'Paraphrasing the motto "by the people, for the people and their patients" is not inappropriate'. In order to assess and improve the safety of anaesthesia, audits are essential. The Royal College of Anaesthetists of UK has formed a Quality of Practice Committee to review progress in this field and to receive debate and export ideas and information. It is recommended that we too should make every endeavour to establish such a committee.

CRITICAL CARE MEDICINE
The anaesthetists' move into intensive care medicine, was triggered by the great polio epidemic of the 1950s, which led to the development of mechanical ventilatory support, and respiratory units to manage such patients. The Korean and Vietnam wars, were associated with greatly expanded knowledge on the pathophysiology of shock. The rapid development of cardiac surgery, throughout the 1960s, led to further understanding of the prevention and management of cardiac cerebral, respiratory, renal and hepatic dysfunction. The Anaesthesiologists have a major involvement in this aspect of intensive care medicine, because of their resuscitation skills and expertise with mechanical ventilation, and their expert knowledge on critical care medicine.

INTERMEDIATE CARE
As there is an inadequate supply of intensive care beds, the establishment of high dependency care, at a level of care intermediate between that in a general ward and intensive care is recommended. Such an intermediate care unit can easily be established in every ward. Such intermediate care facility is cost effective and does not deprive the deserving patient of an ICU bed.

CARDIO-PULMONARY RESUSCITATION
One fundamental aspect of treating critically ill patients is securing an airway and ventilation. It is not surprising then, that the anaesthetist has always been, a key member of any emergency or cardio-pulmonary resuscitation team in hospital. The College has commenced a teaching programme on cardio pulmonary resuscitation in many hospitals for all categories of staff.

The anaesthetist is also called upon often for resuscitation of the new born. This of course is the purview of the paediatrician.

PAIN AND PAIN MANAGEMENT
Anaesthesiologist, with his first hand knowledge on the pharmaco kinetics of the analgesic drugs, and his skills in administering nerve blocks and regional analgesia, secures a well defined role both in acute as well as in chronic pain management.

It is well documented that relieving pain improves outcome.

Nurses routinely record observations of BP, why isn't pain assessment made and recorded at the same time? This simple step that could be taken throughout every hospital in the land would be a major step forward in pain management in this country.

Multidisciplinary pain centres are now an integral aspect of health services in most countries.

Pain has now become a well defined subspeciality in our field in the developed world and we hope with increasing numbers and cadres of consultant anaesthetists this subspeciality will see the light of day in Sri Lanka too although we do practice in a limited capacity.

CONCLUSION
The scope of anaesthesia care extends far beyond the common misperception of 'putting the patient to sleep' or "a whiff of gas!"

Our College has a major role in moulding attitude promoting safety in anaesthetic practice. Our College should work more closely with other colleges wherever possible. Our combined voice would be more powerful and effective in areas of mutual agreement.

We should spend more time in working for international professional societies and participation in international congresses so that we are at par with new development.

Anaesthetic safety has come a long way. Unimaginable just a few decades ago. However much needs to be done in countries like our own, struggling to advance in the field of severe restriction in personnel and equipment.

Anaesthesiologists in Sri Lanka should be proud of the quality of their professional practice. For, they have made possible the successful delivery of operative services in situations never before possible and under extremely trying circumstances.

Human error remains, and will probably always be, the primary cause of accidents. This error may be focused on the performance of the individual, the team or the system. Its origin is likely to be multifactorial and complex to resolve. To this end greater emphasize should be made on the anonymous critical incident reporting study that was commenced in Sri Lanka in 1995 and the establishment of a quality of practice committee would be a useful step.

I quote George Bernard Shaw who said in 1913, "The greatest mistake in life is to be continually fearing you will make one and a life spent in making mistakes is not only more honourable, but more useful, than a life spent doing nothing."

Finally you would have observed my presentation today covered mainly on 'anaesthesiology in relation to control of pain'.

As a concluding comment I leave this thought with you.

The greatest feature which distinguishes man from beast is the man's ability to control pain. For it is this factor alone that makes him superior to any other being on this planet.