Category Archives: Anaesthesia

SA Health Budget Waste – Jack Snelling take note!

There has been a change in SA Health his year as outgoing Health Minister John Hill retires and Jack Snelling steps into place. I don’t envy whoever has this portfolio – the cost of health continues to rise, as does demand – and yet available health budgets are shrinking.

This week the ABC reported $1 billion health cuts over the next 4 years in SA health. The Minister was reported as saying “I think we can reduce the number of clinical staff and still maintain a reasonable level of services.” Personally I disagree – hospitals are already at capacity and despite ‘efficiency saving reports’ from the likes of KPMG, ministers need to realise that you cannot run health like a widget-factory; there needs to be surge capacity and slack in the system. However, I am all for saving money when appropriate. Which is why recent spending on unnecessary equipment by Country Health SA puzzles me.

In late 2012 a new anaesthetic monitor was delivered to us on Kangaroo Island. We were told it was part of an across Country Health SA strategy “to meet requirements” in Operating Theatres. Sure enough, the new monitor is a ‘you beaut’ device, with touchscreen technology and allowing us to do fancy things like spirometry and bispectral index sensing – which we never had before.

The problem is, the old monitor worked perfectly well and didn’t need replacing. I’ve checked and double-checked the ANZCA guidelines – and can’t find a requirement to have these extra functions which we’ve been told are ‘mandatory’. I’m not even convinced of the need for BIS, other than in paralysed patients being transported where risk of sedation failure may be present (read more on BIS here).

The disappointing thing is that we really need an EXTRA monitor in our location.

Currently post-op patients are monitored in ‘Recovery’ which is also our small ‘Emergency Room’. We use the MRX defib as a post-op patient monitor. Which is fine, so long as there is no emergency patient who also needs monitoring. As well as the need for two monitors, there have also been occasions when the anaesthetic monitor has malfunctioned – so having a backup immediately available makes good sense (particularly when you are on an Island!)

Using MRX defib as sole monitor in ED/Recovery - no backup!

Using MRX defib as sole monitor in ED/Recovery – no backup!

So my efforts in the past have been directed to getting an additional monitor for our ED/Recovery…as well as to purchase equipment to meet ANZCA standards (equipment to manage a difficult airway being one particular bugbear). We’ve had some success – we’ve sourced and fitted out a difficult airway trolley and some signage. Sadly there has been no committment by CHSA to supply a fibreoptic device or videolaryngoscope (I ended up purchasing my own) to manage a difficult airway…and have been told there are ‘no funds’ to purchase an additional monitor.

The Health Minister Mr Jack Snelling wants to save money. I get that. But this new monitor allegedly cost $17K. There are fifteen sites across CountryHealth SA which provide anaesthesia – so that’s $255K spent on monitors which may not be needed.

There you go Mr Snelling – a $255K saving for you.

I’ve emailed the CHSA lead for anaesthesia, Dr Sara Norton to ask about this. She tells me she was unaware of the decision to purchase these new monitors and did not consider either BIS or spirometry as mandatory requirements for monitoring. Which makes the purchase of these $17K per piece monitors even more puzzling. To date, Sara has not been able to get an explanation from Peter Chapman (Acting CEO of CHSA) re: this decision.

Seriously – that money could have been better spent in rural hospitals on essential additional equipment. We are repeatedly told there is ‘no money’ and purchase of much equipment falls upon efforts by local charities like CWA and Rotary. I think rural Australians deserve the same access to essential equipment as their metro cousins…and wish that decisions on equipment purchase were made in consultation with local clinicians.

Perhaps Jack Snelling should be asking Dr Peter Chapman – who is making these decisions and where is the governance?

Pecha-kucha SMACC 2013

Well my three ‘pecha kucha’ talks have been uploaded to the SMACC website at http://smacc.net.au/category/pk-talk

Quite a novel format – only 20 slides, 20 secs each – 400 sec only for each talk

Better than ‘death by powerpoint’ @ffolliet would be proud.

SMACC2013 looks to be fun as well as bringing together critical care enthusiasts. Even though a humble rural doctor, I am mindful that critical care does not respect geography. So managing critical care comes under our remit.

Too often we see a divide between super-specialist tertiary centres and the reality of delivering healthcare in rural Australia. Rural docs are often resource limited, and we deal with critical illness relatively infrequently.

Casey Parker and I had a natter about this in Perth at the ACRRM 2012 conference…both committed to rrying to help bring ‘quality care, out there’ – neither of us is prepared to accept a lesser standard of healthcare in the country, purely because of geography.

So my three PK-talks are

- a rant on affordable difficult airway equipment options for bush doctors (but equally applicable to small EDs and ICUs

- a rant on the failure of Australia to adopt an immediate care scheme akin to the UK’s BASICS … Whilst we have outstandingly good retrieval services in Oz, the tyranny of distance means that there is inevitably a gap in the bush, especialy when paramedics in the bush may be volunteers. Rural docs with airway skills are well-placed to fill the gal – but if involved in prehospital work they need to be equipp, trained and audited. I may get drummed out of EMST directorship for some of my comments on this entry-level course…

- a rant on wildlife-vehicle collisions on Kangaroo Island and a novel strategy to reduce the trauma. Classic prevention, not cure – ultimately primary care applied to trauma

Enjoy!

The Love Affair may be over….

Well, no secret that I’ve been a fan of videolaryngoscopes

Not so much because I think VL will replace the skill of direct laryngoscopy (it won’t), but because I think they add another tool to our therapeutic armamentarium – particularly for the ‘occasional intubator’ or the isolated rural GP anaesthetist

The past 18 months or so has seen a proliferation of these devices….and with that comes the danger of ‘too many toys to choose from’

To my mind, the gold standard is a VL that performs like a standard laryngoscope and doesn’t require learning a new technique. Having a video-out port or an SD card to record video for audit and teaching/training makes it even better value. The C-MAC system ticks these boxes but is expensive – frankly too expensive for use in small rural units (although having just witnessed the Health Dept blow $17K on new anaesthetic machine monitors that we don’t need and were not requested nor sanctioned by the County Health lead for anaesthesia does make you wonder)…

The KingVision VL has been an affordable device for small rural hospitals….around A$1000 and with video-out ports so can be slaved to a monitor or PC to watch novices or to record intubations for training. I am not sponsored by them, nor have any affiliation…but it’s no secret that I have been happy with my purchase for the past year or so.

Imagine my surprise when today the screen packed up mid-intubation on a difficult case. Changed blades, battery…no use.

So switched to an iLMA and proceeded with blind passage of the ETT.

image

This is not the first time equipment has packed up on me this year – I have had two anaesthetic monitors fail mid-case, which caused me some grey hairs …. especially as we have no back up monitor here on Kangaroo Island (more cost saving, nice one CHSA). For a while I wondered if it was me causing electrical failures…but when the new $17k replacement monitor failed five mins into a case without me touching it, I realised this was just bad luck. Kudos to my trainers though, who ran through this sort of scenario in JCCA training.

Anyhow, the KingVision VL is now dead. I have emailed their rep, awaiting a response…let’s hope that they will cover this under warranty

If not, I will be mighty pissed. If this is a case of ‘planned obsolescence’ then it would be hard to support this device in the future. Better to go with one of the cheaper ‘throw away’ devices like VividTrac or stump up the dollars for a more expensive but longer lasting device like C-MAC.

Let’s hope KingVision come through with a replacement display/handle.

I will report back….