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The Australasian Society of
Anaesthesia Paramedical Officers
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Anaesthesia Down Under
9th - 12th November 2006
Conference Papers
Starting with Patricia Coyle's paper on disasters and anaesthetic practice, we'll be adding transcripts of the papers presented at the 2006 Conference as they become available.
Coping with Limited Resources - Disasters et al
Patricia Coyle AO BSc(Med) MB BS FANZCA FRCA Dip Trop Med
Perhaps the possibility of having to cope with limited resources is, for some, or even many, of us, in this day and age and in this country, the greatest challenge, the greatest of all possible disasters!
The question “What would I do if …..?” is worthy of attention in both the developing world and the developed world. Safety protocols and incident reporting and management are well established and familiar elements in anaesthetic practice, but complacency has no place. The anaesthetic paramedical officer has at least as much responsibility as has the specialist anaesthetist to give attention to the question. An imaginative consideration of even remote scenarios could be worthwhile and quite interesting.
In the developing world, and in any location of limited resources, it is a question to which answers must be found in advance, but should be known in advance in all types of locations, even the most sophisticated.
Disasters or emergencies, both acute and chronic, usually if not always result in a limitation of available resources.
Causation is natural or man-made or a mixture of both.
Natural causes include earthquakes, tsunamis, volcanic eruptions, avalanches, major floods, cyclones, etc. These are acute events, and such disasters are usually – and almost certainly, if occurring in areas which are significant to the developed world - high profile. Other natural causes include prolonged droughts; the crop failures and ensuing famines often result in great loss of life, and in significant movement of people.
Man-made disasters include conflicts, and, of course terrorist attacks, and, if sudden and large-scale, are high profile, especially if in areas of particular significance to the developed world, or in the developed world itself – eg major cities.
Acute high profile emergencies are relatively short term. This is not to imply that the consequences do not require, in many instances, considerable attention for maybe prolonged periods of time.
Chronic, long-term ongoing “emergencies” may last months, years, decades, and are, for much of the world, maybe virtually all the developed world, of low, or very low, profile. The naturally occurring causes include droughts, floods, famines, etc, and the man-made ones are chiefly conflicts – tribal, national, regional, international. Africa in particular seems never to be without conflicts in at least one area, and often several. The consequences of conflicts are multiple. Conflicts usually, if not always, result in displacement of people from their homes and land. People on the move are unable to plant crops, and/or harvest crops. Thus not only droughts and, at times, floods, result in famine, conflicts too are an important cause of famine. Disruption of healthcare networks and neglect of education are further consequences of the social chaos of conflicts. And all these problems have long term, very long term consequences. All this is chronic disaster.
The responses needed for acute disasters and chronic disasters are very different - as are the responses offered!
The response to any and all disasters needs to be
fast and controlled
basic and adequate
and include both people and materials.
AND should be by invitation and/or mutual agreement.
The immediate needs are the care of the injured and sick, and the provision of basic human needs - food, water and shelter. Of the less immediate needs some clearly require earlier attention than others; roads and transport and communication take precedence over the re-establishment of healthcare networks and education, though these too need early attention. And there are differences in emphasis and in priorities in the responses to acute and chronic disasters.
This presentation deals chiefly with chronic disasters, frequently low profile, though mention will be made of acute disaster responses.
Surely if a disaster is long term, chronic, responses are underway? The answer to this is both Yes and No, and when the disaster is internal to a country, perhaps one or more areas, or involves the whole country, or is regional, that Yes and No is understandable – up to a point. But how does the world in general recognise that point? Only when many have died?
While the needs following or during a disaster are multiple, here the medical aspects of the responses will be considered.
Acute disasters are probably the easiest to speak about, and may well be the simplest to deal with, though challenging and costly.
The military response is arguably the most impressive both in speed of arrival and in efficiency of function. Medical teams, especially field surgery units, and also medical evacuation facilities, will often or usually be supported by engineering teams. Peace keepers may also be required.
Other 'responders', ie non-military, to both acute and chronic disasters include the International Red Cross (ICRC) and non-government organisations (NGOs).
(Note: 'Well-intentioned' is not sufficient reason for a person to go to a disaster area; the contribution (potential) should be greater than the 'cost' – food, water, accommodation, waste disposal.)
The duration of an 'acute' response to a disaster - ?how long ?limits - cannot be
pre-determined, every situation must be assessed – and re-assessed. It is important that ongoing management has been initiated and is sustainable.
Responses to chronic long-term disasters likewise cannot have inflexible limits set in advance, but it is necessary that goals are determined and some limits set. It is important that projects, eg medical, are not open-ended. The aim of expatriates should be to become redundant as soon as possible.
Limited resources
A particular resource – a human one – which may be lacking, often an unrecognised lack until the challenge arrives, is an ability to adapt, to improvise, to invent. Other human resources – knowledge and skills etc – are much more acquirable than this one. It is well if at least one person in a medical team responding to a disaster has an inventive ability; this is especially so in a long term situation, when there is often need to manage with locally available resources.
The resources, the limitations of which are readily recognised, are the material ones, and, in the field of medicine and anaesthesia in particular, a reliable power supply, and compressed gases, especially oxygen, also a water supply. Also tools of trade, buildings, transport, communication.
Now to the actualities of 'coping' - what anaesthetists and others 'do'!
Limitation of basic infrastructure and resources limits the work of anaesthetists – or does it? Certainly there are challenges. And there is great satisfaction in meeting them and achieving safe anaesthesia.
Consider this potential situation, chronic long term eg somewhere in Africa.
No reliable electricity supply
No reliable compressed gas supply NB oxygen
No reticulated water supply.
There can in such a situation be NO dependence by anaesthetists on compressed gas and electricity; manpower will replace a ventilator and atmospheric oxygen will replace compressed oxygen.
Chemical agents available will also probably be limited, at least in comparison with a developed world work environment.
Monitoring procedures will also be limited, but at least ears, eyes and fingers will be available.
What can be done? The following looks at some strategies.
Anaesthesia, an absence of sensation, can be achieved as general anaesthesia (GA) which involves loss of consciousness, and conduction anaesthesia, during which nerve conduction is blocked and consciousness is retained.
General anaesthesia involves the administration of the appropriate agent via either the inhalational route or the intravenous route ( and/or intramuscular route for ketamine).
A vaporiser is needed to allow conversion of an anaesthetic liquid into a vapour to be inhaled.
In the absence of a reliable supply of compressed oxygen, the draw-over technique of inhalation anaesthesia is employed. And in the absence of a commercial draw-over vaporiser, an effective and safe vaporiser can be improvised.
Both general and conduction anaesthesia requires syringes and needles, infusion sets etc. And of course both techniques require the relevant chemical agent(s).
In all instances a supply of fluid for intravenous (or alternative routes) administration is necessary. “Alternative routes” are worthy of thought; they do exist and may buy valuable time.
Monitoring of the patient's vital signs is mandatory. Adequacy of tissue perfusion can be assessed roughly by skin colour and apparent temperature. The pulse is detected by touch. Respiratory movement can or may be visualised. Air entry to the lungs is assessed by auscultation, as is the beating of the heart. A precordial or (preferably) an oesophageal stethoscope, securely fixed in the optimal position, is a very useful monitor of both heart sounds and air entry. A precordial stethoscope can be home-made and, if provided with a long piece of tubing to the ear piece, permits quite extensive movement in the operating theatre by the anaesthetist without interrupting monitoring. And with some experience it is possible to make a reasonably accurate estimate of the blood pressure from the intensity of the sounds.
When a ventilator is not feasible then the patient breathes spontaneously, and hypoventilation can be avoided by intermittent assistance to ventilation. Long acting muscle relaxants should not be administered in these circumstances unless a dedicated manual ventilator – ie a skilled person – is available, and even then there is risk, to which the patient should not be exposed unless there is certainly no alternative.
What is actually done in each case will be influenced by:
- the proposed surgery
- the condition of the patient
- the available equipment and chemical agent(s)
- the skill and experience of the anaesthetist and assistant.
Whatever is done must be appropriate in every sense - suitable to ALL the prevailing circumstances.
All AID must be appropriate and culturally acceptable, and chronic aid must be sustainable ie the benefits will persist after departure of expatriate personnel and foreign funding.
And finally “Has/have the hospital(s) survived the disaster?” Planning has at times, maybe often, assumed that the hospital/s is/are intact. It is essential that provision is made for the situations in which hospitals have been damaged or destroyed; stores of emergency equipment, safe from unauthorised access but readily accessible when needed, are a vital element in all disaster plans. A major disaster such as a terrorist attack in the developed world, usually a major city, and the response to it, is anticipated in existing plans in presumably all countries – plans which are repeatedly tested and re-evaluated. The possibility of one or more hospitals being significantly damaged must never be ignored.
APPENDIX
The following journal references are to articles by TB Boulton and PV Cole about anaesthesia in difficult situations, and specifically, in some articles, ask the question “What would I do if …?” While they are 'old' writings some readers may find them quite interesting.
ANAESTHESIA 1966 vol 21 pp 145, 268, 379, 513
ANAESTHESIA 1967 vol 22 pp 101, 435, 607
ANAESTHESIA 1968 vol 23 pp 220, 385, 597
The “Remote Situations, Difficult Circumstances and Developing Country Anaesthesia” (RSDCDCA) Course is held yearly, most often in Tasmania, organised by Dr Haydn Perndt of Hobart. The 15th course will take place in Darwin in April 2007. These courses are very popular and excellent preparation for disasters of all sorts.
The NSW Anaesthetic Continuing Education Session No 62 Nov 2005
“Remote Anaesthesia…' booklet is well worth looking at if at all possible.
Banda Aceh and a possible Sydney scenario etc.
Some interesting websites
www.usyd.edu.au/anaes/medapteq
www.developinganaesthesia.org
www.jfish.org
www.developaid.org
www.asa.org.au 'overseas aid' then 'overseas aid subcommittee'
www.surgeons.org 'external affairs' then 'international aid'
www.interplast.com.au
www.ossaa.org.au
www.ausaid.gov.au
www.australianvolunteers.com
www.hvousa.org
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The Speakers
| Thursday 9th November |
| 07:30-08:45 |
Registration |
| 09:00-09:20 |
Opening Address – ASAPO President - Ms B Lindbergs |
| 09:20-09:40 |
Official Opening – Government representative |
| 09:40-10:00 |
Welcome Ceremony – Dance Troupe |
| 10:00-10:30 |
Morning Tea |
| 10:30-12:00 |
Australian Key Note Speaker – Dr Patricia Coyle –Honorary Educational Fellow RPAH. |
| 12:00-13:30 |
Lunch |
| 13:30-14:15 |
History, Education & Registration of Anaesthesia Technicians in Australia – Mr Adrian Sage |
| 14:15-15:00 |
Royal Flying Doctor Service – Dr Gerry Costello Director of Medical Services RFDS |
| 15:00-15:30 |
Afternoon Tea |
| 15:30-16:15 |
Burns (Topic Title to be confirmed) – Dr Michael Rudd Clinical Director, Burns Unit RBWH |
| 16:15- 17:00 |
Burns – Why, What and How! - Dr Michael Steyn, Director of Anaesthesia RBWH Qld |
| 18:30-20:30 |
Welcome Reception – Trade Exhibition (included in Full Registration package) |
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| Friday 10th November |
| 07:30-08:15 |
Registration |
| 08:30-09:15 |
NZ Key Note Speaker –Dr Malcolm Stuart – “Anaesthesia Technician Training” the West Coast Way |
| 09:15-10:00 |
History, Education & Registration of Anaesthesia Technicians in NZ – Ms Karen Bennett Chairperson NZATS / Ms Patricia O'Brien Training Coordinator NZATS |
| 10:00-10:30 |
Morning Tea |
| 10:30-11:15 |
Opportunities in Anaesthetic Technology: A vocational Education and Training (VET) Perspective – Ms Diane Lawson CEO Community Services & Health industry Skills Council |
| 11:15-12:00 |
Indigenous Health: An Overview – Dr Rebecca Daniel, Paediatric Registrar, The Princess Margaret Hospital for Children Perth WA |
| 12:00-13:30 |
Lunch |
| 13:30-14:15 |
Organ Donation – What you need to Know – Alana Cresswell, Organ Transplant Coordinator Princess Alexandra Hospital Brisbane Qld |
| 14:15-15:00 |
Lung Transplantation - Past, Present and Future – Dr Keith McNeil Head of Transplant Services - Prince Charles Hospital Brisbane Qld |
| 15:00-15:30 |
From the Recipient Perspective – Mr Chris Wills– Transplant Recipient |
| 15:30-16:00 |
Afternoon Tea |
| 16:00-17:00 |
Free Time / Australasian Society of Anaesthesia Paramedical Officers (ASAPO) AGM |
| 18:30onwards |
Dinner & Stage Spectacular Show – “Tempo Rouge” Conrad Jupiters Casino (included in Full Registration package) |
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| Saturday 11th November |
| 07:30-08:15 |
Registration |
| 08:30-09:15 |
Patient Care within the Operating Theatre - Ms Donna Stibbard Anaesthetic Technician Clinical Specialist Aust/NZ GE Healthcare, Clinical Facilitator ICM |
| 09:15-10:00 |
Anaesthesia for Endovascular Surgery – Dr Aaron Donaldson Staff Specialist RBWH Bne Qld |
| 10:00-10:30 |
Morning Tea |
| 10:30-11:15 |
Non-medical Roles in Surgery & Anaesthesia – Mr. Paul Ward, Cardiff Wales |
| 11:15-12:00 |
Fire in the Anaesthetic Machine – Ms Lyn Sleight – Anaesthetic Technician Western Australia |
| 12:00-13:30 |
Lunch |
| 13:30-14:15 |
Advances in Anaesthetic Monitoring and Record Keeping – Dr Philip Cumpston RBWH Bne Qld |
| 14:15-15:00 |
Alison Holloway Award – Award Winner Presentation |
| 15:00-15:30 |
Afternoon Tea |
| 15:30-16:15 |
Technical Advances in whole Lung Lavage - Garry Walker, Perfusionist Prince Charles Hospital Brisbane Qld |
| 16:15-17:15 |
Free Session / Queensland Society of Anaesthetic Technicians (QSAT) AGM |
| 18:30 onwards |
Gala Dinner (included in Full Registration package) |
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| Sunday 12th November |
| 07:30-08:15 |
Registration |
| 08:30-09:15 |
History, Education & Registration of Operating Department Practitioners in UK Mr Paul Ward |
| 09:15-10:00 |
Anaesthesia in Marine Animals – Dr David Blyde Veterinarian - Sea World Gold Coast Aust |
| 10:00-10:30 |
Morning Tea |
| 10:30-11:15 |
Micronesia Anaesthesia - Dr Arthur Vartis – Townsville Qld |
| 11:15-12:00 |
ENT Anaesthesia – How it was and How it is - Dr Phillip Allen VMO RBWH Brisbane Qld |
| 12:00-12:15 |
Close – Ms Yves Long Conference Coordinator, Secretary ASAPO |
| 12:30-14:00 |
Aussie BBQ Lunch - Poolside |
| 14:00-16:00 |
Discussion – World Society Formation |
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