Dept. of Anesthesia, Christchurch Hospital,
Christchurch, New Zealand.
An item syndicated in newspapers throughout New Zealand on December 15, 1986 stated “Most anesthesia deaths fault of doctors” and went on to quote from an address by Professor Ronald Katz to a meeting of the New York State Society of Anesthesiologist. That this item was reproduced in New Zealand indicates the rising interest by the public in standards of medical practice.
Our medico-legal environment is greatly different to that in the United States. Firstly, lawyers are not paid on the basis of a portion of a court awarded settlement. Secondly, and of more importance, there is no right of an individual to sue a medical practitioner for civil negligence. The government owned Accident Compensation Corporation administers a compulsory insurance scheme under which any accident (including medical misadventure) is automatically the subject of compensation according to a specific set of rules without examination of fault or apportioning of blame.
A Different System
This is not the place to argue the virtues or otherwise of such a system but a perhaps predictable consequence has been a major increase in the number of patients bringing actions against doctors through other channels. The commonest has been a complaint of unprofessional conduct made to the Medical Council of New Zealand (as the statutory body responsible for standards of practice) or to the disciplinary committee of the New Zealand Medical Association. Anesthetists have been the subjects of a number of these complaints. Thus, we have the situation where anesthetists are having to examine their standards of practice without major financial pressures but because of public demand as well as the increased questioning of medical actions which is evident in so many countries.
Anesthetic practice in New Zealand has been historically developed from the British system. It has thus always been entirely physician based. There has been traditional emphasis on the need for clinical skills and observation and (at least until recent years) less on information from external measuring devices. It is only now that there is majority acceptance of the need for a continuous display of circulatory and ventilatory status throughout every general anesthetic. The recent statement of monitoring standards from the Harvard Medical School’ has come at a most opportune time so far as this country is concerned.
We now have specialist anesthetists who have trained in Australia and in North America as well as in Britain. They have increased awareness in the anesthetic community of the ways in which clinical observation can be extended by the use of appropriate monitoring. EKG and peripheral pulse plethysmography is common place. The values of measurement of neuromuscular blockage have become apparent even to those of us who trained in Britain a number of years ago. In major surgical units and some hospitals you will see work done in the same way and to the same high standards as in comparable North American units.
Nevertheless, those of us who are responsible (as heads of departments) for provision of good facilities and modem equipment have major difficulties given the limited budgets available in the State funded Hospitals system. For example, in my own Department we have 28 anaesthetizing locations. A pulse oximeter costs approximately NZSIO,000. Our equipment grant for the 1986-1987 year totaled NZ$30,000. We thus have the dilemma of knowing what is available and what is clearly desirable to enhance patient safety but no way to provide it in the short term. We must carefully note the standards of care as these develop in other parts of the world but cannot necessarily accept them as immediately essential to anesthetic practice here. It is for these reasons that the basic common sense approach of the Harvard statement will be of enormous value to anesthetists in New Zealand.
New Zealand anesthesia owes much to the Faculty of Anesthetists, Royal Australian College of Surgeons (Australia and New Zealand work as a single unit in terms of training and accreditation of specialist anesthetists) for their insistence on high standards of training and of staffing in teaching hospitals. As well, we owe much to Dr. Ross Holland from Sydney, Australia for his work in the examination of anesthesia associated modality. Using criteria based on those of his committee, we have examined anesthesia associated mortality on a national basis during the last eight years. Our findings are at least similar to those reported by other committees although we have perhaps concentrated on individual feedback to reporting clinicians to a greater extent that is apparent in other reports. Of the cases reported to us, 34% included management problems for which the anesthetist could be held mponsible2. This is not “the majority of cases” referred to in the media quotation at the start of this column but perhaps the data base was different in Professor Katz’s study.
Certainly, there is no reason for complacency in this country. Having been associated with our mortality assessment committee since its inception, I am of the view that the critical incident approach pioneered by the Boston group and in Australia by Dr. John Williamson 3 has more potential to improve standards of patient care if incorporated in the activities of a Department of Anesthesia. For one thing, there are more incidents than anesthesia associated deaths. Fortunately, studies can be done on a low cost basis and so, in contrast to equipment, are not influenced by the political whims of Government. These incidents can be examined at local, national or even international level and I hope that we in New Zealand could be part of some major studies. We have much to learn from each other.
References
- Eichhom JH, Cooper JB, Cullen DJ, Maier WR, Philip JH and Seeman RG. Standards for Patient Monitoring during Anesthesia at Harvard Medical School. JAMA 1986; 256: 1017-1020.
- Gibbs JM. The Anesthetic Mortality Assessment Committee 1979-1984. NZ Med j 1986; 99: 55-59.
- Williamson IA, Webb RK and PW SL. Anesthesia safety and the “critical incident” technique. Aust. Clin Rev 1985; 57-61.