Anaesthesia shock: fatal decisions

When will the authorities be shocked into action?
Mari Hudson writes in What's New Doc

Healthy mothers are dying in level 1 and 2 hospitals at the hands of doctors so unskilled in administering obstetric anaesthesia that they should never have been in a position to attempt it in the first place.

This is still happening more than ten years after the first Saving Mothers health report was published (followed by another two), and four years after a 2005 research study showed that the high maternal mortality rate in regional Free State hospitals was directly related to the lack of training, experience and supervision of interns, community service doctors and medical officers.

All these reports as well as the study pointed out “considerable inadequacies that require urgent addressing.”

Almost all young and inexperienced doctors have to regularly resuscitate a newborn baby at the same time as they’re administering obstetric anaesthetics – often without an experienced doctor within reach. In 10% of cases they have to perform the Ceasarean Section.

Tragically, all too often a spinal anaesthetic is administered to patients for whom it is totally contraindicated, with fatal consequences.

“I feel like crying when, during yet another investigation into an obstetric maternal death, I discover that the young, healthy mother died because the medical officer forgot to turn on the oxygen supply,” Dr Gillian Lamacraft, specialist anaesthetist at the University of the Free State (UFS) and one of the chief researchers of the 2005 study, told What’s New DOC.

Most disconcerting is that only one of the 11 key recommendations from the reports and study have been acted upon since 1998. Three more recommendations are about to be implemented in the Free State, but it’s still not enough.

Expert anaesthetists expressed deep concern to What’s New DOC about the ongoing lack of action by both the provincial health authorities and the Health Professions Council of South Africa (HPCSA).

Indications are that the fourth Saving Mothers report, soon to be released, will confirm that the situation has deteriorated even further in the past four years.

What’s New Doc established the following:

1. Still more deaths
   Inexperienced and inadequately trained interns, community service doctors and medical officers continue to make unacceptable mistakes when administering anaesthetics. More than 90% (82 in 91) of anaesthesia-related deaths at level 1 and 2 hospitals between 2002 and 2004in South Africa were avoidable. This trend continues.
2. There is a lack of
   understanding of the risks of spinal anaesthesia on the part of both unskilled doctors and the health authorities. Advertisements for medical officers often ask for experience in only spinal anaesthesia. The unskilled doctors then administer this type of anaesthetic to every patient, resulting in the unnecessary death of patients who are haemodynamically unstable.
3. State hospitals still
   willfully appoint unskilled doctors to positions where they are required to administer anaesthetics. Managers at level 1 and 2 hospitals in the Free State, KwaZulu-Natal and Limpopo among other provinces still appoint interns, community service doctors and medical officers without a diploma in anaesthesia to posts in which they are required to administer general and spinal obstetric anaesthetics – without senior supervision.
   At most level 1 and 2 hospitals outside Bloemfontein there is rarely a doctor with the diploma in anaesthesia, a qualification regarded by medical experts as non-negotiable for anyone who administers unsupervised anaesthesia. Some of these doctors have been working at these hospitals for many years without attempting to acquire the diploma, and there have been recorded fatalities at such doctors’ hands.
4. Provincial health
   authorities continue to fail to provide adequate supervision for interns and community service doctors at level 1 and 2 hospitals. Half of the interns in the study were not directly supervised while administering obstetric anaesthetics during their intern training.
   Half of all the community service doctors were employed in hospitals where no senior support was available. In fact not one had the assistance of an onsite, senior anaesthetist.
5. State hospitals
   still expect a doctor to simultaneously administer anaesthetics and resuscitate a newborn baby. In almost all cases hospital authorities expect interns, community service doctors and medical officers at level 1 and 2 hospitals to perform synchronous tasks. There are simply not enough doctors at these hospitals.
6. Government’s
   abolishment of the system of district surgeons without considering the consequences for state patients was a crucial mistake. The linchpin of rural medicine used to be the district surgeon/general practitioner. When provincial authorities got rid of most district surgeons in the 1990s and stopped allowing GPs to use local hospitals for private cases, many of them left the rural areas and were replaced by inexperienced community service doctors or medical officers of varying quality and training.
   “In the Free State a rural GP is a rare thing and the standard of level 1 hospitals has consequently plummeted, with a few exceptions,” says Lamacraft. “The GPs should be brought back.”
7. The emigration
   of anaesthetists is a cause for concern. About half of the 60 anaesthetists trained in South Africa each year move abroad, says Professor David Morrell of the South African Society of Anaesthesiologists. South Africa has one anaesthetist per 450 000 people – 180 times less than the UK’s one registered anaesthetist per 2 500 people.
8. The HPCSA has
   failed to act sufficiently to protect patients. They’re tasked to protect patients against negligence and malpractice and to set minimum standards for training and healthcare delivery. Yet their only action since the first report has been to extend intern training in anaesthesia from two weeks to two months. Even then the interns are (according to the 2009 intern training log book) only required to have performed five spinal anaesthetics for Caesarean sections.
   There is still no requirement for competence in administering general anaesthesia for C-sections or to be able to deal with the complications of spinal anaesthesia. The 2009 intern-training manual only requires the performance of 40 general anaesthetic procedures for any type of surgery. The HPCSA’s lack of minimum requirements is in stark contrast with minimum requirements in the UK.
   Each intern should have a formal assessment of obstetric anaesthesia skills before being allowed to qualify, says Lamacraft. “South Africa also needs a national standard for doctors who administer unsupervised obstetric anaesthesia, as well as a standard for who those supervisors should be.”
9. The HPCSA does
   little to ensure that state hospitals adhere to the council’s guidelines for intern supervision in anaesthesia. Their guidelines for intern training regarding anaesthesia state that ‘constant supervision for intern training is critically important, with such supervision ideally being from a specialist, or at least a doctor equipped with a diploma in anaesthesia’.
10. There are still no
    specific regulations governing the supervision of community service doctors. This is despite the fact that specialist anaesthetists regard this as essential and the directorate of health deems such support and supervision necessary.
11. This is just the tip of
    the iceberg. The inadequacies above represent a microcosmos of a much more widespread and serious problem: the general lack of adequate supervision of young and inexperienced interns and community service doctors in rural areas.
    Widely publicised incidents such as the community service doctor who cut the bladder of a woman to pieces in Standerton Hospital while attempting a C-section, and other fiascos in Mpumalanga, are symptoms of a widespread predicament.

The bottom line
South Africa needs urgent and appropriate action to solve the deepening crisis resulting from the shortage of senior doctors and nurses in rural areas, says Professor Johan Diedericks, head of the Department of Anaesthesiology at the University of the Free State.

The Diploma in Anaesthesia (DA)
‘This is an excellent examination for doctors who work in rural areas where they may be required to administer anaesthesia. That is what it was designed for in the first place and I strongly believe the qualification should be a requirement for all general practitioners and medical officers working in this field’, says Dr Gillian Lamacraft, anaesthetist.

On a positive note: Free State action

• Free State health authorities have appointed a task team to address the high maternal mortality rate. The task team consists of representatives from the state sector as well as specialist anaesthetists of the University of the Free State.
• The department of anaesthesiology at the University of the Free State has embarked on a special outreach training programme whereby specialist anaesthetists visit level 1 and 2 hospitals, where they train inexperienced doctors. But much of this benefit is lost when the junior doctors depart. One of the main objectives of the task team is to put effective systems in place to ensure that constitutional knowledge does not disappear.
• The department of anaesthesiology of the University of the Free State has also created a new series of lectures on the ICAM system. These lectures are sent to all level 1 and 2 hospitals in the Free State.

This is an edited extract of an article first published in What’s New Doc, 2nd issue, March 2009. What’s New Doc is a publication for medical doctors, produced in association with Health24.

Read more:
Spinal anaesthesia risks
Maternal deaths anaesthesia related
South Africa fails mothers
Anaesthesia related deaths in kids