INSIDE ISSUE: President’s Column · 2017-02-09 · INSIDE ISSUE: Welcome to the first NZSA newsletter of 2015. Advocacy and education continue to be our big drivers. We anaesthetists

April | Issue 41 The newsletter of the New Zealand Society of Anaesthetists

INSIDE ISSUE:Welcome to the first NZSA newsletter of 2015. Advocacy and education continue to be our big drivers. We anaesthetists take for granted that

the systems we need to look after our patients will continue to function – and mostly they do run well – but not always.

In January we discovered a production issue in the Australian supply chain for suxamethonium meant this vital drug might be in very short supply for a month. The NZSA contacted PHARMAC to find out if New Zealand would have the same problem. PHARMAC researched the issue and found that the contract included a clause which ensured a 3-month back-up supply for suxamethonium in New Zealand.

This is the this type of work we do for members – if an issue like this pops up we can help sort it out because we have a strong background of regular communication with PHARMAC and Ministry of Health officials on behalf of anaesthetists. Had there been an issue in New Zealand we would have been involved with those stakeholders to find solutions and ensure the continued supply.

Post-operative medicationsRecently another advocacy issue has come up. As we beaver away in small operating theatres with busy lists it’s easy to feel that we are small cogs in a big machine. One point where we interact with the rest of the hospital is charting post-operative medications.

Prescribing post-op medications is such a repetitive but important task that

the systems we have to use must be safe, easy and quick to use, otherwise patient safety and efficiency of care will be compromised. Anaesthetists take it for granted that others will see it this way – but sometimes we have to work hard behind the scenes to point out the importance of this.

Recently we’ve become involved with issues around the implementation of the Ministry of Health-purchased drug dispensing system Medchart. It’s important that there is anaesthetic input into programmes to implement new technologies such as Medchart, and in this case we are working hard to ensure there is. This system is being rolled out around the country and we want to make sure it is working efficiently for anaesthetists and that anaesthetists are trained properly to use it. If these goals are not achieved patient safety is compromised.

National Maternity RecordA related IT issue is the introduction of a National Maternity Record, the project formerly known as Badgernet (named after Dr Badger, a UK paediatrician who developed a database for UK neonates and mothers). This new system promises to have a single maternity record seamlessly recording all midwifery, obstetric, medical, anaesthetic and neonatal information in one place. It aims to reduce the risk to patients of poor care due to teams lacking vital information.

The National Maternity Record has the potential to alter much of our day-to-day practice in obstetrics. For instance, the epidural insertion record and operating theatre record will probably need to be

President’s Column

The New Zealand Anaesthesia’s newsletter design includes the NZSA’s logo (safety through knowledge) and the symbol on our constitution. The Kotuku, a white Heron, represents the physical person, its shadow represents the spirit. Te Kotuku can be translated as ‘safe’ and Rerenga Tahi as ‘journey’. The flight and return home of the Kotuku, is likened to a patient’s experience under anaesthesia.

Training improves services in the Pacific

Cross country skiing in Canada

Christchurch RWAC course valuable

NZSA Representing, Supporting and Promoting NZ Anaesthetists since 1948Page 2 | April 2015

computerised in delivery suite and in theatre. This probably means doing away with paper records in favour of using a computer in every delivery room; a new epidural record being done in each anaesthetic department; and computerised anaesthetic theatre records in all departments that are linked in to the National Maternity Record.

It’s a great project in terms of trying to get better care for maternity patients but there could be big implications for anaesthesia with regard to computer equipment, new forms, new theatre records and so on.

The advocacy role of the NZSA is to improve anaesthesia involvement in these projects and we’re continuing to talk with the stakeholders involved in these implementations.

Outgoing Trainee Representative Kerry Holmes talks more about the NZSA’s role with advocacy and gives a rather powerful case for membership of a stand-alone society, with regard to happenings in Ireland, in his final Trainee Corner on page 6.

Endoscopy sedationThe NZSA is keen, for patient safety reasons, that the large-scale patient sedation that will be required with a national endoscopy programme has some anaesthetic oversight in its development and quality assurance processes. In particular safe standards of sedation using propofol infusions require anaesthetic oversight. Following our approach, the Ministry of Health gave NZSA and New Zealand National Committee (NZNC) ANZCA the opportunity to have a joint representative on the Advisory Group for Nurses Performing Endoscopies. Executive member Emma Patrick is representing anaesthesia at these meetings in an effort to ensure our input.

Common Interest Group MeetingClearly there are many other issues where the NZSA advocates on behalf of anaesthetists. But there’s always more to

learn and we invest time in learning from and working with other organisations around the world in this area.

Incoming-President David Kibblewhite from Waikato and CEO, Renu Borst, are representing the NZSA at the Common Interests Group (CIG) meeting in Washington in May. This four-day meeting is hosted by the USA ASA and includes presidents, CEOs and other key personnel from anaesthesia societies from the UK, Canada, Australia, New Zealand and South Africa. I am sure David will find this experience of discussions with high-end advocacy organisations most valuable for when he becomes President later in the year.

See our articles on the WFSA and Ketamine on pages 20 and 21 for more examples of the work we do with other national societies and organisations.

ANZCA ASM In May I’ll be representing the NZSA at the ANZCA ASM business meetings in Adelaide as President, as well as carrying out my duties as Anaesthesia Continuing Education Co-ordinating Committee Chair.

EducationVisiting lectureships

Since 1948 the education of anaesthetists has been a core business for the NZSA. We recognise that peripheral centres have different needs to major centres and with the NZNC ANZCA, we have funded five visiting NZAEC lecturers who will each visit two centres to deliver lectures in regional centres during 2015.

AQUA

We continue to support the Annual Queenstown Update in Anaesthesia (AQUA) Queenstown meeting in August in collaboration with JAFA and we encourage you to come along. It’s a great chance to hear the latest updates on a wide range of topics relevant to contemporary anaesthetic practice, meet the clan, and do some skiing / boarding, or just visit this beautiful iconic New Zealand town.

Darwin CSC

In September we have our big Darwin

meeting, the Combined Scientific

Congress, with the Australian Society

of Anaesthetists. It’s going to be your

last chance to meet and hear Dr John

West of West’s Physiology, and there’s

a great scientific programme. Darwin

is a city like no other – dine or take a

dip with crocodiles at crocosaurus,

visit beaches with 10 metre tides, and

visit Kakadu National Park. Our article

on pages 15 & 16 has details of the

social and scientific programmes. I look

forward to seeing you there. We will

hold our AGM at this meeting and I will

be stepping down as President with

Dr Kibblewhite stepping into the role. I

invite all our members to attend.

Obstetric Anaesthesia Special

Interest Symposium

This year we are pleased to support

an inaugural two-day OASIS meeting

with National Women’s Hospital on

November 20 & 21. The NZSA is

providing conference organisation

support as well as underwriting 50% of

the meeting. Registrations have opened.

We only have a limited number of

spaces so please book early. See more

on page 3.

MembershipFinally, thank you to members who have renewed their subscriptions. Your fees allow us to support educational activities, and advocate for our profession and our patients. If you haven’t paid please do so as your fees are important to help us continuing this work.

We are now publishing three editions of New Zealand Anaesthesia a year in April, August and November. I hope you enjoy this edition which has some most interesting articles provided by contributors.

I wish you all the best for winter.

Ted Hughes

President

President’s Column Continued…

NZSA Representing, Supporting and Promoting NZ Anaesthetists since 1948 April 2015 | Page 3

Meeting with MinisterPresident Ted Hughes recently met with Minister of Health Jonathan Coleman. The President explained NZSA’s role within the sector, and in relation to other medical organisations, and commented that we supported the progress in elective surgery, the Minister’s desire for clinicians’ input on decisions, and the focus on wider health initiatives such as tackling obesity and smoking.How workforce issues are affecting anaesthesia and the need for accurate forecasting of future demand were discussed. The President also raised our interest in having anaesthesia oversight for safe sedation for endoscopy procedures and the advantages of this. NZSA and NZNC ANZCA are currently jointly represented on a committee discussing this. We appreciated the Minister’s time, especially when he was busy, as Minister of Sport, with the launch and first games of the Cricket World Cup. We look forward to introducing our incoming president David Kibblewhite to the Minister later in the year. NZSA Executive Committee Members and staff have met with a number of stakeholders to assist progress in our work for members this year. Organisations we have met with include other membership societies both from New Zealand and overseas, ACC, health boards, the Ministry

of Health, Health Workforce New Zealand and Lifebox.

Submissions updateThe NZSA has made the following recent submissions.

• ANZCA Statement on the Assistant for the Anaesthetist PS08 2014, November 2014

• Consultation Scope of Practice and Qualifications Nurse Practitioner, February 2015

Please see our website for details of these submissions. They can be found under about/advocacy. For more detailed information about issues we are advocating for members on see the same section under the Members Only page.

Committee changesMalcolm Stuart has been appointed as Treasurer for the committee, following Mark Featherston who resigned from the position after six year of service. We thank Kerry Holmes for his work as a trainee representative for the past 18 months, and his contribution to organising the Part 0 trainee course in particular. Kerry leaves the committee to take up a fellowship at the Bristol Royal Infirmary in England in June. Kate Romeril and Ghassan Talab continue as the trainee representatives.

We welcome Kathryn Hagen back from Ireland and to the committee. Kathryn was a trainee representative before heading to Ireland on the BWT Ritchie Scholarship for 2014.

NZSA Anaesthetic Technology prize awardedNZSA executive member Kaye Ottaway was delighted to present the prize for Most Outstanding Diploma in Applied Science (Anaesthetic Technology) to the recipient Stacey Dean, left, at the awards function hosted by Auckland University of Technology in December. NZSA sponsors the annual award.

NZSA News


Over recent months a number of interested anaesthetists have stepped forward to work with us on private practice issues.

Thank you to Andrew Munro (Waikato), James Houghton (Tauranga), Neil Mushet (Wellington), Jeremy Foate (Canterbury) and Tim Wright (Otago). In addition to this, Jeremy Cooper, Ivan Bergman, Keith Barclay, Tom Studholme, Giuseppe Di Bartolo and Karen Stuart Smith, of Auckland, have been providing input into the RVG revision.

We’d like to have input from more regional areas. If you would like to have a voice concerning private practice, or to bring issues relating to practice in your area to the attention of the NZSA, please consider putting yourself forward for this group. The subcommittee will meet two to three times a year, probably in either Wellington or Auckland. Travel expenses will be reimbursed by the Society.

The working party and the other recently joined committee members, will meet again in early April to reach an agreement on the proposed changes of the RVG. The RVG will also provide educational material regarding consent, contracting, HDC and Commerce Commission issues relating to anaesthesia.

We welcome back Mark Featherston who took time out from his NZSA work late last year for a few months to recover from illness.

Issues under the spotlightExecutive committee members have been working with stakeholders on a number of private practice issues.

Mark Featherston and President Ted Hughes have been part of the ACC working parties looking at the model of funding and delivery of services since 2013. In March Private Practice Committee member Kaye Ottaway

met with ACC representatives to discuss issues specific to anaesthetic reassessment and preoperative services, and Incoming President David Kibblewhite attended the ACC forum regarding Pain Services in Hamilton.

We have also been discussing with the New Zealand Medical Association (NZMA) the relationship between patients and doctor and third-party contracts in relation to the Affiliated Provider Contracts. The NZMA will be releasing a statement regarding this in the near future.

The first Registered Nurse Assistant to the Anaesthetist course has started this year through the Auckland University of Technology. NZSA has been working with NC-ANZCA and the course developers to review the content, quality and exit exams. The first intake consists of nine nurses from a variety of theatres throughout the country.

Private Practice NewsRe-establishment of the Private Practice Subcommittee was a priority for the NZSA in 2014 and we are pleased to report a number of people have volunteered for this, but we are still looking for representation from some smaller centres.


OASIS on Waiheke IslandThe website is up and running and registrations are open for the Obstetric Anaesthesia Special Interest Symposium (OASIS) being held at Waiheke Island and in Auckland in November. This two-day meeting is hosted by the National Women’s Health Department of Anaesthesia and the NZSA, and will cover current concepts and controversies, and discuss cases relevant to the general anaesthetist involved in the care of pregnant women.It is being held on 20-21 November 2015 and over two locations on separate days – the Auckland CBD and at Onetangi Beach, Waiheke Island.

Varied and interesting programmeNew Zealand anaesthetists, obstetricians and maternal medicine physicians will bring their knowledge and experience to a varied and interesting programme. In addition to talks from an experienced panel, there will be an opportunity for delegate voting via smartphone to enhance the interactive debates on some of the current controversies in obstetric anaesthesia.Workshops that are suitable to meet the requirements of the ANZCA 2013 CPD “Emergency Responses” (CICO, CPR and Anaphylaxis), and which are tailored to obstetric anaesthesia practice, will be held at two Auckland simulation centres before the main meeting. Held over a weekend in late Spring on a Pacific Island haven of beautiful beaches, gastronomical delights and boutique

wineries, this meeting promises to be an excellent opportunity to keep up to date with obstetric anaesthesia in a magnificent family-friendly setting.

The programmeFriday workshopsCan’t Intubate, Can’t Oxygenate (CICO) and Cardiac Arrest workshops with an obstetric focus will be held in Auckland Simulation Centres. There is also an Anaphylaxis Case-Based Discussion to be held on the Friday afternoon only.

The workshops will be divided between the University of Auckland Simulation Centre for Patient Safety at the Tamaki campus and the Clinical Skills Centre, Auckland City Hospital. These are recognised as suitable for ANZCA CPD emergency response activities. Please note that workshop places are limited and allocated on a first come, first served basis.

Saturday symposiumThis full day covers ‘What’s new in Obstetric Anaesthesia’; ‘Enhancing recovery after Caesarean Section’; ‘Blood in obstetrics’ – blood conservation, point of care and near patient testing, and current concepts in obstetric haermorrhage management; GA during pregnancy and the peripartum – obstetric difficult airways and anaesthesia and the developing brain.The afternoon includes an interactive session on real-life case presentations and discussion on current controversies in obstetric anaesthesia.

The speakersThe speakers are Catherine Bryant, senior anaesthetic trainee from the UK, Ulrike Buehner, consultant anaesthetist at Rotorua Hospital, Denys Court, private practitioner with decades of clinical obstetrics experience, Matthew Drake, consultant anaesthetist at Auckland City Hospital, Jack Hill, obstetric anaesthetist National Women’s Hospital, Katherine McKenzie, Obstetrician and Gynaecologist at Auckland City Hospital, Claire McLintock, haematologist and obstetric physician and Clinical Director of Regional Maternity Services at Auckland City Hospital, Marty Minehan, Clinical Director of Anaesthesia for Women’s Health, Mark Moll, consultant anaesthetist Auckland City Hospital, Sharon Rhodes, Specialist Anaesthetist Women’s Health Anaesthesia at Auckland City Hospital, and Niall Wilton, Clinical Director of Anaesthesia and ORs at Starship Children’s Hospital. Speaker profiles are on the website below.

Member’s discountThere is a discount for those who are members of the NZSA and ASA (Australia) so register now to ensure you don’t miss out.

Registration opened in April so check the website for more information:

www.oasis-conference.org.nz

or email: [email protected]


I was quite late into my training before I had any idea there was an NZSA, and it’s only really

been through my work as the trainee representative that I now have a good idea of what the organisation does. I think that most trainees would be the same, and so I thought I’d write my last trainee corner on why I think the NZSA is relevant to trainees and why you should join. The following is my view, and is how I see the NZSA after my tenure as a trainee rep.

What is the NZSA?One misconception trainees may have of the NZSA is that it is a group of elderly white men gathered around a pentagram shaped table who use secret handshakes and get up to who knows what? But this view is only part of the truth (five of the 13 members are women and there are only a few grey hairs around the table!). The NZSA has been around since 1948, actually preceding the College. Its main role is to support and advocate for New Zealand, and only New Zealand, anaesthetists.

Support

The NZSA helps makes anaesthesia a great club to belong to. The Society supports you in your professional development with backing for events like New Zealand conferences, and trainee events like the Part 0 and Part 3 course.

Advocacy

This, I think, is NZSA’s most important role. Put simply, it is all about making noise on behalf of you and your patients. While you’re focusing on your exams, or waiting for the TPS to load, the NZSA will be working on issues that affect your career and the service you provide to patients. So when someone proposes a change to practices, medications or medical equipment that will impact negatively on the work of anesthetists, NZSA will challenge this. This requires wading through proposals and documents, attending meetings and writing submissions so that you as an anaesthetist can have that argument made on your behalf.

You might ask why you need advocacy from NZSA when there are a number of organisations you can join. It’s true there are a few organisations you can join, and I would encourage you in time to

join several of these to keep anaesthesia strongly represented and to keep up your professional development.

The reason several organisations exist is because they all have different roles. NZSA is however, the only one that represents solely the interests of New Zealand anaesthetists. Where we have common ground we are continually working with other organisations to represent ‘Anaesthesia Inc’ if you like. Who are these organisations and how are they different from NZSA?

Australian and New Zealand College of Anaesthetists

The college is responsible for training and standards in anaesthesia across Australasia. All trainee members are trained by ANZCA. The NZSA has a strong relationship with the New Zealand National Committee ANZCA which also does mighty work on your behalf.

New Zealand Medical Association

The NZMA is another organization that NZSA works with. It represents doctors across all settings in the health sector. Its role is broad as is its mission - to promote professional unity and improve the health for all New Zealanders.

The Resident Doctor’s Association

The RDA does a great job of defending the rights of the house surgeon. It has played a key role in getting junior doctors in New Zealand some of the best conditions in the world. It is not really involved in vocational training workforce issues or the world of politics as it pertains to anaesthesia and our workforce.

Associated Salaried Medical Specialists

You’re not involved with ASMS yet, but come your fellowship year onwards you may well be. ASMS is the union representing salaried specialists and other senior doctors and dentists with regard to collective employment agreements along with protection of rights and entitlements. On the professional side ASMS promotes public debate on a broad range of issues relating to the provision of high quality health services. While it has many anaesthetist members, it has a broader focus than our specialty.

Why is advocacy needed?There have been a couple of overseas examples in recent years which show what happens when there’s a need for

advocacy. In one case a strong society was able to help, but in the other anaesthetists got a rough deal.

Some of you may be aware of the Queensland issues, wherein the state government effectively wiped everyone’s contracts and handed them a new one. The Australian Society of Anaesthetists led the charge. This was a bitter fight to slash the budget, and ended in a nasty fashion for some of the people on the side of the common anaesthetist. But if it hadn’t been for the ASA pushing back, the outcome would have been significantly worse.

Which was apparently the case in Ireland. Irish anaesthetists were a relatively well-paid group. Managers decided to offer a new contract to incoming consultants at a much reduced rate. This meant that new consultants were on a contract paying much less than their colleagues in the same department. The College of Anaesthetists of Ireland could not become involved in employment issues and so it fell to their society. Ireland falls under the AAGBI banner for its association - the ‘I’ part being considerably smaller than the ‘GB’ part. Resistance was apparently viewed as particularly feeble by your coalface anaesthetist, and the changes passed easily.

So why should you join?There are two main things to think about here. They can be divided into “what can you do for your society, and what can your society do for you”. The above are examples of what your society is doing for members day-to-day, and added to that are membership benefits and discounts as explained under Membership on the website.

All of the advocacy will obviously happen whether you yourself are a member or not, but joining NZSA and other organisations representing our community gives a stronger voice for all of anaesthesia, giving us more ability to influence for anaesthetists and our patients.

It’s clearly in your interest to have a robust team in your corner for issues that affect you both now, and in your future career. This means having both a strong college, and a strong society.

Kerry Holmes

Trainee Representative

Trainee corner March 2015 In his final Trainee Corner Kerry Holmes discusses why trainees should join NZSA and other membership bodies.


A chat with an executive member

What led you to choosing to study anaesthesia?Early at medical school the idea of anaesthetics interested me. I think because I enjoyed physiology and pharmacology and anaesthesia seemed to have a very practical hands on role in the hospital setting.Can you tell us about your training path, including where you studied? I trained through the University of Otago and Christchurch Clinical School with my first House Surgeon job being at Ashburton and Christchurch Hospitals. After my “OE” in the UK I returned to an SHO job in Hawkes Bay and the following year was accepted onto the anaesthesia training scheme through Hawkes Bay and Wellington. My PFY was spent in Newcastle NSW and from then I went to Oxford for post fellowship experience in cardiothoracics, neuroanaesthesia and plastics. In July 1999 I took up a specialist post at Christchurch Hospital and have been there since.

What was most valuable or influential during your training? It has to be the people who taught me and the patients I cared for. A very kind and experienced anaesthetist in Hawkes Bay took a (calculated) risk in supporting me getting into anaesthesia and mentored me through my first year. My Wellington SOT supported me through my exam attempts, and there was also all the ongoing teaching from the many seniors at Wellington and Hutt Hospitals. Professor Cutfield helped me pursue my cardiac interest in the UK. It is easy to forget that patients allow us to gain the skills we need to become a specialist during our apprenticeship. Anaesthesia can be a humbling experience some days and patients put an enormous amount of trust in our abilities.

Can you describe some of the settings you’ve worked in?I remember fondly the two and a half years I spent in Oxford at both the Radcliffe Infirmary and John Radcliffe Hospital. The Infirmary was located in the centre of Oxford and

had an impressive sculpture and fountain of Atlas at the main entrance. As a follower of the “Morse” detective series I was able to recognise a few of the landmarks around the city and the Infirmary was used to film the Hospital scenes for the program. The John Radcliffe is a large tertiary hospital and a bit impersonal but I got to know the cardiac team well and the tea room was a good place for gossip. I lived within walking distance of the hospital and the surrounding area with parks, walkways and a river was a real delight.

How did you become involved in supporting Grey Base Hospital to ensure it’s kept an anaesthetic service there? I became involved with the West Coast while I was the Clinical Director of Anaesthesia in Christchurch. There were no vocationally registered anaesthetists to supervise the South African locums, which was a requirement of the Medical Council, and the registration pathway. I had the Durban-based anaesthetists spend time in Christchurch to see them work and then supervised at a distance with intermittent on site visits. With the appointment of a specialist anaesthetist to Greymouth my supervision role reduced, but I still provided distant support to the service until the onsite specialist resigned and returned to Sweden. At that stage I had completed my term as HOD in Christchurch so I took on the role of head of anaesthesia for WCDHB and now spend two days a fortnight on site in Greymouth.I have managed to staff Greymouth with four permanent fulltime anaesthetists. All are from overseas and two have full vocational registration, while the other two are under supervision on the pathway to full specialist registration. I continue to build on clinical links with the Christchurch anaesthesia department and am forever grateful for the support the Christchurch team provide.

Why have you volunteered to work with the Society?My intitial involement with NZSA came about when Health Workforce New Zealand (HWNZ) wanted to look at anaesthesia

staffing and alternative anaesthesia providers. I joined the NZSA subcommittee that worked with NZNC-ANZCA to gather information and engage with anaesthetists around the country to discuss issues and solutions. From this a document was presented to HWNZ describing the anaesthesia workforce, the current problems and way forward. Following this I put myself forward for the executive with the aim of being involved in issues that concern New Zealand anaesthetists.

What do you enjoy to work on and what would you like to achieve with the Society?I enjoy working on the things that influence anaesthesia in New Zealand in the broader sense. When you look at anaesthesia care in different countries it’s interesting to find out what has driven the development of a particular model of anaesthesia care. Political, financial, social and economic influences can all have an impact. New Zealand healthcare seems to be influenced by financial and political forces in the main, and it is important that we maintain the high standards of anaesthesia and pain management that we have achieved. Whilst it is important to look at what we do and make changes to our model, we need to make sure our voice is heard politically and publicly over safety and standards of care. It’s a real team effort at the NZSA executive and I enjoy the support that we all give each other.

What do you like to do outside of work?I like to cook and especially having friends around for dinner when I can spend time planning and preparing the food. I’m a big fan of Jamie Oliver due to his mix of great recipies and his attempts at improving the quality of what children and adults eat at school and at home. I have a very old and well worn Ken Hom book and still use it weekly. I enjoy reading and my aim this year is to walk the Milford track in November so have started training for that.

What’s an ideal holiday for you and your family? A beach-based summer holiday in New Zealand is ideal. Hawkes Bay, Bay of Islands, Golden Bay and Mapua have all been great places to spend time with family and friends. I like simple barbecue dinners and plenty of time to swim and read and unwind. Overseas, I have to rate the trip my wife and I did to Barcelona. The atmosphere was so vibrant, the food so fresh and the sights so diverse. We walked all over the city, visited museums and galleries and had a day trip to Monserrat. We were wowed by the architecture and they had the best Diesel shop I had ever seen.

The NZSA Executive Committee is made up of anaesthetists who volunteer to help the Society be the voice for New Zealand anaesthetists. In this edition we profile Graham Roper a specialist anaesthetist in Christchurch and clinical leader of the anaesthesia service in Greymouth.


Lush green fields, dramatic coastline dotted by golden sand beaches, winding narrow roads, walks and hikes so remote you don’t see another soul for hours, friendly natives always willing to help the numerous tourists… It could be a description of New Zealand, but fits just as well painting a picture of Ireland. Which sort of sums up how we felt about the Republic of Ireland - so many similarities with New Zealand. It rains a lot in both places, population circa 4 million, we are situated next door to a larger bigger economy ‘brother’ etc. More than once when asked how we found life in Ireland, I answered that “it is much like New Zealand, just smaller” (the mountains, beaches, and land mass).

However, there are many differences as well, of course, and coming home from a year working under the Irish health system has served to highlight those differences. Ireland’s history and religion weigh heavily on all aspects of Irish life, seeming to often prevent or slow development and hinder change. But it is also what keeps it so quaint - you can visit an Irish pub in a small town and return 10 years later to find the same locals patronising it, the same workers pulling pints and as long as Heinekin hasn’t ruined any more breweries, the same excellent pint of Murphy’s served. And this is what the tourist industry thrives on.But the pervasiveness of being stuck in time can be limiting. It felt like Ireland is yet to make the move to more user-centred service provision - not only in the hospital, but across a lot of its public and private services.

I completed my Peripheral Nerve Block Fellowship at Cork University Hospital in January this year. Professionally, it was a fabulous experience and one I would not hesitate to recommend. What was good? Several things; firstly with only 27 consultants spread over more than 20 operating sites, there was plenty of scope for stepping up. The working week saw me in ‘the block room’ doing the regional anaesthetics for the two acute orthopaedic theatres and overseeing the two RMOs working the theatres. In weekends I ran the acute orthopaedic / trauma theatre alone. Therefore, I was able to practice as a consultant, teacher, and supervisor all with the knowledge I could call for assistance at any stage. Secondly, the work, despite being only acute orthopaedics, was very variable and interesting. Starting often with small children with supracondylar fractures, moving through teenagers with hurling injuries, 30-year-olds with ankle fractures (usually a Monday!) and getting to the hip fracture Octagenarians in one day occurred frequently. I developed a real comfort with looking after the elderly fragility fracture patient and was able to help implement the Anaesthesia side of the Irish Hip Fracture Database information collection. Thirdly, but more importantly, were the people. The level of clinical work by those Irish trained was similar to New Zealand, and the friendliness of the staff was amazing - probably why people stayed working so long within the system of the Irish Health Service Executive.

Challenging health systemThe system really was challenging. Starting from the physical environment, which often needed battling against; corridors too narrow, no storage space so corridors even narrower with kit stacked on the side, heavy electric doors that don’t work or door sensors placed behind anaesthesia machines, no red bell system but poor mobile phone coverage. Then there were the IT systems; blood bank results weren’t included on the lab systems so we needed to call them before every case, and then cross-matched blood routinely took more than an hour to get for a patient who was already group and screened. There were no electronic medical records, but with several hospitals in Cork, the old notes were mostly never available. Despite the anaesthesia record being electronic, these were not sent to a searchable repository. And don’t ask about platelets (they are kept at another hospital, and take over an hour to get, and don’t you even think about having them on stand-by! Hard to have a proper MTP without platelets on site). All the above are small points on their own, but added altogether, can lead to a sense of having to fight the system to get good work done.

Religion ever presentIt was also challenging dealing with a system so affected by religion. There is much less separation between religion and the state than there is in New Zealand. The dominant religion is Catholic and this was manifested in things like the presence of crucifixes in the operating rooms, PACU and wards. One time a ruptured AAA patient, who was doing her best to die prior to induction, was asked by a scrub nurse if she would like to see the priest. Suffice it to say my reaction of “NO, P is a long way down the list from ABC”, didn’t go down well with everyone. This was a lesson for me. Ringing the priest for me meant the last rites, but in Ireland the priest often comes to administer the Sacrament for the Sick. In several hospitals priests also carry an arrest bleep.The issues surrounding pregnancy termination in Ireland were also often present; babies carried to term with Edward’s and Patau’s; national headlines about a brain dead pregnant woman kept alive for almost three weeks whilst the courts decided if it was ok to let her die because of the presence of the ‘unborn’; and women traveling abroad to terminate.And how was Cork itself? It is a city best seen at night, when the lights reflect off the river Lee and the bridges look romantic and the pubs charming as opposed to somewhat grim and dirty. The first word of Irish I learnt was that Corciagh means marsh. Much of Cork is on previous swamp land and being in a valley this leads to damp and wet housing with a heavy smattering of black mould ready to grow across every surface. But back to the people - extremely friendly, always ready with a song or a story - if you can understand what they are saying! For a slice of a proper Cork accent, check out the cartoons by Sminky Shorts on You Tube. I do wish it wasn’t so far or so expensive to visit Cork as we made some fabulous friends. Returning home to the blue skies, warm weather and to work in a world-class hospital, built for purpose, with experienced, interested, and motivated anaesthesia assistance has been fantastic.

Auckland anaesthetist Kathryn Hagen has returned from a year on a Peripheral Nerve Block Fellowship in Ireland, undertaken as a BWT Ritchie Scholar, to take a role as a consultant anaesthetist at Auckland Hospital. She describes some of the differences she found working in Ireland compared to New Zealand.

Plenty to challenge in Irish experience

Kathryn’s children Harry and Ali with partner Shaun at the ruin

on Dursey Island

Brandon Bay, Dingle Peninsula

“Ireland’s history and religion weigh heavily on all aspects of Irish life.”


BWT Ritchie Scholarship Winners 2014The NZAEC awarded three BWT Ritchie Scholarships in 2014 to Dr Kerry Holmes for a fellowship at the Bristol Royal Infirmary, England, and to both Drs Ross Scott-Weekly and James Broadbent for fellowships at the Royal Children’s Hospital, Melbourne.

Kerry HolmesKerry Holmes’ Cardiac Anaesthesia Fellowship starts at the Bristol Royal Infirmary in May. Dr Holmes has completed

most of his training in the Auckland region (after completing his first year at Tauranga Hospital). During 2014 he worked as an Obstetric Fellow on Level 9 of Auckland Hospital, and then as a Liver Fellow on Level 8 at Auckland Hospital. Dr Charles Broadbent nominated Dr Holmes for the scholarship. Dr Holmes has been involved in various teaching roles, including Part 1 teaching, Part 2 Medical Viva teaching, and facilitating on Auckland Hospital’s CISCO DOPS day. He has been the trainee representative on the NZSA Executive Committee and on the Part 0 Organising Committee.Dr Holmes notes that the Bristol Infirmary has a strong background in transoesophageal echocardiography (TOE) and Quality Assurance. He intends to complete the European Society of Cardiography TOE certificate exam during his fellowship, and to upskill in QA work. He also wants to build on his role as a trainee representative with the NZSA by attending the AAGBI trainee conference. Dr Holmes will return to a permanent consultant position at North Shore Hospital in June 2016.

Ross Scott-WeeklyRoss Scott-Weekly will undertake a Paediatric Fellowship at the Royal Children’s Hospital in Melbourne.

Dr Ross Scott-Weekly completed his Provisional Fellowship in Anaesthesia with the Southern District Health Board in Dunedin. In his nomination of Dr Scott-Weekly, Dr Jason Henwood says he “has contributed significantly to the quality of clinical anaesthesia and the teaching of it to fellow registrars and medical students in our hospital. Despite a busy training program as a registrar he has maintained a significant contribution of community service through his work with St John Ambulance. Using his extensive interest in the use of IT he is also collaborating with some of the research team of our department refining the computer modelling of a pharmcio-kinetic study”.Dr Scott-Weekly has recently completed a post-graduate certificate in clinical education through the University of Education, and the Royal Melbourne has committed to giving him the opportunity to practise and improve his abilities in teaching. During his fellowship he will have exposure to a number of paediatric sub-specialities including craniofacial, cardiothoracic, neurosurgical and transplant surgery.

James BroadbentJames Broadbent started his six-month fellowship in Paediatric Anaesthesia in February. This will be followed by a six-month fellowship in

Paediatric Intensive Care Medicine at the Royal Children’s Hospital in Melbourne.Dr Broadbent trained in anaesthesia and intensive care, and has worked at the Hutt Hospital since December 2013. Dr Leona Wilson, CHOD Anaesthesia at Hutt Hospital, noted in her nomination of Dr Broadbent that “As well as being a reliable and excellent anaesthetist and intensivist, he has taken over the equipment portfolio for the anaesthesia department with gusto, promoted research in the intensive care unit, and is beginning to be involved in teaching courses within the hospital and region. The work is part of the solid foundation that any department requires to function well, and shows great promise for the future.” During his fellowship Dr Broadbent intends attending the APLS instructor training course in Melbourne, an emergency airway management instructor course in Perth, and an ultra-sound course in peri-operative echocardiography. Dr Broadbent anticipates that his experience at Royal Children’s Hospital will be invaluable in developing his clinical skills for the care of paediatric patients at Hutt Hospital when he returns from his fellowship.


My motivation for taking a fellowship was both personal and professional. I was excited to work in a different health system and service with different practice and culture, and I would also be given the opportunity to develop skills in echocardiography. On a personal level, as keen mountain bikers and skiers, we were excited to get into the forests and onto the mountains of British Columbia. Vancouver General Hospital (VGH) is Canada’s second largest hospital, after The Ottawa Hospital, and has a broad case mix. The operating complex has around 20 rooms, conducting about 17,000 procedures per year with a significant proportion of patients referred from elsewhere in the province (and the Yukon) for specialist services/operations. Most cases are prolonged and/or complex. There are a variable number of fellows with 3-6 employed at any one time. There is one cardiac fellow, one neuro fellow and the remainder are general fellows with interests in areas such as regional, hepatobiliary, perioperative echo etc. The usual week involves two days of ‘service provision’, two days of ‘fellow days’ in a designated speciality room and an academic day. General fellows rotate through specialities during their ‘fellow day’. So far, I have spent time in ENT, plastics, hepatobiliary and vascular rooms, with the last month doing echo (transoesophageal and transthoracic). I am working to gain proficiency in perioperative echo and have enrolled in an online-TTE course, spent time in the cardiology echo TTE lab with the sonographers, and am accumulating experience of TOE in the cardiac operating rooms. As no-one has previously tried to gain this specific experience at VGH, much of the first few months was spent building relationships and ties which hopefully will continue after I finish.

In addition to studying echo theory and practice, I have become involved in two specific projects to consume my academic time. The first will implement a structured system for patient handover, as the daily practice frequently involves transfer of care towards the end of the day. The second is a research project looking at epistaxis rates after a novel technique is used for nasal intubation. I am also working towards taking the NBE Perioperative Echo exam in July 2015.

Different work practicesWork practice in Canada is quite different to New Zealand and has taken a while to

get used to. The remuneration of British Columbian anaesthetists requires that they have some tie to a patient or procedure that they can bill for. To facilitate administration and academic days for staff anaesthetists, fellows cover their lists on ‘service provision’ days and liberate their time. Covering staff provide break relief but are frequently not seen for the day and there is a presumption that fellows can safely manage most cases alone. This can provide opportunity to manage large cases, but there is frequently little distinction made between ‘fellow’ and ‘service provision’ days, such that fellows often have weeks at a time without much ‘teaching’ or academic discussion. Supervisors seem to view their time with a fellow as an opportunity to work outside the operating room and are normally used as break relief elsewhere within the operating complex. There are very skilled Anesthetic Assistants who can help start major cases and in times of crisis but they are spread thinly throughout the department and are in high demand; there is certainly no Anaesthetic Tech in each room and I did induce anaesthesia without preparing an ETT in the early days. Due to the requirement of staff anaesthetists always being onsite during an operation, fellows are not required to staff the out of hours or weekend roster. As a result, a Fellow salary at VGH is just under $70,000 CAD, which doesn’t go far.Vancouver is an expensive place to live (compared to NZ). Rent is expensive, although bills less so. I recently read an article suggesting that a definition of poverty was when more than 50% of income is spent on housing. We far surpass that 50%,

living in a house half the size of our one in Christchurch. Cars can be bought relatively cheaply but insurance is expensive, no doubt fuelled by the fact there is only one (government-run) provider.

Great facilities for cyclistsWe chose to live in North Vancouver (rather than Vancouver city itself) for the proximity to world-famous mountain biking and access to forests, mountains and space. My daily cycle commute is 15km through a varied city landscape. Vancouver has great facilities for cyclists with most locations linked by cycleways, many of which are one-way/cyclist only/cyclist priority, contributing to a large cyclist population. Inevitably, after almost 4000km of city commuting there have been some disputes with drivers, although most of the issues have related to drivers being too nice and bending road rules to make life easier for me!

Everyone tells you that Vancouver is wet. We arrived to a glorious summer and were a little dubious of how bad it could be. It began raining in September and was consistently damp until early this year. In one week we had more rain (175mm) than the wettest month in Wellington last year (174mm), and a week of 20mm rain daily is not unusual. New waterproof jackets and a boot dryer have become our most prized possessions and the boys have worn their rain suits constantly.

We have explored far more outside the city than within it. So far we have camped in provincial campgrounds and on top of mountains, hiked around lakes and through old-growth cedar forests, ridden bikes from

BWT Ritchie Scholar in Vancouver - interim reportDr Sam Grummitt, Perioperative Fellowship, Vancouver General Hospital, Canada

Sam with partner Jess and their twins Loic and Rohan on the Summit of Mt Fromme after hiking from their back door

“Everyone tells you that Vancouver is wet.”


the Sunshine Coast to the interior and got the boys up hill with muscle, chairlift and float plane. In January the snow arrived and we skied powder, towed the boys on cross country trails, tobogganed for hours, had family ski runs together and bought the boys their first skis.

I am hugely grateful for the BWT Ritchie Scholarship, the opportunities it has given me to make the most of this year professionally and to explore BC as a family. I will be returning to a Specialist Anaesthetist post in Christchurch in October 2015 where I hope to develop

and disseminate the experience and knowledge I have gained this year.

Would I come to Vancouver again? Definitely. I think any fellowship is going to provide a change from previous practice and that is always going to take some time to adjust to. VGH offers an interesting case mix, and the outdoor opportunities are vast. Come prepared to weather the rain, and work for your teaching. As noted previously by Dr Chris Walker, we have had a few bureaucratic hurdles and are happy to pass on our experiences to anyone else planning to work in Canada.

I arrived in the UK in July, at the height of summer, and one of the questions I had for the property managers was whether there was any air conditioning in my apartment, because it was so hot. They laughed, and said I should be much more worried about the insulation and heating!

In true NHS style, my first experience at work was a week of ICU night shifts - not a bad way to find your bearings, but navigating my way around the hospital to cardiac arrest calls was a bit of a challenge!

Papworth has an interesting history, opening at the conclusion of the First World War as a chest hospital specialising in looking after tuberculosis patients. This explains its unusual location, around 15-20min outside of Cambridge city in the small village of Papworth Everard. The location causes a few technological challenges - there is next to no cellphone coverage (think lots of people leaning out windows holding their phones to the sky), and very poor public transport links - not what you would expect of the busiest cardiothoracic centre in the UK.

One of the best things about working here has been the international flavour to the

hospital - it’s well known, so tends to attract many healthcare staff from around the world. There are fellows from all over Europe and further abroad, and nurses from around the world. There’s also a strong Kiwi contingent, with one of my senior anaesthetic colleagues, Dr Roger Hall having recently been appointed as the Chief Medical Officer of the trust. I’ve also had the pleasure of working with Kate and Bevan Vickery, and Allan Brown from Auckland who have all been on their fellowships here. The hospital is spread over a park-like campus centred around the famous Papworth duck pond. It’s a very different experience working at a specialty hospital compared to what I’m used to at home. Although there is cardiology, respiratory medicine and the support specialties (haematology, microbiology, radiology) on site, when patients need services from other departments, then consultants from the other hospital in Cambridge (Addenbrookes) have to travel out here to visit. Given there are some pretty complex patients who are often in the ICU for long periods, it’s not unusual to be calling and trying to coax an ENT surgeon, or gastroenterologist out to visit. This will hopefully become easier in the future, as the hospital prepares to move to a new site adjacent to Addenbrookes in central Cambridge in 2018.

I’ve been exposed to an extremely broad experience whilst I’ve been here. It’s a very high volume centre, undertaking around 2700 major cardiac cases per year. In addition to the regular cardiothoracic workload, it also has a busy heart and lung transplant service. Transplant cases are interesting both in terms of the anaesthetic management, but also the perioperative intensive care required to support these patients, who are often transferred in extremis for urgent transplant workup. It’s also been interesting to gain experience in managing patients undergoing mechanical support - it’s not uncommon for transplant candidates to require Ventricular Assist Device or VA-ECMO insertion to bridge them to transplant. There is a very strong Pulmonary Vascular Diseases unit, and the hospital is the only one in the country to offer Pulmonary

Endarterectomy to patients with chronic thromboembolic pulmonary hypertension. They’re a very interesting cohort to look after, and the experience in managing patients with sick right hearts has been invaluable.

The intensive care is a big unit, with 33 beds, including a six-bed, nurse-led ‘fast track’ unit for routine cases. It’s a semi-open intensive care, and the surgical teams are very involved in management of their post-op cases, especially for the first 24 hours in the unit. Coming from an Australasian training programme, this was a bit of a challenge to get used to as the surgical registrars often come and tinker with the vasopressor infusions and ventilators. Intensive care as a standalone specialty is only really in its infancy here, so it will be interesting to see whether as the specialty matures, it influences the organisational change in ICU that we’ve seen in New Zealand. Papworth is one of the five UK ICUs to be funded for managing severe respiratory failure, so there is a busy VV-ECMO programme operating. I’ve managed to do the ECMO course whilst I’ve been here, and have recently become involved in the retrieval service - this involves a nurse, perfusionist and anaesthetist/intensivist travelling out to referring hospitals, assessing the patient, where appropriate commencing them on ECMO and transporting them back to Papworth. The various respiratory

Dr James Moore, cardiac anaesthesia and critical care fellowship, Papworth Hospital, Cambridge, England

BWT Ritchie Scholar in Cambridge - interim report

James with Dr Fou Lim (Nelson Hospital) at Kings College, Cambridge

Rohan, left and Loic, right, lead the way on the Vancouver forest trails

“Papworth attracts many healthcare staff from around the world.”

Papworth Hospital opened after WW1 as a chest hospital

“Intensive care as a standalone specialty is in its infancy here.”


New Zealand Anaesthesia Education Committee (NZAEC)Applications for the 2015 BWT Ritchie Scholarship close on 31 October 2015The BWT Ritchie scholarship provides financial assistance to New Zealand-based anaesthesia trainees who have passed the final examination for fellowship of ANZCA and are eligible to proceed to training year 5, to gain overseas experience and bring it back to New Zealand. It is also open to those who wish to undertake a further year of study outside New Zealand in the year following completion of their ANZCA fellowship (FANZCA); and to anaesthetists with FANZCA who are also training in pain

medicine or intensive care medicine and who have reached a similar stage for those fellowships. Applicants must be nominated and supported by their training departments.

The 2015-2016 BWT Ritchie Scholarships are valued up to $15,000, depending on the programme(s) of the successful applicant(s).

To find out more about the scholarship and how to apply, please go to the BWT Ritchie page of the NZAEC website: anaesthesiaeducation.org.nz

ICUs will overflow referrals to other centres when they are full, so it’s not uncommon to end up driving to the other side of the country to retrieve a patient.Accreditation in echo is expected, and the department has been very supportive, with regular days scheduled for this, and weekly tutorials. Research was something that I had little experience in prior to coming here, but we’re lucky to have Andrew Klein, the incoming editor of Anaesthesia in the department - he’s been a great research mentor, and we have a couple of projects in progress.Cambridge has been a really nice place to live - it’s about the same size as

Dunedin (but has the decided advantage of only being 45 minutes from London, with fast trains twice an hour). I’ve been trying to make the most of living on the edge of Europe, with trips to France, Spain and Austria. I am looking forward to returning to my job in Wellington at the end of the year. It has been a great experience working at Papworth, and I am confident that I’ll be bringing back plenty of new skills and experience with me. Thank you again to the NZAEC - shifting to the other side of the world is a stressful and expensive exercise, and I’ve been very grateful for the support of the BWT Ritchie Scholarship.

BWT Ritchie Scholar in Cambridge continued…

James enjoyed the All Blacks vs Wales game at Cardiff


The programme has been possible due to a grant of $1000 per year from the NZSA which has been matched by the Australia and New Zealand Intensive Care Society (ANZICS), and with discounts from the Wellington and Auckland simulator centres (and with Hawkes Bay DHB making up the shortfall). This has enabled each registrar to go on an Effective Management Anaesthetic Crisis (EMAC) course.Recently I was involved in teaching for a week in Suva, and caught up with some of our former registrars during the two courses.

Fiji courses valuableThe first, “Beyond Basic: Airway Management” had a significant contingent from the Frankston anaesthetic department, Melbourne (including two of the course authors John Copland and David Brewster) as well as Dr Ross Freebairn (ICU) and myself from Hawkes Bay. Candidates were exposed to a combination of lectures, clinical scenarios and workshops including fiberoptic and surgical airways (with trachea provided by a friendly butcher in town).The second course “Beyond Basic: mechanical ventilation” was a mix of lectures and skill stations dealing with the complexities of ICU ventilation - invasive and non-invasive. With over 400 recognised asthma deaths per year in Fiji, the Suva ICU can have up to six asthmatics presenting in cardio-respiratory arrest and needing ventilation a week.Course candidates were a mix of current Masters of Anaesthesia students (registrars) and in–country anaesthetists. They

came from Fiji, Samoa, Tonga, Kiribati, East Timor, the Solomon Islands and Vanuatu.It was a joy to see our first registrar Dr Kenton Biribo now well established back in Fiji. Kenton is working in a split academic and clinical position with the hospital and Fiji School of Medicine. His duties include consultant cover in the ICU and theatre. Compared to the wide-eyed registrar who got off the plane five years ago in Napier, here was a confident articulate teacher on the airway course, a recognised leader in his department, who was contributing to both undergrad and postgrad student education across the Pacific.

Service improved since trainingFrom Kenton’s time in New Zealand, post caesarean section analgesia in Suva has improved dramatically. With the introduction of spinal morphine, rectus sheath catheters are employed on the post op surgical ward, and a former registrar of his returning to Kiribati is about to audit the introduction of an intra-thecal morphine protocol to Kiribati.

Dr Apiatia Goneyali, our second registrar, remains working in the Pacific having worked in Suva, Tonga and Vanuatu. Dr Tildena, the anaesthetist from Port Vila, came on the courses because Dr Goneyali was in country helping. She told me how she appreciated his help in anaesthetising a recent acute patient with non-rate controlled AF, right heart failure and tight Mitral stenosis. They achieved a good outcome.

Dr Selesia Fifita, our third registrar from Tonga, has worked in Tonga since her return, at times as the only anaesthetist in country. Again she was confident, assured, asking good questions and enjoying some CME. After a lecture on difficult ventilator weaning ‘Sia recounted how she had managed a recent difficult wean over two weeks, building up their protein levels by the addition of raw egg whites into the entral feeds.

Dr Lamour Hansell is spending his second year in Christchurch. He’ll return to Apia in December this year. Dr Jocelyn Christopher from Fiji is with us in Hawkes Bay for 2015. There are big plans for her back in Fiji with respect to obstetric anaesthesia.The complexity of ICU cases on the daily ward rounds was a constant source of amazement - dual fatality industrial gas exposure with the first responders also needing hospitalisation; multi drug resistant sepsis; high spinal injuries; paediatric end stage uncorrected congenital heart disease; and elderly diabetic sepsis. Even in a first-world setting these cases would be extreme. With minimal staffing and resource limitations the ICU team were doing an exceptional job and the ICU focus of the second course seemed especially pertinent. It was humbling and encouraging to be in Fiji teaching and sharing with quality clinicians. The ability to take selected candidates to New Zealand for one to two years and then return them to their country of origin is having a ripple effect across the Pacific. Vulnerable people’s care is being influenced by clinicians (based in Hastings and Christchurch) who will never meet the patients involved, but, who through their teaching of our Pacific registrars are helping train leaders in our profession.

All of the registrars told how useful the EMAC course was to them and expressed their appreciation for the opportunity. Thank you to those New Zealand anaesthetists and intensivists who take the time to teach and get to know our Pacific colleagues and to all the organisations named above for your support of this programme.

For the last five years the NZSA has contributed, via the Overseas Aid Development Committee (OAC), towards training Pacific anaesthetic registrars on rotation to Hawkes Bay. Consultant anaesthetist at Hawkes Bay DHB and OAC committee member, Tony Diprose, gives an update of the programme.

Pacific anaesthetic registrars train in New Zealand

Dr Kavi (ICU Frankston) teaches in the new 20+ bed ICU unit at Suva

Kenton Biribo in the new theatre suite in Suva

Airway course participants with from left Chris Bowden, Ross Freebairn, Lisa Bennett, John Copeland, David Brewster and Tony Diprose

“Vulnerable people’s care is being influenced by clinicians who will never meet them.”


After applying several times and only making it to the waiting list, my expectations were quite high on attending the popular RWAC, held in Christchurch in November.

The concept of an anaesthesia course for those wanting to work in developing countries was started in the UK in 1981, and the Australasian version of the course was launched in 1999 in Hobart. Several courses were then held in Australia before the first New Zealand RWAC in Christchurch in 2011. Now the course rotates annually between Christchurch, Darwin and Frankston.

The five-day course is designed to

help anaesthetists prepare for short or long-term placement in resource-poor countries. It includes draw-over anaesthesia, ether, halothane, ketamine, equipment maintenance, electrical safety, psychology of adaptation, airway management, tropical medicine and sterilisation.

A lot of new knowledge was definitely on offer given that I trained, and am still practising, in the “unreal world” with an abundance of high-tech equipment and staff. Some attendees had experience from overseas aid work; some were there to get an introduction before embarking on work in the real world. Just bringing together so many anaesthetists with an interest in global health made for a stimulating environment.

The course started with an enjoyable get-together dinner on Sunday followed by five full days of mixed activities. Every morning, small groups went into theatres with one instructor. Each participant got to use draw-over equipment to induce anaesthesia in real patients (in the unreal world with all the monitoring in the background!).

This was a brilliant part of the course where one could see that these quite simple but ingenious systems were fully functional and safe. Moreover, the fact the faculty managed to get the logistics to work was impressive. There was clearly a lot of hard work behind the scenes that made it all possible.

The first day focused on draw-over anaesthesia and included hands-on sessions with assembly and

maintenance of different vaporizers. The rest of the week covered a good variety of anaesthesia topics to prepare us for the likes of pharmacology, paediatrics and obstetrics. This was nicely blended with some more general presentations and discussions, including ethics of overseas work, global health, teaching and tropical medicine.

The faculty was superb. The way members shared their experiences from working and teaching overseas was astonishing. We got to hear about very different experiences in Mongolia, Fiji, Nepal, East Timor, Rwanda and Sri Lanka, just to mention a few. These were not only fantastic stories; the speakers also humbly shared some of the difficulties one can encounter in such countries. Listening to these true stories from the real world was inspiring.

I can truly say this was one of the best courses I have been to with a great mix of hands-on activities, theory and discussions. Extracurricular activities included the Christchurch Rebuild Bus Tour, indoor rock climbing, wine tasting and a sumptuous gala dinner. An unreal world hailstorm was also arranged for us to experience.

A nice bonus was all the interesting coffee-break chats I had with new acquaintances, both attendees and faculty. As a result, I would not hesitate to contact someone from the course to discuss a tricky real world situation in the future.

Real World Anaesthesia Course valuableChristchurch Hospital hosted a Real World Anaesthesia Course (RWAC) for the second time in November last year. Gisborne anaesthetist Tomas Goscinski reports he was pleased to be a participant.

Trainer Maurice Lee, left, with participants in the RWAC course

Haydn Perndt doing Leap of Faith at Clip’n’Climb

Mary Brooker (Hawkes Bay) and Haydn Perndt (Hobart)

“The faculty was superb.”


So it is to Darwin we invite NZSA members to travel for the 7th combined meeting with the Australian Society of Anaesthetists – the ASA/NZSA Combined Scientific Congress, also the ASA’s 74th National Congress.

Scientific programOur intention with the scientific programme is always to challenge, enthuse, educate and enhance your working life. We are combining an extensive programme of refresher course lectures, concurrent lecture

sessions, workshops, small-group discussions, and research and poster presentations. In addition, we will continue to look to support our non-medical attendees, especially with our series of basic life support workshops, which we encourage our delegate spouses/partners, exhibitors and sponsors to utilise. Our international, Australian and New Zealand invited speakers are Debra Schwinn from Iowa, BobbieJean Sweitzer from Chicago, Alicia Dennis from Melbourne, Kelly Byrne from

Hamilton and Martin Smith from London. They bring a wide range of topics to enlighten us with and you’ll be certain to find much of interest. Of special interest is our Kester Brown Lecturer, John West, from San Diego, whose contribution to our understanding of respiratory physiology is unparalleled. His visit will be a highlight in all our careers.Expect a stimulating series of lectures across the Congress from Professor West, ranging from his fascinating pioneering work on high-altitude, aviation

Come to the Northern Frontier - CSC Darwin

The details

• ASA/NZSA CSC Darwin

• September 12-15

• Top international speakers

• Great scientific programme

• Crocosaurus Cove

• Kakadu National Park

• Mindil markets

For many reasons Darwin may be regarded as Australia’s frontier – its location on the northern coast of Australia, its booming economic growth, its melding of Australia’s original peoples with the European settlers: a place to push the boundaries of our knowledge.


and space physiology to the latest news fro his ongoing research lab at the University of California, San Diego. Please keep in mind that eh Opening Session and the Kester Brown Oration is open for accompanying partners to attend, even if they have not registered

for the meeting.

You can choose from multiple concurrent specialist sessions covering everything from Specialist Interest Group sessions to indigenous affairs as well as dedicated GASACT stream tailored for trainees on Sunday, 13 September.

In addition to all that is new, you can also look forward to a rolling series of refresher-style presentations across all four days of the Congress. These refresher lectures will each cover one particular aspect of anaesthesia and be very much focused on the practical clinical aspects of the subject matter. As always a plethora of problem-solving learning discussion sessions and workshops will be on offer, including multiple opportunities to

attend workshops that qualify for the ‘Emergency Response’ category of Continuing Professional Development. The final session of the Congress will be held after lunch on Tuesday, 15 September and will run along the lines of a ‘hypothetical’, involving both audience participation and a panel of experts from our invited speakers – you can expect to be informed and entertained to the very last.But our working life is only part of our existence. Our social program is designed to enhance the appeal of trekking north, maximising the outdoor lifestyle and laid-back nature of the Top End – learning and leisure.

In the middle of September you will experience Darwin at the end of the dry season, leading into the ‘build up’, or ‘Gurrung’ in Aboriginal language. It will be hot and dry and for that reason we wish to encourage a relaxed Top End style of meeting – please leave your jackets, ties and smart dresses at home and bring your casual gear. For the annual gala dinner we have taken that idea to the extreme and are planning an open-air party with “Loud & Colourful” as the theme.

Some of you may already be familiar with the very large crocodiles at Crocosaurus Cove, but come and get up-close and personal again, bring the kids and see a real live dinosaur! The Cove is home

to some of the largest saltwater crocs in the country and boasts the world’s biggest display of Australian reptiles. If you’re feeling brave bring your togs and swim with the crocs or jump on the Fishing for Crocs platform and smile for the camera while holding a baby crocodile.

The annual Gala Dinner will be Top End casual for an open-air tropical night under the stars – bring your loudest and brightest clobber to feat under the night sky at the Sky City lawns. Once you’ve enjoyed the food and wine there will be live entertainment to set your feet moving. If dancing isn’t your thing we’ve got you covered with a great location for relaxing with friends.

Now, we know you’re most likely coming quite far for this Congress, so why not sample more of what the Northern Frontier has to offer? Why not turn the Congress into a getaway, bring the family and explore some of the greater Northern Territory?

Details of all the experiences available and the latest on the scientific programme are available on the congress website www.aomevents.com/asa2015

Dr Piers Robertson

Convenor

Captions6. Unloading a patient with customs in attendance7. Very cramped conditions on the Citation Bravo jet8. Ambulance on the runway in Zanzibar

“Please leave your jackets, ties and smart dresses at home and bring your casual gear.”

We are very pleased to provide members attending the ASA 2015 Combined Scientific

Congress and NZSA AGM in Darwin this September with a selection of Post Conference Tours.

Feel like winding down on an idyllic beach in Bali? 2 & 4 night extensions are available with an optional visit to Komodo Island to see the rare Komodo Dragons.

Prices from NZ$1689 per person, share twin

OR join a select group visiting the city of Dili and East Timor for 5 days (4 nights) and discover the magic of these remote and still to be discovered islands.

Prices from NZ$2689 per person, share twin (inclusive of airfares to and from Dili)

For full information and further details – contact the specialists Carole Mills [email protected]

Approved Broker for Travel Managers Group Ltd. Registered Office: Level 7, 2 Emily Place, Auckland.

Post Conference Tours to Bali & East Timor


The African Medical Research and Education Fund (AMREF) is a large organisation based in Nairobi. Its main roles are in training local healthcare workers and addressing public health matters in East Africa. It is essentially unheard of in New Zealand, despite one of the original founders being Sir Archie McIndoe, himself a candidate for most shamefully under-recognised New Zealander.The Flying Doctors are a small arm of AMREF and have a rotating volunteer physician position mainly filled by doctors from Europe and the United Kingdom. The volunteer physician program provides flying doctors for free for retrieval work. Funding is generated to AMREF from clients who are billed for the retrievals (often covered by insurance), allowing AMREF to fund other activities. The Flying Doctors retrieve and transport tourists and locals from Africa to destinations around the world (usually funded by insurance). Profits go towards funding surgical teams, charity retrievals and services provided by the parent body.

Gunshots, psychosis and third-world medicineI first worked with AMREF for two months in 2007. In that time I flew the equivalent of twice around the world in the back of a little turboprop and jet aircraft. Apart from going to a large number of countries in Africa, I also repatriated patients to Italy, Pakistan, Israel, England and the Canary Islands. I picked up people from car rollovers in the bush, a priest who had been shot by the Lords Resistance Army, and a man attacked by a lion and hyenas.My experience this time has been somewhat quieter. February is always quiet apparently, but still an adventure. I have been in police motorcades in Mombasa and Nairobi, with the traffic through the middle of Mombasa stopped for us to hurtle through. I spent a weekend in Nigeria, which was much nicer than expected, and I went into Somalia a couple of times. I’ve seen gunshots, psychosis and some extremely third-world medicine. I’ve had VIPs having seizures in our little cramped cabin, and I’ve intubated a young student on

the runway of Kilimanjaro International Airport after he was delivered by two doctors with GCS 3 and no airway. In my down time I’ve also managed to do a couple of day trips around Nairobi and spent a day visiting a local hospital’s theatre complex to watch some obstetric anaesthesia.The volunteer program is open to anyone with anaesthetic and ICU experience, and applications are accepted from those in ANZCA Advanced Training onwards. It certainly is an amazing experience, and provides an easy, short-term way to do some very gentrified aid work. People tend to come for a month at a time and AMREF have a calendar on their website (www.flydoc.org) where you can see which months are still available. These tend to fill quickly. It is extremely easy to organise as the Flying Doctors take care of the local registration. The whole process was much easier than trying to get Australian registration for example.

Short assignments on offerThe work itself isn’t hugely different from other retrieval organisations, and is usually at a lower level of intensity, but the working environment is unique. Having the organisation based in Nairobi, and with local operations staff, pilots and nurses, means people have a very good sense of what’s safe and what’s not. The Volunteer Physician is the only outsider in the organisation, and so for a month you get an amazing view from the Kenyan perspective. Africa is not without its troubles, and it’s really interesting to talk to

people who have inside knowledge of events. I worked with people who have transported mercenaries and delivered ransom payments to pirates. Since I was last here the Flying Doctors have become a company, which has altered the emphasis more toward profit-making. Profits still go to the parent AMREF organisation, but volunteering this time hasn’t felt as much like ‘aid work’ as in 2007. This might be an important consideration for you if you do want to feel like you are contributing more directly. Also, AMREF is not always impartial like other aid organisations for e.g. Red Cross. Part of the flying is to pick up Kenyan soldiers injured in or near Somalia following combat with al-Shabaab. You would need to be comfortable with this. As with any retrieval job there is a lot of downtime. This can feel quite restrictive as it’s not completely safe to just wander around Nairobi. It is however a perfect opportunity to study, plan overseas fellowships (and write articles for the NZSA magazine!). Nevertheless, I would recommend coming later in the year when it’s much busier.Volunteering abroad is never an inexpensive exercise. While you pay for your own flights to Nairobi, day-to-day living can be done quite cheaply ($15/day) and bed and breakfast is provided.

Working in Nairobi an adventureWorking in Nairobi is not as safe as working in a theatre in New Zealand, but it wouldn’t be an adventure if it were. The day-to-day safety is fine, as the free accommodation is in a good area only a 10 minute walk from the airport. The planes are very good quality and are well maintained. For the aviation nerds, these include a fleet of Cessna Caravans, King Airs and Citation Bravo jets. Flying into Somalia has been the only truly scary experience this time, mainly because of the low, fast approach from the sea to make the plane a smaller target to any bored person with an AK-47 nearby.However, it is at the Volunteer’s discretion as to what flights they are prepared to go on. If you don’t want to see to a particular area, the Flying Doctors have a pool of locum doctors they will call on. These locums also allow you to take time out to see some of Kenya. Taking time off is as simple as saying that you are not available for those few days. Volunteer Physicians apparently sometimes bring family along and head away on safari from time to time.Overall it’s been another amazing experience, and one I can recommend. If you’re happy to accept the drawbacks of the job then it will provide you with a month unlike any other you’ll probably find during your career.

After completing his training in December one thing high on Kerry Holmes’ list of things to do was to return to Nairobi, Kenya, to volunteer for the AMREF Flying Doctors, an opportunity he recommends to other New Zealand anaesthetists.

A month in Nairobi with the AMREF Flying Doctors

Volunteering for AMREF Flying Doctors

• One month assignments

• Based in Nairobi, Kenya

• Prior anaesthetic and ICU experience

• Local registration organised

• Calendar on www.flydoc.org

Unloading a patient with customs in attendance Very cramped conditions on the Citation Bravo jet


In 2013, I was fortunate to take part in the NZSA Lifebox visit to Vietnam, along with Emma Patrick (of the NZSA executive). We distributed 40 Lifeboxes from NZSA and also audited previously distributed Lifeboxes. After this very rewarding visit, I happily volunteered again to re-visit in November 2014.

I attended the 2014 Vietnam Society of Anaesthetists Meeting in Da Lat to promote the Lifebox project. I was also invited to run a Lifebox workshop following the meeting, and to join and teach at the Essential Pain Management project (EPM) in Hanoi. Wayne Morriss and Roger Goucke, founders of EPM, were interested to see if it and Lifebox could share contacts, and even run together, in different countries.

Da Lat, the beautiful capital of the Lam Dong province has about 200,000 inhabitants. It is located in the Central Highlands at 1500m above sea level and has a pleasant temperate climate year around.

Barriers to WHO Checklist discussedI was joined by two anaesthesia registrars from Hanoi, Dr Ha Nguyen and Dr Phan Thuy Chi to run the Lifebox workshop. Both were part of the auditing of Lifeboxes with the NZSA in 2013, and spoke excellent English. Twenty staff from the 17 district hospitals participated - mainly nurses, with some anaesthetists and a couple of surgeons. Their hospitals had between one to five operating theatres, and all but one hospital had some form of pulse oximetry available, but they aren’t in every theatre or in their recovery units.

The average level of English was limited, so my presentations were interpreted. Dr Nguyen and Dr Ha presented the tutorials and led the group discussions in Vietnamese with great enthusiasm and skills.

In our discussions points were raised about barriers to implement the WHO checklist. One participant believed that it had to become the law otherwise it would not be

implemented. Another commented that more surgeons needed to be involved. It seems the surgical checklist is currently used mainly in the larger centres. The downside of running a workshop in a central location is that we didn´t get to see the actual hospitals where the Lifeboxes end up.

Twenty Lifeboxes, previously donated by the NZSA, were distributed along with a recently translated WHO surgical Safety Checklist. Mrs. Lien Morris from Auckland kindly translated this for us. To have the checklist in Vietnamese and local anesthetists on the faculty was invaluable to facilitate the discussions.

It is positive that local doctors like Ha and Chi are capable of running workshops

independently. Ideally more local doctors could be trained to run Lifebox workshops meaning less dependence on New Zealand anaesthetists attending each workshop in the future.

EPM workshop in HanoiThe following three days, I was fortunate to teach (and learn about!) EPM in Hanoi, in a workshop organised by Dr Roger Goucke from Perth.

This was the second EPM held in Hanoi with great collaboration from Professor Nguyen Huu Tu and his team at the Hanoi Medical University. A range of health care professionals including several anaesthetists from regional centres and a senior nurse attended the program.

New Zealand anaesthetists have been very generous with donations to the Lifebox Project, which distributes pulse oximeters to areas of need in Vietnam. Gisborne anaesthetist Tomas Goscinski reports on his second trip to Vietnam as part of the Lifebox project in November 2014.

Lifebox oximeters and training in Vietnam

Tomas Goscinski, Emily Stimson of Newcastle, Roger Goucke of Perth, and Steve Kinnear of Adelaide took the EPM course

A monitor in the waiting room updates families on the progress of patients

undergoing emergency surgery

Participants in the Lifebox workshop workshop in Da Lat, capital of the Lam Dong province

Most of the standard anaesthetic drugs were

available in the hospital in central Hanoi


We were particularly pleased participants came from a wide cross section of the health care spectrum including: anaesthesia, intensive care, cardiology, ophthalmology, rehabilitation, emergency departments, general practice, paediatrics, SOS International doctors, nutritionists, acupuncturists and nurses.

A highlight of the three-day program was seeing the newly trained instructors – some of whom had little experience in teaching - giving the talks and leading the discussions in a very confident way.

In total 82 healthcare professionals were trained. The participants were active, interested and gave positive feedback on the program. Interesting points were raised in the discussions about barriers to adequate pain treatment. One was lack of knowledge, which EPM can help to overcome, especially if the newly trained instructors can do more workshops. Another barrier seems to be a fear of morphine among both doctors and patients. This is reflected by the fact that morphine can only be prescribed by the head of department if outside ICU or theatres.

Viet Duc Trauma Hospital, HanoiOne afternoon, we were invited to visit the Viet Duc Trauma Hospital in central Hanoi, the most advanced surgical care hospital in Vietnam with approximately 1000 beds. The main entrance area was even busier than the already busy standard Hanoi street, with ambulances, scooters, street food vendors and families of patients waiting outside.

Dr Ha and Dr Chi, who both helped with Lifebox and EPM, had their living quarters in a building only 20m from the ED. They were not allowed to cook in the dorm, hence they ate most meals on the street and were experts on where to get the best street food.

The ED was extremely busy with lots of trauma patients. When we were there, four

patients were ventilated in one room. Head trauma from scooter accidents seemed a very common diagnosis. The emergency operating theatres were located in a separate building across a courtyard. In the courtyard, there was plenty of seating for families of patients having emergency surgery. They were updated via a flat screen on the wall with all the patients’ details, time into theatre, out of theatre, type of surgery. This seemed like a brilliant and efficient solution, considering how busy they were. It would have spared staff from answering many questions about progress from families. Confidentiality did seem secondary under the circumstances.

The theatre complex had one clean area with a few theatres, one infected area with a few more theatres and two paediatric theatres. Most patients would be ventilated in the recovery room to improve the turnover rate. Patients could be ventilated for up to a week in the high dependency recovery room until a bed space in a ward was to be available! The issue with getting patient beds in New Zealand seems so trivial in comparison.Most of “our” standard drugs were readily available including Sevoflurane, Propofol and

Rocuronium. ICU was also on the same level and had 20 beds in a fairly narrow area with bays holding two to four patients. Many different ventilators were used. Standard sedation was midazolam and fentanyl mixed in one syringe driver. Many patients had tracheostomies, enabling fairly light sedation. Family members were allowed to visit twice daily and seemed involved in nursing their loved ones. The unit was well equipped with two prisma dialysis units, an ABG machine as well as an ultrasound machine.

We were informed that in the elective surgery complex, kidney transplants were common with glomerulonephritis most common cause of renal failure. Liver transplants, were also performed less frequently. They had access to PET and MRI and we could see a new high rise building was about to be finished with new clinical areas.

Fantastic hospitalityWe were absolutely overwhelmed by our hosts’ hospitability. One night we were taken to the beautiful Indochine restaurant in an old French Colonial Building, where photos of previous guests included Jaques Chirac and foreign ministers from many other countries. The last night we had one of Hanoi´s signature dishes, Pho Boo (noodles in beef broth) followed by a performance of the famous water puppets. It was also great to get to know my three fellow instructors from Australia. Hanoi is a fabulous place for just watching the street life, having fantastic coffee or trying some of the wonderful food.

If you are interested in getting involved in Lifebox or EPM, don’t hesitate. See:

www.lifebox.org

http://www.fpm.anzca.edu.au/fellows/essential-pain-management

https://www.facebook.com/EssentialPainManagement

Lifebox facts• one pulse oximeter costs NZ$350

• NZ anaesthetists have donated 165 lifeboxes since 2011

• instructors volunteer to deliver the lifeboxes and training

• training and education

• to donate go to the Shop under Outreach/Lifebox on our website

The Lifebox vision: “isn’t just about distributing hardware and it doesn’t stop with pulse oximetry. The provision of equipment is a nod, not a solution, to the dangerous shortfalls in global health provision. Education, training, and peer support are key.”

Steve Kinnear, left, and and Roger Goucke enjoying the street food in Hanoi


Federations rely on their members, and WFSA is no different. In New Zealand patients benefit from a standard of anaesthesia second to none in the world and anaesthetists are accorded the resources they need and the same standing and support as any other specialist doctors. This is the result of many years of hard work focused on the quality of anaesthesia care and of advocacy - one can’t provide excellent anaesthesia without excellent anaesthetists so the speciality has to be attractive - by the NZSA, ANZCA, and many individuals. The WFSA provides the coordinated voice for NZSA and over 100 sister societies to advance this cause internationally. Based around a shared vision of uniting the profession, and promoting the safety of and access to anaesthesia, the WFSA has provided a unique and international forum for the specialty since 1955. The NZSA is an important contributor to a global organisation that spans some 140 countries around the world.There are immediate benefits to member National Societies such as sending delegates to the General Assembly, the possibility to host a regional or world congress or being eligible to apply for a range of grants and these are found on our website www.wfsahq.org, but the work of the WFSA goes beyond these. It seeks to bring the profession together on behalf of our patients, including those who are neglected, and on behalf of doctors who work in less well-resourced environments than many of us are used to. It is important for our members to know that the WFSA is working hard and that real progress is being made in areas that we can all be proud of. These include:

Education & TrainingUnder the leadership of Dr Wayne Morriss (a Christchurch-based anaesthetist and Chair of WFSA’s Education Committee) the WFSA now offers over 40 fellowships each year to doctors seeking to improve their knowledge and skills. These fellowships are focused on low and middle income countries, where anaesthesia provision is often severely under resourced, and they make a real difference. An example is the Bangkok Anaesthetic Regional Training Centre (BARTC) where 64 fellows have been trained since 1996. Of these 62 are working as anaesthesiologists in their home countries (a return rate of over 96%). With more than 200 WFSA fellows currently working we estimate that they treat well over 100,000 patients each year. Not a bad return on your investment.The Federation also publishes the Update in Anaesthesia journal and an extremely popular tutorial Anaesthesia Tutorial of the Week which are valued by teachers, students and practitioners. These and other resources, including a Virtual Anaesthesia

Library, are just a click away on our website.We have also agreed a partnership with the International Anesthesia Research Society (IARS) and are very excited to announce the launch of a Global Health Section in Anaesthesia & Analgesia, an initiative that will help to fill the data and research gap that is characteristic of low and middle income environments.

Safety & QualityStandardsAt its World Congress in South Africa, the WFSA endorsed the revised international standards for a safe practice of anesthesia, and funded open access publication of these standards (Merry, A F, Cooper J B, Soyannwo O, Wilson I H and Eichhorn J H. Canadian Journal of Anesthesia, 2010; 57: 1027-1034). In New Zealand, it may seem extraordinary that many parts of the world have no local standards, and that even the underpinning requirement for “An anesthesia professional should be… …immediately present throughout each anesthetic (general, regional, or monitored sedation)” would need to be stated, but it does. The standards also set expectations for formalized departments and facilities that assist in advocacy for anaesthesia providers who could only dream of the standing and support afforded to anaesthetists in New Zealand. Ongoing revision is now led by Adrian Gelb, chair of the Quality and Safety of Practice Committee.The WFSA recently helped to publish the book Occupational Wellbeing in Anaesthesiologists (see p 23). In addition we work closely with the International Organization for Standardization (ISO) on safety issues (ensuring that at least some standards are relevant to low and middle income areas of the world) and provide guidelines on tendering for anaesthesia machines.

LifeboxThe WFSA is a founder and ongoing supporter of Lifebox. Alan Merry, of Auckland, is the WFSA board member for Lifebox, which has made 8,000 operating theatres safer with pulse oximetry, education and advocacy. NZSA has been a huge supporter, and is central to current efforts to advance oximetry, training and advocacy in Vietnam. The project has been supported by the NZSA Lifebox Committee, the London Lifebox office and the Vietnam Society of Anaesthesiologists. Dr Indu Kapoor of Wellington has recently accepted the local leadership role for this work.

Innovation & ResearchThe WFSA provides research grants for young doctors from more disadvantaged environments. We have also launched the Innovation Awards which are designed to encourage and support innovation in anaesthesiology that has had – or is likely to have – a positive impact on surgical patient outcomes. These awards will be conferred at the World Congress of Anaesthesiology

in Hong Kong in 2016.

AdvocacyThis is an exciting area for 2015 as the World Health Assembly considers a resolution on Strengthening Surgery and Anaesthesia as a component of universal health coverage and as the UN finalises text for the Sustainable Development Goals. These matters affect the global health agenda (and budget) and the WFSA is directly involved ensuring that anaesthesia and surgical care are given the priority they deserve. National Societies currently pay US$2.80 per year per member to be part of the WFSA. That’s less than the cost of a cup of coffee. When you consider that over 2 billion people do not have access to surgery and that an individual is 1,000 times more likely to die from complications due to anaesthesia in parts of West Africa than in New Zealand, the investment seems small. When you add in the volunteer contribution – which is what really drives the WFSA – then you realise how much can be done when a membership finds a common cause. The NZSA is a prominent and proud member of this global organisation and the WFSA is all the better for it.

The NZSA is one of 100 anaesthesia societies around the world who are affiliates of the World Federation of Societies of Anaesthesiologists (WFSA). Chief Executive Julian Gore-Booth explains the work the WFSA is doing, and how New Zealand plays a key part in this work.

The role of our global body - WFSA

Dr Wayne Morris (third from left) with doctors as part of the Palestine

Anaesthesia Teaching Mission

Paediatric Anaesthesia Fellowship – Kenya


There has been a steady increase in reporting since the WebAIRS program

was released in 2009 including 852 events that were reported in 2014. Reporting incidents to WebAIRS is an important source of information to increase the knowledge learnt from adverse events as well as attracting 2 CPD credits per hour in the practice evaluation category.

The current leading category of incidents is the Respiratory/Airway category with 777 events reported in total since the program was released in 2009 and the highest subcategory of this group is the Aspiration subcategory with 84 incidents. Aspiration of gastric contents has been known as an important potentially avoidable cause of anaesthesia-related morbidity and mortality since Mendelson’s article was published in 1946(1)

. It is still an important cause of adverse outcomes as was noted in the Safety of Anaesthesia report (2009-2011)

(2)

as well as the most recent VCCAMM report (3)

. In common with these recent reports the WebAIRS data confirms that it is not only the high risk cases where this adverse event occurs, but many of these events occurred during relatively minor cases such as upper

endoscopy, colonoscopy and short duration cases where a laryngeal mask airway was used. Fortunately most of the cases reported to WebAIRS had a satisfactory final outcome, however in the current WebAIRS analysis 8.3% suffered serious consequences including one death and six with serious harm. Fifty one (60.7%) of the reports were associated with some harm as well as twenty six (31%) that were assumed to have no harm. This latter group included one case that was not coded, five reported as a potential hazard and 20 reported as a near miss. A detailed analysis of the WebAIRS data is currently being performed and an article summarising the results is currently under preparation for publication.Program ImprovementsA new version of the registration program was released in February 2015. It had updates to enable individual registration without registering a site and a new simplified ethics approval process. Firstly regarding individual registration, up until recently if a member wished to register as an individual then the member had to register a site under their own name. In the new registration program individual registration is built into the registration process and effective immediately. When membership is confirmed the member can register a new site such as a hospital, day surgery or private practice. Registration of a site is optional and a member can still report incidents and obtain CPD credits without registering a site using the standard individual option. If a member is registered both as an individual and at a site then a member can choose to either report each incident either as an individual or to one of the sites where they are registered. If a member is already registered at a site then

they can add individual membership to their current username by selecting registration from the menu on the WebAIRS website and following the ‘Register as an individual’ option.Finally if any NZSA member wishes to assist with the analysis of the WebAIRS data please contact the Medical Director for further information.References1. The aspiration of stomach contents into the

lungs during obstetric anesthesia. Mendelson C.L. Amer. J. Obstet. Gynecol. 52:191-205 1946.

2. Safety of Anaesthesia. A Review of anaesthesia related mortality reporting in Australia and New Zealand 2009-2011. Edited by Associate Professor Larry McNichol.

3. Victorian Consultative Committee on Anaesthetic Mortality and Morbidity (VCCAMM) Annual Report 2007. Associate Professor Larry McNichol. Chairman VCCAMM.

4. Ethical considerations in Quality Assurance and Evaluation Activities. National Health and Medical Research Council. March 2014. (Available for download from the NHMRC website).

Dr Martin Culwick and Dr Peter Casey

For more information, please contact:

Adjunct Professor Martin Culwick

Medical Director

E: [email protected]

Administration [email protected]

To register visit www.anztadc.net and click the registration link on the top right hand side

Demo at http://www.anztadc.net/Demo/IncidentTabbed.aspx

webAIRS News

Aspiration Outcome Count

Not reported 1

Potential hazard 5

Near miss 20

Harm 51

Severe harm 6

Death 1

Total 84

NZSA has joined more than 80 organisations around the world in supporting the World Federation for the Societies of Anaesthesiologists (WFSA) lobby against proposals to place international restrictions on the anaesthetic medicine ketamine.

The organisations, including Save the Children and Oxfam, endorsed a document explaining their opposition to the proposal before a meeting of the Commission on Narcotic Drugs (CND) in March, in Vienna. They outlined their support of the World Health Organisation’s (WHO) work on this issue and urged States party to the substance control conventions to accept the Expert Committee on Drug Dependence (ECDD) recommendations on ketamine, and abide by the procedural rules of the 1971 Convention on Psychotropic Substances.

BackgroundKetamine is an essential medicine used for anaesthesia. It is often the only available anaesthetic for essential surgery in rural areas of low and middle income countries, where more than 2 billion of the world’s

people live. Scheduling ketamine will leave these populations with no alternative anaesthesia for essential surgery, and will further deepen an already acute crisis.

Because it is readily available, easy to use and inexpensive, ketamine is one of the most commonly used anaesthetic agents. The WHO considers ketamine an “essential medicine” and does not recommend scheduling it under the international substance control conventions. Regarding essential surgery, a WHO document states that ketamine must be accessible in all facilities where anaesthesia is needed, in order to ensure safe and affordable surgical care.

Despite these facts the CND was asked by China to review a proposal to place ketamine in Schedule I of the 1971 Convention. Based on accumulated evidence and data on non-medical use, diversion and trafficking, and evidence of ketamine’s therapeutic value (including evidence provided by the WFSA),

the ECDD continued to recommend that ketamine not be placed under international control, but China was intent on pursuing scheduling.

The WFSA, NZSA and others therefore responded again and lobbied Ministries of Health and country members of the CND on the importance of ketamine. Thanks to this effort, China eventually withdrew their request for a vote at the CND, calling instead for the vote to be deferred whilst more data is gathered.

The futureThe WFSA has thanked members and partners who helped draw attention to the issue. Although well-known by those who use it, more evidence is needed from LMICs on the essential nature of ketamine. The outcome of the CND is a battle won, but it is expected the issue will return to global decision makers and legislators again in the future. For more information see the Ketamine Factsheet on our website under WFSA News and Updates or visit www.wfsahq.org/advocacy

Potential international restriction of ketamine


Occupational Well-Being of Anesthesiologists

Edited by Gustão F. Duval NetoThe World Federation of Societies for Anaesthesiologists has launched Occupational Well-Being of Anaesthesiologists a must read for colleagues, wives, husbands and managers concerned

with the stresses facing the health of anaesthesiologists around the world. In the Preface from the book WFSA President David Wilkinson explains the value of this publication. All people will experience stress during their lives. Stress after all is concomitant with modern living and whatever your job, it is likely that you will suffer moments of extreme stress. Sadly this seems to begin in childhood, and when at school pressures are applied to ‘succeed’ and ‘do well’ by being able to paint, read, play a musical instrument and act in a play all before you are six years of age! Life has become fantastically competitive so that parents seek to push their children and boast about impossible goals achieved which in turn increases the stress in others. Stress is naturally related to income streams, housing, education, work, perceived success and then illness and dying. At times for many there seems no escape and this is true all over the globe in almost all cultures and countries. So if we now add onto this the stress of being responsible almost totally for someone’s life (as the anaesthesiologist often is) it is not really surprising that many people in our profession succumb to the pressures of this stress. Human beings are fallible by definition and so all of us make mistakes. Modern life does not allow this as everything that goes wrong must be the fault of somebody or some organisation and they must pay recompense for the mistake. This compounds stress for the individual who, often for no obvious reason, errs. So by accepting that all anaesthesiologists are under stress to varying degrees we have to find ways to recognise and then deal with that condition. It has been my experience that some people go and play the violin, some try to punish a squash ball by flattening it against a wall and others find kindred souls to whom they can talk and explore the situation in which they are placed. Others mistakenly deny themselves this respite and ignore it or turn to alcohol or drugs to try to remove the problem. This never works in the medium or long term. Of even more concern are the cultures, which may be national or just institutional, who consider it a failure to voice stressful experiences and this will cause suppression and later terrible problems. In the past few decades more and more anaesthesiologists have looked to find

ways to ease stress in themselves and in colleagues. It is now a regular topic at International Anaesthesiology Conferences and numerous articles have appeared in print. Sadly this is not enough and there is still an unacceptable rate of ‘burn out’ or even suicide amongst our profession. Gastão Duval Neto, who chairs the WFSA Professional Well-being Committee, has with the help of the Brazilian Society of Anesthesiology, the Confederation of Latin American Societies of Anesthesiologists and the WFSA, created a wonderful book to try and help our profession further. He has brought together the foremost leaders in the field who have written carefully researched chapters which will show how stress can be recognised, lived with and finally overcome. But this book goes beyond just looking at stress and encompasses the whole of professional well-being in all its forms. We hope that the book will be read by colleagues, wives, husbands, managers and other medical disciplines to permit an insight into the terrible stresses that can occur within our profession. I recall being told by one senior colleague as I started my anaesthesia training that “anaesthesia was either awfully simple or simply awful!”. Although a trite statement it does have a certain basic truth, but what is more worrying is that it is easy to substitute the word ‘life’ for that of ‘anaesthesia’ in that statement. This is then a subject which requires careful consideration by all who work in anaesthesiology to ensure that life or work events do not swamp either young or old lives. We hope that this book will help people realise that they are not alone in experiencing hard times, that help is available and that taking this help will not be deleterious to their future careers; in fact it may save them. We encourage members to read the book on our website under Education/Affiliates/WFSA News

Published by the Brazilian Society of Anesthesiology and the Federal Council of Medicine of Brazil, 2014ISBN 978-85-98632-24-7286 pages

Technology is helping us Monitor & Improve our Health

by Richard MacManus”Hello, I’m Gordon and I am a geek”. But although I am a hard-core geek and programmer I have been reluctant to get involved with trackers: hardware or mobile phone apps which measure, and

monitor, the body in real time. Indeed, to track my weight, I use a pencil and paper. But I was interested in what is happening, and had many questions.

So this book was an opportunity to get answers to some of the questions about the technology. What sort of measurements could I record? How easy are these things to use? How accurate is the data collected? More importantly, once the data is collected, how should it be interpreted? Is this useful, or just an exercise in narcissism?Richard MacManus became interested in monitoring his own health when diagnosed as a diabetic. After beginning to closely monitor his own health he has become quite involved with tracking, and has traveled widely visiting lots of people, trying many of the devices that are available.And there are a lot of possibilities! Trackers range from pedometers to personal genomics: analysis of DNA, and the range is always increasing.The bulk of the book is a number of case studies, ranging from pedometers to genetics, by way of tracking activity, food, weight, brain activity and internal bacteria (the microbiome). Although the author is based in Wellington, many of the stories are based in the USA, and at least in some cases indicate what we can expect soon, rather than what is here in New Zealand right now.The reaction of the medical profession to all this patient-generated information is interesting. The author has found a warm reception from doctors to his own monitoring, and has case studies of doctors who not only recommend, but “prescribe” monitoring to some of their patients. This came as a welcome surprise to me: but still the risks of self-diagnosis are concerning. MacManus makes the point that interpreting the data collected must be done with the aid of informed people. Some of those involved in the industry are not so moderate.MacManus is careful also to point out the benefits of monitoring one’s health in a social network, for support and motivation. He also describes the increasing importance of ‘gamification’: turning what might easily be a chore into a hobby.Of course the book is a snapshot of the technologies available at this moment. MacManus is quick to point out that some hardware will be replaced by phone apps, and that hardware might morph into ‘wearables’, being woven into clothing or even implanted into the body.The author Richard MacManus created the technology blog ReadWrite.com, and is well known for picking what is coming next in technology. Throughout the book, the writer is describing his own experiences and conversations, in a lively and engaging way. He is an enthusiast for the technology, and for taking responsibility for his own health, and makes a persuasive argument that we should take more responsibility too.So, after reading the book, many of my questions are answered. No, tracking your health data is not just an exercise in narcissism. I am still concerned about the interpretation of the data outside of a

Book Reviews


We Thank All of Our Contributors For Their Stories

NZSA Advertising RatesWebsite

Banners 1014 x 188 - $500.00 per month per

Banner (inclusive with 4 issues premium advert in newsletter, a discounted amount of $200 per month will be offered)

Tile option – 195 x 239 - $200 per month

Job vacancies

$175.00 per month for advertising on the website, includes advertising in the Ezine.

Prices exclude GST.

Magazine

Advertising is available in this magazine for 2015 on both standard and premium pages. Options include full page, half page and quarter pages.

Advertising includes complimentary advertising for a limited period in NZSA’s e-newsletter Ezine, which publishes every 3-4 weeks. Conditions apply.

Please provide files of 300 dpi resolution, CMYK, and include embedded fonts in files saved as Word, JPEG, PDF, EPS or TIF.

For advertising inquiries please email [email protected]

Publication dates

The copy due dates for publication of advertisements and articles in New Zealand Anaesthesia are as follows:

Copy due by Published

July 10 August

Oct 10 November

For contributions to the Newsletter or feedback on this issue of

New Zealand Anaesthesia please email [email protected]

Newsletter content may be reproduced only with the

express permission of the NZSA Executive.

Opinions expressed in New Zealand Anaesthesia

do not necessarily represent those of the NZSA.

April 2015 | Issue 41

medical setting, however. Is a weight loss of 0.4 Kg significant? What should I make of a reduction of 3% in blood pressure? But I am now much better informed.Even though the devices and software will change, the implications of self-tracing will not. This is an easy to read, well-paced survey of an important development.

Reviewed by Gordon Findlay for Booksellers New Zealand

Published by David Bateman LtdISBN 9781869538804

The Healthy Country? A History of Life and Death in New Zealand

By Alistair Woodward and Tony BlakelyThe Healthy Country? A History of Life and Death in New Zealand is an intensely detailed book, broken into six sections and a must-have for students and professionals in the health industry.

Otago University Professor Tony Blakely and Auckland University Professor Alistair Woodward have created a great reference book about the history of public health in New Zealand.The book covers everything, from our country’s health pre-Cook right through to 2010, and extending into the (healthier?) future. With life expectancy and mortality

trends kicking off each section, The Healthy Country does make you think harder about your health habits. Looking at the effects and mortality of tuberculosis, ship-board disease, cancer, and suicide, it certainly made me very thankful for living with access to modern medicine.Detailed graphs are sprinkled throughout the publication, helping you to understand highly detailed information. One that caught my attention is in the section Mortality Divergence 1980 to 2010. The graph shows details of cause-specific mortality by ethnicity (Maori, Pacific, European/Other, Asian) and gender. Depressing, yes, but really amazing to see the downward trend of the commonality of these diseases as modern medicine has advanced.

A huge amount of research and effort has been put in by the writers of The Healthy Country to create a solid and thorough history of life and death in New Zealand. While I greatly appreciate the nature of the book, there are probably one too many home truths for a general reader. That said, anyone with a keen interest in this area of New Zealand’s history will find it fascinating, and the book is a must-have for students and professionals in the health industry.

Reviewed by Kimaya McIntosh for Booksellers New Zealand

Published by Auckland University PressISBN 9781869408138320 pages

The first issue of our 1975 Newsletter appeared in March. Mack Holmes’ Editorial was titled “Technicians or Nurses?” and dealt with a problem which NZSA was debating at the time. Did we

want technicians or nurses to assist the anaesthetist, or did we want nurse anaesthetists? This was debated over many years, sometimes quite hotly by those who had experience of working with nurse anaesthetists and those who had not! Mack raised the point that colleagues in the USA, Scandinavia, Europe and elsewhere were surprised that we were happy to have nurses assisting us with critically ill patients in ICUs, recovery rooms and coronary care units, but did not have them involved in routine anaesthetics. Comment was invited!

Articles in this Newsletter included Dick Rawstron’s “Oxygen carriage with particular reference to 2,3-diphosphoglycerate (2,3-DPG)” -- this was from part of his MD thesis; “Paraquat poisoning” by Anne Wills; “The pharmacology of anti-emetic agents” by Bob Coulter, and “Was it the thiopentone or the suxamethonium?” by Jim Cotton (an allergic reaction?). There were several notices including one announcing the formation of the “South Pacific Association of Anaesthetists” to be presided over by our friend Semesa Seruvatu of Apia, Western Samoa. The usual advertisements filled out the rest of this publication.

Basil Hutchinson, Life Member.

From the Archives ~ Forty Years Ago!


Documents

INSIDE ISSUE: President’s Column · 2017-02-09 · INSIDE ISSUE: Welcome to the first NZSA newsletter of 2015. Advocacy and education continue to be our big drivers. We anaesthetists