Anaesthesia in Australia: Two grams-a-keffah?

Warnings before reading:  My apologies in advance for my non-anaesthetic friends for this post.... It's all going to be about work.  I'll also add more photos as they come.  It's challenging to find time to take pictures at work without identifying anyone and without looking like a total knob.

I started my regional anesthesia fellowship in Australia about a month ago, and I have been meaning to blog about how "anAEsthetics" in Australia is different than "anEsthesia" in Toronto for a while now.  But every day, there seems to be more and more to figure out and to talk about.  Plus, it takes me twice as long to figure things out because I can't figure out what people are saying under their high-speed Australian (and British - I estimate about half of the staff here to be from the U.K.) accents.  I have to pause, think about it, and repeat my interpretation back to them to confirm what they have just said.  Or I just ask "Huh?  Pardon?  Sorry?  What?  WHAT?"   I do this so often that I think their impression of me is like this one:

But the more I listen, the more I realise that it's just because they are speaking "'Strain".  As in: "AuS-trai-in"

Anyway, here goes... (So this is where this blog gets a little technical...  )

Anaesthesia in Australia

In general, the Australian system seems to mirror the British system.  They also seem to have a lot more money to throw around, with more personnel, equipment, and drugs available.  Let me start from the top...

Operating Theatres:
This is what they call operating rooms.  It's a historical term, dare I say, outdated?  I don't think audiences are permitted to these shows - even in Australia.  Nevertheless, people use the term "theatre" the way we use "OR" at home.  eg, "Is the patient ready for theatre?."  The rooms are numbered on the daily lists as "Th1", "Th2", etc.  But if we did revert back to the old-school historical theatres, we should start charging for tickets! 

Anaesthetic rooms:
Every theatre has an anaesthetic room attached to it.  It is meant to be used for induction of anaesthesia prior to bringing the patient into the theatre.  The British-trained anaesthetists tell me this system used to work well back in the U.K.  One experienced anaesthetist tells me he was used to a 10-minute turnover time.  He clarified that he means 10 minutes between EtCO2 to EtCO2.  Crazy fast!  However, in this institution, the tendency is to induce in the theatre anyway.  The anaesthetic rooms are still used in the following instances:
- induction of anaesthesia and positioning of patients for orthopaedic joint replacements
- regional anaesthesia blocks (There is no formal block room, but the anaesthetic room is an ok substitute)
- storing additional anaesthesia equipment
- a room for the anaesthetic technician to hang out (more about anesthetic techs to follow)
- a room to hide your coffee or "cuppa" (short for "cuppa tea")

"Anaesthetists", NOT "Anesthesiologists":
Australia and the U.K. do not have nurse anesthetists like in the U.S.  Therefore, all "anaesthetists" are doctors.  The extra syllables aren't required for that distinction.  Plus, we all know how Australians have the need to shorten words whenever possible, so "anesthesiologists" would be way too much for them to handle!

Anaesthetic technicians:
Not the same as what we call "anesthesia assistants", and not quite the same but a bit more similar to "respiratory therapists".  Every theatre, and hence every anaesthetist, has a tech assigned to them.

Anaesthetic techs can be from a nursing background who have completed the technician's course.  Many of the techs are U.K.- trained "Operating Department Assistants" or "ODA's".  ODA's train directly out of high-school for 3 years and learn all the technical aspects of working in the operating room.  They assist the anaesthetist and even scrub in like scrub nurses at home.  However, in Australia, as in Canada, only nurses can scrub in.  So the ODA's now work purely as anaesthetic techs in Australia. 

Example of an airway trolley set up by anaesthetic technicians in the operating theatre.

The techs will check the anaesthetic machines and prepare all the airway equipment and "drips".  They have their own "trolley" on which they place all the airway equipment you want.  They will assist with patient positioning, applying monitors, and with induction and emergence.  They also tape the ETT's and eyelids.   They will draw off art lines, run gasses and send bloodwork for you, but they can't insert IV's or art lines.  The tech is supposed to be with the anesthetist at all times.  Apparently, this is a rule as per the Australian and New Zealand College of Anaesthetists.  So theoreticaly, I should just have to say what I want and it should appear in my hands within seconds.  Although this sounds helpful, I feel naked not having prepared my own life-saving airway equipment and not having it immediately within my arms' reach.  I now warn the techs that I am not used to having so much help and not to feel insulted when they find me rifling through their airway trolleys.  Most of them don't mind.  They are shocked to hear that we don't have techs in Canada.  So far, only one tech has actually stopped me from applying monitors while I painstakingly waited for her with syringes in my hand ready to go.  She joked that I would put her out of a job if I kept it up... at least she sounded like she was joking..... One of the older anesthetists was impressed while watching me wake up a patient.  He then told me he likes to try to extubate a patient by himself because it pisses off the techs.  Apparently it's quite the feat for an anesthetist to wake up a patient alone!

The anaesthetic technician's territory.  The tech prepares all the airway equipment and brings the trolley to the bedside for induction.  But then, they take it away.

The airway trolley (left).  Note the distance away from the anaesthetic machine....!  Apparently, Australian anaesthetists can spontaneously grow freakishly long arms when there is an airway emergency.

Masks - specifically, NO masks:
Anaesthetists (and techs) don't wear surgical masks in theatre.  The exception is during joint replacement surgery in which everybody wears a mask and the surgeons and scrub nurse wear hooded space-suits.

Look Ma, no mask!

 Airway equipment:

• Bougies: Australian/British anaesthetists use bougies the way we use stylets at home.  It's the first adjunct.  However, the techs reassured me that they do have stylets if I want them, they are just rarely used.
• C-Mac: The preferred next airway alternative here.  Storz must be making a deal with the hospital.  This hospital does not even have a Glidescope (THE HORROR!!).  Thank the airway gods that they have fibreoptic scopes.
   

  

  C-Mac

•  Correction: I found the only Glidescope in the city.  It is located at the offsite obstetrical/day surgery hospital rather than at the main hospital.  But it's the crappy clear plastic disposable blade type instead of the my favorite original blue handle type.

The only glidescope in the city.

•  LMA's:  The disposable kind.  They have the Classic and the Supreme (disposable proseal).  I find they fit a lot better than the non-disposable LMA's.  Also, the recovery room nurses are used to taking care of patients with LMA's still in.

• ETT sizes: the default sizes are 7.5 for women and 8.5 for men.  They have smaller sizes if you ask specifically for them.

 More equipment that I had only read about but never seen... until now:

• Target Controlled Infusion (TCI) pumps.  I am learning to use these for propofol infusions.  They work pretty well.  Essentially it's a higher-tech way of titrating to effect.  The benefit is that it takes care of the initial bolus dose with a lower risk of over-dosing or over-compensating.

TCI pump

Entropy

• Entropy monitors.  Essentially like BIS.  Every anaesthetic machine is fitted with a module that plugs into the entropy head-piece and shows some numbers on the monitor.  Many anaesthetists use this for all their cases.

•  Esophageal doppler.  I've been emotionally scarred by that multiple choice question on the exam about the best monitor to detect venous air embolisms.  That section in Miller talked about esophageal doppler and I just figured it was the stuff of dreams because I had never seen it before.  But it's just old hat here.

• LIDCO.  There is one floating around here, but I have yet to use it.  The anesthetists here will use either esophageal doppler or the LIDCO during big abdominal surgeries for Goal-Directed Fluid Therapy in the Enhanced Recovery After Surgery (ERAS) programme.  Also another technique I have heard of but have yet to see at home...

• Venflon cannulas (BD).  These are IV cannulas with an injection port and one-way valve at the hub so that you can give your drugs directly without that dead-space tubing in between.

• Pajunk continuous peripheral nerve block catheters.  I have yet to use them, but they are smaller than the Arrow kits we have at home.  Some of the catheters have stimulating wires in them, which are not removable.

• Portable transport ventilators:  When I told one of the anaesthetists here that we don't have these in Toronto, he looked at me funny and asked "So what do you do when you transport?".  After I answered, he gasped and responded "YOU USE AN AMBU-BAG??!!", his silent eyes saying "Are you from the third world??"

Draeger "Oxynorm".  This baby replaces one of my hands while transporting intubated patients. 

 Drugs, drugs, drugs...

• cefazolin: pronounced Kef-ah-ZOH-lin.  The nurses and tech will ask if I've given antibiotics, specifically "2 grams of KEF?" or "2 grams-a-keffah?"... It still takes me a momentary pause to figure out what they mean before I answer.  So I decided to turn the tables.  I asked one of the anaesthetists if he knew what "cefazolin" (pronounced the Canadian way) was.  He literally stopped in his tracks, took about 10 seconds, and said "OH!  you mean KEF-ah-ZOH-lin!  I had to think about that for a moment!" 

• Metaraminol: like phenylephrine-lite.  Primarily direct alpha with some indirect action.  Less abrupt and almost no compensatory bradycardia.  People here are shocked that we don't have this drug at home and that we use phenylephrine! (One of my new favorite drugs.  I'll have to figure out a way to get this stuff past customs!)

• Adrenaline: just the other name for epinephrine.

• Lignocaine: just the funny other name for lidocaine

• Frusemide: aka furosemide.  Just like the Australians, trying to shorten all the words....

• Levo-bupivacaine:  so good 'ol isobaric racemic bupivacaine isn't good enough here...  I can't find any isobaric bupivacaine anywhere.

• Heavy marcaine 0.5%.  It seems like most people here use heavy for hip fractures with the affected hip down.  Sounds painful to me.  So I've resorted to using isobaric levo-bupivacaine the way I normally use isobaric racemic bupivacaine at home.

• Tropisetron: ondansetron's newer brother from another mother

• Clonidine: Yes we have it at home, but they use clonidine more often for sedation, hypertension, and pain than we do.  Seems to work pretty well when I've used it so far.

• Tramadol: Yes, we also have this at home, but for some reason anesthesiologists don't use it.  But now I do.  They also have the IV formulation.

• Alfentanyl: They use a mixture of morphine+alfentanyl in the recovery room for pain. 

• Fentanyl PCA:  Interestingly, this is the default PCA of choice here.  The next choice is morphine.  They virtually never use hydromorphone.  They also don't often use controlled-release ("contin") opioids.

• Ketamine infusions: are A-OK on the wards!

• Intravenous paracetamol:  aka IV acetaminophen.  It comes in a glass bottle and costs around $14 a pop.

• Parecoxib: an intravenous cox-2 inhibitor.  They think our IV ketorolac is crude and barbaric!

• Other neuromuscularblockers: suxamethonium (other name for succinylcholine), vecuronium, atracurium.

• SUGAMMADEX!!!:  It's still expensive, so you have to have a pretty good reason to use it.  Deep residual paralysis at the end of surgery is a good enough reason to use it.  So far I've used it once (with a pretty strong indication) and it's AWESOME. (My new favorite drug.  Also need to get this one past customs!)

Sugammadex eating rocuronium.  Yum!

 
Fluids:

• Compund Sodium Lactate (Hartman's solution): Similar to Ringer's Lactate.
• Gelofusin: some kind of gelatin that I probably won't use.  Somehow I don't like the idea of Jell-O in blood vessels.  At least they have voluven and volu-lyte.  But so far, none of these guys have heard of pentaspan.

Orders:
We write post-op orders for analgesia, anti-emetics, and fluids that continue until the following day when the surgeons "review" their patients.  Not sure why the surgeons don't just write their post-op orders at the end of surgery.  But that's the way it is here.

Consultant supervision:
"Consultants" are what they call the fully qualified anaesthetists here, which we would call "staff".  After hours, there is a junior and a senior "registrar" (what they call trainees) on call.  They can run a theatre while the consultant is at home.  On the weekends, we run 2 theatres.  The consultant and the fellow each run one room.  The consultant can go home if they feel comfortable with the senior registrar running one of the rooms alongside the fellow.  This would never happen in Canada, but it's the acceptable culture here.

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Overall, it seems like there are more resources for anesthetists in Australia than in Toronto.  There are plenty more differences about the system, the training, the hierarchy, and the patient population.  Essentially, the culture is different.  But our free TV is finally playing a good movie and it's time for me to take a break.

Next time: Anaesthetic culture shock, the sequel.  Stay tuned!