17.02.2020 Health

Rejoinder: Patients At Risk; Nurse Anaesthetists Are Overstepping Their Bounds ― Dr Djabletey

Rejoinder: Patients At Risk; Nurse Anaesthetists Are Overstepping Their Bounds  Dr Djabletey
17.02.2020 LISTEN

I have listened with interest and surprise Dr Djabletey's interview on Certified Registered Anaesthetists. In fact he appeared confused during the interview and could not present the truth to the interviewer, whose questions were on spot. The doctor rather chose to lecture him on matters which had nothing to do with the questions and rather revealed his ignorance in Anaesthesia even as a consultant.

I want to put it to him that there is nothing like simple anaesthesia. Anaesthetic principles are the same no matter the case. The moment you distinguish between cases, you are bound to make the most grievous mistakes in anaesthesia. In anaesthesia we are taught that there is no simple case. He referred to Appendix, hernia, caesarean sections as examples of simple cases in anaesthesia. How can such a doctor be a Consultant in anaesthesia? He needs to be sanctioned by the MDC and suspended from anaesthesia practice because he is a danger to patients in Korle-bu hospital and in all other clinics he offers his services. Doesn't he know that the majority of cases that come in critical conditions and in emergencies are Hernias, appendicitis, caesarean sections and abortions? How can a consultant call these simple cases?

He said that complicated cases should be referred to doctor anaesthetists in higher hospitals. His example of complicated cases included Brain surgery, cardiac surgery and probably patients with endocrine problems. In the first place, these cases are not done in district hospitals. His problem is that he sits only in Korle-bu teaching hospital and does not know what is happening in the districts and rural areas. A missed abortion case is as serious as any other case when it comes to anaesthesia. Is Dr Djabletey a Consultant not aware of this? MDC should recheck his background. There are no cases in anaesthesia that are reserved for doctor anaesthetists. CRAs do about 99% of surgical cases in Ghana without the assistance of any doctor. We supervise each other in the theatre during surgery. Anaesthetists are expected to work in pairs so that at any point there will be one experienced person present. Two heads are always better than one. Unfortunately for Ghana more than 98% of CRAs work alone in the regions and districts without the comfort of a second opinion. Korle-bu hospital has all the luxuries with all the professors, senior consultants and consultants bunched together and competing among themselves as to who is who. Why don't they accept postings to the district hospitals? It is because of fear of failure. No Doctor anaesthetist wants to work alone. They always require assistants. They will never operate even an emergency case alone. Why? The theatre team comprises Surgeons, anaesthetists, Nurses, nurse assistants, cleaners, technicians, nursing students, medical students and at times patient relatives. Any failure or difficulties encountered will be broadcast immediately outside the theatre. The doctors are scared of this and always want a CRA around them so that if anything happens they could easily push it on the indiscretion or negligence of the CRA.

If an anaesthetist fails intubation or Spinal it will be the talking point in the theatre and beyond. 'Eii today in the theatre Dr..... Could not intubate the patient oo, come and see how he/she was sweating'.

Eiii have you heard, hmmm Dr...... Killed a patient in the theatre today ooo, somebody's mother/father, son/daughter. These informations will be the talking points around the hospital. Doctors always want to hide behind the CRAs to avoid these negative tags. They have the comfort in Korle-bu to have professors and consultants in the theater with them. As a result, most of them don't take the practical aspects seriously. The CRAs do almost all the practical aspects of anaesthesia whilst the doctor moves around claiming to be supervising. Anaesthesia is practice and experience and not supervision.

According to Dr. Djabletey, cases beyond CRAs should be referred to Doctor anaesthetist. A falacy. CRAs have taken over cases from Doctors and managed successfully. Most of the doctor anaesthetists can attest to this. Surgeons and theatre nurses are witnesses to reveal these facts.

According to Dr. Djabletey Consultant, he has been practicing anaesthesia for 15 years. I have been practicing for 27 years now. I have practiced from rural to districts and in Accra, anaesthetising thousands of patients with success. He must learn to be humble. Anaesthesia is humility, and experience.

CRAs are not competing with Doctor anaesthetists. We don't belong to the same association, we don't take equal salaries, so what is their concern?

Even in the most developed countries anaesthesia deaths occur. Death is a necessary end and no one can determine how one will die and under what circumstances. No medical test or examinations can reveal every morbidity in a patient. Reactions to anaesthetics are difficult to predict because many drugs are used at the same time. Although we anticipate all these and prepare for them the consequence at times could be disastrous. In such cases, you could be the professor doing the Anaesthesia yet it will happen. I have seen Professor Surgeons puncture big blood vessels in patients and they stood helplessly and watched patients die. In the theatre there are certain cases that you can do nothing about.

In Anaesthesia every patient is accessed according to the American Society of Anaesthetiologists (ASA) classification among others.

The ASA Physical Status Classification System has been in use for over 60 years. The purpose of the system is to assess and communicate a patient’s pre-anesthesia medical co-morbidities. The classification system alone does not predict the perioperative risks, but used with other factors (eg, type of surgery, frailty, level of deconditioning), it can be helpful in predicting perioperative risks.

The definitions and examples shown below are guidelines for the clinician. To improve communication and assessments at a specific institutions.

The examples in the table below address adult patients and are not necessarily applicable to pediatric or obstetric patients.

Assigning a Physical Status classification level is a clinical decision based on multiple factors. While the Physical Status classification may initially be determined at various times during the preoperative assessment of the patient, the final assignment of Physical Status classification is made on the day of anesthesia care by the anesthesiologist after evaluating the patient.

Current Definitions and ASA-Approved Examples are:
A normal healthy patient. Healthy, non-smoking, no or minimal alcohol use.

A patient with mild systemic disease.
Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease.

A patient with severe systemic disease
Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.

A patient with severe systemic disease that is a constant threat to life.

Examples include (but not limited to): recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

A moribund patient who is not expected to survive without the operation

Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

A declared brain-dead patient whose organs are being removed for donor purposes.

Every patient undergoing any kind of surgery must be assigned an ASA classification among other kinds of assessments and classifications before the surgery. All anaesthetists are taught and expected to religiously follow all these principles because if anything happens in the theatre and a legal action is taken, or investigations instituted, all your documents in the theatre will be presented for evidence of negligence or otherwise.

Because of the passion of Nurses to care for patients, Nurses have been at the forefront in all departments in the hospitals. Ghana has only about 4000 doctors with more than 2000 hospitals. Majority of the health facilities in the districts and rural areas are manned by PAs and Nurses. There are more than 4000 Community-based Health planning and Services (CHPS)Compounds that are at the forefront of the Primary Health care in the most deprived areas. They are headed by Community Health Officers who are Nurses. They diagnose and treat patients, deliver expectant mothers where there are no maternity homes nearby in emergency situations. Why are doctors not fighting to change their names to Comminity-based health assistants? Why are they concerned about the title of CRAs? If they feel belittled because CRAs practice the same profession with them, they are free to re-train as General Surgeons, Obstetrics and gynaecologists, Neuro Surgeons, Cardiac Surgeons, orthopedic Surgeons, plastic Surgeons, ENT etc. We assure them that they will receive the best of anaesthetic management from us.

Why are they scared to open a Master's and PhD programs in Ghana? Let the Doctor anaesthetists rise to the challenge and allow the authorities to open up the carrier progression path, after all, majority of their parents live in districts where CRAs are the anaesthetists who will administer to them if the need arises. Won't they be Happy that Master's and PhD holders are attending to Ghanaians in our communities? We are aware of their resistance to our carrier progression but the authorities must disregard people who are averse to national progress.

Israel Laryea, the journalist who interviewed Dr Djabletey was fantastic when Dr Djabletey stated that CRAs were stepping beyond their bounds.

He asked him "In medical practice, things can go wrong and even doctors have committed errors in their line of work."

Dr Djabletey will be the last person to cast aspersions and stones at CRAs. He must appreciate the difficult conditions CRAs work under in the districts without facilities just to help save our people in the deprived areas where doctor anaesthetists have refused to go. Even at Korle-bu where Dr Djabletey has all the modern facilities for anaesthesia, he still commits errors. Whilst pointing a finger at CRAs, he should watch the four fingers pointing at him.

The fantastic journalist asked him again "Why do the CRAs need a physician to guide them since you are all trained anaesthetists?"

Dr Djabletey was confused. We study the same books using the same syllabus. Why does he think he is more knowledgeable in anaesthesia than me? A medical doctor comes out of medical school with almost zero idea about anaesthesia.

The four weeks orientation in anaesthesia department is not for practice but just observation just as the nursing students also come into the theatre to observe and learn the types of anaesthesia and drugs that we use because some aspects of anaesthesia may come in their examinations. Majority of the doctors obtain their diploma without being able to intubate a patient or give anaesthesia alone safely. Apart from Korle-bu where there are several professors of Anaesthesia, almost all the Physician anaesthetists diploma students are taught by CRAs to intubate and do Spinal anaesthesia. How do you turn back to supervise a person who just supervised you to become an anaesthetist?

After 3 years of Nursing as state Registered Nurses, one had to practice Nursing for three years minimum to qualify to train as CRA for 18 months full time in residence, practicing anaesthesia for the entire 18 months. The student goes for lectures daily and to the theatre for practice daily for 18 months. Afterwards you go for 2 years full course also residential to obtain a Bsc degree in Anaesthesia.

Presently, Nurses go for 4 years full course and residential to obtain a Bsc in Anaesthesia. The same syllabus, books, equipment, drugs and techniques used by CRAs are the same used by Dr Djabletey and his colleagues. No one single group of health staff are a god to themselves. It is a team work. Anaesthetists cannot work alone, Surgeons cannot work alone. Each group needs another to achieve its goals and objectives in the hospital setting. Even during surgery, Surgeons become confused and Nurses offer their help to assist them out of difficulties. CRAs have assisted Surgeons as well out of difficult situations. Surgeons have also done same to help anaesthetists. These are facts that cannot be contested. All who work in the theaters know that no one is perfect. There is no case in anaesthesia that is beyond a CRA. If there is, then it is also beyond the physician anaesthetist as well. We have all studied the same principles and practice. There are no surgical cases meant for a physician anaesthetist and another for a CRA. Dr Djabletey is being economical with the truth.

Whether it is Neuro surgery, cardiac surgery or whatever, the principles of Anaesthesia are the same. All you need is a second or third anaesthetist to assist because two heads are always better than one. This saying is very apt in anaesthesia.

A physician anaesthetists diploma, membership and fellow are just carrier progression to increase their salaries and beautify their CVs. CRAs would have been holding PhDs and professorships if the Ministry had opened up the carrier progression for CRAs. I appeal to the ministry to do that to help lift the image of Ghana in the medical field.

Israel Laryea asked Dr Djabletey to give a typical example of a case that a CRA could not do. Dr Djabletey Consultant, started lectures on endocrinology. Is he saying that CRAs did not study the effects of the endocrine system on the body during anaesthesia?

For the avoidance of doubt and for the benefit of the general public, I post below the DETAILED CURRICULUM of the Anaesthesia program, Definition and Guidelines of the Clinical Rotations in Basic (Core) Anaesthesia Training.

During this rotation the resident will be assigned to theatre lists in the fields of General Surgery

Orthopaedics and Trauma
Obstetrics and Gynaecology
Day care Anaesthesia and Resuscitation.
The level of involvement will be at all phases i.e. pre, intra and postoperative care, resuscitation and acute/chronic pain management wherever it may be required. The first 12 months for any trainee will be in basic anaesthesia and resuscitation.

This rotation is specially designed to cover management of labour pain, operative obstetric cases and resuscitation of the critically ill obstetric patient and neonate. Experience with regional analgesia and anaesthesia is to be obtained during this rotation.

Paediatric anaesthesia cover congenital anomalies and major procedures in the neonatal and other paediatric

age groups.
An introduction to the following subspecialties will be done.

During residency training all trainees are expected to become proficient in the following

skills and procedures:
*Administration of general and local anaesthesia
* Administration of inhalational anaesthesia
* Administration of intravenous anaesthesia including total intravenous

* Simple infiltration and nerve blocks
* Airway management
* Oropharygeal and naso-pharyngeal airways
* Laryngeal mask airways
* Endotracheal intubation
* Fibre optic intubation
* Ventilation modes and techniques
* Vascular Access
* Peripheral intravenous cannulation
* Central venous cannulation
* Arterial cannulation
* Insertion of pulmonary arterial floatation catheter (Swan-Ganz)

* Measurement of cardiac output
* Insertion of chest drains
* Regional Anaesthesia and analgesia
* Subarachnoid anaesthesia
* Epidural analgesia and anaesthesia and analgesia
* Intravenous regional anaesthesia (Biers’ block)

* Brachial Plexus Block
* Stellate ganglion block
* Major nerve blocks and field blocks
* Monitoring
* Basic e.g. clinical evaluation
* Standard e.g. NIBP, ECG, Pulse oximetry,PNS, Temperature, ETCO2

* Advanced e.g. ICP, SSEP, BIS
* CPR including cardio-version
* Interpretation of arterial blood gas analysis.
* Reading 12 lead ECG for arrhythmias and ischaemia

* Reading and interpreting Chest-X-ray, and other imaging techniques.

* Reading and interpreting basic laboratory data on FBC, electrolytes, renal and liver

* Management of acute pain, PCA, PECA, NCA, and chronic pain e.g. cancer pain.

• Upper airway- nose, pharynx, larynx, trachea

• Lower airway- bronchus, alveoli, diaphragm
• Cardiovascular system
• CNS and vertebral column and canal
• Autonomic nervous system
• Foetal circulation
• Major nerves of the upper and lower extremities

• Major nerve plexuses (brachial, lumber, and sacral)

• Surface anatomy for the major nerves, veins, arteries (upper and lower limbs)

• S.I. units
• Work and Energy
• Electricity
• Ultrasonic waves(Electromagnetic spectrum)
• Gas laws
• Fluid and gas dynamics
• Vaporization and vapour pressure
• Medical gases production, storage and delivery

• Recording of biological potentials
• Pressure
• Temperature
• PH
• Measurements from the catheter to display
• Gas analysis
• Monitoring of neuromuscular function
• Cardiac output
• Respiratory function tests
• Humidity, Nebulizers and humidifiers
• The anaesthetic machine and its safety features

• Anaesthetic circuits
• Mechanical ventilators
• The basic anaesthetic equipment: Laryngoscopes, Masks, laryngeal mask

airway, spinal and epidural needles
• Medical gases and gas cylinders.
• Physiology of nerve and muscle
• Respiratory system and blood gases, oxygen transport and delivery

• Cardiovascular system (heart as a pump)
• Cardiac conduction (rhythm generation and conduction)

• CNS and Autonomic nervous system
• Renal system
• Acid base system
• Electrolyte and body fluids and homeostasis.

• Hepatic function
• Haematology, basic haematology functions
• Physiological changes during pregnancy
• Nutrition including TPN
• Immunology introduction
• Fat, Protein and Carbohydrate metabolism
• Temperature
• Endocrinology
• Pharmacokinetics and pharmacodynamics
• Inhalation anaesthesia, mechanisms and agents

• Local anaesthetics, mechanism and agents
• Intravenous anaesthesia drugs
• Analgesics, narcotics and their antagonists
• Muscle relaxants
• Anticholinergic and anticholinesterases
• Antiemetic and antihistamines
• Inotropic and pressor drugs
• Antihypertensive drugs
• Antiarrhrrythmics
• Antimicrobials and cytotoxics
• Bronchodilators
• Clinical trials
• Pharmacogenetics
• CNS drugs
• Renal drugs
• Basic statistics
• How to read medical journals
• How to critique medical journals
• How to write articles
• Library studies
• Pain pathways, acute, chronic and cancer pain

• Head injury and conditions with increased intracranial pressure

• Ischaemic heart disease
• Valvular heart disease
• Hypertension, essential and other causes
• Cardiac arrhythmias
• Malignant hyperpyrexia
• Hypothermia
• Anaemia, sickle cell and other haemoglobinopathies

• Diabetes mellitus
• Acute and chronic renal failure
• Patients with liver disease
• Endocrine diseases and morbid obesity syndromes

• The patient with respiratory disease (obstructive and restrictive)

• Congenital diseases in neonatal and paediatric patients

• Arthritis and other orthopaedic problems
• Shock syndromes (hypovolemic, cardiogenic, septic, and anaphylactic)

• The psychiatric and mentally challenged
• Genetic and congenital diseases relevant to anaesthesia.

• Pregnancy related diseases
• Infections and infestations
• Connective tissue and degenerative diseases
• Neuromuscular diseases
Resuscitation and critical care management of all the above cases and their

perioperative management.
• Preoperative assessment, patient preparation for surgery

• Principles of obstetric anaesthesia
• Principles of paediatric anaesthesia
• Principles of geriatric anaesthesia
• Principles of neuro-anaesthesia
• Principles of cardiac anaesthesia
• Principles of thoracic anaesthesia
• Dental and day care anaesthesia
• Principles of mechanical ventilation (IPPV)
• The use of blood components and massive blood transfusion

• Anaesthesia for bronchoscopy and airway laser surgery

• General anaesthesia techniques and principles

• Regional anaesthesia techniques and principles

• Airway management (the normal and the difficult airway)

• Post-operative care (Recovery Room) including to control

• Anaesthetic complications and mishaps and their prevention.

CRAs undergo the same programs full time for 3½ to 4yrs. Presently the BSc program is 4 yrs full-time.

The Certificate program which I underwent in 1993 followed the syllabus above. My Bsc Anaesthesia at KATH followed the same curriculum. Nothing has changed. Can Dr Djabletey tell the whole world, which part of this program is taught differently to CRAs.

If there are any differences then the Ministry of health must hold the MDC responsible for endangering the lives of patients in Ghana by hiding aspects of anaesthesia from CRAs who administrator 99% of all anaesthetics in Ghana.

When the journalist finally asked Dr Djabletey what his fears were if the issues of CRAs are not handled comprehensively, he answered, "they don't know it all." That is certainly true and applies to all persons and humanity. Nobody knows it all. I don't believe he was trying to mean that he and his colleagues physician anaesthetists know it all. Let him ask his conscience. Korle-bu can testify that Dr Djabletey and his colleagues don't know it all.

I appeal to the good people of Ghana to ignore the prophet of doom Dr Djabletey. Patients are in very good hands with CRAs. Despite the harsh conditions that we work in, in the districts and rural areas, we are able to save millions of ghanaians who would not have survived if CRAs were not in the hospitals and clinics.

Why is Dr Djabletey and some of his colleagues so bitter against CRAs? We have not asked to be called doctors. We have not asked to be given a doctors salary even though we do the same work. We have not asked to belong to your association.

Because of all these fears, we don't want the name 'physician' to appear in our name because we are not physicians. We prefer a neutral name ' Certified Registered Anaesthetists.

I was a State Registered Nurse (SRN). After Anaesthesia I want to be called a Certified Registered Anaesthetists. What is your problem?

We are responsible for all cases that we do legally. No Doctor carries the responsibilities of CRAs if anything went wrong. Each carries his/her own cross. We are not assistants to doctors. We work autonomously in a team of Surgeons, Doctors, Nurses, Technicians, Nurse assistants, cleaners among others for a successful surgery. None in the team know it all. We collaborate, we watch each other and draw attention to anyone going wrong or something going wrong in the theatre because by such team work will success crown all surgeries.

In conclusion, I want to appeal to physician Anaesthetists to be content with what they have and leave the CRAs to peacefully practice their chosen profession. The safety of patients under anaesthesia is the goal of all Anaesthetists. There is no anaesthesia for doctors and another for CRAs all over the world. They should disabuse their minds and allow peace to prevail in Ghana.

CRA 1994