Anaesthetics

To the Editor: Incidents involving assaults on staff by medical equipment are uncommon, but have been reported in this Journal before. 1 We report another “attack”, involving an x-ray machine and an anaesthetist. A woman was scheduled for endoscopic retrograde cholangiopancreatography in the radiology suite. During induction of general anaesthesia, the patient’s foot moved against an x-ray table control knob (Box). This triggered slow, downward movement of an x-ray “C-arm”, which was positioned above the head of the unsuspecting anaesthetist. Tracheal intubation was rudely interrupted when the C-arm met the anaesthetist’s head and pushed it towards the patient’s face. However, the radiographer in attendance quickly reversed the movement just before the anaesthetist and patient collided. The radiology suite is often regarded as an unfriendly environment for anaesthetists.2 This incident reminds us that, in some cases, it may be frankly hostile! A patient’s foot activates a control knob on an x-ray table

Richard H Riley · Leigh J Coombs

Matthew J Bragg,* Paul Middleton* * Emergency Physician, Prince of Wales Hospital, Barker St, Randwick, NSW 2031. braggmATsesahs.nsw.gov.au To the Editor: We read with interest the case reported by Williamson and colleagues of an adult survivor of near-drowning complicated by cardiorespiratory arrest. 1 This is a remarkable account of survival with near-intact neurological recovery from what was a very bleak initial clinical scenario, and the pre-hospital and hospital personnel responsible for his resuscitation should be congratulated for their efforts. However, the authors’ use of therapeutic hypothermia in this case does not necessarily support their contention that “controlled hypothermia . . . should be used in near-drowned patients who have spontaneous circulation but remain comatose”. As presented, the case illustrates the benefit of supportive care in general, and the use of appropriate controlled ventilation in particular. As the authors noted, “gentle hyperventilation to ‘blow off’ excess CO2” corrected the hypercapnia and acidosis. The graphs of arterial pH, lactate level and Pco2 presented in the report show a linear improvement in all three indices after controlled ventilation, before hypothermia measures were begun. Indeed, the commencement of hypothermia had no discernible impact on these trends. While there is some evidence in the literature for the use of controlled hypothermia after cardiac arrest,2 there is no direct evidence of its benefit for victims of near-drowning. We do not feel that controlled hypothermia can currently be recommended as standard of care for near-drowning on the basis of this single case report.

Matthew J Bragg · Paul Middleton

Jonathan P Williamson,* Stan Braude† * Intensive Care and Respiratory Registrar, † Intensivist, Department of Respiratory and Critical Care, Manly District Hospital, Darcy Road, Manly, NSW 2095. JonowilliamsonATozemail.com.au In reply: We agree that our patient’s survival from the near-drowning incident was primarily attributable to the initial and subsequent supportive care. Clearly, the contribution of hypothermia to his survival cannot be quantified from one case. However, previous studies have shown that the use of controlled hypothermia in comatose survivors of out-of-hospital cardiac arrest improved survival with good outcome. 1,2 These studies did not focus on drowning victims — a study in this group would be extremely difficult — but had neurological recovery in patients with anoxic brain injury as principal outcome. In this sense, it can be argued that the aetiology of the brain anoxia is not in itself important. The Amsterdam World Congress on Drowning in 2002 recommended the use of controlled hypothermia in the comatose near-drowned patient. 3 This is a relatively simple procedure (albeit labour intensive) and is becoming the standard of care in many hospitals for out-of-hospital cardiac arrest. In these hospitals, its routine use in the near-drowned patient would not be difficult. Given the evidence so far accumulated in its favour, and the lack of adverse effects if undertaken correctly, it seems justified to seriously consider its use in the near-drowned patient. We therefore argue that the ventilation and supportive care of our patient aided his physiological recovery, while the neurological recovery was at least partly due to the hypothermia.

Jonathan P Williamson · Stan Braude

John R Gowardman,* Catherine Kelaher,† Joy Whiting,‡ Peter J Collignon§ * Intensive Care Physician (currently Launceston General Hospital, Launceston, TAS 7250), † Medical Student, ‡ Data Manager, § Director of Infectious Diseases and Microbiology, The Canberra Hospital, Canberra, ACT, and Professor, Canberra Clinical School, Australian National University, ACT, and University of Sydney, NSW. john.gowardmanATdhhs.tas.gov.au To the Editor: Bloodstream infections are frequent in healthcare settings and cause significant mortality and morbidity. 1,2 Most of these infections are caused by intravenous catheters, particularly central venous catheters (CVCs). Over 250 000 catheter-related bloodstream infections occur annually in the United States, 1 and over 3000 in Australia.2 Many CVCs are retained when no longer essential. For example, a recent one-day audit in a US teaching hospital found that 15% of CVCs (11/74) were “unjustified” most of these had been inserted in the intensive care unit but retained unecessarily after discharge from the unit.3 The risk of bloodstream infection is much higher with CVCs than with peripheral venous catheters (4.0 versus 0.2 per 1000 line-days).2,4 Such simple facts are often overlooked or inadequately emphasised in preventive programs, and CVCs may be retained for convenience. Our intensive care unit maintained an informal clinical practice of routinely removing CVCs when patients were discharged from the unit. However, an audit found that many CVCs were retained, often inappropriately, thus exposing patients to needless increased risk.5 A formal intervention policy aimed at improving CVC removal was implemented. This included a month of staff education, culminating in introduction of a formal written policy in March 2003. CVCs were to be removed when no longer clinically required or at discharge from the intensive care unit, unless the patient met predetermined retention criteria (ie, administration of vasoactive or venotoxic drugs [eg, dopamine or vancomycin] or parenteral nutrition solutions; poor peripheral venous access [after two attempts] with ongoing need for intravenous therapy; or transfer to another intensive care or coronary care unit). We undertook a prospective observational study of all patients with CVCs in the intensive care unit of our hospital in the period March to August 2003. Patients were grouped according to whether the CVC was removed per policy before or at discharge from the intensive care unit; whether it was retained per policy at discharge from the unit; or whether it was retained in breach of policy. All patients were followed up for 7 days after CVC removal. Those who died within this time were excluded from the analysis. We studied a total of 305 CVCs in 272 patients (Box). We observed: high compliance with the written policy (91%), significantly lower CVC in-situ times when policy was followed (5.1 v 8.1 days), low CVC reinsertion rates (7%), no difference in incidence of bloodstream infections between the groups. This study demonstrates that a formal policy directed at early CVC removal is effective in lowering CVC in-situ times without incurring clinical cost to the patients (eg, excessive CVC reinsertion rates). Policy breaches were infrequent (8% of all CVCs), but, when they occurred, CVC retention appeared unnecessary, and CVC in-situ times were significantly prolonged. The risk of sepsis with CVCs may be substantially lowered by policy-driven removal of CVCs, without compromising patient care. Comparison of patient characteristics and CVC outcomes when removal policy was followed versus when it was breached Policy followed Policy breached P (policy followed v breached) CVC removed CVC retained* Total CVC retained Patient characteristics Number of patients 176 71 247 25 Age (years) (SD) 60.2 (17.9) 64.9 (15.7) 61.7 (17.5) 69.0 (15.3) 0.02 ICU length of stay (days) (SD) 4.7 (8.2) 3.3 (5.2) 4.3 (7.6) 2.1 (2.0) 0.06 APACHE II score (SD) 14.7 (6.9) 14.8 (7.0) 14.6 (17.5) 14.2 (5.1) 0.31 Ventilation time (h) (SD) 51 (89) 46 (123) 51 (103) 31 (55) 0.19 CVC outcomes No. of CVCs (% of all CVCs) 202 (66%) 77 (25%) 279 (91%) 26 (8%) nt In-situ time Hours (SD) 97 (115) 202 (186) 124 (148) 197 (136) 0.009 Days 4.0 8.4 5.1 8.1 Tips cultured (% of CVCs) 136 (67%) 51 (66%) 187 (67%) 19 (73%) nt Tips infected (% of CVCs) 20 (9%) 11 (14%) 31 (11%) 4 (15%) 0.51 Catheter-related bloodstream infections Total no. 2 (1%) 0 2 (1%) 1 (4%) nt Per 1000 CVC days 2.5 0 1.4 6.0 0.33 CVC reinsertions (% of CVCs) 15 (7%) 4 (5%) 19 (7%) 0 0.38 Mean no. of ports idle (per day) na 1.5 na 1.6 nt Peripheral catheters Total no. 260 36 296 50 nt Mean no. per patient 1.5 0.5 1.2 0.5 nt Mean in-situ time (h) 63 66 64 81 nt CVC = central venous catheter. nt = not tested. na = not applicable. * Reasons for appropriate CVC retention were drug administration (32%), poor peripheral access (34%), transfer to another high dependency unit (25%) and total parenteral nutrition (9%).

John R Gowardman · Catherine Kelaher · Joy Whiting · Peter J Collignon

Desmond O’Brien Emeritus Honorary Anaesthetist, The Prince of Wales Hospital, Randwick, NSW 2031. hdobrienATbigpond.com.au To the Editor: Tonti-Filippini condemns denial of elective surgery to smokers as discriminatory.1 He disregards the fact that surgery requires anaesthesia, which may require serious consideration before undertaking non-urgent surgery, and in no way involves discrimination. He mistakenly regards denying elective surgery to those who continue to smoke as discrimination, in breach of the Hippocratic Oath, and the Australian Medical Association (AMA) Code of Ethics. In fact, to proceed with elective, especially cosmetic, surgery in a heavy smoker is more in breach of the Oath and the AMA Code than not proceeding, for the following reasons. Smokers are at a significantly greater risk under anaesthesia than non-smokers because, firstly, smoking reduces the capacity of the lungs to take up oxygen, thus increasing the risk of hypoxia and its consequences to heart and brain.2 It also causes coughing and breath-holding during anaesthesia,2,3 creating surgical difficulties, and the risk of error. Postoperative coughing causes additional pain (especially after thoracic and abdominal operations), and increases the risk of postoperative bleeding, infection, delayed healing and even wound breakdown.4,5 Rather than being discriminatory, delaying elective and cosmetic surgery until he or she stops smoking is very much in the patient’s interests.

Desmond O’Brien

Hypothermia is now standard care for some types of cardiac arrest Out-of-hospital cardiac arrest is a leading cause of unexpected death in the developed world, occurring in about 1 in 1500 adults each year.1 Successful recovery from out-of-hospital cardiac arrest depends on the rapid activation of the “chain of survival”: an immediate call to the ambulance service, bystander delivery of external cardiac massage and expired-air breathing, defibrillation and the provision of advanced life support by paramedics.2 Unfortunately, survival with good neurological outcome at hospital discharge is rare after out-of-hospital cardiac arrest. Studies in Perth and Melbourne show that less than 5% of these patients survive to hospital discharge.3,4 As the average response time of ambulances in most Australian cities is between 7 and 12 minutes, considerable neurological injury occurs during this prolonged period of cardiac arrest, even with bystander cardiopulmonary resuscitation. While paramedics may restore spontaneous circulation and transport some patients alive to an emergency department, most remain comatose because of the severe anoxic brain injury.4 To improve outcome, considerable emphasis has been placed on shortening the time between cardiac arrest and defibrillation. As decreasing ambulance response times towards 5 minutes would be prohibitively expensive, alternative approaches to earlier defibrillation have been proposed. These include fire-fighters co-responding with ambulance services to patients with suspected cardiac arrest,5 or installation of automatic defibrillators in public places.6 On the other hand, recent data from Canada have cast doubt on the effectiveness of paramedic advanced life-support programs, which did not improve survival rates when introduced.7 What therapies are available after arrival at the hospital? In most cases, no immediate cardiology intervention is required, and treatment has therefore been largely supportive until the neurological outcome could be determined. Common intensive care practice has been to defer neurological assessment for at least 3 days, to allow more accurate clinical assessment.8 Recently, an “old” therapy for anoxic brain injury — therapeutic hypothermia — has been re-introduced into clinical practice. In this issue of the Journal, Williamson and colleagues (page 500) describe the use of this therapy in a patient who was comatose after near-drowning.9 The use of mild therapeutic hypothermia after cardiac arrest was first described in the 1950s, but later abandoned without being formally tested in clinical trials.10 Interest in hypothermia was revived in the early 1990s when animal studies and preliminary clinical studies suggested benefit. Subsequently, two prospective, randomised, controlled clinical trials have been conducted.11,12 In a recent Australian trial, patients who remained comatose after resuscitation from out-of-hospital cardiac arrest were treated with either 12 hours of therapeutic hypothermia (33°C) or standard care.11 At hospital discharge, 49% of those treated with hypothermia were discharged home or to rehabilitation, compared with 24% of those treated with standard care. In a European study, 55% of patients treated with hypothermia (33°C for 24 hours) had a favourable outcome at 6 months, compared with 39% of those treated with standard care.12 Subsequently, the International Liaison Committee on Resuscitation (which includes the Australian Resuscitation Council) endorsed the use of therapeutic hypothermia for patients with anoxic brain injury after out-of-hospital cardiac arrest, particularly when the initial cardiac rhythm is ventricular fibrillation (Box).13 Therefore, this treatment should now be regarded as a standard of care for this condition. However, a number of issues require further consideration if therapeutic hypothermia is to be applied more widely. Firstly, uncertainty remains about the effectiveness of this therapy in patients with out-of-hospital cardiac arrest due to causes other than ventricular fibrillation. Patients with asystolic out-of-hospital cardiac arrest have a dismal prognosis,14 as do those with coma after near-drowning, hanging, or other causes of asphyxia. Clinical data on the effects of therapeutic hypothermia in these groups are lacking. The role that therapeutic hypothermia played in the recovery of the patient reported by Williamson and colleagues is uncertain. Secondly, a protocol needs to be established in the emergency department for the rapid induction of hypothermia in patients who are unconscious after out-of-hospital cardiac arrest. In most hospitals, this will require consensus to be reached between emergency physicians, intensive care physicians and cardiologists on the indications for the provision of this treatment. Finally, there are technical issues to be considered in the rapid induction of hypothermia. In previous studies, hypothermia was induced through surface cooling with ice packs and/or refrigerated air blankets.11,12 This approach is slow and logistically difficult in busy emergency departments. Other technologies for the rapid induction of hypothermia are therefore under investigation.10 Currently, we are exploring the use of a rapid intravenous infusion of large-volume (30 mL/kg), ice-cold crystalloid fluid to induce hypothermia. Preliminary data suggest that this is relatively simple, effective, inexpensive and not associated with pulmonary complications.15 As there is often a delay between resuscitation and emergency department initiation of hypothermia, cooling in the ambulance would be ideal. In a study supported by the National Heart Foundation, paramedics in Melbourne are now infusing large-volume (2000 mL), ice-cold crystalloid fluid, together with a muscle relaxant, immediately after out-of-hospital cardiac arrest to induce hypothermia as soon as possible after resuscitation. If this is confirmed as feasible, further studies are planned which will examine the use of therapeutic hypothermia after asystolic and asphyxial cardiac arrest. Recommendations on therapeutic hypothermia from the International Liaison Committee on Resuscitation In October 2002, the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation recommended: Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32°C–34°C for 12–24 hours when the initial rhythm was ventricular fibrillation. Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest. Preliminary data from clinical trials of perinatal asphyxia indicate that induced hypothermia is feasible and safe, but data on long-term neurological morbidity are not yet available. Until additional paediatric data become available, clinicians should tailor therapy for individual patients based on their assessment of the risks and benefits of hypothermia.

Stephen A Bernard MD, FACEM, FJFICM

Clinical record A 46-year-old English tourist became distressed when caught in a strong rip while swimming at a Sydney beach. An off-duty lifesaver dragged him to shore, where he was found to be apnoeic but had a weak pulse. After a minute of mouth-to-mouth ventilation, his pulse was lost, and chest compressions were begun. Ten minutes after cardiac arrest an ambulance arrived, and a wide complex bradycardia with no pulse was documented. During resuscitation, a total of 3 mg adrenaline, 70 mmol sodium bicarbonate and 1.5 mg atropine was administered. At 26 minutes after the cardiac arrest, the patient regained a pulse and was noted to be in atrial fibrillation. By this point, he was intubated and ventilated. On arrival in the emergency department, his systolic blood pressure was 90 mmHg, pulse rate was 136 bpm and irregular, and core temperature was 34.7°C. Auscultation of the chest revealed coarse bilateral crackles. His pupils were fixed and dilated. Initial arterial blood gases showed a severe mixed respiratory and metabolic acidosis, with a temperature-corrected pH of 6.47 (reference range [RR], 7.35 to 7.45), Pco2 of 98.6 mmHg (RR, 32.0–48.0 mmHg), Po2 of 104 mmHg (RR, 83.0–108 mmHg), arterial lactate level of 29 mmol/L (RR, 0.5–1.6 mmol/L), base excess of –28.1 mmol/L (RR, –2.0 to 2.0 mmol/L), and HCO3 level of 7.1 mmol/L (RR, 22–32 mmol/L). Chest radiography showed changes consistent with aspiration pneumonitis. The ventilator was adjusted to hyperventilate and reverse the respiratory component of the acidosis. Computed tomography of the head and neck revealed no abnormalities. It was decided to use controlled hypothermia to limit further hypoxic brain injury. The patient was packed in ice, and cooled intravenous fluids were administered, aiming for a core temperature of 33°C for a period of 12 hours (Box 1). The patient’s condition improved rapidly. The heart reverted to sinus rhythm spontaneously within a few hours, with no subsequent electrocardiograph or biochemical evidence of myocardial injury. The metabolic and respiratory acidosis normalised over the 10 hours after injury (Box 2). After 12 hours of hypothermia, cooling was ceased, and his core temperature was allowed to rise to 37°C. He was extubated on Day 3 after admission and discharged from hospital on Day 7. Neuropsychological assessment performed 2 weeks after the injury (including Wechsler Memory Scale Three and Delis–Kaplan Executive Function System) revealed relatively intact cognitive function, although there was moderate impairment in new learning ability and capacity for visuospatial information, and slowed information processing. This may be consistent with hypoxic brain injury, but, alternatively, might have been present before the accident. Repeat assessment 5 months after the accident (in the United Kingdom) revealed normal psychometric performance, with persisting impairment of visuospatial processing and organisational abilities. The patient and his family reported he was functioning just as he was before the injury, performing domestic duties and caring for his elderly mother. The World Health Organization reported 409 272 drowning deaths worldwide in the year 2000, making this the second leading cause of unintentional injury death globally, after road traffic accidents.1 The burden of near-drowning morbidity has not been defined but is likely to be high. Acidosis, especially pH < 7.0, usually correlates with a poor outcome. However, in drowning, the prognosis is often less grim, and patient survival has been reported after pH levels as low as 6.29.2 In our patient, the acidosis had both respiratory and metabolic components. The respiratory component, caused by apnoea, was the most readily correctable with gentle hyperventilation to “blow off” excess CO2. This had a rapid effect on the pH. The metabolic component was most probably a result of both physiological and pathological processes — the extreme muscle exertion while struggling in the surf and end-organ hypoxia as his respiration and circulation failed. In intensive care, blood lactate levels > 10 mmol/L are associated with 95% mortality.3 Our patient’s arterial lactate level was 29 mmol/L. We believe one reason for his good outcome was that the acidosis had a different aetiology to that in most intensive-care patients, in whom sepsis, hypoxia and shock predominate. This case therefore highlights the importance of continuing resuscitation efforts despite severe acidosis and fixed dilated pupils in drowning victims, as ultimate neurological recovery is still possible. Hypothermia is not a novel therapy for near-drowning. For over four decades, favourable outcomes have been reported for victims of near-drowning in ice-cold water.4 The effects of hypothermia are thought to be mediated by a reduction in brain metabolic requirements, limiting hypoxic cellular damage. A 1986 trial in Canada used hypothermia in near-drowned children to reduce intracranial pressure and limit brain injury.5 However, the death rate in the hypothermic group was higher than in the normothermic group, with most deaths attributed to neutropenic sepsis. This complication is now thought to occur only in children.6 The study also used lower temperatures and a longer period of hypothermia than is now recommended. This may have contributed to the poorer outcome and subsequent lack of interest in hypothermia for near-drowning. Interestingly, survivors in the study were more likely to be neurologically intact if they had been assigned to the hypothermia group. This suggests that the benefit of hypothermia may be not in preventing death but in improving neurological outcome in survivors. Recent evidence for controlled hypothermia as a neuroprotective therapy has been published in a study assessing its benefits in treating out-of-hospital cardiac arrest.7 This study used moderate (33°C), short-term (12 hours) hypothermia. Based on the favourable outcome of this and similar studies, the 2002 World Congress on Drowning, in Amsterdam, recommended this therapy for near-drowning victims who have restoration of adequate spontaneous circulation and remain comatose.8 A recent ILCOR (International Liaison Committee on Resuscitation) advisory statement also suggested that hypothermia may be beneficial for other rhythms causing cardiac arrest in settings such as drowning.9 We suggest that, in near-drowning cases where the patient remains comatose yet has adequate circulation, controlled hypothermia is an important tool to maximise neurological recovery. Further, severe acidosis should not be seen as a poor prognostic marker and should not preclude ongoing resuscitation efforts. Lessons from practice Severe acidosis or fixed dilated pupils are not useful markers for prognosis in the near-drowned patient. Controlled hypothermia at 33°C for 12 hours should be used in near-drowned patients who have spontaneous circulation but remain comatose. Controlled hypothermia cannot be recommended at present for children because of the risk of neutropenic sepsis. 1 Patient’s temperature over time after near-drowning 2 Arterial pH, lactate level and Pco2 over time after near-drowning* * Shading indicates reference ranges.

Jonathan P Williamson MB BS, BSc(Med) · Stan Braude MD, FRACP · Rowland Illing MRCS · Paul Gertler BA(Hons), MPsych, MAPS

Timothy J McCulloch Anaesthetist, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. tmccullATusyd.edu.au To the Editor: Chilov and colleagues have presented an updated set of guidelines for management of hip fracture, which included the statement “regional anaesthesia is recommended for most patients”.1 The evidence for this recommendation was graded as Level I (National Health and Medical Research Council) and was supported by a single reference, namely a systematic review from the Cochrane Database by Parker et al.2 Parker et al performed a meta-analysis of the published trials examining the effect of regional versus general anaesthesia on a variety of outcomes after surgery for hip fracture. A possible difference in 1-month mortality was found in favour of regional anaesthesia, but this difference was borderline using one statistical model (relative risk, 0.7; 95% CI, 0.5–1.0) and non-significant using another model. There was no significant difference in mortality at 3 months or 1 year, and no significant difference in a variety of other outcomes. Appropriately, the authors concluded that “both regional and general anaesthesia produce comparable results and therefore anaesthetists should choose which technique is most appropriate for each individual patient”.2 One of the many difficulties in interpreting meta-analyses of regional anaesthesia is that most of the published trials were performed some decades ago. For example, one study that contributed a large proportion of the data within the Cochrane meta-analysis was conducted between 1980 and 1982, and patients were explicitly excluded if they were receiving low-dose anticoagulation therapy.3 The relevance of such trials to patients receiving general anaesthesia today is highly questionable, given the improvements in general anaesthetic drugs and techniques and the importance now placed on routine thromboprophylaxis. There is a wide range of opinion within the specialty of anaesthesia regarding the place of major regional blockade, with little outcome-based evidence to support any particular advantage of these techniques. Although medical practitioners can benefit greatly from the efforts of reviewers to develop guidelines based on the best available evidence, care must be taken to ensure that recommendations do not go beyond what is supported by available data. Particular care needs to be taken when recommendations are made for areas of practice outside the reviewers’ expertise. The authors of these guidelines might consider withdrawing their recommendation regarding choice of anaesthesia.

Timothy J McCulloch

Michael N Chilov,* Ian D Cameron,† Lynette M March‡ * Intern, Concord Hospital [corresponding author], 50 Mi Mi Street, Oatley, NSW 2223; † Chair, Rehabilitation Medicine, University of Sydney; and Director, Aged Care and Rehabilitation Services, Northern Sydney Area Health Services, Rehabilitation Studies Unit, Ryde, NSW; ‡ Senior Staff Specialist in Rheumatology and Clinical Epidemiology, Department of Rheumatology, Royal North Shore Hospital, St Leonards, NSW. mchilovATgmp.usyd.edu.au In reply: We thank McCulloch for his comments regarding the use of regional anaesthesia in the surgical management of hip fracture. He makes the point that surgical and anaesthetic techniques have improved and implies that the advantage seen for regional anaesthesia in published studies may no longer be present. Given that controversy still exists, we would recommend that further randomised controlled trials be conducted. However, for the following reasons, we stand by our recommendation that the available evidence supports the use of regional anaesthesia for most patients with this condition. Our current recommendation is unchanged from the earlier version of the guideline (published in the Journal in 1999),1 and is also consistent with at least one other published guideline.2 A number of the concerns raised by McCulloch were addressed in the response to a letter by another correspondent after the publication of the original guidelines.3 While we acknowledge that the review by Parker et al4 only found the reduction in mortality at 1 month to be of borderline significance, when our review team reassessed the original articles using the Cochrane Collaboration protocol we reached a summary odds ratio for mortality of 0.68 (95% CI, 0.49–0.96). With time and further studies we expect that this estimate of effect will become more precise as the power of the meta-analysis is increased. This view is supported by a systematic review of all randomised studies comparing regional anaesthesia with general anaesthesia across surgical specialties. The study of Rodgers et al found a statistically significant reduction in mortality (odds ratio, 0.70; 95% CI, 0.54–0.90) when regional anaesthesia was compared with general anaesthesia.5 This overall point estimate is very similar to that of Parker et al in their meta-analysis of patients with hip fracture. Although lack of power meant that statistical significance did not exist within individual surgical specialties, there was, in fact, little difference in the effect across surgical groups, with no significant heterogeneity between studies. Serious complications of regional anaesthesia (eg, spinal haematoma) are extremely rare, as shown in the recent PEP study in Australia and New Zealand that reported no cases in 4603 patients undergoing regional blockade.6 This should be compared with the number needed to treat with regional anaesthesia to prevent one death of 38, according to the data of Parker et al.4 There is no doubt that our recommendation needs to be considered in the context of individual patient characteristics and, while the recommendation may not apply to all patients with hip fracture, we feel that the available evidence supports the use of regional anaesthesia.

Michael N Chilov · Ian D Cameron · Lynette M March

Michael J O’Leary Intensive Care Physician, St George Hospital, Gray Street, Kogarah, NSW 2217. m.olearyATunsw.edu.au To the Editor: Hore and colleagues argue for “integrated critical care” as a solution to the problem of providing intensive-care cover for patients in rural and non-tertiary metropolitan hospitals.1 They claim that such an approach is required uniquely in these hospitals, whereas in tertiary centres “subspecialists would be involved in each phase of the management process”. That this occurs is undisputed; however, it is far from the optimal model of care.2 Over the past 3 decades, the management of critically ill patients has evolved to require its own specialty. Other than in the traditional critical-care disciplines of anaesthesia and emergency medicine, training in critical care is not a significant component of specialty training programs. Within tertiary hospitals, therefore, the requirement that critically ill patients be cared for by specialists trained in critical-care medicine (and not a “committee” of subspecialty experts) is no less important than in the rural setting. There is consequently little difference between the skills and experience required of tertiary and rural critical-care specialists, and the continuum of critical care is the same in both settings. The recent creation of the Joint Faculty of Intensive Care Medicine by the Royal Australasian College of Physicians (RACP) and the Australian and New Zealand College of Anaesthetists (ANZCA) has enabled many of the past artificial barriers to effective critical-care training and accreditation in Australasia to be broken down. It is now possible to enter intensive-care training from varied training programs, including those of the Australasian College for Emergency Medicine, the RACP and the ANZCA. Completion of training is recognised by successfully passing a broad-based critical-care examination. The argument that training could and should include rural practice is well made. However, any comprehensive critical-care training will inevitably require some high-volume experience only available within a tertiary institution. That there are differences in emphasis in the workload of our rural colleagues should be recognised. However, our job is essentially the same. There is no need for a separate specialty, but there is a need to ensure provision of high quality critical-care services to all patients into the future.

Michael J O’Leary

Neil T Matthews Dean, Joint Faculty of Intensive Care Medicine, Australian and New Zealand College of Anaesthetists and Royal Australasian College of Physicians, 630 St Kilda Road, Melbourne, VIC 3004. jficmATanzca.edu.au To the Editor: The article by Hore et al1 raises many important issues for acute-care medicine in rural settings, including the need for specialists to be multiskilled and collaborate across disciplines, the lack of professional support for rural training programs and rural specialists, and the difficulty of overseeing multidisciplinary credentialling. These issues are not unique to acute-care medicine or to the Joint Faculty of Intensive Care Medicine (JFICM). They are problems for other faculties and colleges, rural healthcare facilities and governments. Many rural specialist services in Australia and New Zealand have the benefit of considerable expertise provided by medical practitioners who are not necessarily Fellows of the relevant specialist colleges. They should be supported by collaborative efforts of the relevant colleges, which should develop initiatives to increase the numbers of specialist medical practitioners working in rural settings. The JFICM, representing some 464 Fellows and 391 trainees, has been developing frameworks to support rural intensive care. JFICM’s goals are to develop a more flexible training program to encourage rural training; to establish a rural officer on the JFICM Board; to support a rural focus group, working through rural structures with the Committee of Presidents of Medical Colleges; and to explore liaisons with other colleges. The argument for developing a specialty of integrated critical-care medicine implies that current programs are deficient and cannot provide a holistic, integrated approach to rural acute care. Hore and colleagues argue that “there is no formal program for training specialists for multidisciplinary rural critical-care practice”. I must correct them on this point. Their proposal in fact eloquently describes the elements of the JFICM training program, which has existed since 1977. An internationally recognised and comprehensive intensive-care/critical-care training program, its status has been confirmed with its successful accreditation by the Australian Medical Council. The authors also suggest that “critical care” is in some way different from “intensive care”. This is not contemporary reality. The terms “intensive care” and “critical care” are one and the same. Healthcare workers in rural and remote locations have collaboratively developed multidisciplinary working relationships that provide comprehensive acute and non-acute healthcare. The same approach should be used by authoritative bodies to resolve important issues for rural specialists and training programs. The issues do not require establishing a separate specialty. The above comments notwithstanding, the suggestion by Hore and colleagues that specialties involved in acute care lead a collaborative process to strengthen clinical links is to be applauded. The discussions need to be inclusive of medical specialists working in intensive care medicine.

Neil T Matthews

John Stokes Director of Intensive Care, Mater Private Hospital, Fulham Road, Pimlico, QLD 4812. john.stokesATmatertsv.org.au To the Editor: Hore et al1 raise some very pertinent issues relating to the delivery of integrated critical care in the rural setting and raise the possibility of a new specialty to help solve the problem. The issue of providing many services in rural, remote and regional Australia will not be solved by more subspecialisation, which is actually having the effect of centralising services in major metropolitan centres distant from important and productive portions of our population. Rather than propagate another group of subspecialists, our medical colleges, and in particular the Australian Medical Council (AMC), need to look at new ways to empower specialists and generalists who work in regional areas to continue to provide services without their expertise being undermined in the eyes of the public. We need to encourage state governments to spread services more widely rather than to centralise and remove rural services. The push for so-called “centres of excellence” that draw all patients to a few centres is for the convenience of the few and is financially attractive to governments. Artificial standards for care (produced by the medical colleges), with restrictions on practice related to the number of patients treated or the number of patients ventilated, are unrelated to the quality of care delivered to individual patients. These restrictions may soon lead to many specialties not being sustainable outside capital cities or major urban centres because of insufficient caseload to meet the guidelines. In regional areas, specialists (such as anaesthetists) who have the experience to provide additional services (eg, intensive care), but not the formal recognition, are being discouraged from doing so by the college guidelines and the current legal climate. My observation of the actions of most medical colleges is that, by their good intention to maintain standards, they are supporting the concentration of services but are discouraging the wide delivery of services. Surely, when we do studies that demonstrate that care is better delivered in special or centralised units, the aim should be to find out why, and to seek ways to deliver that expertise in less specialised and more decentralised units, rather than to immediately call for more centralisation of services. This, I believe, is the real challenge for our AMC and our Committee of Presidents of Medical Colleges.

John Stokes

Craig T Hore,* William Lancashire,† John B Roberts,‡ Robert Fassett§ * Director of Critical Care, † Director of Critical Training, ‡ Director of Emergency Medicine, Port Macquarie Base Hospital, PO Box 2466, Port Macquarie, NSW 2444; § Director of Renal Unit, Department of Medicine, Launceston General Hospital, Launceston, TAS. horeATmaynegroup.com In reply: We thank the correspondents for their interest, insights and discussion. In general, there appears to be much common ground between our views and theirs, although a few points of clarification need to be made. We do not argue that a “committee of subspecialty experts” undertakes critical care in tertiary centres, as O’Leary suggests. The subspecialists we refer to are those within the discipline of critical care, particularly intensivists, emergency physicians and anaesthetists. In tertiary settings, these specialists operate predominantly within their base critical-care “subspecialty”. In rural settings, they are also involved in the other phases of critical care on a regular basis. Hence, while the principles of critical care are similar in rural and metropolitan settings, their effective delivery differs. We do not question that the Joint Faculty of Intensive Care Medicine (JFICM) provides a comprehensive intensive-care training program. However, there are very few JFICM-accredited intensive-care units in Australia outside metropolitan centres, and few JFICM-endorsed specialists working in the public sector in rural and remote intensive-care units.1 Unfortunately, this suggests that the current JFICM program is not addressing the needs of rural and remote centres. Indeed, in their recent review, the Australian Medical Council encouraged the JFICM to give more opportunity and encouragement for trainees to gain rural experience.2 The steps being undertaken by the JFICM that Matthews outlines are encouraging. We believe the statement by Matthews that “intensive care and critical care are one and the same” is insular and at odds with the reality of critical care, especially outside tertiary metropolitan centres. It is pleasing to note that O’Leary includes emergency medicine as a “traditional critical-care discipline”. There are strong clinical and curriculum similarities between emergency medicine and intensive-care medicine that cannot be overlooked. In this respect, rural centres may be leading the way in further breaking down barriers. The formation of the JFICM has been a positive step, but it remains a liaison of only two bodies. A greater presence from emergency medicine, rural anaesthesia, rural medicine and surgery would be beneficial and a significant step towards a truly multidisciplinary specialty. We reaffirm that, to ensure high standards of critical care for rural patients, solutions need to match the existing realities of rural practice. We agree that these must be collaborative and inclusive. The integrated critical-care model has been successful in a number of rural hospitals and offers potential for wider implementation.

Craig T Hore · William Lancashire · John B Roberts · Robert Fassett

Objective: To determine the effect on cardiac arrests and overall hospital mortality of an intensive care-based medical emergency team.Design and setting: Prospective before-and-after trial in a tertiary referral hospital.Patients: Consecutive patients admitted to hospital during a 4-month “before” period (May–August 1999) (n = 21 090) and a 4-month intervention period (November 2000 –February 2001) (n = 20 921).Main outcome measures: Number of cardiac arrests, number of patients dying after cardiac arrest, number of postcardiac-arrest bed-days and overall number of in-hospital deaths.Results: There were 63 cardiac arrests in the “before” period and 22 in the intervention period (relative risk reduction, RRR: 65%; P < 0.001). Thirty-seven deaths were attributed to cardiac arrests in the “before” period and 16 in the intervention period (RRR: 56%; P = 0.005). Survivors of cardiac arrest in the “before” period required 163 ICU bed-days versus 33 in the intervention period (RRR: 80%; P < 0.001), and 1353 hospital bed-days versus 159 in the intervention period (RRR: 88%; P < 0.001). There were 302 deaths in the “before” period and 222 in the intervention period (RRR: 26%; P = 0.004).Conclusions: The incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing an intensive care-based medical emergency team.

Rinaldo Bellomo MD, FJFICM · Donna Goldsmith RN · Shigehiko Uchino MBBS · Jonathan Buckmaster FJFICM, FANZCA · Graeme K Hart FJFICM, FANZCA · Helen Opdam FJFICM, FRACP · William Silvester FJFICM, FRACP · Laurie Doolan FANZCA · Geoffrey Gutteridge FJFICM, FANZCA

The medical emergency team (MET), which may be summoned by anyone in a hospital to treat a patient who appears acutely unwell, has been generally accepted as scientifically rational, with no adverse clinical outcomes and only modest resource requirements. Despite this, many centres appear to be awaiting “gold standard” evidence of its effectiveness. We suggest that the quest for evidence is providing scientific justification for institutional inertia, and that further delay in implementing this system may even be unethical. We propose that decisions about changes in healthcare should consider scientific rationality, clinical reasonableness and resource implications, as well as evidence and ethical implications. A medical emergency team (MET)1 can be simply described as a cardiac arrest team with changed calling criteria. Anyone in a hospital may summon the team to a patient who appears acutely unwell, even if the patient has not actually had a cardiac arrest. The introduction of a MET may be accompanied by education on better recognition of acute illness, and an ongoing audit and education process. There is an implied and unquantified increase in the workload of the intensive care unit (ICU) staff, and a need for them to shift the focus of their work (at least temporarily) outside ICU. The in-hospital response to acute illness has been shown to be suboptimal.2 As a remedy, the MET system appeals to many, but has been the subject of ongoing debate. There have been no suggestions that there may be adverse clinical outcomes from a MET; rather, the concept has been challenged on the basis of the quality of the evidence.3 In this age of evidence-based medicine (EBM), such a challenge is justification for a pre-emptive halt to change, while evidence is accumulated. Possible resource implications have also been a point of discussion.4 Perhaps the most important (though unstated) factor preventing implementation of the MET system is that it represents a change to established hospital systems, hierarchies, and departmental responsibilities. In this regard, we feel that the quest for evidence has provided scientific justification for institutional inertia. New evidence for the MET systemThose who have been following the debate about the possible benefits of the MET in hospitals will welcome the study by Bellomo and colleagues5 in this issue of the Journal. In a major teaching hospital, introducing a MET was associated with a 65% reduction in cardiac arrests. Perhaps more surprisingly, there was a 26% reduction in the overall hospital death rate, equivalent to three lives per 1000 admissions. The authors did not limit their study to patient outcomes, but also considered some resource implications of the MET system and characterised the interventions by the MET. The increased workload does not appear to be excessive. Interestingly, most interventions appeared relatively “simple”, a finding somewhat reminiscent of that in a study of interventions by a hospital trauma team.6 Are patients dying while we wait for evidence? The results of Bellomo et al support the findings of others,7 and appear to strongly support the MET system. However, those who enjoy academic disputation should not lose heart — there are plenty of opportunities to dispute some aspects of the study, and the MET system generally. This ongoing controversy may also teach us much about the possible ethical implications of misuse of the concepts of EBM, and the dangers of attempting to base decisions about the delivery of medical care solely on “evidence”. The limits of evidence-based medicineEBM may be misused in scientific debate. Desire for scientific certainty and enthusiasm for scientific rigour may lead to inappropriate discounting of anything less than Level 1 evidence. The more rigorously EBM is applied, the less the evidence that the intervention being studied is effective — the “stainless steel” law of evaluation.8 This can lead to an apparent inability to prove anything, so that EBM produces a lot of “negative” outcomes. These limitations have been well recognised by Sackett et al9 and others.10 Despite this, there remains a widespread perception that EBM requires high-level evidence, such as randomised controlled trials. It is easy to misconstrue the resulting absence of evidence of benefit as being evidence of absence of benefit. The conclusions drawn from examining the evidence can be determined by the framing of the question and the standard of proof required — both of which can be controlled by those with established power or authority. The EBM website, Bandolier, comments: “The trouble is that people use phrases like ‘evidence-based medicine’, or ‘meta-analysis’ or ‘systematic review’ as some form of talisman. Attach one of these phrases to a point of view and an argument is won!”.11 Armed with the talisman of EBM, opponents of change can point to lack of evidence, or, if evidence is abundant and homogeneous, to weaknesses in study design. With apparent impartiality, other, less convincing reasons for conservatism may be concealed. Earlier in the ongoing MET debate, Buist et al reported on the introduction of a MET,7 with similar results to the study by Bellomo and colleagues. The extensive correspondence that the article by Buist et al generated drew attention to confounding factors, lack of applicability in other settings, failure to describe a mechanism of benefit, the use of historical controls, the possibility of a Hawthorne effect, and even accused the British Medical Journal of using an inaccurate and sensational cover title and a fake photo.12 Many of these criticisms are justifiable in (inappropriately rigorous) EBM terms, but we may be seeing the “stainless steel” law of evaluation at work — the more rigorously the criteria for EBM are applied, the less the evidence that the intervention is effective. Ellis (and Sackett) et al recognised the limitations of EBM in regard to life-saving treatment in emergency settings.13 In 1995 they acknowledged that certain interventions were “self-evident”, defined as interventions that, if omitted, would do more harm than good. “Face validity” may be accepted on the basis of “convincing non-experimental evidence”. This must be possible if innovation in acute, life-saving medicine is to continue. Ethical aspects of EBM misappliedThere have been a number of recent critiques of EBM and ethics, including some by Australian authors.14-16 Many of the issues raised, including funding and service decisions, and impact on research activity, are of some relevance to the MET controversy. Enthusiasm for EBM has grown at a time of increasingly overt economic constraint in healthcare. In this setting, EBM has been used as a justification for rationing decisions. At a national level, politicians have proposed that health funding should follow evidence (as defined by EBM).17 At a hospital level, “lack of evidence” may provide a useful justification to avoid shifting funds to facilitate system change, particularly for changes (such as a MET) that may result in “turf wars”. Regardless of funding, “lack of evidence” may provide service managers or clinician leaders with a justification to avoid involvement in service activity they would prefer to avoid for reasons unrelated to patient welfare. Uncritical application of EBM may also change the “respectability” of research or other activity that is not organised in the EBM paradigm. This may divert scarce resources (dollars, intellectual energy and enthusiasm) into research involving large randomised controlled trials. In many areas of healthcare, greater improvement in patient outcomes could be achieved by locally focused effort, based on quality improvement or process redesign methodology. It is interesting to speculate on what else could have been achieved with the funds, energy and intellect that have been and are being expended on research to produce evidence about the MET system. Implications for MET implementationMost of the foregoing discussion may seem to be of interest to philosophers, but only a diversion to clinicians. But consider the implications of the “quest for evidence” with regard to the MET. The MET concept was established at Liverpool Hospital, Sydney, in February 1990. Reports of the initial results, and experience with the MET, were presented at various conferences after 1991, and formal publications in peer-reviewed journals were produced after 1995. The concept was generally accepted as a scientifically rational and clinically reasonable response to the challenge of acute in-hospital illness. No adverse clinical outcomes have been suggested, and the resource requirements for the MET system are modest. Many would suggest that in a “reasonable” health system the MET system would have been introduced generally by (say) 1997, with appropriate audit of the effects of implementation. In fact, despite attracting international interest in the concept, introduction of the MET system in Australia has been patchy (about 25% of hospitals with ICUs). Many centres appear to be awaiting evidence — in particular, the multicentre trial of the concept sponsored by the Australian and New Zealand Intensive Care Society (the MERIT study) currently being conducted. But if the results of the study by Bellomo et al are extrapolated across Australia, introducing the MET system nationwide would prevent some 5000 hospital deaths annually. Could it be that thousands of Australians have died waiting for evidence to be collected to justify an intervention that is scientifically rational and clinically reasonable, with modest resource implications? Appropriate evidence-based decision-makingAll changes in healthcare have some risk of adverse outcomes, cost implications, and, once implemented, may be difficult to reverse. Clearly, decision-making must be based on something other than intuition or whim. It is appropriate to require some level of evidence for any decision (whether to change or to not change). But in some areas of medicine, it is unrealistic to ever expect evidence approaching the “gold standard”. In these areas, asking for “gold standard” evidence may be mischievous. We propose that decisions about changes in healthcare should consider three Rs and two Es. Is the proposal scientifically rational? Is it clinically reasonable? What are the resource implications? Is there evidence to guide our decision? What are the ethical implications? The three Rs should allow the proposal to be broadly categorised on the basis of risk (including cost) and benefit. The requirement for evidence should be proportional to the apparent risk and benefit. For interventions with a high risk (cost) and marginal benefit, particular rigour may be worthwhile in assessing the evidence. Recent examples of such interventions include activated protein C18-20 and cyclooxygenase-2 (COX-2) selective inhibitors,21,22 in which evidence was produced to support the intervention, but the cost of the evidence-based decision was high for a marginal benefit. If the evidence was even slightly flawed, the conclusion could have been very different. Conversely, in the case of interventions with high apparent benefit and low risk (including cost), it may be more illuminating to rigorously examine the motivation for opposition to the change, rather than accept as justified the demand for better or more evidence. We would suggest that the MET system fits the latter category. ConclusionThere is no doubt that the “best available evidence” is an important component of medical decision-making. EBM should be seen as a powerful method to identify the best available evidence to assist decision-making. However, EBM is not an impartial or value-neutral force in modern medicine, and has as much capacity for abuse as any other double-edged sword forged by science. EBM should not be enlisted as a tool to prevent healthcare changes that may benefit patients but are uncomfortable or challenging to the established order. In many areas of medicine, when considering possible interventions that are rational, reasonable, and with modest resource implications, it is appropriate to implement change without “absolute” evidence. It may even be unethical to delay change while inappropriately demanding more evidence. How many people should be allowed to suffer or die in the absence of “Level 1 evidence”, when reason suggests change, and our duty of care demands it?

Ross K Kerridge MB BS, FRCA, FANZCA · W Peter Saul MRCP, FRCA, FFICANZCA

Critical care encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management, and retrieval. In metropolitan teaching hospitals these elements are often distinct, with individual specialists providing discrete services. This may not be possible in rural centres, where specialist numbers are smaller and recruitment and retention more difficult. Multidisciplinary integrated critical care, using existing resources, has developed in some rural centres as a more relevant approach in this setting. The concept of developing a specialty of integrated critical-care medicine is worthy of further exploration. In Australia, "rural" centres have been defined statistically as local areas where most of the population resides in centres of 10 000–99 999 people, and "remote" centres where the population is less than 10 000 people.1 It has been claimed that a two-tiered system of hospitals has developed, one tier composed of "centres of excellence", and the other of hospitals more limited in their range of expertise and technology.2 The first tier is predominantly hospitals in the heart of capital cities, while rural hospitals fall into the second tier. In this hierarchical system, metropolitan teaching hospitals are often perceived as setting the standards for practice, but this perception can be challenged. Standards are sometimes based as much on opinion as evidence and are not necessarily universally applicable.3 It has been questioned whether a resource-intensive intervention should become a standard of care if it produces a small benefit in clinical outcome in trials in large institutions, when a greater benefit may be gained by giving a greater number of patients a more basic minimum standard of care that is sustainable across the entire healthcare system.4 Metropolitan tertiary hospitals provide a super-specialised level of care that is essential for some patients, but not sustainable outside resource-concentrated centres. On the other hand, rural base hospitals and metropolitan district hospitals provide a broad spectrum of hospital and community medicine, and therefore training opportunities, that may no longer be available in major tertiary hospitals.5 With respect to hospital practice, then, it could be argued that it is the second-tier hospitals that currently deliver the generic standard of care. Part of the problem with rural healthcare systems is that models of care applied to super-specialised metropolitan practice are assumed to be relevant to rural practice. A different level of care does not necessarily equate with a lower standard of care. Indeed, structuring resources to match the specific rural milieu may well lead to more appropriate care for this setting and therefore better care. Wakerman and Humphreys6 suggest that a distinctive "rural health" approach is needed because rural Australia is sociologically, culturally, economically and spiritually different from metropolitan areas, and that a hallmark of rural and remote healthcare is innovation generated by local need and community action.6 This approach has been successfully applied in a number of rural centres to the problem of providing critical-care services in the face of limited numbers of medical specialists. Medical specialist involvement in rural intensive care in Australia — the status quoRecent reviews of intensive-care activity in Australia found that 37% of Australian public-sector intensive-care units7 and 34.5% of medical specialists working in public-sector intensive care8 were in rural and remote centres. The nature of the work in these units differs from that in metropolitan centres. Many are combined with high-dependency and coronary care, with over half the patients admitted being in these categories.7 The medical specialists involved also differ in their qualifications and background from specialists in major metropolitan hospitals, as training, recruitment and retention difficulties limit the number and type of specialists available in rural centres. Of the specialists currently involved in rural intensive care in Australia, only a small number have qualifications endorsed by the Joint Specialist Advisory Committee in Intensive Care (JSAC-IC).8 Instead, the majority have backgrounds in anaesthesia, emergency medicine, general medicine and/or general surgery and have acquired expertise in intensive-care medicine through specific training, clinical practice, or both. In addition to their base discipline, many specialists are also involved in other phases of critical care. Traditionally, this multiskilling has developed out of necessity. Increasingly, however, it is occurring by choice, as it can result in efficient use of skills and afford a unique and interesting casemix for specialist medical staff, while at the same time providing benefits to critically ill rural patients and rural communities. Models of integrated critical careTrunkey9 proposes that physicians and surgeons are evolving towards three types of practice: ambulatory care, hospital-based practice and intensive care. We suggest that the third branch is actually critical care. Critical-care medicine is the multidisciplinary healthcare specialty that incorporates the knowledge, skills, attitudes and problem-solving abilities required for the recognition and early management of patients with acute life-threatening illnesses and/or injuries.10,11 It encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management and retrieval medicine. Clearly, critical care is a continuum that begins at the onset of critical illness or injury, and continues through the transportation process and the acute hospital care process.12,13 The principles for managing critical illness and injury are similar, regardless of patient location or diagnosis. The aim is to keep alive those patients who have a reasonable chance of survival.14 In rural Australia, this may require organisation of resources in a fashion that is different from that undertaken in metropolitan centres. In metropolitan hospitals, subspecialists would be involved in each phase of the management process, but this may not be possible in rural centres, where specialist numbers are smaller. This is where a multidisciplinary critical-care physician becomes particularly valuable. This specialist has many of the characteristics that have recently been attributed to those of a "hospitalist".2,15 Through local innovation and necessity, models for effectively delivering critical care using existing resources have been developed in several sites in rural Australia, including Tamworth Base Hospital and Port Macquarie Base Hospital in New South Wales. These models of integrated critical care (see Box) involve a hospital-wide approach, acknowledging that care of critically ill patients is a collaborative endeavour, not the exclusive domain of an intensive-care unit. The critical-care facilities are located nearby and share specialist medical staff, resident medical staff, career medical officers and nursing staff. Integration has resulted in a more seamless interface between the various phases of critical care and between the respective disciplines. Although multidisciplinary and multiskilled, individuals are not required to perform multiple tasks at any given time — for example, when on duty in the critical-care unit, they are not given other responsibilities. Rather than being partisan about individual specialty groups, the focus has been on providing the most appropriate services to meet the needs of critically ill patients and their rural communities, using the most appropriate resources. Thus, these successful models are based on cooperation rather than competition or duplication. This was recognised in the 2001 NSW Government Action Plan for intensive-care services.16 The Plan recommended that, in rural hospitals, a formal working relationship be developed between staff of the intensive-care unit and anaesthetic or emergency-department consultants to provide appropriate senior medical cover for the unit.16 A collaborative approach for the future?Currently, there is no formal program for training specialists for multidisciplinary rural critical-care practice. Training in many of the relevant base specialties remains metropolitan-based with a metropolitan focus. For example, of the registrars working in Australian public-sector intensive-care units identified in a recent survey, only 3.7% were in rural and remote areas, and the majority of these were not JSAC-IC trainee registrars.7 To address this disparity, a fresh approach may be required. In rural and non-tertiary metropolitan centres, critical-care practice has characteristics that distinguish it from tertiary metropolitan practice. Integrated critical-care medicine could therefore be defined as "the practice of critical-care medicine that occurs in non-metropolitan Australia" and developed as a distinct specialty, with appropriate input from existing specialty Colleges and societies. Specialist training could be provided at appropriate rural sites rather than concentrated in tertiary metropolitan centres. Alternatively, strong subspecialty groups could be developed within existing Colleges, with a unifying cross-College standing committee and joint training. Approaches to critical care vary throughout the world,12,17-19 and a number of approaches tried elsewere may provide suitable models for integrated critical-care medicine in Australian rural areas. Whatever model is adopted, given the backgrounds of the majority of specialists currently involved in critical care in rural Australia, the specialties of emergency medicine, anaesthesia and intensive-care medicine will need to lead the process. Like anaesthesia, emergency medicine and intensive-care medicine have significant clinical links, and these need to be encouraged and strengthened.12,13,19 ConclusionTo ensure high standards of critical care for rural patients, it is vital that realistic solutions continue to be developed that match the existing realities of rural practice. The integrated critical-care model has successfully provided quality services in a number of hospitals and offers potential for wider implementation in rural areas. The concept of developing a specialty of integrated critical care is worthy of further exploration. This will require collaboration and cooperation between all stakeholders. Features of integrated critical care Multiskilled critical-care specialists trained and experienced in the various aspects of critical care in rural hospitals. Multidisciplinary critical-care teams that provide: a more seamless interface between the various phases of critical care and between its respective disciplines; a rapid response to, and a continuum of care for, critically ill and injured patients; clinical leadership in evaluating and managing critically ill and injured patients, both in the hospital (including the emergency department, critical-care unit and hospital wards) and in the community (including retrievals, and support for ambulance crews, peripheral hospitals and general practitioners); and training of medical students, medical staff, nursing staff and allied health professionals to recognise and provide a systematic approach to critical illness and injury. Team members who are empowered to work beyond perceived traditional boundaries, but within the realms of their clinical expertise and credentials, to enable the best use of available resources.

Craig T Hore MB BS, FACEM · William Lancashire FRACGP, CCFP · John B Roberts MB BS, FACEM · Rob Fassett MB BS, FRACP

Re: Fatal intravenous misuse of transdermal fentanyl (Med J Aust 2002; 177: 552-553) by Mark D Reeves and Corinne J Ginifer. In Box 2A (page 553), the computed tomography scan of the brain was not the correct image. The correct image is given below. The html and pdf versions of this article were corrected on the website on 12 May 2003. A: Brain — arrows indicate areas of low attenuation in basal ganglia.

Mark D Reeves MB BS, FANZCA · Corinne J Ginifer MB BS, FACEM

Persistent pain is a complex mix of physical and psychological symptoms and is ideally managed by a biopsychosocial approach. Often the relative contributions of family and personal relationships, finances, work, past pain experiences and personality outweigh those of the nociceptive or neuropathic processes from which most pain originates. Recent advances in our understanding of the pathophysiology of pain may lead to improved drug treatments; however, non-drug treatments — education, lifestyle modification, exercise and reassurance — should be used routinely to improve patients' quality of life. Patients with persistent pain that is difficult to control or has complex psychosocial influences, or who have a history of medication misuse, should be referred to a multidisciplinary pain centre. Selected patients may be offered invasive options such as nerve blocks or spinal-cord stimulation. The best outcomes are achieved in patients treated in group-based pain-management programs using cognitive-behavioural therapy to improve physical function, change unhelpful thinking and improve patients' understanding of their situation.

C Roger Goucke FANZCA, FFPMANZCA, FAChPM

For theatre staff, the most precious drug in Buka. When the theatre drug safe has nothing in it bar a packet of tea, you know you are in an unusual operating theatre. When I volunteered for a fortnight in October 2001 with AusAID in Bougainville, which lies between the Papua New Guinea mainland and the Solomon Islands, I knew I'd have to resurrect my Third World anaesthesia skills. One can come to terms with halothane anaesthetics and a single syringe — the real test is the tea in the drug safe. For the record, that packet of tea made the best "cuppa" I'd had in a long time. You put several spoonfuls of tea into a strainer and run hot water from the urn through the strainer until your cup has the desired strength. Two tablespoons lasted all day. It worked — thus passing the acid test of all Third World medicine. Faced with a 13-month-old little boy up for three hours of bilateral talipes surgery, I racked my brains: what was the best way to gas him? First World anaesthesia was precluded by the absence of any endotracheal tubes smaller than 5 mm. Anyway, the ventilator didn't work. So I gave the kiddie a knockout premed and snuck up on him with the halothane. Just a few seconds before his Mum and I fell asleep the kid succumbed and I stuck in a laryngeal mask. He breathed himself to sleep for three hours and the surgeon had no complaints. It's a bit like the old air force adage, "Any landing you walk away from is a good landing". Over the years, I've done lots of tours of "good works" — from trips with the Flying Obstetric Service out of Roma, Queensland (about 500 km west of Brisbane), to those with the Forward Surgical Troop with INTERFET in East Timor in 1999. Nothing has given me the satisfaction of "a job well done" as much as this AusAID tour, and I recommend it to others unreservedly. Our orthopaedic team left Buka knowing there were half a dozen kids walking around the place who couldn't otherwise have done so. How does that compare with the list of arthroscopies that is my usual bread-and-butter? Back of BukaThe Bougainvilleans are trying desperately to put behind them the '89 to '99 "crisis" — their term — when a move to secession left a potentially well-off country devastated by war and pollution (eg, from heavy metal run-off from abandoned mines). Conversations with the intelligentsia left me with the distinct feeling that their support lay with the Bougainville Revolutionary Army (BRA), although they would never admit it, and any conversation on the topic is conducted sotto voce. I was one of a four-man team of orthopaedic specialists who, since the peace treaty of 1999 and supported by AusAID in partnership with the Royal Australasian College of Surgeons, have made an annual trek to Bougainville. Airfares and accommodation organised for us, we arrived without a hitch on Buka, the northernmost of the two main islands of Bougainville. First, we had to separate the "VIPs" from the deserving cases. The surgeon had been here before — indeed, his father was a much-respected "expat" from the days before the crisis — and knew that the first patients to be seen in outpatients would be the important people in the village. The trick is to admit that they need surgery but put them off until the real work is done. We did this very effectively, finishing our 25 cases of the visit with three arthroscopies of knees (the postmaster, the bank manager, and the police chief). Interestingly, from a professional point of view, these last three patients had more postoperative pain than that experienced by all the (far more serious) cases put together. Education is obviously related to pain perception. We were accommodated in a hotel at the opposite end of the village from the hospital. Getting from one to the other involved a long and sweaty walk each morning and evening, sometimes in the dark. A throwaway remark, by a fellow guest and expat, put things in perspective. When we asked whether the locals would harm us, he replied that they would rob us, but they wouldn't kill us or rape us (one of our team was a theatre sister) and, if they did, the village would be pretty cheesed off about it and would probably exercise payback on the perpetrators. When AusAID teams weren't in Buka anaesthesia was reduced to its true role in the spectrum of medicine and was provided, perfectly adequately, by two "technical officers", who, as far as I could see, had been trained in the "recipe technique" (eg, "give two inches of the big syringe and about half of the little syringe"). They provided a service that would be envied in many Australian public hospitals: they never argued with the surgeon, and nine times out of ten the patient went to sleep on demand and woke up afterwards. I discovered — the hard way — that a speedy recovery phase was in your own interest, as you recovered your own patients. If you weren't careful, then, when everyone else was drinking tea, you were still applying jaw support. Our team of four knitted together quite quickly. Sister Mary-Lou — whose name, along with those of all the others in this story, has been changed . . . to protect me! — had never done anything like this before. She worked her feet off for 10 days but gave away her Third World inexperience by expressing disappointment when she found out that the only chemist's shop for a thousand miles did not stock self-tanning lotion, this amidst the second-blackest people on earth after Ugandans. She also let it slip, at the end of the trip, that probably nothing we used was truly sterile, as all the bundles were coming out of the steriliser still wet. If she'd told us this at the beginning, we would probably have gone home, but after two weeks we'd adopted a Bukanian attitude to sterility (ie, near enough is good enough). After all, if one can be "a little bit pregnant" then there's nothing wrong with "nearly sterile". A senior orthopaedic registrar joined us for part of the trip; an excellent fellow who worked very hard, saw things he'd only read about, and was imbued with the concept of pro bono work. The resident doctors, nurses and other staff at the hospital were extremely hospitable to us, and my expressed interest in fly-fishing was rewarded with a social outing in one of the locally built "banana boats" — twenty-three feet of unbreakable fibreglass, with a seriously large outboard. However, as these men fished for the table rather than sport, I felt they found my efforts with a fly rod and "feathers-for-bait" amusing and inconsequential but were too polite to say so. Out and about in ArawaWe spent the weekend in Arawa, the old provincial capital; getting there involved a painful 4-hour trip over dirt roads and tracks in a 4WD "troop carrier". Arawa is now a burnt-out shell after the BRA razed it to the ground in 1989. However, a new hospital has arisen from the ashes thanks to Australian aid and, at the time of our visit, had been open for only six weeks. It had a staff of two: an Australian doctor, only four years out, and a nurse from New Zealand. The doctor was away in the highlands seeing patients, but had already done a laparotomy for stab wounds and a caesar. I read, with morbid fascination, his guide to anaesthesia that was pinned to the wall of the theatre. It enumerates a Plan A, then a Plan B (both simply lists drug doses and techniques for giving a very basic anaesthetic). For Plan C, it simply says: "There is no Plan C". We shared accommodation (with hot showers) with several Kiwi policemen, who were there under an NZAid plan to set up an impartial police force. One of them, a young sergeant, described all the expats in Bougainville as either "mercenaries or misfits". Mature consideration revealed that, on social contact thus far, he was probably correct. However, we couldn't decide which group we fell into — one term was as pejorative as the other. Interestingly, several of the locals we met changed their attitude towards us when they clarified that we were not paid for our efforts and were not affiliated to any religious organisation (unless the RACS considers itself as such?). Tom, the Buka hospital carpenter, had accompanied us to Arawa. He had offered his services as a guide and general factotum, having said that his family came from this area and that he would like to visit them. Over the weekend, it became clear that our friend and ever-helpful guide was actually persona non grata in the area over a past relationship involving the daughter of a prominent local leader. Notwithstanding this social drama, Tom felt himself truly to be part of the team, joining the ward round of all the local "orthopaedic" patients rounded up for us to see during our visit. I might add, as a mere anaesthetist, that I thought his contribution to management was at least as sensible as the experts', and probably took more note of local exigencies. I've always maintained that orthopods were just carpenters with chrome-plated tools. The most threatening few moments of my trip actually happened in Arawa rather than Buka, when the "Team Leader" (his words, not mine) Dr Bones sent me off to find beer to sustain us over our weekend there. Tom established that it wasn't available legally. But, he had an address. We set off in the ambulance with Sister Mary-Lou riding shotgun and soon found ourselves in a back street with unnumbered houses. Tom disappeared, coming back with the going price (remarkably reasonable in the circumstances). Then it was my turn to enter the house, without Tom but with 60 kina and a tachycardia. It did cross my mind that the speech of the locals involved in the transaction sounded unusually Australian, but at the time I was more involved in getting out with a case of local beer and both legs working. Back in Buka, I learnt that these locals were the sons of a Buka nurse who had given up everything to educate her boys in Australia. I was quite proud to think that an Aussie education had given these lads an honourable profession. If you have a few weeks on your hands and can't stand the prospect of spending it on the links or the harbour, give a thought to volunteering your services to AusAid. It will not only broaden your horizons but also "reset your thermostat" as far as the truly important things in life are concerned. Now that I've retired from the black art of anaesthesia, these trips are the only thing I miss about "my old life".

Douglas N Gow

To the Editor: In general, it is unwise for the medical practitioner to stray from those fields in which he or she is trained. To illustrate this point, I report the case of an anaesthetist (me) caring for a patient undergoing general anaesthesia for open repair of a fractured ankle. The operation was nearly over. The ankle had been repaired and the theatre nurse left the scene to assemble the materials needed for a leg cast. The patient was breathing spontaneously via a laryngeal mask airway. Before wound closure, the orthopaedic surgeon requested intraoperative radiography. A large X-ray machine was wheeled into the theatre, and the radiographer positioned it over the patient, took several images and then left to process the films. The surgeon wanted to resume surgery immediately, but who was going to remove the unattended x-ray machine, still poised directly over the operative field? I volunteered. I hit a button on the panel. It manifested as the command for "reverse": accordingly, the machine backed itself into the wall of the operating theatre, trapping me in between. At the same instant, a loud noise — consistent with partial upper airway obstruction — emanated from the anaesthetised patient. I had to free myself from my captor. Immediately. My release strategy incorporated pressing most of the buttons on the x-ray machine in a random manner. As all were imprinted with unrecognisable symbols, this seemed a reasonable, and eventually effective (if not a recommended), method for determining the "forward" function. I quickly returned to the patient's head and managed the airway problem. Thankfully, the patient's oxygen saturation did not decrease and the remainder of the anaesthetic was uneventful (the x-ray machine having been escorted out of the theatre by the radiographer on his welcome return). Although I had been willing and, in fact, keen to expedite the surgical procedure, I suggest that doctors avoid the lure of driving foreign vehicles (they can be savage beasts).

Richard H Riley

Patients undergoing surgery need good advice not only about whether a particular elective procedure is truly necessary and likely to be of benefit, but also about the nature and chances of an adverse outcome from the surgery itself. Those with heart failure, coronary artery disease, diabetes or emphysema are more likely to suffer serious complications or death after major surgery. Epidural anaesthesia and analgesia may be a preferable technique in such patients,1 as epidural block can attenuate the neurohumoral stress response to surgery,2 potentially improving postoperative cardiorespiratory function and reducing complications. Many small randomised controlled trials (RCTs) have supported this conjecture, but, because most serious complications after anaesthesia and surgery are rare, none has had sufficient power to demonstrate whether epidural block significantly improves postoperative outcome. A solution to this problem is to combine the results of all available trials in a meta-analysis. Applying this approach to data from 141 RCTs involving 9559 patients, Rodgers et al showed that the use of epidural or spinal block (with or without general anaesthesia) resulted in a significant 30% reduction in mortality after surgery.3 Outcomes causing major morbidity (major morbidity endpoints) such as thromboembolism and pneumonia were also reduced. Another recent systematic review found that epidural block reduces postoperative myocardial infarction.4 Although these findings are supportive, they were based exclusively on small RCTs, and meta-analyses sometimes give conflicting results when compared with large RCTs.5 In 1984, Yusuf et al explained how large, simple randomised trials can reliably detect moderate effects on important but uncommon outcomes such as death or major morbidity after surgery.6 Two of us are part of an Australian group that has recently published the results of a large multicentre RCT of epidural block in 888 high-risk patients undergoing major abdominal surgery (the MASTER trial).7 Patients were randomly allocated to receive general anaesthesia with or without epidural block. The epidural block was established before the commencement of surgery (epidural anaesthesia) and epidural analgesia was continued for three days after surgery. All other care was left to the discretion of the anaesthetist and surgical team: most patients were managed in general surgical wards after surgery, although some required high-dependency or intensive care. Thus, our trial was a test of effectiveness in routine practice and its results can be generalised. There was no significant difference in mortality at 30 days or in overall morbidity — 57% of epidural and 61% of control group patients had at least one morbidity endpoint (sepsis, respiratory failure, myocardial infarction, heart failure, renal failure, gastrointestinal [bleeding or need for parenteral nutrition], hepatitis, or haematological [anaemia, leukopenia, or thrombocytopenia]) or died (P = 0.30). Mortality at 30 days was low in both groups (epidural, 5.1%; control, 4.3%). Of the eight morbidity endpoints studied, only one, respiratory failure, occurred less frequently in patients managed with epidural block (epidural, 23%; control, 30%; P = 0.03). Another large RCT published recently showed similar results.8 Thus, there is no evidence that epidural block improves outcome in most patients undergoing major abdominal surgery with general anaesthesia, other than for respiratory complications. Nevertheless, in the MASTER trial, pain scores over the first three days after surgery were significantly lower in the epidural group. This difference occurred despite most participants in the control group receiving multimodal analgesia.1 This demonstrates some benefit from epidural block: a reduction in pain may assist deep breathing and coughing after surgery, and this may help prevent atelectasis and pneumonia. The MASTER trial, and other recent data,3,8 provide some evidence to support this conjecture. What are the risks of epidural block? One should take into account the risk of an epidural haematoma when an epidural or spinal needle is placed, particularly in a patient receiving anticoagulation therapy (eg, perioperative thromboprophylaxis). The risk of epidural haematoma or abscess is very low, with estimates varying widely from about 1 : 1700 to 1 : 200 000.9,10 Concern regarding damage to the spinal cord (leading to paraplegia) or nerves must be weighed up against the benefits of improved postoperative analgesia. Evidence-based practice is dependent on good quality research, and the best evidence comes from large trials.6 The MASTER trial provides reliable information for doctors and their patients on which to base their decisions regarding the best methods of anaesthesia and analgesia after surgery. Epidural block seems to provide additional benefit for patients at increased risk of postoperative respiratory complications. When considering use of epidural block, doctors and patients also need to weigh up the benefits of improved pain relief against the (rare) risk of paraplegia and other nerve injury. Our experience has been that some patients will choose postoperative epidural analgesia after being given this information.

Paul S Myles MPH, MD, FCARCSI, FANZCA · Ian Power FRCA, MD, FFPMANZCA, FANZCA · Konrad Jamrozik DPhil, FAFPHM, MFPHM

Fentanyl is a synthetic opioid with a potency about 200 times that of morphine. It has been misused since it was first introduced, mostly by medical and paramedical personnel because of limited access. Illicit manufacture of fentanyl and its analogues ("China White") occurs sporadically and has been associated with regional fatal epidemics in the United States.1 With the introduction of a transdermal delivery system for fentanyl (Durogesic, Janssen-Cilag) for managing chronic and cancer pain, there is a widening pool of individuals with access. Prescribed transdermal fentanyl patches can be sold or stolen. Clinical recordA 35-year-old woman with a history of intravenous drug use was brought by ambulance to the emergency department after an intravenous overdose of the contents of a transdermal fentanyl patch. The ambulance had been called to a private home where there were two people unconscious, a man and a woman. Both appeared to have had acute narcotic overdoses. It was later confirmed that they had shared (and injected intravenously) the contents of a transdermal fentanyl patch (5 mg) found at the scene. Both patients were rapidly assessed by the ambulance officers, and the initial resuscitation concentrated on the male patient, who, at first assessment, appeared to be in a more critical state. He was unrousable and was reported to have Cheyne–Stokes respiration. His blood sugar level was checked (10.5 mmol/L) and he was given 1.2 mg naloxone intravenously. He recovered consciousness within five minutes and subsequently absconded from the scene while the second patient was being treated. In the interim, the female patient had suffered a cardiorespiratory arrest. Cardiopulmonary resuscitation was commenced, with the assistance of police officers who were also in attendance. According to ambulance records, her initial rhythm was electromechanical dissociation, which subsequently deteriorated into ventricular fibrillation. A direct current countershock (200 J energy) was applied. The patient went into asystole. She was intubated and intermittent positive pressure ventilation with 100% oxygen was started. Naloxone 1.6 mg, adrenalin 10 mg (total dose) and atropine 2 mg were administered intravenously. Subsequently, she developed a narrow complex tachycardia with a rate of 130 beats/minute and had a palpable cardiac output. The total time spent at the scene was 40 minutes, and transport time to hospital took 5 minutes. On arrival at the emergency department she was unconscious, with a Glasgow Coma Score of 3. Her pupils were dilated and non-reactive to light. She was making occasional attempts at respiration and was ventilated as above with 100% oxygen. Her heart rate was 120 beats/minute in sinus rhythm, systolic blood pressure 55 mmHg and oxygen saturation 97%. One litre of Haemaccel and a noradrenalin infusion were administered, resulting in an initial improvement in systolic blood pressure to 95 mmHg. It was evident that she had vomited at the scene, and clinical signs were consistent with aspiration, which was later confirmed on chest x-ray. Laboratory results for arterial blood, serum and urine are shown in Box 1. She was transferred to the intensive care unit, where she subsequently developed diabetes insipidus, abnormal liver function, disseminated intravascular coagulation and had ongoing haemodynamic instability. The next day, cerebral computed tomography (CT) scan showed changes in the basal ganglia and mild generalised cerebral swelling consistent with severe hypoxia (Box 2A). A CT scan of her abdomen showed generalised changes in the bowel wall and mesentery consistent with bowel necrosis (Box 2B). Surgical intervention was considered to offer little in view of the severe neurological damage and multiorgan failure. Following extensive discussion with family members, inotropic support was withdrawn and she died soon afterwards. DiscussionSurprisingly, this is the first report of death caused by intravenous misuse of a fentanyl patch, although there have been fatalities after oral ingestion.2 Non-fatal inhalational misuse has been reported.3 In one death (a funeral home employee who obtained a patch from a deceased person in a nursing home), the route of administration was never determined.4 Finally, there is a report of respiratory arrest from intentional intravenous misuse of transdermal fentanyl in a patient with chronic pain.5 Transdermal fentanyl is used in the management of both acute and chronic pain.6 In Australia, it is listed on the Pharmaceutical Benefits Scheme for pain caused by malignant neoplasia, but it has increasingly found a role in the management of chronic non-malignant pain. Durogesic patches are available in four sizes, the smallest designed to deliver 25 μg/h of fentanyl (total 2.5 mg fentanyl), the largest 100 μg/h (total 10 mg fentanyl) (Box 3). Extracting the contents of a patch can lead to a large variation in the dose administered, making a dangerous habit perilous. The pharmacokinetics of fentanyl only add to the danger. Fentanyl is highly lipid-soluble and has a large volume of distribution (60–300 L). A 2 μg/kg dose leads to high immediate serum concentrations (up to 11 ng/mL) that fall rapidly to less than 1 ng/mL after one hour.7 The offset of action is mainly by redistribution. An effective analgesic concentration of fentanyl ranges from 0.3–0.7 ng/mL.8 Serum concentrations in health professionals who died after fentanyl misuse have ranged from 0.1–5 ng/mL,1 in keeping with the average concentration of 3 ng/mL found in a larger series of deaths from fentanyl misuse.9 The serum fentanyl concentration in our case accords with concentrations given in other published cases. The absence of detectable opioid in the urine was consistent with a recent overdose. Alterations to the formulation or presentation of the patch might make it harder to misuse the drug intravenously, although previous experience with temazepam in several countries has shown that such changes are not necessarily the answer. In response to the ease of misuse of temazepam, the pharmaceutical industry produced a gel-filled formulation that would be as "resistant" as possible to injecting. However, it has since been shown that the gel-filled preparation is readily injectable,10 and results in more medical complications, including superficial thrombophlebitis, abscesses and deep venous thrombosis. There are several case reports of ischaemic necrosis of digits resulting from intra-arterial injection of temazepam.11 To date, all reported deaths from misuse of fentanyl patches have been the result of other than intravenous misuse. Prescribers need to be alert to the potential for misuse and the consequent risk of fatality. They need to impress on patients the importance of secure storage of patches. Stricter regulation of fentanyl patches could be enforced by accounting for patches after they have been dispensed (eg, ensuring that, on the death of a patient issued with patches, unused medications are returned). A more draconian measure would be to require that used patches be returned before more can be issued. However, this would not prevent the theft of patches, and would put the onus of returning used patches on patients already suffering from debilitating pain. It is clearly necessary to continue to strictly control the availability and prescribing of these patches, which potentially are a highly sought after product on the black market. However, it is also important to avoid widespread public warning of the risk, which might serve only to advertise a novel activity for risk-takers. 1: Laboratory results in a patient after intravenous misuse of transdermal fentanyl Arterial blood (reference range) pH 6.88 (7.36–7.44) Pco2 62 (36–44) mmHg Po2 170 (85–100 mmHg on room air) Bicarbonate 11.3 (22–26) mmol/L Base excess – 22.6 mmol/L Haemoglobin 114 g/L Serum Paracetamol Negative Salicylate Negative Benzodiazepines Negative Tricyclic antidepressants Negative Fentanyl 2.0 ng/mL Ethanol 0.16 g/L Urine Cannabinoids Negative Opioids Negative Amphetamine Negative 2: Computed tomography (CT) scans A: Brain — arrows indicate areas of low attenuation in basal ganglia. B: Abdomen — arrows show changes consistent with bowel necrosis. 3: Transdermal fentanyl patch Fentanyl, dissolved in ethanol (a flux enhancer) and gelled with hydroxyethyl cellulose, is held in a drug reservoir between a backing layer and a rate-controlling membrane on an adhesive base.

Mark D Reeves MB BS, FANZCA · Corinne J Ginifer MB BS, FACEM

Objective: To assess the practicality of using personal digital assistants (PDAs) for the collection of logbook data, procedural performance data and critical incident reports in anaesthetic trainees.Design: Pilot study.Setting: Two tertiary referral centres (in Victoria and New Zealand) and a large district hospital in Queensland.Participants: Six accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their ANZCA training supervisors.Interventions: Registrars and supervisors underwent initial training for one hour, and supervisors were provided with ongoing support.Main outcome measures: Reliable use of the program, average time for data entry and number of procedures logged.Results: ANZCA trainees reliably enter data into PDAs. The data can be transferred to a central database, where they can be remotely analysed before results are fed back to trainees.Conclusions: This technology can be used to monitor professional performance in ANZCA trainees.

Paul D Bent MB BS, BMedSci · Stephen N Bolsin MB BS, FANZCA · Bernie J Creati MB BS, FANZCA · Andrew J Patrick MB BS, FANZCA · Mark E Colson MB BS, FANZCA

Anaesthesia: a concise handbook. Graham Arthurs. London: Greenwich Medical Media, 2001 ($69.30, ix + 159 pp). ISBN 1 84110 080 3. This pocket-size book aims to bring together helpful information for safe and effective everyday anaesthetic practice. It is based upon the personal notes of the author and is made up of a series of topics organised in alphabetical order. Many pages are devoted to key areas such as airway management, cardiac resuscitation protocols, emergency scenarios and nerve blocks. The range of topics covered is broad. It includes such things as fluid resuscitation through a rectal tube (in the absence of IV access), how to set up tubing for one-lung lavage through a double-lumen endotracheal tube, and even how to manage the situation when penile turgescence limits the ability to pass the cystoscope! It also includes sections on CXR interpretation and management of asthma in the emergency department that would be better suited to a medical handbook. As a result of this breadth, there is often a lack of sufficient detail to make the book seriously worthwhile. Although some of the content relates more to the United Kingdom style of anaesthetic practice (which includes more intensive care), the book does contain some interesting case reports and anecdotes (which are well referenced) and does attempt to emphasise the physiological principles upon which many of our interventions are based. I have several criticisms. The book often fails to emphasise the key points of a topic. For example, the section on the treatment of hyponatraemia recommends the use of hypertonic saline without warning of the dangers of rapid over-correction, and the section on ventilating the asthmatic patient does not consider the issue of dynamic hyperinflation, which can be lethal in these patients. Also, some of the recommended treatments do not reflect contemporary practice (eg, intermittent CO2 inhalation as a treatment for postdural puncture headache). The book is not particularly well organised and is repetitive in places. Some important areas, such as postoperative nausea and vomiting, are given scant attention. Added to this, the “point form” style in which it is written makes it difficult to read. Although good in concept, I would find the book difficult to recommend to anaesthetic trainees or anaesthetists. It lacks sufficient detail to be of real use, has many gaps and describes many procedures or ideas more suited to Third World anaesthesia than current Australian practice. Sesto CairoAnaesthetist, Alfred Hospital Prahran, VIC

Sesto Cairo

To the Editor: Safety is a rather subjective concept, so to use the word without definition, as Clarke et al did,1 is somewhat misleading. One possible definition is that the complication rate for general practitioners is no greater than for anaesthetists in the same circumstances. In the study by Clarke et al,1 the GPs were allocated the lower-risk cases and the anaesthetists were allocated the more difficult ones. Direct comparison was made without any adjustment for this difference. The data suggest that the GPs had similar or higher rates of adverse events or interventions despite handling lower-risk cases. The most recent data on anaesthesia-related mortality reports 20 deaths at endoscopy from 1994–1996, with a note that this is likely to be an underestimate.2 Using the authors' denominator of 430 000 endoscopies per year, an estimated risk of anaesthesia-related death is therefore about 1 in 64 000. The risk of anaesthesia-related death for all surgery is quoted as 1 in 63 000, which implies that anaesthesia for endoscopy is of average risk. The sample size of 28 000 lacks sufficient power to make any comment on safety as regards the risk of death. Although I applaud the clinical standards of the authors' institution and fully agree that propofol has many clinical benefits over other agents, Clarke et al do not prove safety in the use of propofol by non-anaesthetists.

Patricia Mackay · Patrick J Hughes