Emergency physicians: additional providers of emergency anaesthesia?

I read with interest the editorial ‘Emergency physicians: additional providers of emergency anaesthesia?’ (Lockey 57: 629–31). As a UK trained SpR currently working in an Australian teaching hospital, I feel I have some insight into anaesthetic department and emergency department (ED) led emergency anaesthesia. In the UK, the emergency stabilisation of a patient requiring intubation and ventilation within the emergency department most frequently falls to the anaesthetist (generalist or intensivist). In a few departments where ED trainees have had some anaesthetic training and are encouraged to perform rapid sequence induction, the ongoing management in the UK will usually fall to the anaesthetist, which, as pointed out in the Editorial, can be wholly unsatisfactory. In Australia, the management of the patient requiring intubation and ventilation is usually undertaken by ED doctors, and is continued by them until the patient is either admitted to the ICU or undergoes the necessary surgical procedure. This practice is helpful, as an experienced anaesthetist is not tied up with the inevitable delay of theatre work. However, intubation and ventilation are not all that is required. The emergency doctors are unable to stay with the ventilated patient, whose ongoing monitoring falls to the nursing staff, while the doctors attend other patients. ED nursing staff are not ICU nurses, and are not trained in this area. An inadequately sedated patient may not be obvious to them, especially when muscle relaxants have been used, and inadequate sedation may only become apparent when a trained anaesthetist sees the patient. The only request to date for my attendance to the emergency department in Australia for early airway management was following the recent Bali bombing. On this occasion, three patients with serious burns, including to the face and airway, were admitted in rapid succession. It was clear that the department was set up for managing the airway problems. All necessary drugs were ready for use and I suspect this was because they do this all the time. Our expertise was sought because of anticipated problems, but a team approach certainly made a potentially stressful situation run remarkably smoothly. In short, there aren't enough doctors in either department alone to address emergency department anaesthesia. However, with support from the anaesthetic department and with training of emergency doctors and nurses in the care of the critically ill anaesthetised patients, I believe that we can go a long way to improving patient care in this situation. H. Vlachtsis Royal Perth Hospital, Perth 6847, Western Australia E-mail: hvlachtsis@hotmail.com