Paediatric anaesthesia — who should do it?

Without wishing unduly to prolong this correspondence, may we be allowed to reply to Dr McNicol's response to our letter. We have no doubt that, as McNicol says, change to paediatric anaesthetic services is possible when there is a will to carry it out. What we doubt is whether the changes proposed would improve paediatric services and we do not accept that there is evidence to support this assertion. Perhaps we did not make our point clear enough about the problem with a designated paediatric anaesthetist; Dr McNicol seems to have missed it. Yes, you could transfer all sick children (supposing enough referral beds could be provided). We have no problem with this principle, though we do have doubts about whether the system could cope with the numbers. Our point, however, is: who will treat the child until he/she is stable enough for transfer and who will do the transfer (in what kind of partially monitored ambulance)? And, realistically, who will treat the patient when there is no room to transfer? One of the anaesthetists other than the designated paediatric anaesthetist, deskilled by lack of recent experience? We then have just the situation we would seek to prevent: the least experienced dealing with the sickest, in an acute emergency. We do not think McNicol has addressed this point. We are taken to task for going back to the references and forming our own opinions. We felt it our duty, when the potential results of a course of action are so bizarre, so to do; this is the only way to avoid the sort of repetition of opinion which results in speculation being treated as fact. McNicol states that it is not true that, as we state, Atwell & Spargo [1] contains no UK anaesthesia source other than NCEPOD 89 [2]. We stand by this, as the only other UK reference, Bowhay & Morgan-Hughes [3], contains only throughput data, not outcomes and is thus of no relevance to the debate as to quality. We dismiss the non-UK data, not out of hand, but because their comparability cannot be established; it is known, for example, in another field, orthopaedics, that the average operator in the USA replaces 10 hips a year, whilst here the average is over 100. We therefore believe that extreme caution is necessary in transferring conclusions from other countries to the UK. The conditions are potentially very different and when the conclusions from these sources are used to oust UK data, we do not find this acceptable. McNicol believes that surgical disasters can be prevented by better anaesthetic cover and we cannot ‘wash our hands’ of surgical deaths. But what can we do about them, when, as is often the case, we do not even know of these patients' existence? More to the point, why should we be using the existence of surgical deaths to justify re-organisation of anaesthetic services? It would not make any difference and it does not make sense. We do not think McNicol can overcome the fact that there is little or no evidence to support the proposed major reorganisation of anaesthetic services and that what evidence there is is insufficient to justify the likely seriously deleterious outcome. We wonder whether his anxiety for a solution has clouded his judgement, but suggest that sometimes it is necessary to recognise that, whilst the situation is imperfect, everything else is worse.