A young woman tragically died recently after a cosmetic operation carried out at a beauty clinic. Manslaughter charges have been brought against the practitioner, who allegedly has qualifications obtained overseas but was not registered to practise in Australia.
The Australian and New Zealand College of Anaesthetists, the Royal Australian College of Surgeons and state ministers are examining the regulations around who can deliver sedation and general anaesthesia, and the licensing of using high dose local anaesthesia.
Who can legally deliver anaesthetics?
The Australian and New Zealand College of Anaesthetists is the body responsible for the teaching, training and licensing of specialist anaesthetists who are referred to as “fellows”. Specialist anaesthetists have a medical degree, and undergo extensive further training to be qualified to administer anaesthetics.
For many doctors, certification as a specialist anaesthetist is the culmination of more than a decade of examination, full-time training and dedication to the safe practice of anaesthesia and sedation. Specialist anaesthetists practise in many different environments, and not just the operating theatre.
GPs can also receive special training to administer anaesthesia to low risk patients in remote and rural areas, a vital service.
Sedation and local anaesthesia are also frequently used in emergency departments and intensive care units, delivered by doctors who are specialists in areas such as emergency or intensive care medicine. They are trained in anaesthesia with skill sets in airway management and resuscitation. These doctors work in safe environments, and in highly trained teams of nurses and other health professionals.
The Australian and New Zealand College of Anaesthetists has several guidelines, specifying a code of conduct. These include the responsibilities and skills necessary for a medical practitioner to give sedation, criteria for the location in which the anaesthesia is to be administered, patient selection, drug selection, and availability of emergency equipment. These are endorsed by multiple other professional bodies and colleges.
The practitioner in the recent case in Australia was allegedly practising contrary to state regulations, with credentials not recognised in Australia. This may not be uncommon, and is challenging to regulate until disaster occurs.
How do these disasters occur?
General anaesthesia and sedation are very safe in Australia when the drugs are administered by doctors with training in pharmacology, airway management and resuscitation. But there are gaps in the regulation, particularly around “sedation” and local anaesthesia, which have been under scrutiny by some groups for some time.
Dentistry and cosmetic surgery are two areas that may be vulnerable to these loopholes. The Australian Health Practitioners Regulation Agency has a guide for dentists on administration of intravenous sedation. This is when a drug, usually an anti-anxiety drug, is administered for a dental procedure where the patient stays awake.
The document excludes general anaethesia as dentists are not expected to put patients to sleep during procedures. For intravenous anaesthesia they must have another health-care practitioner present, who may be a nurse. Regulations and licensing of sites varies from state to state, and patient selection and drug dosage are key features of safe practice of this type of sedation.
The regulators of dental sedation and beauty clinics haven’t endorsed the Australian and New Zealand College of Anaesthetists’s guidelines, meaning there are loopholes that can be exploited by dodgy practitioners.
This means a lot of things can happen that are outside the margins of safety, but may not come to light until there is a disaster. Because these loopholes exist in the law, what these practitioners are doing may not be illegal, although unsafe.
There’s a fine balance, which varies greatly between patients, in the margin of safety and effectiveness for the drugs we use to sedate and desensitise patients. Loss of consciousness, and therefore loss of protective reflexes, can occur rapidly and unexpectedly. This takes many years of training and experience to get right.
Cosmetic surgery is currently under fierce debate in Australia as it falls outside the regulations of the college of surgeons. As the recent case highlights, there are practitioners who are not following the codes of conduct proposed by the regulatory bodies.
This is complicated by a lack of availability (or possibly feasibility) of “appropriate training” outside what is offered by the college of anaesthetists, and the somewhat unpredictable nature of the drugs, especially in inexperienced hands.
How can you be sure you’re in safe hands when going under?
Professor David A. Scott, the current president of the college of anaesthetists recommends patients choose the location of their surgery wisely - particularly if you’re elderly or have other disease.
Ask the doctor administering the sedation if they have the necessary qualifications and training to do so - and check if they’re on Australia’s list of medical practitioners overseen by the Australian Health Practitioner Regulation Agency.
And we should all make some noise to make sure the government enshrines these regulations in legislation. Until then there will be loopholes for unscrupulous practitioners to use to circumvent the guidelines, compromising safety.