ANZCA Bulletin - June 2009 - Australian and New Zealand College ...

fellowship affairs featureDiving and Hyperbaric Medicine:Roundtable discussionContinuedAt a purely theoretical level,anaesthetists are best positioned toperform this job. With regard to the actualanaesthetic skills, the sort of generalpurpose anaesthetic skills like intubationand ventilation and the maintenance ofanaesthesia during procedures are possiblyof slightly less relevance. But again, ananaesthetist is a very useful individualto have around the chamber when youare dealing with critically-ill patientspotentially coming down from the intensivecare unit, ventilated with invasive linesand requiring for organ support during thehyperbaric treatment, so I would see thoseas areas of similarity.IM: Diving and hyperbaric medicineitself is actually two rather differentspecialties. Diving medicine involves takingan acutely unwell, acutely injured patientand coming to a differential diagnosisand managing appropriate treatment.Hyperbaric medicine is moreof an ongoing treatment in a very differenttype of population to the divers. Bothareas are quite different to the practiceof anaesthesia. One area of relevance toanaesthesia is in the acute managementof divers, which may involve a complexretrieval process and often anaesthetistsor critical care practitioners are wellversed in retrieval issues.MW: The bulk of our patients havechronic wounds or radiation injuriesthat we’re treating, and a lot of them aremedically quite unwell. Anaesthetists havethe skill of being able to assess people’smedial conditions and make sure that theyare stable and everything’s optimised asfar as medical treatment is concerned,and we can then anticipate their responseto increased atmospheric pressure andgas density. It’s similar to a preoperativeassessment. With respect to Ian’s previouscomment about intensive care patients,there are some units that treat a lot ofintubated ventilated patients. For example,at the Alfred Hospital in Melbourne theyare running some special trauma researchprojects where they actually have a lotof critically ill ICU patients treated intheir chamber. Their chamber is locatednext door to the ICU, and they utilisetheir ICU and anaesthetic registrars quitesignificantly to run the hyperbaric unit.DC: The Alfred would probably be anexception to that rule. Certainly here inHobart I’m the only intensive care specialistin town with an interest in diving andhyperbaric medicine. There’s a moderateamount of further education necessary forme to convince some of my ICU colleaguesof the potential for benefit from hyperbaricoxygen treatment.What opportunity is there forresearch or completing formal projects?DC: There are loads of opportunities; thething that we lack is the time and the moneyto do it. This is a field of medicine that lendsitself to research. There are huge numbersof unanswered questions regardingeverything from basic physiology to cellularbehaviour under hyperbaric conditions.Unfortunately most hyperbaric units arerunning on very small numbers of FTEs sopeople have significant other calls on theirtime which prevent them from doing thissort of research. Also, because hyperbaricoxygen as a drug isn’t patentable, there’svery little industry sponsorship availableto fund these big trials. Although there islots of potential for research there are just acouple of small limiting factors that getin the way at the moment.MW: Having said that, all of ourregistrars have easily been able to completetheir formal projects in their six-monthattachments. There are lots of opportunitiesfor research. There are many internationaltrials running at the moment which it ispossible to join. There’s a lot of theoreticalphysiological work also. One of our localrespiratory physicians is very interestedin using our chamber to look at cellularbehaviour in cystic fibrosis, for example.There are lots of non-hyperbaric medicineapplications available for research andcertainly it’s one of the big areas where a lotof research is currently being done.IM: I would add there is a greatopportunity for anaesthetic registrars tocomplete their formal project requirementfor anaesthetic training. The Diving andHyperbaric Medicine journal of the SouthPacific Underwater Medical Society ishopefully going to be indexed on Medlinevery soon, so a publication in that journalcould be considered for the anaestheticformal project.Has training in diving and hyperbaricmedicine affected your progress inanaesthesia training?IM: I suppose the main issue is timeaway from anaesthetics and practicallygiving anaesthetics. My experience isthat one seems to deskill in anaesthesiaas a trainee very, very quickly so I’m a bitworried about returning to anaesthetics.However, this unit is good in that we gettime off to attend anaesthetic tutorials orto attend theatre during the week. So theremay be a period of deskilling but I think theoverall benefits outweigh that.MW: It’s probably no different to doinga term in emergency medicine or even goingto ICU for a term as far as maintainingclinical anaesthesia skills goes.DC: Likewise with pain medicine.MW: You’re still exposed to patients andyou’re still doing clinical work, you’re justnot actually in theatre putting people off tosleep and waking them up. Although it’s abit of a break away from anaesthesia, I don’tthink it impedes your progress in training.I think it’s just another one of thoseoptional rotational turns that can giveyou a bit of a broader education.DC: I certainly think the majority oftrainees in diving and hyperbaric medicinethat I have seen come through this unitor have met elsewhere have been welladvanced in their training programs. Inmany cases they’re doing it post-part twoexamination and they work it into theirtraining as an elective-type term in theirfellowship. Certainly when I did my firstregistrar rotation here, which was sixmonths, I already had both the intensivecare fellowship and the anaesthetic parttwo examination and I think a lot of othertrainees fit a similar pattern.Has exposure to diving andhyperbaric medicine affected yourfuture career pathway?IM: Okay, well I’ll start with that, beingthe most junior here. This exposure hasgiven me further interest in the area and itmay well be that I attempt to do some divingand hyperbaric medicine as a consultant.38The ANZCA Bulletin June 2009