Anaesthesia Gets Safer and More Selective – Dr Fred Muller’s 30 years of insight

In recognition of National Anaesthesia Day on October 17, Northland District Health Board is raising awareness of the role of anaesthetists and regional anaesthesia.

In November, anaesthetist Dr Fred Muller is retiring from Northland District Health Board. Fred talked about changes in the role of anaesthetists over three decades at Whangarei Hospital.

Dr Fred Muller qualified as an anaesthetist in Bloemfontein, South Africa, and entered private practice in Durban in 1979. He first became interested in New Zealand after meeting a GP from Natal who had had a great experience working in Whanganui and, in a roundabout way, made contact with Dr John Swinney, who was head anaesthetist at the time.

“I got into a catch-22 situation at first –  the hospital said we’ll give you a job if you get residency – but the government said we’ll give you residency if you get a job!” Fred says.

At the time, NZ and South Africa both offered world-class medical facilities – but the clincher was that visiting NZ to assess the situation in Whangarei coincided with the opportunity for Fred to see Bob Dylan performing at Mt Smart Stadium.

“I came out in February 1986 and John showed me around the hospital. I used the opportunity to also assess schools and house prices as there were strict exchange controls in place in South Africa for emigrants.

“My wife wanted me to pick Auckland [to settle in] because our one year old daughter was diagnosed as profoundly deaf while I was in NZ and she thought there would be more support there. But Whangarei was more rural, had more affordable housing and fewer traffic hassles.  Further, the hospital offered us temporary accommodation in West End Avenue at a nominal rate.”

“So in a way, Bob Dylan had an effect on where we ended up living – and I did get to see him at Mt Smart.”

Fred said NZ hospital standards have always followed or been on par with Australia, Canada and Britain and fresh interns from other countries always bring new ideas.

In the 1980s – when ‘putting people to sleep’ was the prevailing conception of what anaesthesia could and should do – the barbiturate Sodium Thiopentone (Pentothal) was most often used. “It  would make people groggy and sick for hours afterwards,” Fred says. “We now have the general anaesthetic propofol (Diprivan) which is a big improvement in that patients awake clear-headed and are much less likely to be nauseous.”

Another major development was the arrival of the laryngeal mask airway (LMA) meaning direct vision wasn’t necessarily needed to secure the patient’s airway.

“LMAs became common practice in the 1990s. Propofol and LMA became used together [because] you couldn’t easily use the LMA with Thiopentone.”

“The downside has, however, been a reduction in our skill with endotracheal intubation which, in turn, has led to the arrival of more ‘toys’ in the form of video laryngoscopes and flexible bronchoscopes,” Fred says.

Anaesthetists are increasingly performing ultrasound-assisted procedures. “With these devices we can directly observe the needle tip in relation to muscles, nerves and blood vessels and can observe the anaesthetic injection, verifying its correct placement.”

“You would almost be bordering on negligence if you didn’t use ultrasound for some procedures these days.”

The growing acceptant of epidurals (the injection of anaesthetic superficial to the dura membrane enveloping nerve roots) are another aspect Fred has seen change.

“When I was training, the default approach for a Caesarean section would be a general anaesthetic;  now it’s more common to do an epidural or spinal anaesthetic.  I have found that most mothers prefer to be awake and bond early on with their newborn [by taking advantage of an epidural.]”

Fred has dealt with an average of six to 10 patients per day over the years.

The role of the anaesthetist has undergone changes, Fred says. “Initially our contact time with patients was more limited. Nowadays we are seen as peri-operative physicians establishing, for example, nurse-led Pre-operative Assessment Clinics.

They guide patients to complete a questionnaire and can channel more complex cases to ourselves at the daily specialist-led clinic at which we establish a rapport with patients and their whānau and can initiate referrals to other specialities such as cardiology and haematology. Patients most commonly are admitted on the day of surgery whereas the previous practice was to have to come into hospital the day before.

“The peri-operative journey is now more user-friendly and we endeavour to minimise cancellations on the day of surgery. Patients are required to give informed consent to procedures and anaesthesia and this process facilitates that.”

“Another innovation has been the Pain Team. We document the anaesthetic and procedure and initiate post-operative pain management. The daily pain round enables the regimen to be reviewed and, if warranted, tweaked to optimise patients’ comfort, recovery and mobilisation.” Fred stressed that technicians and secretaries help keep the anaesthetic department coherent. “The latter have the unenviable task of trying to keep a collection of disparate clinicians reasonably happy.”

The skills required in the Post-Anaesthetic Care Unit (PACU) have also changed significantly and the PACU team diligently manage patients’ awakening, airways, local anaesthetic infusions, blood pressures and pain scores.

“In the past the recovery room was little more than somewhere for patients to ‘sleep it off,’” Fred says.

Fred agrees National Anaesthesia Day is successfully correcting misconceptions about the role of anaesthetists and fewer patients express surprise when hearing that an anaesthetist has undergone as rigorous and lengthy a training as any surgeon.

“I did a basic medical degree which was six years long, then an intern and senior intern year, then anaesthesia specialisation was another four years – so 11-12 years all up.”

“Patients’ feedback is that they have found National Anaesthesia Day very informative. They are now less apprehensive about anaesthesia.  The public is becoming more aware of what we can do to lessen the likelihood of complications.”

Dr Fred Muller

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