Part 1/2: Non-Operating Room Anaesthesia – Creating a safer environment

Thank you to GE HealthCare for sponsoring this podcast.

Dr Krish Radhakrishna: Welcome to this podcast on Non-operating Room Anesthesia. Nora is a frequently used acronym for Non-operating Room Anesthesia to indicate that anesthesia is administered in a setup that is different from traditional theaters. These areas may be situated in other parts of the hospitals and very often far removed from the main theater complex. Increasing number of patients in different age groups are done here and for a variety of procedures. In this podcast, we will be talking to doctors with considerable experience in the field to learn more about this subject. Our focus is to identify issues that may arise and how we can make NORA a safe place for delivering care. I'm Dr Krish Radhakrishna. I'm a consultant anesthetist in the University of Coventry and Warwickshire, and I'll be in charge in this session. I'm going to start with two of our speakers initially. One, Dr. Nazia Khan, who works in London, and Dr. Richie Marcus, who works in a pediatric hospital in Birmingham. The factors that are coming to play in these two areas are very similar, but the age group they are dealing with are different. It'll be interesting to see how this works.

Dr Krish Radhakrishna: I'm going to start off with Dr. Nazia Khan, who did her anesthetic training in the East of England university before completing a fellowship in MSI in perioperative medicine at University College of London. She then joined Geis and St. Thomas as a consultant anesthetist, where she developed a special interest in the interventional radiology and pre-assessment, going on to become clinical lead for pre-assessment. I will now introduce my second speaker, Dr Richie Jan Marcus, who is a consultant anesthetist at the Birmingham Children's Hospital since April 2001. Today, he'll be talking to us on Nora in a pediatric setup. Welcome to you, Richie. I would like to start with you, Nazia. First of all, Nora is a very significant area of speciality where different specialities meet and complex challenges arise. Could you please outline the setup in your hospital where you work? I'm looking at how far it is, how well connected it is to the main theaters, just the setup so that how easy it is for you to access emergency backup if you need it.

Dr. Nazia Khan: Thank you so much for inviting me, Krish. Well, Krish, I think the first challenge that I have in my trust is that we're already on two different sites. We have Guys Hospital and we have St. Thomas's Hospital. We have Nora being practiced across all the sites. We have the Lane Fox Unit, which is respiratory long-term wean. We of course also have interventional radiology, endoscopy, dental, and they're all quite far away from theaters. I would say probably interventional radiology at St. Thomas is the closest to theaters, but things like the Dental Suite is on the 23rd floor of the tower wing, a completely different set of lifts to the rest of the hospital. Distance is certainly a big issue for Nora care in my trust, Certainly. But I think one of the things that we've implemented is having designated anesthetic leads for each of these sites so that we have someone who is championing good standard practices and trying to have standardization across all the different Nora sites and being that link between their team and the anesthetic team.

Dr Krish Radhakrishna: Come back to you with the same question. I'm trying to understand the layout in the Birmingham Children's Hospital, where I know hypoxia occurs very quickly and you have less time, and some of the babies you deal with are always more complex than some of the adults we deal with. Could you highlight some of the issues that you have in your setup?

Dr. Ritchie Jan Marcus: Yeah, well, thank you for inviting me. And yes, we have quite an extensive set of out-of-theater operating suites. We're lucky in that our cardiac cath lab is in one of our main operating theater suites, but we also perform anesthesia in a number of other sites. In our radiology department, which is two floors down from our main operating theater suite, we anesthesize in both CT scanner, two MRI scanners, an international radiology suite and in nuclear medicine. We also have a 3T MRI scanner that's a standalone unit further away. We also have a standalone endoscopy suite and a separate oncology procedures room, and that's in another block, again, two floors down from another of our operating theater suites. We also have some off-site work. We undertake pediatric radiotherapy at the Adult Queen Elizabeth Hospital, which is about three miles away. And we also provide services to Birmingham Dental Hospital, which is also three miles away. What we've managed to do in terms of making our service a bit safer is we do have a consultant who is free of other commitments during the day who we can call on should we need help. Yeah.

Dr Krish Radhakrishna: So are we looking at traveling by car between sites or are they all walkable distances in Birmingham's children?

Dr. Ritchie Jan Marcus: Within the hospital, they're all walkable within three or four minutes. But the two off-site hospitals hospitals we use are a car journey away. The Queen Elizabeth Hospital, the radio therapy is in one of the departments there, so it is part of a big adult hospital, whereas the Birmingham Dental Hospital is a completely stand-alone dental theater on a site where there's no other health care other than dentistry.

Dr Krish Radhakrishna: Yes, that could be quite challenging because I have experience of that in North Wales, where I used to travel 40 minutes to a dental clinic, where I used to do dental chairs in those days, which is not often done. But you both, in a way, hinted towards the problems that you have. But when you are dealing with such a complex situation as a consultant, What are your priorities when you're working in such an area? When you go to work in one of these remote areas, how do you go about ensuring safety? Nazia?

Dr. Nazia Khan: I think for me, over the years that I've worked, I think preparation is key for me, actually. It's trying to preempt any issues I think I'll have with these patients in advance, which has been a challenge, certainly in my area is interventional radiology. But having regular staff there has meant that communication is easier, and so they can highlight these patients to us in advance, and therefore we can do the due diligence that is needed or the workforce or staff, additional staff that may be needed or the equipment like OptiFlow or vibroactive scopes and things. I think certainly for me, putting my efforts into the pre-assessment side and working with the nurses in pre-assessment in IR to try and also build up their assessment style and making sure that they're getting the right information has been a big part of tackling these high-risk patients I feel, in these areas.

Dr Krish Radhakrishna: What about you, Richie?

Dr. Ritchie Jan Marcus: I think you can almost go back a couple of steps from that. I think some of it is how you set up the areas to start with. We've certainly found that the areas where anesthesia has not been involved in setting up the area we find slightly harder to work in because the logistics aren't quite as good as if we'd been involved from an early stage. But also how as a department, you equip the areas and basically treat them like an operating theater. So across pretty much all the areas, we have the same anesthetic machines that we have and the same monitoring that we have in our operating theaters, apart from places like MR, where we have to use a slightly older anesthetic machine because there isn't one of the same format yet that is MRI conditional. We make sure that we have a number of safety boxes for untoward incidents like anaphylaxis, arrhythmias, MH, and we make sure that in the outlying areas, they either have one or have access to one within two or three minutes walking distance for someone to collect if we need it. And I'd also agree, actually, preparation, knowing what's coming is very helpful.

And also, like Nazia said, again, if you can have a set of regular staff in those areas, it does make life a lot easier.

Dr Krish Radhakrishna: Yeah. So is there sufficient backup? I know, generally, hospitals have the on-call teams who get very busy, depending on, I'm sure in Birmingham's children, it would be very busy. And similarly in London, the on-call team are always in the theater and quite busy. So when a crisis occurs, now, as you said, you have a dedicated person who is actually free to attend. But do you have a similar backup set up in pediatrics in Birmingham?

Dr. Ritchie Jan Marcus: So we have what we call our admin consultant of the day, who is free of clinical commitments, and they are available if they're not being used somewhere else, obviously, to come and help. And I think generally, when you're working outside the operating theater, there's no pride involved. And if you need an extra pair of hands, it's much easier to get that person down to help you at the start of the case rather than wait for a problem to happen. Some of the other problems we find in some of the isolated areas is the mobile phone reception can be quite poor, and therefore, actually just getting someone to phone the admin person can be difficult sometimes. So, yeah, I'd say if you think there's going to be a problem, get a pair of hands down before you start.

Dr Krish Radhakrishna: Yes. Have them in the complex before you actually start the anesthetic, which is a good way to do it. Another thing is the teams that you work with. I know from my personal experience that when I go to do a remote anesthesia in an area which is different, I often get teams that are new there. I have always argued for a dedicated team who do that all the time because they provide the continuity of service. In the radiology suite, if you have somebody who does anesthesia or healthy anesthetists, the same team comes in, it's a lot easier to work. I wonder if you have the issues of differing team members on different days that makes you create quite an issue of communication and preparation?

Dr Nazia Khan: I think certainly in our Trust, I think we're quite lucky in that way that a lot of the Nora areas do have the same team or similar teams. I can definitely see the benefit When I first started, I didn't have a regular anesthetist or any one. Having the regular anesthetist has really ironed out a lot of issues and problems and has made the list much more smooth running. But the person who does change often is actually our ODP. You can see a big difference when you have ODPs that are familiar with the area. They can also guide you a little bit sometimes. If you're new to the area, sometimes when I go to endoscopy and I haven't been there in a while, a familiar ODP who does work there all the time can really guide me, and I really value their input. So definitely, I think workforce and having regular team does make things safer. And I've seen that over the six or years that I've been down in IR.

Dr Krish Radhakrishna: And about you, Richie?

Dr Ritchie Jan Marcus: So, yes, we vary between the two areas. So the more high-risk areas, such as the Cardiac Cath Lab and the IR suite, we do tend to have, we certainly have dedicated theater staff in there, and we do have dedicated ODPs if they're on duty that day. And the same applies in the radiology suite that we have two regular ODPs. And it's definitely if you get someone else, you notice the list doesn't run quite as smoothly as if they're present. The oncology procedures and endoscopy tends to be any one in terms of ODPs and anesthetists. And And the off-site stuff, again, it is small teams that go and do that, who do it regularly. The only thing I would say is that we do have to be able to provide some out-of-hours service in some of these areas as well, even if it's not that common. So having exposure of your on-call team OPs to those areas can make things easier for when you have to go there out of hours. And I think there's a a little bit of a balance between making sure that you train your on-call ODP staff in those areas against having the regular team there during the week.

Dr Krish Radhakrishna: And Nazia, how do you How do you deal with who checklist and team briefing in these areas when you go? Is it as effective as in traditional status?

Dr Nazia Khan: I think definitely. I have to say in IR, The way we do team briefing is actually we've got two IR rooms and we team brief together, so the whole unit team briefs. And that's actually very beneficial, I find, because then we can understand what's happening in each room and we can support each other. There is a lot of changes to our list during the day because we also have to cope with the emergency work that comes in. It's trying to ensure that we're getting through all our patients safely and not letting too much downtime of theaters. But in terms of in other places, I think Team Brief is done. There's probably not as much emphasis on it or not as much importance of it, particularly in endoscopy. But I do think certainly having Team Brief just allows, especially people who are new to the area, that opportunity to just understand what their team is, what the goals is of that day, and what the issues they think could be of the day. And similarly with the WHO checklist, and we've gone digital in our trust, so the WHO checklist has to be completed for patients who are having any anaesthetic-led care.

Dr Nazia Khan: So making that mandatory, I think, again, just adds that safety profile for when things are a bit unfamiliar to people.

Dr Krish Radhakrishna: Yeah, that's interesting that certain areas cannot do briefing very well. And is that because of culture? It requires a cultural change for certain people in certain specialities to participate in it? Is that is something that has to come from higher level and made mandatory?

Dr Nazia Khan: I think definitely Nora areas, because they do a lot of mixture of work where sometimes they don't need team briefings or they manage their practice without team briefing, then to do it for sometimes and not do it for other times, I think that's perhaps where the cultural importance isn't there. But I think it's better overall to introduce, to have team briefing as a must, almost, so that people then embed it into their culture, and then they don't also perceive it as a barrier to time. I think sometimes people think, Oh, it will take too long. But once you start doing it and you realize the importance and the value, you realize that, one, it doesn't take that long And actually it's worth it the time that you do spend. But yes, I do think it's something that probably needs both the culture shift from bottom up and from top down.

Dr Krish Radhakrishna: Yeah. Thank you, Nazia. Richie, do you have similar problems on the pediatric side? Are they more diligent in Birmingham?

Dr Ritchie Jan Marcus: I think on the whole, we're pretty diligent about doing team briefs. In radiology, sometimes we don't include the radiologist, but we definitely We have a radiographer present. And certainly for MRI, that can be very useful because if we've picked up that the child might have cardiac implants or other implants that will be an issue with going in the MRI scanner, that can be sorted out before the child actually arrives. And I think also having a specific time out for the area you're working in is also helpful. For example, like you say, in interventional radiology or in cardiology cath lab, you'll have a radiographer present and plus or minus a cardiology technician, and they are part of the team and they have things to say as well. And again, in MRI, there are clearly certain things that have to be gone through that are not part of a normal timeout checklist, for example, the MRI safety stuff, and to check whether there are any additional procedures that may need doing outside the MRI scanner, like blood taking or EUA teeth or something like that, that quite often get added.

Dr Krish Radhakrishna: I think Nazia and Richie, both of you have highlighted many of the challenges that people who come to work in these areas face, not only US anesthetists, the surgeons, the nursing staff, and everybody is facing similar issues, and they have to work together as a team to get the best, do the best for the patient. In fact, we do. A large number of patients do very, very well, and these are carried out very well in most parts of the country. But it is known from publications and what has been said in various research in the peer-reviewed journals, that there's a higher incidence of mortality and morbidity associated with Nora. We have already discussed some of these factors, like the location, the distance, the equipment, teams. Are there any other factors that contribute to these higher figures in non-operating room anesthesia? Ritchie?

Dr Ritchie Jan Marcus: I think having read some of these articles, I think what you have to bear in mind is the patients and procedures that you're doing in these areas as well, as often these are high-risk procedures in often unwell patients, especially in IR suites, in the hepatology endoscopy lists, and in the cardiac cath lab. And certainly when we've looked at our own cardiac arrest rates within the hospital, the cardiac cath lab is significantly higher than anywhere else. So I would put high-risk procedures in certain areas and high-risk patients as a big factor there, whereas some other areas like the oncology day unit and the endoscopy suite for gastroendoscopes, I think a pretty low risk on the whole.

Dr Krish Radhakrishna: Do you have, Nazia, to contribute to the discussion or you agree with Richie, mostly?

Dr Nazia Khan: I definitely agree. Rightly said, NAP7 identifier We've identified that, particularly in radiology, though it was at 1.7% of the caseload, the number of reports for cardiac arrest was 2.7%, and their mortality figures were significantly higher than their average. There has to be something to it. Certainly, we do, of course, get all the bleeding patients for embolization, NIR, we get PE patients, sick patients coming down, sick patients. There certainly is an element of just the cohort patients that come. But I do think the higher mortality figures that that seven certainly reported, I think there is more to it than that. I do think that some of it is not because it's not all about the patients that are emergency patients. Some of those cardiac arrests were in elective cases as well, I'm sure. Those patients we can't explain away by just the nature, there was more to it. I think that's certainly probably an element of that is unfamiliarity with their environment. Also knowing how to utilize your team. Ir is a good example. I had a area rest from anaphylaxis. Actually, I leaned on them for vascular access to put the art line, center line in to take bloods and gasses and things like that.

I knew how to utilize my team, but I don't think that's obvious to people who don't regularly work down there, that they can lean on them in that way. That's just one example. I know DIP Trust in the country that are getting radiographers or the nurse radiologist to run the cardiac rest. They have them in IR, so that then the IR consultant can then finish that embolization, for example, that they've got on table. It's also about upskilling our staff so that when there is a critical incident or a cardiac arrest, we all feel more confident to run them and to try and get the patient through safely.

Dr Krish Radhakrishna: Yeah, I agree with that. Do you think Protocol. Richie, you have done a lot of work there, and you, Nazia. When you have done all this work, is it worth designing a protocol to guide those who take over from you in the future? Do you have protocols and guidelines that you use in your trust?

Dr Nazia Khan: In terms of being lead for the IR, I don't think we have protocols such. We do have some guidelines, more guidance for people who come new into it. I think one thing that I've tried very hard to do is get a network going between anesthetists, both in my trust and in other trusts, to make more collaborative efforts, make it appear more enjoyable or sexy in a way, so people are more drawn to actually being involved in these Nora areas than they previously would have done. I've used that approach as opposed to having more protocol or guidance for any successor that I have. I feel networking is very valuable, I think, to try and promote more people into the NeuraPractice.

Dr Krish Radhakrishna: Do you think, Nazia, that you are doing more and more non-operating room anesthesia than you did before? Are they on the increase?

Dr Nazia Khan: We're definitely increasing at Our Trust, previously, anesthetic lists were three times a week in IR, for example, and now they're every single day. Similarly, endoscopy is always requesting more and more time from anesthesia, so we're definitely doing a more. The other issue that I think we face, and I think we all face, is that they're more high risk, these patients, and the data definitely shows that. Certainly in Our Trust, the number of ASA1, for example, went from 25 to just 15%, which means the ASA2s and 3s have all increased. An ASA3s went from 35 to 40%, 45%. That's a big jump in numbers. We do about 5,000 cases a year in IR, for example. So that is a big jump in numbers of high-risk patients. So the volume is increasing and the complexity is definitely increasing. And what they can deliver is also increasing. So they're offering these procedures to more high-risk patients as well, where previously perhaps they wouldn't.

Dr Krish Radhakrishna: Richie, would you like to add to that?

Dr Ritchie Jan Marcus: Yeah, I think in terms of the amount of work we're doing, I had a look at what goes on within the Children's Hospital in Birmingham itself, excluding the off-site workings, and probably 30% of the anesthetic minutes, if you like, or 30 minutes, are now Nora cases. It's probably increasing slowly. We've certainly had an increase in interventional radiology, and there's certainly been a lack of interventional radiology for pediatrics across the country, and we've managed now to get quite a stable, robust service up and running. In terms of passing things on, I think as a department, for the cardiac anesthetists, we're all on a WhatsApp group. We talk regularly. Those who do IR are often from the We live a group of anesthetists, and they talk quite regularly. And the others, we're regularly talking and getting advice from colleagues when we need it. There's little protocolisation, I would say on the whole, mainly because it's quite a varied... Apart from maybe the radiology with MR and CT, the procedures we're doing are quite varied, and it's quite difficult to protocolize a lot of it. I think one of the things that did come out of the recent NAP report was championing the use of arterial access more in the cardiac catheter lab for high-risk cases, and that's something we're probably going to have to take on board.

Dr Krish Radhakrishna: That's interesting to know. And also, we looked at all the factors here. You looked about the stopping We looked about the stopping, we looked about the patient selection, the tasks that we have to do here. So we looked at all the factors that affect systems engineering initiative for patient safety. If you use that acronym, CEEPS, too. We almost touched on everything there. But one thing that we have to look at is the environment we're working, because some of these areas have huge equipment, and often the anesthetist is often pushed to your corner somewhere in that complex room, and that in itself puts a lot of pressure on us. Then from that point, we have to access emergency medication or emergency kit that may not be as easily accessible as we do in traditional theaters. Would you like to say something about that, Richie, and then Nazia?

Dr Ritchie Jan Marcus: Yeah, certainly. I think I'll go back to one of the first points I made, which is it's really helpful if Anesthesia can be involved in the setting up of the facilities so that these things are... Our role is considered. For example, in our cath lab, we have a drug cabinet behind us with all the emergency drugs in so we can immediately access it. However, when we're in the interventional radiology suite, we're isolated away from the anesthetic room and there isn't a drug cupboard available. So little things like that can really affect how you work. The other thing we found very useful when we did have to move our cardiac cath lab down into the interventional radiology suite was just doing some dry runs of how the room would be set up and how we would manage any arrests that happened in there. And that did prove to be very useful. I think the final thing I would say, again, is sometimes when you're in a corner, unless you've thought about it, sometimes you can't actually see the screens that the radiologist see in the IR suite and in cath lab. And again, if that's not been considered in how the lab is set up, then there has to be some later alterations to the room so that you can actually get a view of what's going on.

Dr Nazia Khan: I can definitely echo Ritchie's point about being involved from the start because you can really tell when an anesthetist hasn't been involved from the start when it comes to planning a room. Certainly, our endoscopy suite is fantastic for the endoscopists, but for us, it's very difficult to even access the airway when they are there with their very large monitor. I certainly find myself frequently in IR moving my anesthetic machine and trying to optimize the ergonomics of the area so that I have got a clear view of everything, of the access to the airway, and also enough room for, of course, the interventional radiologist to do their part. The environment is definitely makes a big, big difference. Anytime it's not ergonomically right for us, I think it does impact our our processes. And then it just adds a little bit of almost strain to the whole environment. It's those human factors that start to come into play when we can't see things exactly the way we want, or we're not able to sit in front of the screen the way that AAGBI, for example, recommend. You do see that it starts to cause

Dr Krish Radhakrishna: You mentioned human factors. One particular issue is knowing the names of the different team members and giving very clear, closed-loop communication is not possible sometimes.

Some people are just throwing information in the air and nobody knows who it is targeted at. Often it occurs because people do not know the name. Some people have wear name badges. In our hospital, we wear hats that have names, which makes it easier. Have you thought about these issues? Do you have anything like that to help people know you by name and be able to communicate more effectively?

Dr Nazia Khan: I'm quite loud and boisterous at work. I think everyone knows me by name, certainly, and I are. But I think we certainly benefit from the fact that we have regular staff. But yes, sometimes, of course, there are people that are new coming in, and we don't have any specific name band or more than the usual. But I do think actually it would be really useful to have hats, for example, that have everyone's name on it. Or actually, again, just investing in team brief and spending that little bit of time to ensure we've introduced everybody and everybody has heard everyone else's name so that then later, if there is an issue, you can actually call people by name. I think there are the processes there, but it's just about investing our time in making sure they work for us.

Dr Krish Radhakrishna: Do you do have anything like that? Identify people. Name, badges.

Dr Ritchie Jan Marcus: No, we don't Currently, most of the theater staff do wear badges. We tend not to. I think one of my colleagues is thinking about investing in hats with our names on it. We do introduce everyone at Team Brief, and it's useful when we have a regular team. I mean, I now, I'm getting older. It takes at least three times for someone to tell me their name before I remember it now if it's someone new. So yes, maybe some prompts would help me.

Dr Krish Radhakrishna: Yeah, it makes a difference now that the names are there. People just call you by name. I tell you one incident where in cardiac status, the person doing the procedures said, Heparin 5,000, and I reached out for Heparin. Then I realized he was actually talking to the other person to give 5,000. If you had not named the person, there would have been 10,000 units of heparin going in. This communication is very important. You say, Look, I want you to give 5,000. They say, Yes, you want me to give 5,000. That closed loop, which is a very important thing in human factor. Sometimes it doesn't happen in a noisy atmosphere and lots of noise of the machines and people. That, I think, is an important aspect of safety that people have to invest on. It's simple but effective. We are almost towards the end, but I have a couple of questions for you. Ritchie, would you like to share a critical incident that you had that you probably learned from and you changed the system? I would like you, Nazia, also to come out with some incident that you shared.

Dr Ritchie Jan Marcus: I think there's a couple of things. I mean, if you're talking about a serious incident, I'd already talked about having a dry run for when we moved the cath lab down to the interventional radiology suite, but I ended up anaesthesising a neonate down there for a ductal stent for duct dependent congenital heart disease. And unfortunately, when they deployed the stent, it managed to kink the duct. The saturations went down to about 20% and the baby arrested. And because we'd done all the planning and we'd had all the trial runs, we were able to just establish ECLS within within 50 minutes. And the child had a good outcome from that, having later gone on to theater to have a BT shunt done. So that's one example where actually just the pre-planning of a move enabled us to do that. And some other little incidents I think are worth talking about. No matter how much you try in MRI to exclude all metal items, once we took a patient in for an MRI head, and just as the child was being moved into the scanner, into the projectile zone, there was a loud bang that startled both me and the radiographer, and we realized that the 5P piece had been secreted down this child's plaster of Paris on their leg, and when they got into the scanner, that flew out and hit the scanner.

Dr Ritchie Jan Marcus: So I don't think there's anything you could do about that. And then I think one final anecdote from MRI, which is not really a critical incident as such, but I think shows some of the problems you can have, is we admit some patients direct to radiology, scan them and send them home from recovery in radiology. And this child had come from an MRI head with a family who were involved in health care. I can't exactly remember what they were involved in, but we anesthetized the child. They had an enormous brain tumor with raised intracranial pressure and hydrocephalus. And we had to go to the parents afterwards and say, look, we would like you to stay here. You can't go home at the moment because we need to talk to the neurosurgeons. And then, of course, they want an explanation of why that is. And the radiologist had to come and explain to them that they'd found something bad on the scan. So in that diagnostic part of the hospital, you do very occasionally have to deal with these difficult issues with parents as well. So I think those would be a taste of some of the incidents and experiences I've had in the last few years.

Dr Krish Radhakrishna: Very fascinating. You need to be on your toes, I was saying, Richie. You have to think on the spot sometimes, however well-prepared you are. That's when your experience comes to your aid sometimes. Nazia, any interesting incidents you have faced?

Dr Nazia Khan: Well, I think when I first started as a consultant, I was anesthesizing a patient and ended up having anaphylacrystoic bronium. I was new, new blue-eye to it all. We managed fine, but it was because actually I had a fantastic ODP, and she really helped me. Together as a team, we delivered good care to that patient. But one thing we did do then afterwards is have an anaphylaxis box on the anesthetic machine, so that's ready to go if it was to happen again. To rock your own, as you know, does happen every so often. Another story that I did, again, What I found quite challenging was that I was in IR at Guys, and it really is on another part of the building, and this patient was having this hyperpneumic peri-arrest there. We put out the and they just didn't know where IR was. It comes back to your very first point about location. It took them 20 minutes to eventually find where IR is in Guys because they just didn't have a clue. And so now we're doing as what Richie did earlier is of having dry runs of starting to do high fidelity in-situ simulation training and including the Recess team as well, so that we can hopefully get from people more familiar with the location and familiar with any critical incidents as that may happen.

Dr Krish Radhakrishna: That's fascinating. Richie and Nazia, thank you for sharing your experiences. One, what I would like to have people go away with is a positive image of it. The work here is challenging, but it is something that requires a lot of input and experience, and it's gradually getting better and better thanks to people like yourself who put in so much effort into it. What is the advice Richie for you to the organization? And Nazia, what is the advice from you to the individuals who take up non-operating room anesthesia? I would like to start with Richie. What is your advice you would give to the organization so they can make it better?

Dr Krish Radhakrishna: I agree.

Dr Ritchie Jan Marcus: So the main bit of advice I would give is, involve anesthesia from the start when you're planning any services. That would be my biggest bit of advice.

Dr Krish Radhakrishna: I agree. Totally. I totally agree. Nazia, what about the individuals, the young consultant who's... One of his job plan is anesthesia for people going for MRI or endoscopy. What advice would you give him?

Dr Nazia Khan: It's a tricky question, I actually have to say, but I think the advice I would give is that you're only going get out what you put in. If you want something to be better, then you need to put in the time and the effort to make it better. It can get better, and I've seen it get better. Actually, if you invest your time as a regular anesthetist in these areas, those challenges will go away to a degree, and it will be better, and you will be more enjoyable. I think a final point that I would probably say to any consultant who asked me about IR, for example, is that the reason I continue six years in is because actually every week I do that list, it's always a different list. Every case is different. That does keep me on my toes, and it does keep me enjoying avoid in the cases. That's the pleasure that I get, and I think other young consultants could get it, that no one, two lists are alike in any of these areas, I'd say. Those perhaps are my two pieces of advice.

Dr Krish Radhakrishna: Yes, excellent. This has been such a wonderful talk. Talking to you, we've learned so much. This brings us to the end of the podcast. Thank you indeed.

Thank you to GE HealthCare for sponsoring this podcast.