Anaesthesia in the Southern Hemisphere − an Australian Perspective

There are many differences between the way Americans and Australians train for and practice anesthesiology. There are also many cultural and language differences even though we do speak English. You would be surprised at the number of people who comment on my excellent English, they think it is a second language for me!

After undergraduate training of five-to-seven years, depending on the University, we routinely have three-to-five years of general hospital work as residents rotating through multiple specialties. A training position in Australia is referred to as a “registrar” (which is the equivalent of a resident here). The training period is for five years and then the registrar may obtain attending status. There are two barrier exams. One exam must be passed prior to year three of training and covers physiology and pharmacology. The second exam must be passed in the fourth year of training and covers all clinical aspects of anaesthesia. This exam is comprised of a three-hour multiple-choice paper, a three-hour short-answer paper, and 12 Viva (oral) exams. The Viva’s are held over one-and-a-half days and are given in groups of four at a time, each lasting for 20 minutes. Nine of these are anaesthesia-based scenarios, one involves interpretation of test results (any investigation is fair game), and two involve patient assessment with real patients being examined by an internist and an anaesthesiologist. The cases vary from congenital heart problems, valve lesions, and rheumatoid arthritis, to brittle diabetics—anything is fair game. I saw only the second case of dextrocardia in my life during my anaesthesia clinicals! For most people in Australia, it takes from 8 to 10 years after graduation from the university to qualify as an attending. During the course of one’s training approximately 7,500 to 10,000 anaesthetics are given.

There are no nurse anaesthetists in Australia. Hence, we are not referred to as anaesthesiologists but as anaesthetists, as there is no one else to confuse us with. We routinely work with an anaesthetic technician (one per room) and usually staff only one room at a time, although in teaching hospitals this may be extended to two rooms if there is a senior attending in the next room. The attending, therefore, stays for the entire case.

The health system is different than in America, Australia being a partly socialized system with universal health coverage for all citizens. It is funded by a 1.75% deduction from all workers salaries. The public hospital system is well developed and all the teaching hospitals and major centres are public. They are the place to go if you are really sick. The private hospital system is needed to complement the public system. Mostly elective surgical and acute/chronic medical patients are cared for in the private system. It is a very efficient surgical system. People can elect to be privately insured for a yearly fee. The main differences in being a private or public patient are in two areas: choice of physician and length of wait for elective surgery.

In general, things are pretty much the same as far as anaesthesia is concerned. We tend to use generic names for drugs and some drugs available here are not available in Australia, such as etomidate, sufentanil, and IV diltiazem. Attendings are employed either directly by the public hospitals as staff specialists or contract as visiting medical officers (VMO). VMOs work in the private system as well as in the public system, while the staff specialists do not. VMOs are mobile workforces who are able to respond to changes in needs in both the public and private systems as demands change. It is not uncommon for VMOs to work at more than one hospital. I was routinely working at eight different hospitals prior to my stay here in America, (three were public and five were private hospitals).

Now for Some Tidbits

Although we are part of the Commonwealth of Nations, Britain has absolutely no influence on Australian politics. The Queen does remain the Head of State but in reality has no power. There is a move at present to change our constitution to become a republic.
The direction of flow of water down the plug hole is a random event although there are some that would argue that it always goes down the other way to the Northern Hemisphere.
Kangaroos, although common in the bush, are not seen hopping down the main streets of the cities. They are considered a pest by farmers and are often shot.
Australia has a land mass almost equivalent to the United States, but a population of only 19 million, of which 90% live on or near the coastline. We do, however, have about 250 million sheep.
We drive on the correct side of the road (the left) with the driver in the right-hand seat of the car. The pedals of the Australian cars are similarly arranged as American cars, but the turn signal is on the opposite side of the steering wheel (the right side). Allegedly, Henry Ford, in an attempt to patent his mass-produced motor car, moved the driver to the left as opposed to the middle or the right of the car so he could claim his vehicle was different enough to have exclusive patent rights. I could be incorrect about this and I am happy to be informed if this is not the case!
From Detroit Metropolitan Airport it takes approximately 17-and-a-half hours to fly to Sydney (excluding time in transit). LA to Sydney is non-stop and about 13 hours. Airfares vary and range from U.S. $1,000-2,000.
One U.S. dollar buys about $1.57 Australian at today’s rates.
Australia is a very multicultural society. The largest Greek city in the world outside Athens is in Melbourne. We have large numbers of Italian, Middle Eastern, European, and Asian immigrants. Just about any type of food can be obtained in the larger cities due to this mix. It’s a gastronomic delight.
The Aborigines were the original inhabitants of Australia. They have the longest documented culture in the world with artifacts and paintings dating back 40,000 years. Unfortunately, they were not treated well by the settlers in 1788 during the establishment of the first white penal colony in Botany Bay. There remain many unresolved issues with respect to land rites and discrimination.
Australia is unfortunate in having many species of venomous creatures, both on land and in the sea, including 38 terrestrial snakes and 23 sea snakes, 22 spiders, four ants, the honey bee, three wasps, two beetles(!), six scorpions, two caterpillars, and various centipedes, millipedes, mosquitoes, sand flies, thrips and other insects. The platypus and echidna both have venomous defense systems.
In the coastal waters there are two blue-ringed octopi, seven jellyfish, cone shells, two stone fish, 21 other fishes including the flathead, the Port Jackson shark, 11 rays, starfish including the crown of thorns, corals, anemonies, urchins, stinging sponges, marine worms, leeches, frogs and toads.
As far as snakes go, Australia is home to the 10 most lethal in the world, and of the world’s top 25 venomous snakes, Australia has 21. The diamond-backed rattlesnake is ranked number 25 in the world, with the Indian cobra and black mamba 12th and 13th, respectively!
The white pointers and tiger sharks, although not venomous, do have a nasty bite!
Australia has some very unique animals, mostly marsupials (pouched mammals). We have the only two monotremes in the world—The Platypus and the Echidna. A monotreme is an egg-laying mammal and both are also potentially poisonous. Contrary to its colloquial name, a Koala is NOT a bear-it is a marsupial. The wombat is interesting in that its pouch opens towards the rear instead of towards the front as all other marsupials do. This adaptation stops the pouch from filling with dirt as the animal burrows building its home.
Due to the vast distances and isolation of some Australian communities, the Reverend John Flynn established the Royal Flying Doctor Service (RFDS). This was the first air medical service in the world and relied for communication on a pedal-powered radio. Families would have a chest of medicines which were coded and a diagnosis was made by radio and treatment prescribed. If needed, patients were medevaced out. The service still operates today on the same basic principles but obviously with a lot more sophistication. A side arm of the RFDS is the flying obstetric service based in Roma, Queensland, that will bring an anesthesiologist and obstetrician by plane to most parts of the outback with ancillary staff and equipment to do a crash C-Section just about anywhere. Australia also has a very well developed school of the air, for education, which has been enhanced significantly by the power of Internet services.
Australians are not all like Crocodile Dundee (although we all think we would like to be) and we do not all drive Subaru Foresters. Fosters is not the most popular beer, in fact it is much more popular overseas than at home. Each state has a predominant local beer.
Australia has varying laws from state-to-state regarding drinking and driving. In New South Wales we have some of the toughest laws in the world. The limit is 0.05 for drivers of at least two year’s experience and 0.00 for younger drivers. We have random breath testing by which the police can pull you over for no reason and breath test you. They also set up roadblocks and pull all drivers over. The penalties are severe and have contributed to a large reduction of morbidity and mortality from road trauma.

Scenery and lifestyle are brilliant in Australia. It is certainly worth a vacation there maybe even a 12-month appointment!