Monday, June 22, 2015
By Marcelo S Ramos M.D. The physician performs better whenever he (or she) can focus only on the procedure he (or she) is doing on the patient. Well, I admit it seems quite obvious, but I want to stress the point that whenever the physician has to bear with the responsibility of handling an expensive and fragile equipment, he (or she) cannot help to be as worried about the equipment as he (or she) is about the patient.
It happens to any of the novices who get the privilege and the task to train fibreoptic intubation. I can say so, because some years ago I was one of them. My biggest fear was to damage the fibrescope while in my hand, because at that time, I was a novice and any damage would probably be judged as lack of expertise in the use, and would probably not occur in more experienced hands. Damage to the fibrescope in the hands of a master, well it happens, it is an unavoidable consequence of the use. This is true! Any fibrescope (as anything in the world) has a determined useful life span, even when handled only by the best experts. To be fair I have to say that I overused the fibrescope to get my skills much beyond the usual life span of most devices (used for more than 20 years!).
What I want to point out is that I would certainly acquire my skill much faster (and with much less stress) if I never had to consider the price (and fragility) of the device I was using. If the scope is supposed to be discarded after use, I would be more confident as a novice. I am not a novice any more now if the device happens to break in my hands probably nobody will say it was misuse, but a consequence of normal use. However, this does not take the entire burden of responsibility for the equipment from my shoulders.
If the physician knows that the device is only a (disposable) tool that will be discarded regardless if he (or she) was successful (or not) in the intubation, the performance would be better, because all the responsibility shifts from the use of the equipment to the decision to use a scope. That is the reason why I defend the point of view that the residents and novices in endoscopic techniques should train with disposable flexible endoscopes only, as the AMBU a-scope in any of its versions.
If it is cost effective (or not) to choose a disposable device over a reusable device multiple factors need to be addressed. If the hospital is private, everything including the most improbable items are disposable, in order to charge either the patient or the insurance company. The (private) hospital makes money using disposable items and every effort is directed to the use of disposable items with the somehow shameful, (and sometimes clearly made up) "excuse" of "avoiding infection". On the other hand, when the hospital is public, nothing is disposable, even the items in which it is more than proven that the disposable material is clearly cost effective. Public hospitals stick to the reusable devices, even wasting scarce resources.
The cost effective balance of the disposable endoscope will depend on many factors, and the number of intubations per month is just (a minor) one of them. The costs of maintenance and repair of endoscopes is subject to variations according to the commercial agreement between manufacturer and hospital. (It may even be free, depending on the commercial agreement of the endoscopy department; or may be included in the maintenance with a fixed cost for the whole "fleet" of endoscopes of the hospital; or it may be huge, almost as high as, and sometimes higher than the price of a new device).
I am not concerned about the question if it is "money wise" (or not) to buy disposable or reusable endoscopes. My opinion is about the well-being of the physician, who would be much more comfortable using a disposable device, and more focused on the primary target (the patient), if the eventual burden (or phantom) of the expensive cost of the repair of a piece of equipment is not over his (or her) head when performing an already difficult task. It is better for the doctor who performs the task, not to be aware or concerned about the cost of a repair of the equipment in case of damage. Indirectly the use of a disposable endoscope is also better for the patient, because the doctor will perform better.
I recently read an interesting publication (Anaesthesia 2015, 70, 699–706) that made a cost comparison between disposable and reusable endoscopes for intubation, but this is a study that is irrelevant for other realities different from the reality of the British hospital in which the study was done (as is the case for both the hospitals in which I work).
Usually costs are considered negligible when related to reprocessing of the reusable endoscopes for intubation (in terms of either personnel or the equipment used for reprocessing). The hospital will have to reprocess all the GI endoscopes anyway, since there are no (at least AMBU did not make it yet) disposable gastro/colono/duodenoscopes.
In the public hospital in which I work this is the reality. It may be different in the private hospitals. Here, the use of disposable flexible endoscopes for intubations could even be profitable.
Marcelo S Ramos,
Hospital Universitário - Universidade de São Paulo
Cancer Center A. C. Camargo - São Paulo - S. P. Brazil
Reflections over the disposable versus reusable flexible endoscopes