I enjoyed reading this letter but am curious as to the legal basis and evidence for the statement that 'anaesthetists who use U/S without formal training for cannulation could leave themselves open to litigation if a critical incident occurs' and also the basis for the statement that 'those who do not use U/S for cannulation are legally vulnerable in view of the NICE recommendations'.

Have these opinions been obtained from a recognised legal source or are the authors themselves legally qualified and, therefore, fit to make these statements or are these statements merely the personal views of the authors? Are the authors aware of any legal matters arising from either lack of formal training or the non use of an U/S machine in attempting to cannulate a central vein?  

Should the authors have these sources, could they please document and reference them in 'Anaesthesia'.

C. Greenhalgh

Consultant Anaesthetist,

Glasgow Royal Infirmary

Thank you for your interest in our letter and for highlighting the important issue regarding the legal position for anaesthetists. Our opinions are based on information gathered from the Medical Defence Union (MDU) advisory services and from the guidelines published by the Royal College of Radiologists (RCR). Regarding the use of ultrasound without formal training, the MDU advice was that 'they would need to be able to justify that they had met the standards expected of a registered medical practitioner’ and ‘they were competent and had sufficient training to carry out a procedure'. However, this may be difficult to prove in view of the lack of guidance in this area. Furthermore, the Royal College of Radiologists states that 'all those who provide an ultrasound service are ethically and legally vulnerable if they have not been adequately trained' [1]. They also state that 'NHS trusts in the UK, which provide professional indemnity to practitioners, are unlikely to be able to mount any defence to an action brought against an untrained practitioner’. 

If an anaesthetist does not follow the NICE guidelines [2] by using ultrasound for central venous cannulation when one is available, and has a complication, the MDU advisory service states that 'the Bolam principle has not been replaced by guidelines, but these may shape what is reasonable practice over a period of time’ and ‘furthermore it is necessary to justify acting within or without an authoritative guideline (for example, from an organization such as NICE) on a case by case basis’. In other words we have to have a good reason why we have not followed the NICE guidelines to mount a successful defence.

We are not personally aware of any legal matters arising from either lack of formal training or the non-use of an ultrasound machine in attempting to cannulate a central vein. However, Scott [3] reported three cases where civil actions for damages were being sought as a result of not using ultrasound guidance after 'inadvertent arterial cannulation with central venous catheters’. He states ‘the cost of the cases were likely to approach £500 000’.

N. Harris

University Hospital of Wales

Cardiff

References

1.        Royal College of Radiologists. Ultrasound training for medical and surgical specialties. www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf. (accessed 8/6/09)

2.        NICE. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology Appraisal Guidance No. 49. September 2002. NICE, London

3.        Scott DHT. ‘In the country of the blind, the one-eyed man is king' Erasmus (1466-1536). British Journal of Anaesthesia 1999; 82: 820-1.