Dr Tony Behrman, medicolegal and business consultant at Medical Protection Society (MPS), has previously warned about the potential difficulties we may face from ever longer periods of load shedding.
With Stage 6 rolling blackouts and its resultant loss of up to 8 hour of power per day we need to mitigate the risks inherent in this new situation, he writes.
Numerous articles demonstrates the many challenges faced by healthcare workers, particularly those in the state sector, in the course of their daily duties.
Here are some further impacts on patients, doctors, and hospitals both private and public, and advice on how to mitigate those.
Communication failures between doctors, patients, and other healthcare providers
Patients needing urgent attention may be unable to fully charge cellphones due to four-hour load sheds and hence have difficulty contacting the appropriate healthcare facility. Emergency call centres may become severely pressurised, to the point of becoming dysfunctional.
Worse, however, cellphones are now unreliable – even if charged – because of competition on the local high rise cellular masts. The power storages backing up the masts cannot take the intermittent outages and as they fail, calls drop, phones compete with one another for place on the remaining masts, and communications fail.
Patients connected to fixed line Telkom may be able to use their lines, but many have surrendered them for various reasons.
Private doctors on call are also in a difficult and unenviable position in that many cannot receive distress calls or make outgoing calls. Almost as frustrating, calls which are successfully made are often dropped, or interrupted with a different person’s call intervening, making not only the availability, but also the confidentiality of a medical call, questionable.
Always place a clear message on your cellphone or other answering device indicating that if you do not respond within a set time, it could be because their message did not reach you.
Doctors in large state institutions are equally affected unless within the immediate precinct of the hospital.
Patients' datafiles and the internet may be inaccessible and home devices used for life support may also become compromised, including nebulisers, CPAP machines, oxygen generators, fridges for temperature sensitive medication etc.
Family doctors and specialists in private stand-alone practice
It is now only possible to run a private practice if it has back up power from either multiple Uninterruptible Power Sources (UPS)s, from an inverter feeding a bank of batteries, or by using a petrol or diesel generator.
The Occupational Health and Safety (OHS) Act dictates you must provide safe lighting to common areas and emergency exits unless you are in rented accommodation, where this would be the landlord’s duty.
Clearly, you should also provide power for patient comfort, e.g. multiple lighting sources, a cooling device in extreme heat, a fridge for cold chain, and power to run the business side of your practices.
Back up batteries and an inverter
Before the Stage 6 load shedding, the easiest choice was to install one or more back up deep cycle lead calcium batteries, fed by an inverter. An average battery can store and then deliver 100 amp per hour at 12 volts. This should deliver a net 720 watts per battery, for one hour, after consideration is given to the conversion inefficiencies in the system of approximately minus 40%.
This sounds like a lot of electricity until you realise a kettle requires 2000 watts. Remember too that this is the TOTAL energy able to be delivered by that single battery and not the amount it can deliver hourly for four hours.
The following items are used on an hourly basis in a practice:
• An average incandescent light bulb draws 60 watts (replace these with LEDS at 7 watts per hour) and if you have 10 of these = 600 watts.
• Circular fans draw 50 watts, and you may need two or three for summer months = 150 watts per hour.
• Computer printers cause a huge initial surge when they start print ing(and can pull as much as 1800 watts in a sudden surge), then settle at 30 watts hourly.
• TV screens run at various wattages but an average older colour TV draws 150 watts per hour: substantially less for an LED screen. (Try not to operate your practice TV during load shedding)
• Cold water dispensers use 100 watts per hour
• Laptops pull up to 100 watts per hour; your desktop PC uses 450 watts per hour.
• A fridge can use as much as 220 watts per hour depending on size.
• Phone chargers pull seven to 15 watts per hour.
While the above figures are approximate, as your own systems may differ, collectively this list adds up to more than 1 700 watts per hour and we have just 180 watts per hour available from one lead calcium battery. So you will need multiples of one battery.
Problems with recharging batteries
Lead calcium batteries take between eight and 12 hours to fully recharge, and need several hours to cool down. Unfortunately, the load shedding schedule results in them being discharged before they are fully recharged, so the average lead calcium battery, under the rolling blackout Stage 6 regime of load shedding, will not last more than two years before becoming unreliable.
Sometimes the batteries fail internally, with one or two of their cells being unable to charge. The inverter, however ,continues to push current into the failed cells, which can heat up critically, possibly release hydrogen gas, and either burst, ignite, or even explode.
Maximum vigilance is required to monitor your systems which must be professionally set up to industry standards, lest your short-term insurance repudiates a claim. Tell your insurance broker you have an inverter and ask whether there is an exclusion or extra premium.
Cost
Cost is a huge factor. Currently a pure sine wave inverter and two lead calcium C20 batteries can cost R16 000.00 plus VAT.
Lithium-ion batteries are more reliable, last longer but are far more costly, a lithium system costing upwards of R25 000.00 and peaking amore than rR60,000.00 plus VAT, depending on your requirements. Lithium batteries also bear a fire risk. You cannot use your old lead battery inverter to charge lithium batteries, or use water to extinguish a lithium battery fire.
Medical aid increases seem to have ignored this when offering increases below CPI for 2023.
Doctors in non-hospital medical centres and shopping centres, should prepare for rental increases as landlords may seek to recoup the costs of these alternative sources of power.
Risk in state, private medicine, when faced with electrical uncertainties and constraints
MPS has experienced a limited number of medico-legal cases where load shedding has been a critical aspect. There is also often a delay between an incident, and a claim. We continue to monitor the situation closely and any claim would be assessed on a case-by-case basis.
Our focus now remains on advising which steps may prevent foreseeable risks and problems.
You will be assessed by the court against what steps a "reasonable healthcare professional" would have undertaken under similar circumstances.
Close cooperation between senior, junior, and administrative staff is paramount and even more essential when faced with limited power resources.
Clear chains of command must be set up. No one, from the most junior to the most senior, should pressurise or be pressurised to perform any procedure against their better judgment when all of the parameters, including reliable power sources, are considered.
No colleague should ignore genuine warnings of incipient danger to the continuity of the current power supply, unless faced with a life-threatening situation. Financial considerations must be secondary to patient safety.
Colleagues should be regularly updated at meetings with management on the maintenance schedules of all emergency electrical generation equipment, the backup power available, response times of the various backup modalities and the reliability of diesel supply to, and quantum of diesel stock on hand.
The average base-load generators in hospitals consume 2000 litres of diesel per 24-hour day when running.
Currently the cost of diesel averages about R22.00 per litre x 20 working days per month (leaving out weekends) equals R 880 000.00 per month, per hospital.
If necessary to run during Stage 6, which is one four-hour period and two two-hour periods (or eight hours out of 24 or 33%) this represents an extra running cost to each hospital of just under R290 000 per month.
Some chains with 40 to 50 hospitals are facing unbudgeted costs of more than R14m per month per large hospital group.
This will undoubtedly filter through to the end users as the medical aid schemes have already set their pricing for 2023.
Load shedding and patient consent
Doctors should consider the need to incorporate load shedding into their consent procedures and explain the possibilities to patients. Cold cases may need to be cancelled at short notice or postponed, and even semi-urgent cases may require triage and referral.
Again, healthcare professionals will be assessed by the court against what steps a "reasonable healthcare professional" would have undertaken in similar circumstances.
Sensitive equipment in MRI scanners, CT scanners, anaesthetic equipment, pathology laboratory equipment, incubators and ICUs etc – all of which depend on reliable sources of power – may outstrip their UPS, inverter and finally diesel power supply. This could affect patient’s lives and/or thousands in wasted or spoiled tests/scans, or going into millions to replace critically damaged equipment.
Diesel as a critical resource
If diesel goes into short supply and the matter become one for the Provincial Disaster Management teams, a different scenario may unfold. The WCDOH is well prepared for this eventuality with their own diesel tankers and close liaison with both the state and private hospitals, however, if diesel is nationalised, then certain key points will be attended to as a priority over others. We my see enhanced forms of triage and referral to only certain hub hospitals where the diesel may need to be prioritised.
General comments
Cold chain interruptions and resultant adulteration of food, vaccines, pathology specimens, pharmaceuticals, sewage pump failures, sterile procedures under threat due to lack of steam sterilisation production, chaos at intersections when traffic lights are out, and a possible new Covid-19 sub-variant, all point to the need for awareness of personal stress management techniques and potentially, counselling.
We encourage members to use our 24/7 independent and confidential counselling service, a benefit of membership. Members are also encouraged to contact MPS for advice if unsure of their medico-legal risk when it comes to managing the impact of load shedding.
See more from MedicalBrief archives:
Coping with power outages – advice for healthcare professionals
How to navigate medico-legal matters in healthcare practice
MPS launches research initiative to improve patient safety, clinician well-being
How to manage frustration from working in resource-constrained institutions