Dr Tony Behrman, Medicolegal and Business Consultant at Medical Protection further warns about the increased risks patients and colleagues now face due to increased load shedding. 

I have 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 eight hours of power per day we need to mitigate the risks inherent in this new situation.

A recent Daily Daily Maverick article demonstrates the many challenges healthcare workers, particularly in those in the state sector, are now facing in the course of their daily duties.

Here are some further ways it will impact patients, doctors, and hospitals both private and public, and advice on how to mitigate risks.

Communication failures between doctors, patients, and other healthcare providers

Patients in need of urgent attention are now in a disturbing position, as they may be unable to fully charge their cell phones due to prolonged 4-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, cell phones are now unreliable – even if charged – because of competition on the local high rise cellular masts. The power storages which back up the masts cannot take the intermittent outages and as they fail, calls drop, cell 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 a variety of reasons related to poor service delivery, or may have fallen prey to cable theft.

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 cell phone 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.

Patient’s datafiles and the internet may not be accessible 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 which 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 that 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

Prior to 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 1 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 that 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 which it can deliver every hour for four hours.

The following items are used on an hourly basis in a practice:

While the above figures are approximate and illustrative only, as your own systems may differ, collectively this list adds up to over 1,700 watts per hour and we have just 180 watts per hour available from one lead calcium battery. You will therefore need multiples of one battery.

Problems with recharging batteries

Lead calcium batteries take between eight and 12 hours to fully recharge and then need a few hours to cool down. Unfortunately, the current 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 it becomes unreliable.

It is not unknown for the batteries to fail internally, with one or two of their cells becoming unreliable and 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 therefore required to monitor your systems which must be professionally set up to industry standards, lest your short-term insurance repudiates a claim. Advise your insurance broker that you have an inverter on site 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 set you back R16,000.00 plus VAT.

Lithium-ion batteries are more reliable, last far longer but are far more costly with a lithium system costing upwards of R25,000.00 and peaking at well over R60,000.00 plus VAT, depending on how extensive your requirements are. Lithium batteries also bear a fire risk. Remember that you cannot use your old lead battery inverter to charge lithium batteries. You also cannot 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.

How to approach risk in state and private medicine when faced with electrical uncertainties and constraints

As we have only recently moved into Stage 6 – and prior to that the deterioration in the availability of power has been more gradual – MPS has experienced a limited number of medicolegal cases where load shedding has been a critical aspect. There is also often a delay between an incident occurring, and a claim being made. 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 healthcare professionals on steps which may help to prevent foreseeable risks and problems.

A healthcare professional 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 always paramount and it is 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 judgement when all the parameters including reliable power sources are considered.

No colleague should go against genuine warnings of incipient danger to the continuity of the current power supply, unless faced with a life-threatening situation. It goes without saying that 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 at that facility.

The average base-load generators in the hospitals consume 2000 litres of diesel per 24-hour day when running. Currently the cost of diesel is in the region of R22.00 per litre x 20 working days per month (leaving out weekends) equals R 880,000.00 per month, per hospital.

Should it be necessary to run during Stage 6, which is one four hour period and two,  two hour periods (that is 8 hours out of 24 or 33%) this represents an extra running cost to each hospital of just shy of R290,000 per month. Some of the hospital chains with 40 to 50 hospitals, are looking at unbudgeted costs of over R14 million 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 unsuspecting patients. Cold cases may need to be cancelled at short notice or postponed, and even semi-urgent cases may require triage and referral.

Once 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 be at the cost of 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

Should diesel go into short supply and the matter become one for the Provincial Disaster Management teams, a totally 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 should diesel be nationalised, then certain key points will be attended to as a priority over others, and one may 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 sterilization production, chaos at intersections when traffic lights are out, and a possible new Covid-19 subvariant, all points to the need for awareness of personal stress management techniques and potentially counselling.

We would encourage members to utilise our 24/7 independent and confidential confidential counselling service service which is a benefit of membership. Members are also encouraged to contact MPS for advice if unsure of their medicolegal risk when it comes to managing the impact of load shedding in their chosen avenue of medicine.