Anaesthesia
News
No. 254 September 2008
The Newsletter of the Association of Anaesthetists of Great Britain and Ireland.
ISSN 0959-2962
GAT in
Liverpool – report
“Real anaesthetists treat
more than one species”
21 Portland Place, London W1B 1PY, Tel: 020 7631 1650, Fax: 020 7631 4352, Email: [email protected], Website: www.aagbi.org
Anaesthesia News September 2008 Issue 254 1
2
Anaesthesia News September 2008 Issue 254
Contents
Real
anaesthetists
treat more than one
species:
Part one
03Real anaesthetists treat more than
one species: Part one
06 President’s report
08Guest Editorial - Welcome to
‘The Class of 08’
10Gat Page - “Welcome aboard the
Liner Hotel" Report of the GAT ASM
2008
16 Dear Editor…
18The History page - Thomas Beddoes
and his Gas Factory
22NAP4 - The 4th National Audit
Project of the Royal College of
Anaesthetists: Major Complications
of Airway Management in the
United Kingdom
Jonathan Cracknell BVMS CertVA
CertZooMed MRCVS
Zoological Society of London
25 Peter Baskett memorial service
I am a veterinarian. More specifically: a
zoo and wildlife veterinarian. I recently
read an article in Anaesthesia News on
primate anaesthesia and on discussing
with the editor the finer points of the
techniques used I have been invited
to write an article on “A day in the life
of…” covering the work that I perform.
I thought how dull would that be.
Morning meetings, look over a few
fences, review some import legislation
and quarantine regulations for the new
Giant Anteater that is coming into
the collection and then look at some
faeces to ensure my new anti-helmintic
programme was working as I hoped. It
isn’t all about getting out my big gun and
firing off rounds of anaesthetic loaded
darts like some sort of terminator-esque
clincian spouting “I’ll be back” whilst I
sort out a vehicle for the meerkat to go
back to the theatre. I then thought what
would interest a human anaesthetist?
Hmmm, most of my experiences
of GAT and having anaesthetists
visit my place of work has
consisted of, “Can we see
the elephant endotracheal
tube?”
which,
when
produced, results in much
Anaesthesia News September 2008 Issue 254
25 Anaesthesia Aphorisms
27 Dr.Ruxton
28Committee Focus - Members’
Wellbeing Section now online
picture taking and childish glee. That’s
not something that I can reproduce
in text (although there are pictures to
sate your appetite). So I considered the
best way to approach this was to look
at some of the methods we employ to
anaesthetise the animals in our care,
which include all of the taxonomic
groups: our patients range from ants to
elephants. As an American colleague
of mine once said, “ Real doctors treat
more then one species”. I feel that this is
a little harsh and may relate to his failed
entrance to medical school, settling for
veterinary medicine instead, but there
is some truth in his statement when
applied to veterinary anaesthetists!
The first and most unlikely group to
start with would be the invertebrates,
a group with a huge amount of
variety. Generally there is little that
needs to be done under anaesthesia
The Association of Anaesthetists of Great Britain
and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Website: www.aagbi.org
Anaesthesia News
Editor: Hilary Aitken
Assistant Editors: Iain Wilson, Mike Wee and
Val Bythell
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McCormick Creative Ltd,
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Email: [email protected]
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of Great Britain and Ireland
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3
Cross section of the ET
tube: these provide much
merriment for human
anaesthetists!
except injured or sick patients being euthanased and
assessed by a pathologist. However with large arachnids
becoming popular and expensive there are increasing
numbers of clinical procedures that require anaesthesia.
Taking tarantulas as an example, anaesthesia is
required to examine the mouth for the presence of a
zoonotic nematode (Panagrolaimidae family). Volatile
anaesthetics can easily be used with the spider being
placed into a suitably sized container to act as an
induction chamber. To maintain the spider for longer
procedures a small face mask can be used with a latex
glove placed over the opening, a small hole is made in
this and the opisthosoma (abdomen) is inserted through
with the legs and head free for examination (figure 4).
The reason this works is that insects and arachnids have
spiracles or book lungs that are located on the ventral
aspect of the abdomen. When looking at the large shed
skins you can see these structures quite clearly.
Other challenges within this group include land and
aquatic invertebrates, and consideration even for
molluscs where a hefty dose of cyclohexamine usually
does the trick. Cephalopods such as the octopus can
be anaesthetised with aquatic anaesthetic agents
including magnesium chloride or ethanol. Rebreathing
systems can be used utilising a pump that recycles the
water across the gills using a system of drip tubing. A
similar example of this will be discussed with the next
taxonomic group: the fish.
Like invertebrates the fish are a massively diverse group
ranging from the small to the large (whale sharks can
weigh up to 13,000kg), and from fresh water to salt
water. These are probably the two major issues when
selecting anaesthetic modalities for fish, apart from the
most obvious problem that they live in water and do not
breathe air. Fish husbandry and anaesthesia is all about
controlling the physiological parameters and quality
of the water; any changes in water quality are rapidly
reflected (through the gills) in the animal and therefore
monitoring of the aquatic environment is equally
important, if not more so, than monitoring the patients
themselves. In fish that are large enough, injectable
agents can be used for induction. Both the intramuscular
and the intravenous route can be used. Alpha-2agonists, cyclohexamines and benzodiazepines have all
been reported. However the doses required, especially
for intramuscular injection, are often much higher
when compared to the higher vertebrates. For instance
ketamine in rainbow trout is used at a dose of 130-150mg/
kg and has a reported duration of only 20 minutes. A
4
Above: Invertebrates are popular pets and more
is expected from veterinarians when they are
presented with medical concerns. Here a Redkneed tarantula is undergoing fluid therapy.
Anaesthesia can be maintained using a facemask placed over the abdomen where the
“book lungs” are located, leaving the head and legs available for procedures.
Anaesthesia News September 2008 Issue 254
much easier technique for more manageablesized species that can be put in a bucket or small
tank is the use of aquatic-borne agents. There are
many available but the only licensed agent in
the UK and USA is Tricaine methane sulfonate
or MS222 to its friends. Generally it is extremely
safe but its potency increases in soft, warm water
and in young fish. It is difficult to maintain a
uniform depth of anaesthesia with this agent as it
slowly crosses the blood brain barrier and brain
concentrations continue to increase even after the
blood level has equilibrated with the water level.
MS222 is taken up across the gills which are one
of the most efficient gas exchange systems on
the planet: this is logical when you think about
it, as they are required to extract respiratory gases
from water where concentrations are often low.
When anaesthetising a fish there are two main
techniques: (i) add the MS222 to a bucket of the
fish’s own water, when anaesthetised the fish can
be removed for a brief period to enable blood
sampling, skin scrapes for parasites, or for another
basic diagnostic modality, or (ii) where procedures
require a longer anaesthetic time (e.g. surgery) then
a rebreathing system can be set up which consists
of a range of bags of different concentrations of
MS222; a drip line is placed into the mouth and the
anaesthetic solution is passed across the gills, with
concentrations being changed as depth changes
are required; much like changing the infusion
rate on a syringe pump or changing the inspired
concentration on a vaporiser. With both techniques
recovery is achieved by placing the fish back into
a tank of anaesthetic-free water. If opercular (gill
slit covering) movement has stopped then CPR
consists of treating the fish like a toy car and driving
it through the fresh water tank: the forced flow of
water through the mouth and across the gills not
only hastens the excretion of the anaesthetic agent
(equivalent to IPPV driving off inhaled gases) but
a l s o
increases
the heart rate
via a complex
reflex
system.
Something to be
remembered
when
undertaking
piscine
surgery is that fish do not
have eyelids, so surgery is
often best performed in the dark
with a small light on the surgical
area only as this vastly reduces the
level of stimulation and therefore the
amount of anaesthetic solution required.
It is an interesting experience conducting
surgery and anaesthesia in the dark with
water flowing over the operating site and very
close to all the electronic monitoring apparatus.
The larger of our
endotracheal tubes, this
one is a 35mm and is used
for giraffes.
That is an introduction to some of the work I do and
in the second part of this series I’ll provide what I
hope is an insight into the anaesthesia of the higher
vertebrates including the herptiles (amphibians and
reptiles) and avian anaesthesia, with the third and
final part discussing the mammals from the small
harvest mouse to the elephants and whales. All of
these patients provide their own challenges to the
anaesthetist. However with a small knowledge of
an animal’s basic anatomy and physiology, and
what I like to call the “Blue Peter factor” (sticky
backed plastic and good improvisational skills)
the world of zoo and wildlife anaesthesia is a
rewarding and exciting one. As James Herriot (or
James Alfred Wight) said “It shouldn’t happen to a
vet” but it usually does.
Anaesthesia of fish is becoming
more common, and this is leading to
developments in surgical procedures. Here
a stone fish is undergoing preoperative
ultrasound for a coelomotomy to remove
an ovarian mass.
Anaesthesia News September 2008 Issue 254
5
P r e s i d e nt ’ s R e p o rt
President's Report
September 2008
T
his is my last President’s
report and time to reflect
on my period of office. The
two years has certainly gone
quickly, as I was told it would, but it
has been a fascinating time. The role of
President has a number of features; some
ceremonial, some administrative and
some political. In all of them I have been
helped by my fellow officers, Council and
the indefatigable staff at Portland Place
and I would like to thank them all for
their assistance. The Honorary Secretary
in particular works closely with the
President, and William Harrop-Griffiths
has been an excellent companion in this
regard.
The ceremonial duties have been
enjoyable and I have had the opportunity
to represent the AAGBI in the four
corners of Great Britain and Ireland and
further afield. Anaesthetists everywhere
have many issues in common and similar
experiences. We have shared AAGBI
standards and guidelines with many other
countries, but one of the most important
things we can share is our system of
organisation so they can stand on their
own feet locally. Until anaesthetists get
an organised professional group in their
6
country it is very difficult for them to
make an impact on care standards and
patient safety. Elevating anaesthetists’
own professional status is all very much
part of that process. Some countries are
still where we were prior to 1932 before
Henry Featherstone and his colleagues at
the Royal Society of Medicine recognised
the need for an independent association
to develop anaesthesia here.
An academic base is also vitally important
for any specialty and the new National
Institute for Academic Anaesthesia (NIAA)
is developing well, currently running the
first cycle of research grants supported by
the four partners: the AAGBI, The Royal
College of Anaesthetists, The British
Journal of Anaesthesia, and our own
journal Anaesthesia. (www.niaa.org.uk)
Revalidation is upon us again and
Graham Catto, in his talk at the Scottish
Standing Committee Open Meeting
in February, said that it should not be
arduous but easily achievable by the
vast majority of consultants. However,
anaesthetists cannot be truly excellent
in a dysfunctional department, so it is
in everyone’s interest to have robust
departments of anaesthesia facilitating
practice to the highest quality standards
possible.
As more devolution to
Foundation Trusts takes place in England
it will be increasingly up to local
consultants and departments to stand firm
and maintain national standards. There
may well be financial implications for
Trusts but none of us should shrink from
insisting on the provision of the correct
facilities, whether clinical, educational
or administrative, to deliver the highest
levels of professional care to our patients.
We must direct NHS spending to the
doctor- patient interface where the cost/
benefit ratio is maximal, and away from
untested schemes wasting billions of
NHS pounds on whims and foibles.
Lord Darzi’s report “High quality care for
all” was better than expected although
similar to previous reports. As always the
devil is in the detail and a lot of that that
has still to be revealed. AAGBI is pleased
that the report supports the setting up of
Anaesthesia News September 2008 Issue 254
P r e s i d e nt ’ s R e p o rt
Sir John Tooke’s NHS: MEE. We must
all now make “high quality” our new
watchwords. Encouraging more doctors
into management roles is laudable and
Lord Darzi wants doctors applying for
most chief executive posts in future.
This should not be cosmetic and they
must continue to think as clinicians with
GMC ethical standards supporting the
NHS core healthcare aims at the doctorpatient interface. Whenever things are
suggested to paper over a crack or a
wheeze to fudge the EWTD we must
ask, “where is the quality in that?” - for
quality you can generally read safety.
We should all remember the transcript
of the fateful meeting that approved the
delayed Space Shuttle Challenger launch
in exceptionally cold weather. It was
emphasised that there was no engineering
evidence at that temperature but the
chairman said Congress was reviewing
NASA funding and told the engineers
to ”vote like managers this time”. If you
think safety is expensive, try having an
accident.
Medical manslaughter is a growing
challenge and the joint meeting of
AAGBI and the Association of Surgeons
(ASGBI) last year showed we must all
find a way to ensure this remains a rare
event. Society requires a group of people
to do medical work with living patients.
However society needs to understand
that sometimes human beings make
mistakes. Whenever a patient dies in
these circumstances, the learning curve
for the patient’s relatives, the police and
journalists is usually considerably steeper
than that for the medical profession. A
protocol exists for liaison between the
Health and Safety Executive (HSE), the
Police and Crown Prosecution Service
(CPS) to investigate work-related deaths.
Incidents where evidence indicates
that a crime of manslaughter may have
been committed are examined but
these organisations need to understand
that complicated clinical situations and
Anaesthesia News September 2008 Issue 254 human errors are not necessarily the
‘evidence’ that they may at first appear to
be. Fortunately a large number of cases
are dropped once this is appreciated but
if we can find a way of informing the
process at the earliest stage possible it
is in everyone’s interests and will avoid
wasting police time.
The Overseas Anaesthesia Fund (OAF)
which Mike Harmer started goes from
strength to strength, and the ‘Anaesthesia
in the developing world’ supplement
to Anaesthesia published in December
2007 is still getting plaudits. Iain Wilson,
Isabeau Walker and David Bogod are to
be congratulated for their work on this.
Earlier in the year I made a presentation
in the Houses of Parliament to the All
Party Health Group on ‘Anaesthesia in
Africa’ and in June was invited to the
World Health Organisation (WHO)
in Washington for the launch of their
“Safe Surgery Saves Lives” initiative.
Out of 230 million major operations
worldwide, seven million patients have
complications and one million die. The
WHO believes this can be halved and
now recognize that there is no safe
surgery without safe anaesthesia. Part of
the project is a checklist which includes
a working pulse oximeter being on every
patient before induction. This coincides
with aims of the Global Oximetry (GO)
project, which the AAGBI partners with
GE Healthcare and the World Federation
of Societies of Anaesthesia. To our great
delight at the meeting in Washington the
WHO formally agreed to support the GO
project which they are now looking to
roll out worldwide.
Equal pay for anaesthetists performing
NHS work in non-contracted hours will
continue to be a goal and it has been
achieved in many NHS Trusts and some
Independent Hospitals. Our colleagues
at the Royal College have recently put
a supportive statement on their website.
As parity has been achieved in many
NHS Trusts and some Independent
Hospitals, the case is made. Universal
implementation still remains in the hands
of our members.
The AAGBI Heritage Centre safeguards
the specialty’s museum and archive. The
history of the specialty is really significant
and none of us should forget the hardwon lessons and why we have got to
where we are today. During the last two
years I have presented numerous copies
of Tom Boulton’s excellent book on the
AAGBI’s history1 in which it is clear that
history certainly repeats itself as life goes
in cycles.
Being President has been a marvellous
experience and recently on the radio
politicians reflected on how they
felt on leaving office, admittedly
sometimes abruptly. Some likened it to
a bereavement; others turned to alcohol
(I will watch that one) and Malcolm
Rifkind said when he stopped being
Foreign Secretary he sat in the back of
his car and it didn’t go anywhere! Being
President of the AAGBI isn’t quite like
that - apart from having no chauffeur,
we serve a further year on Executive
as part of a continuity process. When I
hand over to Dick Birks in Torquay I will
wish him every success and hope that he
enjoys the Presidency as much as I have.
I have also had tremendous support not
only from Council and Executive, but
also from many ordinary members who
have made suggestions or performed
tasks on behalf of the AAGBI: they know
who they are, but thank you again. It
has been an honour and a privilege to
serve the AAGBI in this role and to play
a small part in continuing to develop our
wonderful specialty.
David Whitaker
Reference
1. Boulton TB. The Association of Anaesthetists of
Great Britain and Ireland and the Development of
the Specialty of Anaesthesia. London: Association of
Anaesthetists of Great Britain and Ireland; 1999.
7
G u e st E d i t o r i al
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’
8
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It is the start of a new ‘academic’ year,
bringing back distant memories of the
smell of floor polish, gym bags, coat
hooks set at an impossible height, new
teachers and old friends. ‘New starters’
to anaesthesia for 2008 will mostly be
in post by now. If you are one of these
doctors, I’d like to extend a very warm
welcome to our specialty and to our
Association. I hope you enjoy anaesthesia
as much as I have.
One of the changes brought about by
MMC that may prove to be lasting is
that the academic year (albeit brought
forward by a month to start in August)
pervades clinical medicine to a greater
extent than hitherto. I vigorously opposed
this change as a programme director
given responsibility for implementing it;
my main objection being that recruiting
an entire year’s worth of trainees at once
was simply not practical because of
the sheer numbers of people involved,
and the service impact of their absence
from clinical duties. The other major
objection was that there would be huge
service implications of carrying ‘gaps’
8
in trainee rotas from the time they arise
(at random through the year) until the
next annual recruitment round. In the
event, these objections seem to have
been overcome somehow – recruitment
this year was a bit less traumatic than
in 2007, (particularly for me as I didn’t
participate at all) and gaps in rotas have
been plugged somehow (I think you
can form a picture of exactly how by
inspecting the adverts in the BMJ – a
mixture of Trust grade appointments, and
also some further consultant expansion
involving resident on-call duties, seems
to be the answer).
As these practical difficulties have been
overcome - or perhaps it is just that
I haven’t had to deal with them - I am
now coming round to the view that this
change may be a very good thing. There
are big organisational advantages for
schools of anaesthesia in having new
starters all start at once. Educational
events, particularly mandatory courses
and meetings can be planned so that
they take place at the appropriate point
in the curriculum. Collecting data
Anaesthesia News September 2008 Issue 254
G u e st E d i t o r i al
about programmes should also be more
straightforward.
The most significant change, however,
could be much more subtle – the infusion
of a more definite academic undercurrent
into clinical anaesthesia. Stamping an
academic year onto clinical training
sends a strong message that training is a
priority, and also imposes the academic
rhythm on clinical departments, so
that we are all dancing to the same
music. There has been much handwringing about the decline of academic
anaesthesia. This year has seen the
successful inauguration of the National
Institute of Academic Anaesthesia (see
www.niaa.org.uk), a partnership between
the AAGBI, its journal Anaesthesia, the
RCoA and the BJA. We hope that this
project will flourish and that, as a result,
academic anaesthesia in the UK will go
from strength to strength. It is possible
that the move to an academic year will
also contribute to the welcome reversal
of the decline in the fortunes of academic
anaesthesia, and in this spirit I welcome
the change.
A new academic year might also prompt
a few resolutions. I plan to try and tidy
up my corner of the office, which will
hopefully placate the two unfortunate
(and
especially
tidy)
colleagues
condemned to share the space with me.
More seriously, I have studied the ‘Ten
practical steps for doctors to fight climate
change’ and the reasons to take these,
published in the BMJ 1,2. I am convinced
that we should be doing a lot more than
we are currently doing. There are hopeful
signs such as the commitment by the
NHS in England to reducing greenhouse
gas emissions by 60% by 2050 which
was announced in June, but the scale
of ‘carbon waste’ involved in our daily
lives can seem overwhelming. The
NHS produces an estimated 18 million
tonnes a year of CO2.2 Some of the ‘ten
practical steps’ proposed by Griffiths and
Anaesthesia News September 2008 Issue 254 colleagues are difficult for an anaesthetist
to engage with – advising our patients on
a better diet, more walking and cycling is
arguably beyond our remit, and attractive
as ‘advocating to stabilise the population’
is to an obstetric anaesthetist recovering
from 12 hours hard labour on a very
pressurised delivery suite might be, this
is also something I don’t think we can
realistically work on at the moment.
I am prepared to cycle more – I have
cycled to work pretty regularly for the
last 15 years, so no big change there. I
will try to fly less – I have taken 21 oneway short haul flights in the last twelve
months – no prizes there. I will try to eat
less meat, and to drink tap water. I will
also try to be a champion: to put climate
change on the agenda. In that spirit, I
would like to invite you all to contribute
your suggestions for a list of ‘ten
practical steps for anaesthetists to fight
climate change’ which we will publish
in due course. Email your suggestions to
[email protected]
Val Bythell
Assistant editor
References
1.Ten practical steps for doctors to fight
climate change. Griffiths J et al. BMJ
2008;336:1507
2. Why should doctors be interested in
climate change? Personal View. Gill M.
BMJ 2008; 336:1506
Before writing to me about helmet-wearing, please visit www.whycycle.co.uk or www.
cyclehelmets.org
9
G AT PAG E
Gat Page
“Welcome aboard
the Liner Hotel"
Report of the GAT ASM 2008
2-4 July, The Liner Hotel, Liverpool
Liverpool – European Capital of Culture
2008, home town of the GAT Chair, the
other end of the Manchester Ship Canal
(for the convenience of the AAGBI
President, attending this meeting 30
years after his first) and the place to be
as a trainee anaesthetist for this year’s
GAT ASM. Yes, there was some culture
involved too, but more of that later.
10 The Local Organising Committee,
with Professor Jennifer Hunter at the
helm, had put together a top quality
scientific programme which kicked off
with a group from Alder Hey Children’s
Hospital. The Alder Hey canteen always
serves spare ribs on a Thursday; is it
simply coincidence that the scoliosis
surgery takes place that day too? We
never did find out, but we did learn
about the management of Duchenne
Muscular Dystrophy patients in this
context. The next talk, entitled “New
blocks on the kids” for all you poptrivia fans, fuelled the debate over the
effectiveness of some traditional nerve
block techniques - 1 “pop” or 2 for your
Ilioinguinal nerve block? Prior to lunch a
Anaesthesia News September 2008 Issue 254
G AT PAG E
red flag was raised regarding mediastinal
masses in children – an area with a high
risk of mortality and morbidity which has
been traditionally under-estimated by
trainees. The take home messages were
to maintain spontaneous ventilation,
avoid neuromuscular blockade and get
several pairs of hands in theatre to help –
a small ODP will not be enough!
The speakers for the first afternoon
session came from the Cardiothoracic
Centre in Liverpool. Did you know that
the first oesophagectomy was performed
in 1914, and that the patient lived for
thirteen years post-operatively? Every
time she wanted to eat she had to
connect a red rubber tube between her
oesophagostomy and gastrostomy sites,
which must have been a mean party
trick! This was just one of the gems
imparted by our speaker, who went on
to describe how the Liverpool team now
routinely administer 50mls of oral cream
three hours pre-operatively to ease
identification and ligation of the thoracic
duct. This obviously generated some
lively debate! A thought-provoking talk
Simon Mercer receives the Abbott History prize from Lisa McCabe of Abbott
on transoesophageal echocardiography
use followed. It quickly became apparent
that it is not something in which we can
dabble; completing the accreditation
process would be a time-consuming
challenge for most trainee anaesthetists.
Our final speaker talked us through
the minefield of post-thoracotomy
analgesia, in particular thoracic epidural
vs. paravertebral catheters. Personal
experience and the set-up of your unit
are the most influential factors in the
decision-making process, following full
and frank discussion with your patient.
The final session centred round intensive
care matters. Professor Martin Leuwer
spoke about the role that white adipose
tissue plays in sepsis, an interesting
research area. We were reminded
of the seriousness of meningococcal
septicaemia, and the day finished with an
Dr Hilary Eason (whose suggestion it was)
models the eco-friendly conference bag
Anaesthesia News September 2008 Issue 254 entertaining talk about the gravitationally
challenged surgical patient which, as we
all know, is an expanding problem.
The evening’s social event, for which
GAT is undeniably famous, took place
at the Pan-Am Club in the regenerated
Albert Dock (no, the weather map from
“This Morning” is no longer there!). A
hot buffet and in-house DJ helped the
assembled crowd to experience a little
of Liverpool’s famous hospitality (but
maybe not a lot of culture...)
First up on day two was a session on the
difficult airway. It was interesting to learn
that decreasing access to NHS dental
treatment has lead to an 8-fold increase
in the number of dental abscesses
presenting to hospital. We heard about
the approach to anticipated difficult
airways currently being practiced in
Liverpool, involving awake fibreoptic
intubation using remifentanil infusion
and topical vasoconstrictor, following
which a healthy amount of debate
11 The Anaesthetists
Agency
safe locum anaesthesia,
throughout the UK
Freephone: 0800 830 930
Tel: 01590 675 111
Fax: 01590 675 114
Freepost (SO3417), Lymington,
Hampshire SO41 9ZY
email: [email protected]
www.TheAnaesthetistsAgency.com
12 Anaesthesia News September 2008 Issue 254
G AT PAG E
and discussion ensued. The session
concluded with an informative talk on
the difficult paediatric airway.
The rest of the morning was given over
to the Registrar’s Prize competition. This
year we had a record thirty submissions,
from which six were selected for oral
presentation. The wide-ranging subject
matter stimulated many questions from
the floor. Congratulations to Dr Sarah
Love-Jones from Bristol for winning
first prize with “Homotopic stimulation
can reduce the area of allodynia in
patients with neuropathic pain” which
pioneered an innovative use of bubble
wrap. Dr Muhammad Malik from
Galway won second prize with “A
comparison of Macintosh, Truview,
Glidescope and Pentax Airwayscope
laryngoscopes in patients with cervical
spine immobilisation”, and Dr Simon
Parrington from London came third with
“Interim results of the airway anaesthesia
survey 2007”. All our entrants are to be
congratulated on the high standard of
their presentations.
After lunch came the trainees’ conference,
during which we enjoyed a talk from Dr
Bhaskar Tandon about his experiences
working in Sweden. He talked about
his ideas for a British-Swedish exchange
programme, which although still in
its infancy, is a potentially exciting
development. Dr Rob Broomhead from
the GAT committee enlightened us about
who PMETB are and what they actually do
– a question on the lips of many trainees
given the recent substantial fees hike –
and Dr Mike Parris updated the audience
on recent MMC developments, including
a section on the Darzi Review which
was released three days previously: he
should be congratulated on reading this
important document in such a short timeframe in order to share the basics with us,
showing the audience a great example
of the tasks facing the GAT committee.
There was also a lively panel Q&A session
Anaesthesia News September 2008 Issue 254
centring
round
career maintenance
and
development.
In particular, the
panel recommended
moving onwards and
upwards in ways
which may include
taking
a
locum
consultant post in
preference to run-out
training at the end
of the SpR training
programme.
This was followed
by the GAT Annual
General
Meeting,
a report of which
is
available
on
our website. Dr
Jane Sturgess, our
departing honorary
secretary,
was
thanked
for
all
her
hard
work;
congratulations to Dr
Nicholas Love who
has been elected
to fill her vacancy
Chris Meadows presents the Pinkerton medal to Dr Mike Grocott
on the committee.
The Chair’s report
reminded
the
Seventy-eight posters were accepted for
audience of the continued work of the
this year’s audit competition, a challenge
committee in support of the Tooke Report
for the judging panel given the wide
recommendations, and a fair and open
range of topics. Congratulations go to Dr
application process for International
M Agarwal and Dr J Dasan for their audit
Medical Graduates. Formal thanks
entitled “First oral intake following ELSCS
were extended to the Local Organising
under Regional Anaesthesia”, Dr T Martin
Committee, Professor Jennifer Hunter and
et al for “Rubbish and Waste in the NHS”
SpRs Dr Liz Clark and Dr Lindsay Parker,
and Dr N Sudhan and Dr P Kalia for “Are
for the fantastic ASM Programme, and
preoperative tests done as directed by
to Dr Hilary Eason for suggesting ecoNICE Guidelines?” The chairman of the
friendly conference bags. Dr Meadows
judging panel looks forward to seeing
entertained us with the fact that the last
some of the subjects back next year with
time GAT was held in Liverpool he was
completed audit cycles.
being born just up the road, and this time
his 4 week old son Charlie had put in
his first GAT attendance during the lunch
hour!
Dr Simon Mercer from Liverpool won
the Abbott History Prize with his essay
13 G AT PAG E
on “Anaesthesia in the
Armed Forces: a history of
the Triservice Apparatus”.
It was noteworthy that its
invention was marketed so
that “anaesthetists would
now be able to carry the tools
of their trade in a briefcase,
like GPs”. Its use at extremes
of temperature has also been
deemed a success: anyone
fancy cuddling a vaporiser
like they did in the Falkland’s
war?
It was a pleasure to welcome
Dr Mike Grocott, one of the
members of the Caudwell
Xtreme Everest team, to
give the annual Pinkerton
Lecture. It was comforting to
learn that some of the best
altitude performers come
from sedentary backgrounds,
and some super-fit tri-athletes
struggle under these conditions! The
Caudwell expedition collected literally
mountains of data (his pun, not mine)
which will be analysed for years to
come, and he shared many fascinating
photographs and stories. He admitted
that he may have climbed Everest, but
this was his first GAT ASM!
Thursday night found us enjoying more
culture amidst the tropical foliage of
the Sefton Park Palm House for the GAT
Annual Dinner. Then the DJ was let loose,
and stole the show.
The Friday morning Medico-Legal
session, chaired by Professor Jennifer
Hunter, was well-populated considering
the previous evening’s activities. The
first speaker corroborated our previous
day’s advice on the future of anaesthetic
training. There followed an excellent
talk on the Mental Capacity Act and
the changes which apply to patients
who lack capacity – about 50% in the
14 Delegates at the Annual dinner
ITU at any one time. Above all we must
always be seen to be acting in the best
interests of the patient concerned, not
their family or even society as a whole,
which has some obvious implications for
research. The session finished by posing
the question “Is a good death possible
on ICU?” which appears to have no easy
answer.
This session coincided with the final
parallel workshop sessions on the
Difficult
Airway,
Cardiopulmonary
Exercise Testing (for which the word on
the street was to avoid going on the bike,
wear a skirt and high heels,) Ultrasound
Guided Regional Anaesthesia and a trip
to the Merseyside Simulation Centre.
These sessions were popular and the
general feedback has been very positive,
so thank you to all of those involved in
their organisation.
The conference ended with a debate
entitled “Physicians’ Assistants in
Anaesthesia – Filling the Vacuum”
spoken for by Dr William Horton from
University Hospital, Aintree, and against
by Dr Simon Bricker from Chester. Dr
Horton was going to have a tough job
convincing 246 people to change their
minds on the matter, but he seemed
pleased to have gained two abstentions
at the end!
All that remained was for Dr Whitaker
to thank Liverpool for having us and
putting on such a great programme,
presenting thoroughly deserved flowers
and champagne to the Local Organising
Committee. It just remains for me to
thank everyone involved, including the
staff at 21 Portland Place for all their hard
work at another superb GAT ASM. The
show now sets sail for Cambridge next
year – see you there!
Dr Felicity Howard
Honorary Secretary, GAT Committee
Anaesthesia News September 2008 Issue 254
Anaesthesia News July 2008 Issue 252
15 …
r
o
t
i
d
E
r
a
e
D
Mroe on durg eorrrs
I rceetleny raed a jkoe pecie form
Cmabrdgie Uvinseritiy in wihch all
the ltteres of the wrods were jmbuled
(ecxpet for the fsrit and lsat).
Surprisingly it is sllit qiute esay to raed
the dcunmeot. The pnoit bneig taht the
barin atcs lgarley on pttaren rcgoitienon
and does not atcllauy raed ecah ltteer
one by one. We are all uesd to wrod
geams in wchih a wrod is aeddd to a
pshare but tihs wrod is not seen. Tihs
is aenohtr empxale of the barin uinsg
peattnrs and atnipictoian.
It smees to wrok wtih wdros of up to
aoubt seevn lttrees but for lngoer wrdos
is lses rlieblae. As tihs eordnraiilartxy
cntroeivd eamplxe iutsllaerts.
It orrueccd to me taht tihs has
ipmrtoncae for aanthestists, and in
mdiociaetn eorrrs. One colud sepucltae how ipmorantt
tihs is for dgurs scuh as cyclizine,
ephedrine morphine eevn epinephrine
and ergometrine. Colud we dsgien
durg neams wtih mroe dsircmiintiinag
shpeas? Prheaps Cmabdrgie or Ofxrod
Uvniseritiy wluod like to eplxroe tihs
fthuerr.
Yuors scinreely.
TM Cook (yes, I have changed the
letters!)
Csnultonat ahnaeesttist
Btah
Drug packaging (again)
So there I was in the Labour Ward Theatre setting
up for the section. I asked the ODP for a box of
phenylephrine, so he picked up a box of prednisolone
by accident and chucked it to me. The accompanying
photos go some way towards explaining the origin of
this near-wrong-drug incident: identical packaging of
two very different drugs.
Our Labour Ward Theatre is organised by a fantastic and obsessive ODP called George.
On the wall-mounted drug cupboard in theatre there is a list prepared by George of all
the drugs that should be there. The idea is that the Labour Ward pharmacist checks the
contents of the cupboard against the list every day and tops up the supply of any drugs
that are running short. At no point in the list does the word “prednisolone” appear. I
chatted to the pharmacist and – guess what? She had made the same mistake as the
ODP – she thought it was a box of phenylephrine. This is understandable and nonnegligent human error of course. However, one thing worries me particularly about
this occurrence. The NPSA is spending a lot of time and money trying to decrease
the incidence of “wrong-drug” errors in anaesthesia and is apparently exploring two
possible “solutions”: double-checking of all drugs used by anaesthetists and the use of
prefilled and bar-coded syringes. It is argued by some that this latter approach would
have the desired effect by replacing the haphazard and rushed preparation of drugs by
anaesthetists in theatre with the careful drawing up and labelling that could only be
achieved in the almost sepulchral calm of a modern pharmacy.
Suddenly, this doesn’t look like such a good idea – apparently pharmacists (or at least
some of them) are human too!
Name and address supplied but withheld to protect a really great pharmacist.
What did you say?
Gaining consent for anaesthetic or surgical procedures can be very difficult, particularly if there are language barriers as recently
highlighted in the March edition1. I would like to highlight a novel use of medical equipment to overcome a different communication
barrier.
Recently during an emergency list we were asked to provide sedation for a patient needing a lumbar puncture. On arrival to theatre, we
realised there was no signed consent form. The patient was deaf, and nursing staff had removed her hearing aids, so any communication
was extremely difficult. Our problem was overcome by a quick-thinking ODA, who gave the patient my stethoscope. We spoke to her
easily holding up the diaphragm, and so gained consent and proceeded without any further delay.
Chris Jones, SpR
Epsom and St. Helier University Hospitals NHS Trust
1. Puja Sadhi, Language barrier. Anaesthesia News, March 2008, P32
16 Anaesthesia News September 2008 Issue 254
Preoperative preparation
ERRORS of OMISSION
As an ST1 in anaesthetics, I have recently come
to realise the sheer scale of public misconception
about our profession and the job we do. I
recently encountered a 15 year-old girl who
was accompanied by her mother for an elective
procedure. The patient was rather nervous and
mum apologised for this. She further went on to
explain that she had tried to make things better
by making her daughter watch the movie 'Awake'
the day before so that she would know what to
expect! I suspect there isn't an anaesthetist in the UK
who hasn't heard of this movie. It is a Hollywood
'psychological thriller' which is supposed to
depict awareness during anaesthesia and has been
extensively debated in the media by both the public
and profession1,2.
I read the anaesthesia aphorisms in the June edition of Anaesthesia News
anticipating the usual wit or insight, but was disappointed to read the
following "no-one has ever died as a result of NOT having an arterial line
or epidural inserted."
I am not a parent, but I would like to think that if my
child were going to have an anaesthetic, 'Awake'
would not be my first choice bedtime movie. I am
keen to canvass the views of parents out there and
compile a list of recommended pre-op movies to be
included in patient information leaflets. I nominate
Toy Story.
Adrian WONG
ST1 Anaesthetics
Portsmouth Hospitals NHS Trust
1.Bogod D. Awake – passing gas on the silver
screen. Anaesthesia News June 2008, p28
2.Galley H. and Hall B. Editorial - Films, facts and
fictions. Anaesthesia 2008: 63; 692-694
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News, AAGBI,
21 Portland Place, London W1B 1PY
or email: [email protected]
Due to the volume of correspondence
received, letters are not normally
acknowledged.
This is of course nonsense. The statement is as illogical as stating that
'no-one has ever died from not having an operation'. While I fully
understand that these aphorisms are there to amuse (and I did once have a
sense of humour until the NHS robbed it from me in 2006) I think such a
comment is potentially dangerous, in whatever context it is written.
It is easy to point the finger when things go wrong as a result of
interventions: these are “active” complications or “complications of
commission”. What is much harder to identify is the possibility of
complications arising because of the failure to perform a procedure or act
in a particular way. These are “passive” complications or “complications
of omission”. Errors of commission are easily related to the act that caused
them, while identifying the act that was not done which led to a different
complication is far harder.
It is recognised that non-invasive blood pressure measurement techniques
over-read during hypotension. The patient who is monitored in this way
and suffers harm during unrecognised hypotension HAS been harmed
by failure to place an arterial line. It is also recognised that epidural
anaesthesia reduces the risk of respiratory complications and respiratory
failure. The patient with uncontrolled pain from fractured ribs or after
surgery, who develops a chest infection, then respiratory failure and then
dies on intensive care HAS died for want of an epidural. I have seen both
of these occurrences and while it is natural and easy to point at active
complications, we mostly forget, ignore or dismiss those of omission. It
was 'just bad luck!'
I've spent much of the last few years studying complications of anaesthesia
in the National Audit Projects (NAP). One of my concerns has always
been that the projects identify only complications of commission and do
nothing to identify those arising from omission. I believe this will be one of
the challenges in reporting these projects to the profession, our colleagues
and the public. In addition to the NAP projects I have been interested in
the complications leading to claims against the NHS litigation authority
(NHSLA). Having studied more than 1000 claims relating to anaesthesia
in the NHSLA database I do not recall a single claim relating to errors of
omission.
I suspect this failure to recognise and understand (or sue on account of)
errors of omission also hampers our inability to advance our practice. It
may be true that 'nobody sues over NOT having an arterial line or epidural'
but I think our patients deserve better than that. It is a problem that I
believe merits more serious debate. I suspect complications of omission
are far more common than those of commission: it’s just that they are
not recognised. My aphorism would be 'patients suffer every day due to
the complications of omission, these are frequent, important and mostly
ignored.'
Tim Cook
Consultant anaesthetist, Bath
Anaesthesia News September 2008 Issue 254
17 T H E H I S T O R Y PAG E
Thomas Beddoes
and his Gas Factory
The life of Thomas Beddoes, a man of conceptual intuitions and
great conviction, occupies a pivotal role in the evolution of
modern anaesthesia. His contributions come from his work
in pneumatic medicine and establishment of a Pneumatic
Institution. As the first anaesthetics were administered
by inhalation of gases and vapours, evolution of
anaesthesia would have never been possible without
a comprehensive understanding of the existence of
identifiable and variously distinctive materials that
exist in the gaseous state. Knowledge of some of these
gases and their clinical application in medicine played
a cornerstone role in the development of modern
anaesthesia.
Joseph Priestley (1733-1804), is credited as the first to
suggest that inhalation of carbon dioxide, then known
as ‘fixed air’, might be used to treat diseases: in particular,
his proposition that soda water prepared from ‘fixed air’
should be used to prevent scurvy among sailors on a long
voyage was recommended to the Royal Navy by the College of
Physicians. However, Thomas Beddoes was certainly the first person
to institutionalise the administration of gases to treat diverse ailments,
and surely stands in the first rank of those individuals who set the stage for the
introduction of clinical anaesthesia.
Thomas Beddoes
Early life and Career
Thomas Beddoes was born in Shifnall, Shropshire on 13th April 1760. In 1776,
he was enrolled in Pembroke College, Oxford University, where he became
proficient in several languages and was awarded a Bachelor of Arts degree in
18 Anaesthesia News September 2008 Issue 254
1781. He also studied botany, geology,
and pneumatic medicine with which
he remained obsessed for the next 25
years, and completed his Masters in Arts
(1783).2 He began studying medicine
in Edinburgh but completed his MD
in Oxford (1786). He began his career
as a lecturer in chemistry at Oxford in
1787. Displaying his linguistic skills,
he translated into English the scientific
works of Spallanzini (1784), Berrman
(1785), Scheele (1786) and published his
dissertation on Mayow’s work (1790).3
Pneumatic medicine and the
Pneumatic Institution
Beddoes published his first major treatise
on pneumatic medicine “Observation
on nature and cure of calculus, sea
scurvy, consumption, catarrh and fever”
and performed his initial trials of gas
inhalation in patients in 1792 but the
equipment for generating, storing and
administering the gases was crude and
imperfect. Consequently, he conceived
the idea of establishing a pneumatic
institution and began soliciting support
and financial help from his brother
Joseph, William Reynolds (a landowner
from Shropshire), and Davies Gilbert
(1767-1839), his pupil in Oxford.
He also developed friendships with
many members of the Lunar Society of
Birmingham, such as Erasmus Darwin,
James Watt, and Richard Edgeworth and
asked them to solicit support for him in
scientific circles.
Beddoes chose Dowry Square, Hotwells
Spa at Clifton in Bristol to establish
his Pneumatic Institution. Medical
activities began in May 1793, and soon
flourished into a successful practice,
treating patients suffering from diseases
including cancer and tuberculosis using
oxygen, hydrogen, carbon dioxide,
impure carbon monoxide and fumes
produced by burning of feathers and
charred meat to treat such ailments.4 In
Anaesthesia News September 2008 Issue 254
his work, Beddoes was assisted by James
Watt (1736-1819) in the design and
development of apparatus for generation,
storage and administration of gases, and
together they published “considerations
on the medicinal powers of factitious
airs” in five parts between 1794 and
1796.3
with nitrous oxide firstly on animals and
then on himself and sent his results to
Beddoes, deducing that nitrous oxide
was not responsible for the plague.
Impressed by his work and on Gilbert’s
advice, Beddoes appointed Davy as his
superintendent at the newly opened
Pneumatic Institution.2
The VIP Visit
Laughing Gas
In December 1793, Georgiana, Duchess
of Devonshire, visited the Pneumatic
Institution4 and highly impressed,
she suggested that Beddoes extended
the facilities available, replacing the
outpatient facility with a hospital.
Beddoes began to work on the idea
in 1794 and by 1797 had collected
sufficient funds from donations and
subscriptions to found such an institution.
Members of Lunar society of Birmingham
contributed significantly to the launch of
the Pneumatic Medical Institution, which
was formally opened in1799.3
Davy worked at the institute from 1799
to 1801 during which he experimented
with all the known gases but his main
interest remained nitrous oxide. He
established its specific gravity, solubility
in water and blood, and measured the
rate of uptake of nitrous oxide by his
own body, using a spirometer specially
designed for him by William Clayfield
(1772-1837), a pupil of Watt. He also
measured the capacity of his own lungs
by inhaling hydrogen. He studied the
effects of nitrous oxide on small animals
and observed that the progressive
reactions in animals preceding death
from breathing pure nitrous oxide
were very different than those killed by
privation of ‘ordinary’ air. He described
these reactions as ‘Struggling, Repose,
Convulsions and Resuscitation’ - if the
animal is subsequently allowed to breathe
pure air. These reactions are very similar
to the stages of anaesthesia described in
1937 by Arthur Guedel (1883-1956).
Humphrey Davy – The
Superintendent
Humphrey Davy (1778-1800), famous for
his invention of the miners’ lamp, came
from a family of craftsmen in Penzance,
Cornwall, and became an apprentice to
a local surgeon, Mr Borlaise, when he
was just 16. Although he didn’t attend
University he became a self-taught
chemist and came to the attention of
Beddoes through Davies Gilbert, and
also Gregory Watt (son of James Watt),
who had visited Cornwall to recuperate
from pulmonary consumption.3 Davy
became interested in nitrous oxide after
reading “considerations on the medicinal
powers of factitious airs” by Beddoes
and Watt, in which they quoted Samuel
Mitchell’s (1764-1831) assertion that
‘dephlogisticated air’ (nitrous oxide) was
contagion, responsible for the spread
of plague. Davy began experimenting
While breathing nitrous oxide, he
discovered that the gas relieved pain
in his sore gums and had pleasurable,
euphoric and exhilarating effects and
he probably coined the term “laughing
gas”. He later became addicted to
the gas. In January 1800 he published
his book, ‘Researches chemical and
philosophical; chiefly concerning nitrous
oxide or dephlogisticated nitrous air and
its respiration’ in which he noted;
“…As nitrous oxide in its extensive
operation appears capable of destroying
physical pain, it may probably be
19 used with advantage during surgical
operations in which no great effusion of
blood takes place.”1
It is ironic that despite discovering its
analgesic effects and suggesting its use
during surgery, Davy never pursued
the use of nitrous oxide for surgical
analgesia, and contemporary surgeons
of his era also failed to realise the
significance of the discovery. However,
Davy had opened the door that led to
the discovery of modern anaesthesia.
The dream that never came
true but….
In reality, the vision of Thomas Beddoes
to revolutionise medicine through
pneumatic medicine came to nothing
with closure of the institution in 1802,
yet the influence of his work on gases
and vapours was to prove seminal
in the development of inhalational
anaesthesia. Together with Watt he
designed and built apparatus which was
capable of delivering gas in measured
volumes. He did not conceive that the
pain of surgery could be alleviated by
the use of gases but his appointment of
Humphrey Davy as the superintendent
of the Pneumatic Institution in October
1798 would prove to be a milestone
on the road to development of modern
anaesthesia. The historical importance
of the Pneumatic Institution doesn’t lie
in its achievements but in the extensive
researches carried out by Humphrey
Davy at the Institute. Beddoes died on
Christmas Eve 1808.
Iftikhar Ahmed
Specialist Registrar
Leicester Royal Infirmary
Dowry Square, Hotwells Spa at Clifton in Bristol. The Pneumatic Institution
References:
1. Davy H. Researches chemical
and philosophical; chiefly concerning
nitrous oxide or dephlogisticated
nitrous air and its respiration. London:
Johnson, 1800: 1-580. (Facsimile
Edition. London: Butterworth, 1972)
3. Bergman NA. The Genesis of
Surgical Anaesthesia. Wood LibraryMuseum, 1998; 76-77.
4. Cartwright FF. The English
pioneers of anaesthesia (Beddoes, Davy,
Hickman). Bristol: Wright, 1952: 1-338.
2. Slater EM. The Evolution
of Anaesthesia. British Journal of
Anaesthesia. 1960; 32: 31-198.
20 Anaesthesia News September 2008 Issue 254
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Anaesthesia News September 2008 Issue 254
21 NAP4
The 4th National Audit Project
of the Royal College
of Anaesthetists:
Major Complications of Airway
Management in the United Kingdom
A
irway management is, of
course, a cornerstone of
safe anaesthetic practice.
Major complications occur
only infrequently but their impact
is devastating and their incidence is
unknown in the UK. The opportunity to
learn from a detailed analysis of a cohort
of such cases has never existed before.
The 4th National Audit Project
(NAP4) is an ambitious project being
conducted jointly by the Royal College
of Anaesthetists (RCoA) and the
Difficult Airway Society (DAS) in cooperation with the National Patient
Safety Agency (NPSA) with the aim of
discovering the incidence of serious
airway complications and examining
each reported case for common themes
and learning points. This project closely
22 follows, and we hope builds on, the
model used for the successful NAP3
audit of central neuraxial blockade,
which is due to be reported in November
of this year.
Starting on September 1st 2008 and
running for one year, it will determine
the incidence of major complications
of airway management in the UK.
To achieve this objective it will be
necessary to undertake a snapshot of
current airway management practice,
providing the denominator, followed
by a year-long data collection of major
complications to provide a numerator.
There is good evidence that major
complications of airway management
are not restricted to routine anaesthesia
and many of the most difficult airway
management challenges occur in the
emergency department (ED) and the
intensive care unit (ICU). For this reason
we are collaborating with the College
of Emergency Medicine (CEM) and the
Intensive Care Society (ICS) and request
that all major complications of airway
management (whether cared for by
anaesthetists or other specialties) that
occur in theatres, the ED, and ICU are
reported to NAP4.
We anticipate that most reports will
be from anaesthetists directly involved
with management of these cases, but
will be happy to receive reports from
intensivists, emergency physicians,
operating department practitioners,
anaesthesia nurses and even surgeons!
We are in contact with the professional
organisations of these groups to seek
Anaesthesia News September 2008 Issue 254
their support with this project. Further
cases may be identified by contact with
NPSA or NHSLA.
What should be reported?
We are interested in the complications
of airway management in NHS hospitals,
and the project includes both adults and
children. As stated above, complications
may arise during treatment by
anaesthetists, emergency physicians and
intensive care doctors, and all should be
reported.
This project is ONLY designed to collect
data on major complications of airway
management.
• Death.
• Brain damage.
• E mergency surgical airway
needle cricothroidotomy
Neck haematoma
or
• U
nanticipated ICU admission:
only where the complications of
airway management are the cause
of admission or lead to an adverse
outcome.
In order for the project to be achievable
we need to focus only on those cases
with a poor outcome that is clearly
identified as caused by difficult airway
management.
Therefore we do not wish to be informed
of the following
• Cases admitted to HDU
• C
ases which would have been
admitted to ICU even without
airway management difficulty,
unless the airway management
difficulty resulted in significant
adverse outcome.
• D
ifficult
airway
management,
no matter how difficult, without
adverse patient outcome (though
we do wish to collect all cases of
emergency surgical airway/needle
cricothyroidotomy)
Anaesthesia News September 2008 Issue 254 We estimate that approximately 100200 cases (less than one per hospital)
may be identified in one year, but this is
speculative. In most cases your hospital
would report no cases, sometimes one
and rarely two. The project will be
co-ordinated centrally, and supported
locally by a network of Local Reporters
(LR) who will gather event details once
a case has been reported. At the time of
writing over 97% of UK hospitals have
an agreed local reporter in post. As the
project progresses we anticipate the LR
may be supported by local reporters in
ICU and the ED.
We are aware that staff involved in such
incidents may have suffered trauma
themselves. We anticipate a role for the
LR in supporting doctors involved in
these cases: advice on sources of support
will be provided as part of the project
process.
How is data reported?
All qualifying events should be reported
initially to the project team by email;
[email protected]. It will be possible for
anyone to notify the RCoA of a case fitting
the inclusion criteria shown above. The
only information required at this stage
will be the date and time of the event,
the hospital where the complication
occurred and the name and contact
details of the person reporting. It is
important that no information identifying
the patient is sent. Where someone other
than the anaesthetist reports the case it is
unnecessary and unwanted to identify an
anaesthetist.
After notification of an event the RCoA
project lead will liaise with the LR
to confirm that an event fulfilling the
inclusion criteria has occurred, after
which the case will be added to the
RCoA list of confirmed cases. The LR
will be asked to co-ordinate uploading
of the case details to a secure part of the
DAS website. To enable the audit team
to gain a clear picture of the events that
took place the data collection form is
detailed. Questions are not posed to
judge or to imply criticism, but to seek
the information needed to determine
themes and learning points arising from
these challenging cases.
23 Access to this area of the website will
require a unique username which will be
sent to the LR by the RCoA after the event
is confirmed. Before submitting data the
LR will need to create a password. The
combination of username and password
will ensure that only the person entering
data has access to entering or modifying
it. The DAS project lead will be able to
read the entered data and judge when
more data is required: the RCoA lead
will not. When more data is required the
DAS project lead will ask the RCoA to
inform the LR. When a report is complete
the username will be destroyed and the
link between the RCoA list of reported
cases and data on the DAS website will
be broken.
The RCoA will have access to the hospital
location of every notified event, but not
to the details on the DAS website. The
DAS project lead will have access to
the report on the DAS website but will
have no access to information on identity
of hospital, patient or clinicians. No
patient- or anaesthetist-identifying data
will be requested, and if entered it will
be removed.
What if I do not know whether to report
a case?
Dr Ian Calder (nap4moderator@rcoa.
ac.uk) will act as a moderator. His
role will be to advise LRs and those
completing forms if they are unsure
about inclusion criteria or the data to be
submitted. He will be independent both
of the RCoA and DAS.
Reviewing the cases and reporting of
results
The data reported will be reviewed in
detail by a panel from DAS, the RCoA
and specialist societies, to seek themes
and learning points. A formal report
of the project will be published by
the RCoA and DAS in 2010. This will
include quantitative analysis (incidence
24 calculations) and an analysis of cases
identified. This will be in the form of
clinical review seeking learning points
and cross specialty education. The
findings will be sent to all those who
have assisted in the project.
Approvals
The project process has been approved
by the National Research Ethics
Service and by the Department of
Health (Patient Information Advisory
Group). It is endorsed and supported
by the Association of Anaesthetists of
Great Britain and Ireland, Association
of Paediatric Anaesthetists, Obstetric
Anaesthetists Association, Intensive
Care Society, Intensive Care National
Audit and Research Centre, College
of Emergency Physicians, College of
Operating Department Practitioners,
Association for Perioperative Practice,
the Chief Medical Officers of England,
Northern Ireland and Scotland, the
Medical Defence organisations, and we
are continuing discussions with several
other organisations.
We believe this is an important project.
Reports of such events are often
incomplete and the subject remains
controversial even within the profession.
At present we do not know the incidence
of these major complications or
whether patterns exist in their causes or
consequences. It is likely that learning
from these events is a local process
and lessons that might be more widely
applicable are not disseminated. We
hope this project will teach us much
about both the scale and nature of this
problem. It offers us a chance to increase
our knowledge, make better risk: benefit
assessments in patient care and enable
more robust disclosure of risk to patients.
We believe more knowledge will also
directly improve patient safety.
The key to success of the project is
universal involvement. We urge you
to discuss this project within your
departments and liaise with your
emergency and ICU colleagues. If
questions or concerns arise, please
do not hesitate to contact one of the
project leads.
Tim Cook
E mail [email protected]
Nick Woodall
E mail [email protected]
Audit Co-Leads, 4th National Audit
Project (NAP4)
Anaesthesia News September 2008 Issue 254
Peter Baskett memorial service
A Memorial Service for
Peter Baskett, AAGBI
President 1990-92,
will be held in Bristol
Cathedral at 1.30pm on
Saturday 20th September,
followed by a short
reception at the Thistle
Grand Hotel, Broad St,
Bristol. All friends and
colleagues are welcome
to attend.
Overheard at the
GAT meeting…
The scene: a social event during the
GAT ASM
The cast: one well-refreshed delegate, a
buxom barmaid in low-cut top, a younger
barman.
The Delegate has just paid the barmaid
for his drinks, and she has gone to the till.
He addresses the barman. “Do you ever
get the urge to just stuff the money down
her cleavage?”
Barman (affronted), “No – she’s my
mother.”
Anaesthesia AphorismS
Submitted this month by John Asbury, Glasgow, Ramana Alladi, Ashton-under-Lyne, and Yoav Tzabar, Carlisle.
Obsessional attention to detail at the start
of the case will mean an easy time for the
remaining duration.
Monitors do not tell lies but may not tell
the whole truth either.
If a surgeon misses you in your absence,
you are a good anaesthetist.
Anaesthesia News September 2008 Issue 254 Patients expect a personalised treatment
from every anaesthetist.
It's easier to cannulate a vein when the
patient is normovolemic and all is calm,
than to wait till major haemorrhage and
panic happens, and then look for veins.
Be suspicious of, and always check, a
cannula inserted by somebody on the
ward before relying on it.
Defensive medicine is now an
uncomfortable reality, so write your notes
so that you can defend your role and
actions later on.
High science and elegant equipment
are great, but people are often damaged
by mundane things such as airway
disconnections; keep a balance.
Giving an anaesthetic is one person’s job.
25 Dr_Podcast_88X124_advert(2)
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Register early – strictly limited to 30 participants
For details & application forms visit:
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Or email [email protected]
26 Annual Conference –
“A Risky Business”
6th November 2008
at
Royal Court Hotel, Coventry
A inter-professional meeting designed for
anaesthetists and all healthcare workers involved
in the preoperative process.
Registration:
£190 (members of the POA)
£225 (non-members)
For further details including registration forms,
please visit www.pre-op.org or contact
[email protected]
5 CEPD POINTS
Anaesthesia News September 2008 Issue 254
It’s
a
fag
for
Dr.Ruxton!
Although he just wafts in through the wall like any good ghost, he likes to think he is still earthbound, and Dr.Ruxton asks why he is
unable to get in and out of my hospital without walking through a giant ashtray?
For that is what it is. The entrance to our surgical block faces onto a pleasant courtyard and turning circle for cars. It is a reasonably
pleasant place for patients to sit in fair weather and watch the well world go by. Unfortunately it is completely overrun by smokers,
night and day, summer and winter. In the summer they sit down as soon as they can – pushing a drip stand with infusion monitor is
hard work on cobbles - and do so adjacent to the
doors, so that their fumes waft inside and down
the corridors. In winter, they huddle around the
doors, holding them open so that the hospital
warmth escapes past them to contribute to the
heat death of the Universe, in exchange for their
fumes that waft inside etc. etc.
I wouldn’t mind so much, if it weren’t for the
mess. Our fair city has a university and is a smaller
version of Newcastle – Party City! – on Friday
nights. On Saturday morning, venturing in early
for the trauma list, on our streets the residues of
innumerable cigarettes and the occasional ‘sixteen
pints and a kebab’ are as clear to see as their
original owners are, being stitched up and fixated
on that list. But by the time the list is finished, all
is cleared up. Well done, the City Fathers!
The fag ends outside our hospital are never cleared
up. The earth in the flowerbeds has risen six
inches and still the filter tips are in drifts. The bins
overflow with fag packets and the security man
sits inside at his desk and thanks me as I close the
doors against the icy blast. Okay, we are as short
of funds as anywhere, and manicured lawns and
new bedding plants every month might be only
appropriate when Royalty visits. But the Council
has machines that clean the pavements. We are
not far from the city centre and quick turn around
the courtyard once a week would keep the filter
drifts at bay.
Anaesthesia News September 2008 Issue 254 27 C o mm i tt e e F o c u s
Members’
Wellbeing
Section
now online
The AAGBI is pleased to announce
that the Members’ Wellbeing Section
is now up and running on the website.
It appears in the menu list on the left
hand side of the home page, and pages
currently available include a list of
useful organisations for doctors with
difficulties, and links to helpful articles
and publications.
Through this section members will
be able to access and download
the Members’ Resource Pack. This
publication was in the process of being
finalised as this issue of Anaesthesia
News was being prepared, and it will
be available on the website this autumn.
This has been a major project for the
Welfare Committee and I would like to
thank the committee members and cooptees for all their hard work.
There are two sections to the Resource
Pack. The first contains information
which we feel will be useful to help
members cope with the vicissitudes of
life. It includes sections on topics such as
bullying and harassment, and advice on
coping strategies for stressful situations of
all types. There is a section on problems
specific to the training years, and helpful
28 advice about the signs of stress to look
out for in self or colleagues. The second
section contains a list of organisations
that can be approached in times of
trouble.
it is! We would very much appreciate
feedback on the Resource Pack. What
else would you like us to add? Are there
other areas on which we should provide
information?
This is just the beginning. Although we
are pleased with the result we know that
there is bound to be a lot of information
missing - but we need you to tell us what
Di Dickson
Chairman
AAGBI Welfare committee
Anaesthesia News September 2008 Issue 254
THE MERSEY COURSES
FOR
THE FINAL FRCA PAPERS
OCTOBER 21ST
The Final MCQ Week
14.00 Sunday 5th – 12.00 Friday 10th October
Five Intense Days (08.00 – 20.00)
Close Analysis of MCQs
With Emphasis On
Medicine & Intensive Care
Surgery & Obstetrics
Measurement & Equipment
Neurosurgical Anaesthesia
Cardiothoracic Anaesthesia
Paediatric Anaesthesia
Chronic Pain
Statistics
£300
The Final SAQ Weekend
14.00 Friday 10th – 16.00 Sunday 16th October
The Mersey Method of Dealing with the SAQ Paper
Master Classes in Style & Technique
Time Management & Discipline
Practice & Analysis
£250
NOTES
Discounted Subscription to Both Courses - £450
Venue - Aintree Hospitals, Liverpool
Details – Assessments – Application Forms
MSOA.ORG.UK
Anaesthesia News September 2008 Issue 254 29 Help for Doctors
with difficulties
The AAGBI supports the Doctors for Doctors scheme
run by the BMA which provides 24 hour access to
help (www.bma.org.uk/doctorsfordoctors). To access
this scheme call 0845 920 0169 and ask for contact
details for a doctor-advisor*. A number of these advisors
are anaesthetists, and if you wish, you can speak to a
colleague in the specialty.
If for any reason this does not address your problem,
call the AAGBI during office hours on 0207 631 1650
or email [email protected] and you will be put in
contact with an appropriate advisor.
*The doctor advisor scheme is not a 24 hour service
British Association Of Indian Anaesthetists
7th Annual Meeting, Saturday 11th October 2008
Wellcome Trust Conference Centre
Genome Campus
Hinxton
Cambridge CB10 1RQ
The scientific programme will include lectures and discussions from
Professors Chris Dodd, David Menon, Sandip Pal, Mervyn Singer
and Drs. Willam Haropp-Griffiths, Dominic Bell, Suresh Reddy, Dan
Wheeler, Anand Sardesai and other eminent speakers.
The meeting is open to all anaesthetists.
Anaesthetists in training presenting papers are eligible for prizes.
The deadline for abstract submission is 15th September, 2008.
CME 5 Points
Chief Guest: Prof. D. Dasgupta,
Mumbai, India
For further details, contact the Organising Secretary
Dr Rama K R Rebbapragada, Consultant Anaesthetist
Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ
Tel: 07929998187 (Mob.)
E-mail: [email protected]
[email protected]
Website: www.baoia.org
30 Anaesthesia News September 2008 Issue 254
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