Anaesthesia
News
No. 263 June 2009
The Newsletter of the Association of Anaesthetists of Great Britain and Ireland
ISSN 0959-2962
The Irish consultant contract
and the credit crunch
From anaesthesia
to hairdressing
Competency testing
– a guinea pig’s view
21 Portland Place, London W1B 1PY, Tel: 020 7631 1650, Fax: 020 7631 4352, Email: [email protected], Website: www.aagbi.org
Anaesthesia News June 2009 Issue 263
1
SEEING IS A GOOD THING.
Ultrasound Facilitated Epidurals
“In my experience, when used as a teaching tool, ultrasound aids with the learning curve and also increases
patient safety and comfort.”
Jose Carvalho, MD, PhD, FANZCA, FRCPC, Mount Sinai Hospital, University of Toronto, Canada
Evidence-based medicine has shown ultrasound facilitated epidurals increase accuracy and decrease
punctures. If a patient is overweight or has curvature of the spine, determining the depth of the ligamentum
flavum, becomes unpredictable by palpation. The M-Turbo® ultrasound system allows you to see the exact
space and depth to perform your puncture.
The durable 3.04 kg system can sit right next to your patient for optimal positioning.
The SonoSite M-Turbo is the ultimate tool in your hands.
Call 01462 444800 to contact your local sales representative.
www.sonosite.co.uk
©2009 SonoSite, Inc. All rights reserved. Subject to change. MKT01646 03/09
2
Anaesthesia News June 2009 Issue 263
Contents
03 Anaesthetist to Hairdresser: Is the grass really greener? (or is it just the hair?!)
06 Editorial - Inside this month...
08Executive Page: AAGBI Foundation
Launch
11Committee Focus - Irish standing
Committee
Anaesthetist to Hairdresser:
Is the grass
really greener? 13GAT Page - Professionalism in Anaesthetic Trainees
16 History Page - Chloroform for the Kaiser
18Competency Testing at the GMC – on the
Receiving End!
21AAGBI members develop Paediatric
Anaesthetic Drug Dosage Calculator
22 Resilience and Safety
(or is it just the hair?!)
24 Dear Editor…
26 One of those days…
292009 AAGBI Annual Congress Art
Exhibition, Liverpool
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
Deputy Editor: Val Bythell
Assistant Editors: Mike Wee and Isabeau Walker
Advertising: Claire Elliott
Design: Amanda McCormick
McCormick Creative Ltd,
Telephone: 01536 414682
Email: [email protected]
Printing: C.O.S Printers PTE Ltd – Singapore
Email: [email protected]
Copyright 2009 The Association of Anaesthetists of
Great Britain and Ireland
The Association cannot be responsible for the
statements or views of the contributors.
No part of this newsletter may be reproduced without
prior permission.
Advertisements are accepted in good faith. Readers
are reminded that Anaesthesia News cannot be held
responsible in any way for the quality or correctness of
products or services offered in advertisements.
Anaesthesia News June 2009 Issue 263
Pay is terrible, no pensions, there are no
‘real’ days off for the boss. I’m working
late evenings and Saturdays - so why did
I do it? Why did I actually swap career?
It’s a long story!
requirements! Gradually I recruited more
I thought about hairdressing when I
was about 10, long before wanting
to be a doctor. It didn’t stimulate any
encouragement from my parents who
were convinced I was capable of getting
a well-paid, secure, more intellectual
job. In the sixties it was not easy for a
boy with no sisters to have hairdressing
as a hobby. Only one or two men were
emerging as celebrity hairdressers, and
they were all assumed to be gay! So my
attention turned to sciences, initially
electronics and then biology, and I went
to Barts.
still my passion to do hair continued. I
At this time my crimping was limited to
attempts on a few willing girlfriends until
I married Mary who became my lifelong
model. She was tolerant enough
to have short or long, curly or
straight, blonde or dark hair
depending on fashion
and
my
training
house, new bridging loan, new job, new
clients, mainly from nurse friends, and
gained confidence.
We moved to Dunedin, New Zealand for
a year while I was a Senior Registrar and
joined a hairdressing evening course
with one of the theatre staff – great fun
until things became too busy.
Nicola
was one and George was about to be
born. Not the time to start a new career!
When we moved back to the UK it was
all systems go to find a senior registrar
job in the South West, and then after that
to get a consultant post. I was immersed
in research into computerised control of
propofol infusions. Spare time for hair?
Not a hope! I was very fortunate to get a
job at Torbay and we settled in well. New
schools all made for a busy and fulfilling
life. I was still doing the family chops but
few others.
I enjoyed my anaesthesia and took on
various challenges. But gradually two
things happened - I became heavily
involved in the computing side of clinical
3
audit and more and more people wanted
me to do their hair. (Diverse interests or
what?) In the late 1990s I reduced my hours
by one day a week to make time for these
other interests.
At this point my wife was getting a bit
fed up with women visiting the house for
a styling session. Too much colour ended
up on the dining room carpet! I decided to
see if I could actually do the job properly,
and work part time in a salon. First of all
I would need to get a qualification. So
with some trepidation, I went along to
our local technical college to meet the
hairdressing training department. I toured
the training salons. Age range 16 – 22,
99.9% female, all looking pretty cool. You
know how sometimes you feel like a fish
out of water? Next stop was the interview!
I really thought I would be gently told that
I wouldn’t fit in (not that they are allowed
to be ageist or sexist or degreeist!). It was
just the opposite. There was a course which
was held two evenings a week, it had a few
more mature students and they needed a
man ... to balance things up! So I was off.
After the first session I was welcomed into
the fold and it was wonderful to be taught/
reassured about all the things I had taught
myself over the years.
Even though this was a small part of my
week it took over a lot of my thinking, and
even enhanced my social life – hairdressers
love partying! I obviously did okay because
two years later in 2002, I found myself on
stage on the NEC (below) as one the eight
finalists for hairdressing student of the year
award. Amazing! I was actually “cutting it”
in my life long passion! Could it last?
I started working in a salon as a trainee on
Saturdays and soon brought in my own
clients. As my clientele expanded I did
some Mondays as well. Life was getting
busy again especially as I was working
more and more on Electronic Patient
Records (EPR).
At this time I had been heavily involved
in the South West EPR project. On the day
that we were to announce the successful
supplier the DoH rang up and pulled the
plug. This was a blow to myself and many
other keen clinicians who had ploughed
many personal hours into it. We were
told that the NHS would have its own EPR
project soon. But initially I had no stomach
for it and so went back to anaesthesia.
All was going well, I could cope with 1.5
days in the salon and 4 days anaesthesia.
But the National Programme for Information
Technology (NPfIT) desperately needed
working clinicians. I was soon tempted to
give advice and then time to this new, well
financed, IT project. Unfortunately Fujitsu,
which was the service provider for the
southern part of England, decided that all
the meetings should be held in Slough and
so it wasn’t long before I was catching the
fast train to Reading 3 or 4 times a month.
Disaster struck when the owner sold the
salon I was working in. Luckily I found a
much funkier salon on the main road and
they let me move in, temporarily, renting a
chair. But this time it was at realistic rates
and I found it much harder to make any
sort of profit. You have to work quickly and
accurately to earn anything!!
So now I was really busy, two days a week
in salon, plus hospital and NPFIT work –
increasingly in Slough. Something had to
go! Salon work was booming, NPfIT work
an intellectual challenge, and I still enjoyed
passing gas. Then out of the blue the current
salon owner asked if I would be interested
in buying the salon. I knew this was a good
business, and if the staff would stay I should
4
be able to keep the place running and do
a bit of Health Informatics as well (.... oh
yeah?!) It would be easier to do that than
try and keep accredited to do locums or
private anaesthesia.
But could I afford to give up anaesthesia?
Could I retire? I was 55, so yes I could, but
with a 25% reduction in pension for taking
it early and the loss of 5yrs superannuation.
But of course I would have other income
from the salon and any informatics work,
wouldn’t I?
So I bought the salon in July 2007 and gave
it a refit.
2 years on
Firstly running a small business single
handed is very time consuming – much
more than I naively thought. Delegation is
possible but to whom? Do I use my existing
(nine) staff who are better at hairdressing
than running businesses? Or pay a lot for a
new manager? This not only costs but would
rock the boat enormously. I have learned
it’s a very close working environment, with
lots of strong feelings!
Secondly, once I had left my permanent
NHS job there seemed to be few offers
for part time informatics jobs. These were
mainly full time from commercial firms
(eg Fujitsu), or part time for the NHS but
based in Leeds or London 3 days per week.
Neither was possible.
Thirdly I began to really enjoy both the
challenge of the business and of course
being in the thick of it – hair of course! At
last I could really concentrate on honing
Anaesthesia News June 2009 Issue 263
but these have to some extent been
replaced ... I’d better not expand!
10.It’s fun being in the driving seat. At
last being able to make decisions
and see them implemented without
interminable committee work or red
tape. Even Health and Safety makes
more sense! But nothing happens if you
don’t make it happen. Training courses,
decoration, stocking up, web sites,
repairs, wages, personnel development
and many other things are driven from
the top. I have learned a lot about
myself and drawn heavily on skills
previously learned.
my skills and expanding my range of
hairdressing. When I am not too busy
sorting out staff issues, or suppliers or
finances, I can immerse myself in the job I
love. I am still doing hair competitions and
now getting my staff to join in! (see picture
below left)
The key differences between anaesthesia
and hairdressing for me are:
1.It’s creative. I can think out of the box as
much as I like and give it a go (usually
with the client’s approval!)
4.I did get a buzz from saving lives and
reducing suffering, and fortunately
there are still many of you who
enjoy it. Hopefully anaesthetists will
continue to get more recognition and
job satisfaction. But for me practising
medicine is not a ‘fun’ side of life. It’s
made me realise how much we doctors
see the harsher side of life.
5. It’s great not being on call!
6.Working in the salon you make people
happy.
2.It’s practical. I like learning practical
skills. Anaesthesia has some key ones
such as inserting lines, epidurals and
tracheal tubes. But it is a relatively
small part of the job. The elegance with
which you do it is often missed by the
patient, and is rarely part of exams. The
way you cut or style hair is noticed, and
has a profound effect on the final result.
So you work hard at getting better and
better.
7.You hear a different side to their lives
than when talking to them as a doctor.
You are more of an equal status.
3.There is more direct feedback from
clients (they are not heavily drugged
when I have finished with them!).
Perhaps I shouldn’t need this but it
makes a difference. You can see their
delight!
9.The working environment is a bit of
culture shock. It’s not like a hospital with
4000+ employees. Most of my staff are
under 22 and all female but fortunately
they still take me clubbing! I miss the
in-theatre banter and “medical” jokes
Anaesthesia News June 2009 Issue 263 8.I definitely don’t earn as much! Money
could become an issue, especially as
the credit crunch looms but I think
(hope) this is only a minor risk. The
business is well established, I have a
reasonable pension and my wife still
works.
I miss, however, the challenges of health
informatics and try to keep up with the
progress of NPfIT. But it seems that progress
is slower than anyone would have hoped.
I don’t think I will miss much if I go back
to it when I’m 60! The frustration of seeing
so many health IT projects emerge and
then crash over the last 20 years was very
wearing.
All in all I am very pleased I took the
plunge. It's been a life-long passion that
needed to blossom. Things could go very
wrong with the business but hopefully
I will still have a capital investment. Or I
could find that after five years I can’t stand
doing another head of highlights! But by
then I hope I would know enough about
the business to delegate.
My advice to anyone who has had a
longstanding passion to do something
alongside a medical career is to give it your
best shot. Do what you can to sample it
before swapping careers and make sure
that you are secure enough to survive if it
doesn’t work out. But you won’t regret the
fact that you tried it!
Roger Tackley
www.rthairandbeauty.com
5
Editorial
Inside this month...
This month in Anaesthesia News we’ve got
one of those stories which I knew I had to
get as soon as I heard about it. I actually
chase up articles relatively rarely (unless
you’re a Council member who’s promised
me a report) but a few months ago I just
about dropped my morning coffee when I
read in my newspaper a short item about
Roger Tackley, who’d given up anaesthetics
to be a hairdresser, and immediately longed
to know more. So I’m very pleased that
Roger has managed to take time out of his
busy days running his own small business
to tell us all about it. Have you ever thought
about doing something else? I know I have.
But like most of us, it was only a pipe
dream, and the practicalities of earning a
living intruded. I’m sure I’m not the only
person who will read Roger’s article with
admiration and a twinge of envy that he had
the desire and gumption to see it through.
I’ve told him that if ever I’m in Devon, I’ll
come in for a “do” if he promises to put that
green dye away. It occurs to me that this is
my second editorial about hairdressing (see
October 2008). I don’t think that happened
much when Ed Charlton was in charge...
Annual Congress is not too far away, and I
hope many of you are planning to attend
what promises to be a fantastic event
in Liverpool in September. As well as
organising your study leave, I hope you’ll
read Stephanie Greenwell’s article about
the art exhibition and consider whether
you might exhibit. Every year there’s a
wonderfully diverse range of talent on
show, and as a former exhibitor myself I
can only echo her remarks about the pride
6
you take in getting nice feedback about
your work, and that you mustn’t be too
modest. Anaesthetists are always hiding
their lights under bushels (and letting the
ruddy surgeons take the credit) but this is
one occasion when you’re among friends,
so forget about thinking your art’s no good,
and let everyone see it. Last year’s runaway
winner started out as a doodle and ended
up being a fascinating piece of art you could
look at for hours. Everyone was talking
about it, to the amazement of its creator,
Robert Cruickshank. This year, it could be
you... But even if it’s not, you will not regret
taking part. Although John Edwards cribbed
the original idea from (I think) the ASA
meeting, it’s the only medical art exhibition
of its type I’m aware of in the UK.
Andrew Hartle, the chairman of the
AAGBI’s safety committee, has contributed
a thought-provoking article about how
anaesthetists have to deal with the sharp
end of failures, whether they be power
failures, or failures in the supply chain.
I’m interested to hear about your supply
problems as we seem to be increasingly
afflicted with them – in the last two weeks
we have had intermittent or more prolonged
non-availability of 2ml syringes, face masks,
hats, and surgical skin clips. None of these
are exactly rare items whose availability
might be unpredictable – we use them all
on a daily basis. Our supply chain has been
streamlined as it’s financially inefficient to
carry huge amounts of stock (I knew that
when I worked in Woolworths in 1974),
but it seems our managers may have gone
too far, and the process may need to be
finessed somewhat. Let Anaesthesia News
know what you’ve run out of recently.
Fortunately our hospital seems to have got
its power supply sorted – for a few years
we got plunged into darkness on a number
of occasions, but that hasn’t happened
for a while. (Allegedly on one occasion,
an engineer had disabled the automatic
back-up to work on it, tripped out the
main power supply and was plunged into
darkness himself, so couldn’t find any of
the vital switches to restore power). One
of my anaesthetic room checks was, as
Andrew advises, that the torch on top
of the fridge was present and working,
but I haven’t done that for a while. Must
do it tomorrow! However, we do know
where the emergency power sockets in
the anaesthetic department are – when
they’re having a generator test (Wednesday
mornings) it’s where the kettle is plugged in.
And finally, anaesthesia gets the blame for
lots of things. However, in this month’s
issue Frank Bennetts has taken it to a whole
new level (and he’s one of us). On page
16 you can read why the First World War
might have been our fault!
Hilary Aitken
Editor
Anaesthesia News June 2009 Issue 263
The 8th International
Conference on
Evidence Based
Peri-Operative Medicine
The IET, London, 29th June - 3rd July
Call the booking line on
0161 603 47 1 9
or visit www.ebpom.org
10
C
Po PD
ints
!
Secure upto 15 CDP points minimum!
EBPOM 2009 is fast approaching,
so don’t miss out!
SPEAKERS INCLUDE
• Prof Henrik Khelet
• Prof Sam Machin
• Prof Monty Mythen
• Dr Paul Older
• Prof Don Poldermans
• Dr Andy Rhodes
• Prof Kathy Rowan
• Dr Neil Soni
• Prof Matt Thompson
• Prof JP Van Bessouw
• Prof JL Vincent
• Dr Andy Webb
Cardio Pulmonary
Exercise Testing
Course
ONLY 32 delegate places available!
The 8th Evidence Based Peri-Operative Medicine
5C
Conference will again take place in London at the IET
PD
P
o
confirmed for 2nd and 3rd July 2009, with associated
ints
!
events and workshops at the same venue on
Monday 29th, Tuesday 30th June and Wednesday 1st July.
• Dr Angela Bader
• Dr Scott Beattie
• Prof David Bennett
• Dr Andy Bodenham
• Dr Ian Calder
• Dr Tim Cook
• Prof Giorgio Della Roca
• Dr Roshan Fernando
• Prof Lee Fleisher
• Dr Mike Grocott
• Dr Mark Hamilton
• Dr David Hepner
• Dr Ross Kerridge
29th & 30th June 2009
1st July 2009
The 2nd National
CPET Meeting
Delegate places will be limited!
Ap
CP
pro
D
ved
2nd & 3rd July 2009
8th EBPOM
Conference
Delegate places will be limited!
Visit the website for the full
programme for each event
www.ebpom.org
Anaesthesia News June 2009 Issue 263
7
Executive Page
AAGBI
FOUNDATION
LAUNCH
On the 2nd April we were delighted to
• To represent members’ interests
to run down and it was subsumed into the
welcome back Professor Michael Harmer,
• To encourage and support worldwide
Research and Education Trust.
Medical Director, Wales, and former
President of the AAGBI to formally open
the new Association of Anaesthetists of
Great Britain and Ireland Foundation. What
is the Foundation? For this we need a little
history lesson.
cooperation
So it was at this point that the AAGBI
These remain its main aims. The AAGBI’s
effectively divided into two organisations.
involvement in research and education
The AAGBI itself became a company and
increased over the ensuing years to the
the AAGBI Education and Research Trust
point at which it was felt necessary to
became a charity with all its attendant
legally constitute a ’Research Trust’ within
tax and other benefits. Incidentally the
At its launch in 1932 the aims of the AAGBI
the organisation. This was achieved in
‘AAGBI Education and Research Trust’ had
were:
1955. By 1959 a trust fund was set up
reputedly the longest name in the charity
and named the ‘Research and Education
commission handbook.
• To advance and improve patient care
• To promote and support education and
research
Trust’. These two merged in 1969 when the
original Research Trust funds were allowed
In 2008 there were major changes in
Company Law affecting all companies
including the AAGBI. This gave us an ideal
opportunity to review all the memoranda,
articles and regulations of the AAGBI
and its charity. This was ably carried out
by Dr William Harrop-Griffiths, the then
Honorary Secretary. One of the suggestions
was to rename the rather long-winded
AAGBI E&R Trust to the AAGBI Foundation.
This change is not simply of name: it is a total
re-launch of the charity arm of the AAGBI.
Central to this is a complete restructuring of
the charity’s finance. At present most of this
is gifted from the AAGBI company. In the
future most of the investment portfolios will
be within the Foundation and monies will
of course accrue from other activities of the
Foundation such as its major meetings. This
AAGBI President Richard Birks with Professor Mike Harmer
8
is much more in keeping with how other
Anaesthesia News June 2009 Issue 263
Council members Isabeau Walker, Ellen
O'Sullivan and Iain Wilson at the official
launch of the AAGBI Foundation
charities are financed and consequently
with the possibility of attracting more
Finally
this sits more easily with the Charity
central government monies via the trusts.
International Relations Committee which
Commission requirements.
Education continues to be the core
As with other charities there will be separate
business of the AAGBI. The two main
trustees, who will be the Vice Presidents
meetings, Annual Congress and the Winter
of the AAGBI, along with the Immediate
Scientific Meeting, together with the ever-
Past Honorary Secretary or the Immediate
popular GAT trainee meeting, seminars
Past Membership Secretary, again bringing
and core topics meetings all continue
the Foundation more into line with other
to grow in popularity. Add to this more
charities.
electronic educational tools, podcasts and
The aims of the charity will continue to be
research and education but with a particular
emphasis on patient safety, increasingly
videos covering our ‘glossy’ launches and
the AAGBI is well prepared to meet future
educational challenges.
With the aim of emphasising the focus on
AAGBI has had a Safety Committee since
safety, the AAGBI is producing some of
1974).
its ‘glossies’ as safety guidelines, some of
be a major part of the newly formed National
Institute for Academic Anaesthesia along
with its journal ‘Anaesthesia’, the Royal
College of Anaesthetists, and the British
Journal of Anaesthesia. Now entering its
second year it has already demonstrated a
robust selection system for grant resourcing
Anaesthesia News June 2009 Issue 263
which have been reported in the national
press recently. There is a strong association
with the National Patient Safety Agency
who now have a representative on our
Safety
Committee,
and
must
not
forget
the
is part of the Foundation, with its many
examples of providing educational tools
to developing countries particularly in
Africa. It is particularly appropriate, as
Professor Harmer launches the Foundation,
that we should mention the Overseas
Anaesthesia Fund (OAF) which is a standalone charity set up by Professor Harmer
in 2006. It has been more successful than
ever anticipated and has helped provide
equipment and teaching aids overseas. It
has been particularly involved in the Global
important in this day and age (although the
On the research side the AAGBI is proud to
we
the
Oximetry project aiming to eventually
provide pulse oximeters to all Third World
operating establishments.
Let us hope that all these areas under the
wing of the AAGBI Foundation continue to
thrive in their new restructured home.
National
Dr R Birks
Institute for Health and Clinical Excellence
President AAGBI
are interested in ‘badging’ some of the
glossies.
9
The Anaesthetists
Agency
safe locum anaesthesia,
throughout the UK
Freephone: 0800 830 930
Tel: 01590 675 111
Fax: 01590 675 114
ad.landscape
8/4/09
13:13
Freepost (SO3417), Lymington,
Hampshire SO41 9ZY
email: [email protected]
www.TheAnaesthetistsAgency.com
Page 1
THE INTENSIVE CARE SOCIETY
FORTHCOMING EVENTS 2009
THE STATE OF THE ART 2009 MEETING
MONDAY 14 – TUESDAY 15 DECEMBER 2009 | HILTON METROPOLE, EDGWARE ROAD, LONDON
Mark your diary now!
Once again the ICS will be bringing together leading figures
and international speakers within the field of intensive care
to speak at our most prestigious and important meeting of the
year. Day one of the meeting will provide a choice of parallel
sessions with the clinical practice and research forums. Day
two will be dedicated to state of the art topics of relevance
to intensive care medicine.
Submissions of free paper abstracts will be accepted for
presentation in the research and clinical practice sessions.
Applications for the Research Gold Medal Award are also invited.
CPD accredition: TBC
Further details including a full meeting programme, registration
details and guidelines for free paper submission may be
obtained from the ICS website www.ics.ac.uk/meetings.
10 Did you know the ICS regularly runs other events including one
day practical seminars held in central London? With convenient
start and finish times these meetings are designed to enable
you to make the most out of a day and to ensure you stay
ahead of all the latest developments.
Not a member of the ICS? Register today and receive
the following:
• Reduced meeting rates
• Insurance cover for emergency patient care
• Free quarterly Journal of the Intensive Care Society
• Monthly enewsletter
• Members access on ICS website-coming soon
To register for any ICS meetings and view full
programme details please visit www.ics.ac.uk/meetings.
All seminars will take place at Churchill House,
35 Red Lion Square, London WC1R 4SG
Anaesthesia News March 2009 Issue 261
Committee Focus
Irish standing Committee
Economic ‘climate change’ impacts
on a health service - a case report
A toxic debt butterfly fluttered its wings in
a far off North American bank creating the
wisps and eddies of an economic hurricane
as the sides in a new consultant contract
for Ireland concluded their negotiations
in mid-2008. This is said to herald a new
way of working in the Irish Health Service,
a potential response to the ‘Working Time
Directive’ with a way out of “dependence
on non-consultant grades”. Promises of
increased consultant numbers were offered
as a stimulus if the contract was agreed
by December’s end, which included an
estimated 24 million euro pay increase for
the current consultant establishment. Private
practice would be capped or abolished
depending on the version of the contract and
consultants would spend more time with
public patients. The sun was still shining.
The Department of Health and Children
and the Health Service Executive had also
started to look strategically at the delivery
of important services such as Oncology.
Recommendations from external and
internal reports were to be implemented
with appropriate capital funding. The Health
Service was hoping to gear itself so that
many other services would develop ‘best
practice’ models of patient access and
care. The earlier wisps and eddies became
gusts but the economic warmth still had an
autumnal glow.
By November the gusts strengthened to
a good south-westerly and the economic
slowdown became a full stop. Some
eighty percent of consultants would sign
the new contract but many would remain
unconvinced with its terms and the definition
of the proposed clinical director posts.
A budget was hurried through the Oireachtas
(Irish Houses of Parliament) in the beginning
of December in response to an impending
deficit in the exchequer. Attention was
diverted from Christmas to the loss of state
supported medical services for all of the ‘over
seventies’ and education cost curtailments
for schools. The seniors in society mobilised
and had the Government rescind its plan to
means-test them. It was clear that
there would be no savings
from this quarter of
upwards of 24 million
euros.
Meanwhile the winds
turned icy with gale force. The climate
was really changing! Cold tentacles of fiscal
rectitude could be felt down the corridors of
many public offices as staff were
encouraged to shore up all losses
Anaesthesia News June 2009 Issue 263 in revenue and minimise wastage, if not
turn down the heat. Patient services were to
be maintained but it was clear that certain
projects could be at risk. The resources
available for reorganising the acute
sector’s hospitals and its streamlining with
primary care were threatened. At ground
level consultants were being loaded with
paperwork to obtain resources, allowances
and leave. Locums for leave were not being
granted. However, this was not uniform and
its apparent application varied between
hospital networks.
However, it was Christmas time after all and
the goose was getting fat; the media were
also happy to inform readers and listeners
that this was also the case for consultants’
salaries in such cash strapped times. The
notion of pay cuts especially for ‘high’
public salaries was in vogue. A whirlwind
of activity took place and levies and taxes
that amounted to a pay cut were imposed on
all public sector employees. The increased
awards for those who had signed their
contracts earlier would also be delayed.
After meetings with representative bodies
the Minister indicated that her department’s
budget estimates allowed for the increased
consultant payment in the New Year (2009)
but would be subject to a verification process
and the installation of clinical directors.
By the New Year further estimates by the
Department of Finance indicated a two
billion euro deficit for 2009 and further cost
containments were sought. The hurricane of
economic chaos was by now blowing hard.
The Health Service Executive pondered
changes in the working conditions of non-
11 consultant hospital doctors (NCHDs). There was perceived leverage
in reducing overtime and recently won ‘allowances’. A Labour Court
ruling against the NCHDs and Irish Medical Organisation in January
2008 has convinced human resources that practices were open to
further immediate change. In February, the groundwork was laid for
non-payment of NCHDs’ lunchtime breaks in March. The introduction
of shift patterns has not happened yet and all is to be the subject of a
High Court case, due to be heard in April. In the meantime the NCHD
contract will probably be revised before July’s rotation.
Call the booking line on
0161 603 4719
or visit www.ebpom.org
“All changed, changed utterly:…”?
From the specialty’s viewpoint many colleagues are concerned that
ultimately the relationship of consultant and NCHDs as trainees will
become blunted if not distant. Furthermore, anaesthesia colleagues
are concerned that a ‘hospital-at-night’ arrangement may become
the norm for their own practice especially if NCHDs have further
restrictions placed on their working day or their recruitment.
March is almost finished at the time of writing and the new consultant
contract has not yet been honoured. However the Department
of Health and Children has had to conduct its “implementation
verification” process – a review of consultant submitted work
plans. This has concluded. It was latterly awaiting the uptake of the
clinical director posts as a further criterion. In the meantime, the
representative bodies have asked new contract holders to continue
working the new terms even where private practice has been lost.
The Minister continues to reassure the representative bodies and the
Oireachtas that the new pay arrangements will be met.
In the same month the Health Service Executive finally concluded
that patient services would probably be affected. It remains unclear
what this will mean but there are many guises it could take: forced
acute hospital closures and/or amalgamations may take place at an
increased pace, restriction and policing of diagnostics and treatments,
and theatre closures have been mentioned.
The gap between funding and expenditure by the Health Service has
shrunk as the unemployment rate rises for the first time in many years.
The number of people entitled to free social and medical care is rising
as a consequence, with primary care spending taking the major part
of any financing for this pattern. It is thought many will also opt out
of private care as a household saving and healthcare insurers are
reckoning on a reduced income for 2009. The significance for private
hospitals and consultants engaged in private practice is awaited.
This has undoubtedly been an inauspicious time to embark upon
change management and the reorganisation of the totality of
healthcare in Ireland. It has been so far at least bumpy and the eye of
the storm may not yet have been entered. Budgets, resource accrual
and deployment have not yet been delegated to consultants but the
number, scope and rapidity of measures that have recently been
introduced and continue in response to the economic maelstrom
appear chaotic. This could tell on that important factor of trust while
a government supplementary budget is awaited at the time of writing
in April.
Rory Page
Convenor, Irish Standing Committee
12 The 8th International
Conference on
Evidence Based
Peri-Operative Medicine
The IET, London, 29th June - 3rd July
Secure upto 15 CDP points!
EBPOM 2009 is fast approaching,
so don’t miss out!
The 8th Evidence Based Peri-Operative Medicine
Conference will again take place in London at the IET
confirmed for 2nd and 3rd July 2009, with associated events
and workshops at the same venue on Monday 29th,Tuesday
30th June and Wednesday 1st July.
29th & 30th June 2009
10
C
Po PD
ints
! Cardio Pulmonary
ONLY 32
delegate
places
available!
5C
Po PD
ints
!
Delegate
places
will be
limited!
Exercise Testing
Course
Ap
CP
D
pro
ved
1st July 2009
The 2nd National
CPET Meeting
2nd & 3rd July 2009
8th EBPOM
Conference
Delegate
places
will be
limited!
Visit the website for the full programme for each event
www.ebpom.org
Anaesthesia News June 2009 Issue 263
GAT Page
Professionalism in
Anaesthetic Trainees
Felicity Howard
Honorary Secretary, GAT
Committee
I recently attended a session at a conference
entitled “Meeting the challenges in medical
education.” During the question and answer
session at the end I was surprised and
disappointed to hear the professionalism
of today’s anaesthetic trainees being called
into question by the (mostly consultant)
delegates. A lack of enthusiasm and
motivation, “whinging” and the dreaded
phrases “clock-watching “and “shift
mentality” were all mentioned. That set
me thinking, on behalf of all my trainee
colleagues, about what professionalism
actually means in practice.
What does it mean to be professional?
We hear the word “professional” virtually
every day of our lives. We are obliged
to undertake “Continuing Professional
Development”. The Royal College of
Anaesthetists (RCoA) has a Professional
Standards Committee which is concerned
with how well a service is delivered both
at departmental and individual levels. The
newspapers are full of tales of professional
footballers, which at times sounds like
an attractive alternative. But what does it
actually mean?
The Oxford English Dictionary defines
“professional” as follows:
• Adjective 1 relating to or belonging to
a profession. 2 engaged in an activity
as a paid occupation rather than as an
amateur. 3 worthy of or appropriate to a
professional person; competent.
Anaesthesia News June 2009 Issue 263
• Noun 1 a professional person. 2 a person
having impressive competence in a
particular activity.
As anaesthetic trainees, we can certainly
relate to the first two adjective definitions
(assuming none of us is working for free)
but I wonder how many of us feel “worthy”
or would confidently state that we have
“impressive competence”? It would
appear that, in achieving competence
through our RCoA competency-based
training programme, we also achieve
professionalism. But is this the whole
story? After all, no-one in the conference
room appeared to be questioning trainees’
competence.
David Morrell takes the definition further
and describes six characteristics of
professionals [1]. These involve:
• the existence of skills or expertise
extending from a broad knowledge base
• providing a service based on a special
relationship between provider and
receiver
• public recognition of authority
• independence from the influence of the
state or commercial sector
• emphasis on being educated rather than
trained
• having a legitimised independent
authority
Elliot Freidson [2] identifies autonomy as
the characteristic central to professionalism,
in that a profession has the right to control
13 how and by whom its own work is done.
This is especially interesting given the
recent re-configuration of our professional
governing body, the General Medical
Council, to include a greater proportion of
lay members.
Why do we need to be professional?
The RCoA CCT in Anaesthetics I: General
Principles. A manual for trainees and
trainers (August 2008) dedicates Section
4.7 to professionalism. It defines medical
professionalism as “…a set of values,
behaviours and relationships that underpin
the trust the public has in doctors …
professionalism means more than clinical
competence…”
It divides professionalism into two areas:
• Attitudes, communication and behaviour
• Professional knowledge and skills
We are all expected to learn, acquire and
develop these areas during our training,
and should be regularly assessed to ensure
we are meeting these standards. This is
usually part of the RITA/Annual Review
of Competence Progression, but precise
methods will differ between Schools of
Anaesthesia.
Can professionalism be taught?
We would all agree that professional
knowledge and skills can easily be taught
and examined. There has been significant
progress in recent years in the teaching of
communication skills – both with greater
emphasis at undergraduate level and more
formal post-graduate teaching programmes.
But what about attitudes and behaviour
– especially in a population aged from
their mid-twenties onwards? It is well
recognised that problems in these areas are
major factors in the occurrence of critical
incidents, particularly in relation to teamworking, and also in complaints against
doctors. They can also cause problems
within individuals’ training. Obviously,
personal character traits will play a part in
this, but we are never too old to learn from
14 our colleagues. Reflective learning and
evaluation may be useful tools to aid the
process, especially if used in the context of
a mentoring relationship. It could be argued
that, by our stage in life, this process may
involve more of a modification of behaviour
processes or rectifying our shortcomings
rather than learning completely new skills.
Just as children learn from role models as
they grow and develop, we should not
under-estimate the value of positive (and
sometime negative) role models in our
places of work. One of our privileges as
trainees is the opportunity to work with
many different colleagues, and being able
to take something away from every learning
opportunity.
When and where should we be
professional?
We clearly have a duty to our patients
and colleagues to act with the utmost
professionalism at all times in the working
environment. This, I believe, extends outside
the realms of our departments and hospital
trusts into other areas of our professional
lives, including attending meetings and
conferences as representatives of our
profession. To a greater or lesser extent we
probably also carry these core professional
values away from the workplace, allowing
them to impact on other areas of our lives.
So where did it go all wrong?
There have been many factors, both internal
and external to our profession, which have
deeply affected trainees in recent years
and continue to exert a significant effect in
the erosion of professionalism today. The
implementation of Modernising Medical
Careers (MMC), in particular the Medical
Training and Applications System (MTAS)
fiasco of 2007; the changing work patterns
associated with implementation of the New
Deal contract and the European Working
Time Directive (EWTD), particularly the
transition to shift working patterns and the
accompanying fatigue (it’s no better than in
the “good old days” of 24-hour on-calls); a
new generation of medical graduates who
have only ever worked shifts and always
been strictly observed by trust monitoring
officers; the endless need to fill in forms
and tick the correct boxes; I could go on…
How can we fix it?
All of us anaesthetic trainees should, to
quote Professor Sir John Tooke, be “aspiring
to excellence” in our work – this includes
professionalism. Whilst it appears, on first
inspection at least, that every change to
our training in recent years is doing its
best to prevent us achieving excellence,
we must never give up striving for it. Every
opportunity, however small, can be used
to demonstrate our professionalism – be
it something as simple as filling out leave
request forms correctly and in plenty of
time, volunteering to help out a colleague,
mounting a challenge to a perceived
injustice or simply smiling in the face of
adversity and quietly getting on with the
job.
To the consultants present in that room I
would like to say this: look more closely
at your trainee work colleagues. Training
conditions are always changing and so will
be very different now to when you trained.
If you can get beyond the “it’s not how it
used to be…” attitude, you will find many
trainees who are aspiring to excellence in
their own, maybe small, ways. There will
doubtless be several who are struggling
with their motivation; perhaps you can find
a new way of nurturing and inspiring them?
We are the future of your profession; help
us to continue to set a shining example
through the continuing development of
professionalism.
Felicity Howard
Honorary Secretary, GAT Committee
References
[1] Morrell, D. What is Professionalism?
Catholic Medical Quarterly (February
2003)
[2] Freidson, E. A Study of the Sociology of
Applied Knowledge. (1988). Dodd, Mead
and Company.
Anaesthesia News June 2009 Issue 263
MERSEY
The August Menu for the
September Final FRCA
The Final FRCA MCQ Course
14.00 Sunday 9th – 12.00 Friday 14th
£300
The Final FRCA SAQ Weekend Course
14.00 Friday 14th – 13.00 Sunday 16th
£250
The Final FRCA Crammer (Booker) Course
14.00 Sunday 16th – 16.00 Friday 21st
£500
The September Menu for the
October Primary
The Primary Viva Weekend Course
14.00 Friday 11th – 12.00 Sunday 13th
£250
The Primary OSCE Weekend Course
14.00 Friday 18th – 13.00 Sunday 20th
£250
The Primary OSCE/Orals Week Course
14.00 Friday 25th – 16.00 Friday 2nd October
£600
For
Venue – Format – Facilities – Courtesies – Concessions – Application
Please See
msao.org.uk
Anaesthesia News June 2009 Issue 263
15 History Page
Chloroform for the
Kaiser
Anaesthesia has been of great benefit to
mankind for more than a century and a half.
But its use in 1859 to enable the delivery
of the infant who became Kaiser Wilhelm
II might be considered as the reverse of
beneficial. This man was substantially
responsible for the German military buildup leading to World War I, with the deaths
of more than six million combatants. Had
his birth taken place thirteen years earlier,
before the 1846 discovery of anaesthesia,
perhaps the whole course of history might
have been changed.
Queen Victoria’s eldest daughter - also
named Victoria - married the heir to the
Prussian throne in 1858. Pregnancy quickly
resulted and in January the following
year she went into labour. The Queen,
concerned about her daughter’s condition,
sent her physician, Sir James Clark and
her personal midwife, Mrs Innocent to
Berlin about a fortnight before delivery
was due. The labour was prolonged and
extremely painful and when the regular
German attendants realised that outside
help was urgently needed the British team
were allowed to attend the Princess with a
local expert obstetrician, Dr Eduard Martin.
He found that delivery of the breech from
the exhausted Princess was hampered by
entrapment of the infant’s left arm with the
head in the pelvis.
Perhaps at the suggestion of the Queen, who
had appreciated analgesia with chloroform
16 during her recent confinements, Sir James
had brought a bottle of the anaesthetic to
Berlin. He used it to ease the Princess’s
pain, deepening anaesthesia while Martin,
with great difficulty, brought down the
arm, causing gross damage to the brachial
plexus. He then delivered the head but
noted that cord pulsation, and the infant’s
heart rhythm and rate had deteriorated
during the traumatic procedure. The onset
of spontaneous respiration in the infant was
delayed for several minutes.
Umbilical cord compression, which must
have occurred here, is a well-recognised
complication of breech delivery, and
consequent
cerebral
hypoxia
and
hypotension may result in brain damage
in the infant.
Inhalation anaesthetics
administered to the mother are rapidly
transferred across the placenta to the fetus,
so the neonate’s cerebral hypoxia may
have been intensified by deep chloroform
anaesthesia and its respiratory and cardiac
depressive effects. This series of misfortunes
may have profoundly influenced both the
life of the child surviving the difficult birth,
and world affairs when the child became an
adult and his nation’s hereditary autocratic
leader at the early age of twenty-nine.
What sort of person then - child and adult did Wilhelm turn out to be? There is general
agreement that he was a hot-tempered,
intolerant youth whose rudeness to his
mother before strangers shocked observers.
His mother and tutor concur that as a child
William was not possessed of brilliant
abilities, or strength of character. At his
A-level exam equivalent he passed tenth of
a class of seventeen. On leaving school his
life was mainly devoted to the army, but his
adjutants thought that he continued to have
the mind of an immature teenager. His
mother complained to the Queen that at
twenty, her son was becoming chauvinistic
and ultra-Prussian to a degree, with a
violence and barbarism which was painful
to her.
On inheriting his throne in 1888 the Kaiser
showed utter contempt for the elected
representatives of his country and spoke
of the German parliament as ‘that pigsty’
and of the opposition as ‘dogs who should
be taken out and whipped.’ However the
country now had a parliamentary system so
that it was to some extent a constitutional
monarchy, and by controlling the budget
the Reichstag had power over the Kaiser’s
worst excesses. Bismarck, his Chancellor,
declared to a newspaper editor that
Wilhelm was mentally disturbed, and
around 1900 it is clear that rumours were
circulating in Germany about his mental
state and plans were even being considered
for removing him from the throne as ‘unfit
to rule’. But these came to nothing.
Anaesthesia News June 2009 Issue 263
The loyalty of many monarchists was
now under strain. To them, Wilhelm’s
overestimation of his own abilities, his
tendency to make snap decisions and give
unwise spontaneous speeches and indulge
in overdramatic gestures often seemed the
height of irresponsibility. In June 1891,
three years after gaining power, he planned
to increase the size of his army and redeploy
its strength. In a speech given in May of
that year, Wilhelm claimed that he, alone,
was master of the Reich and would tolerate
no power in others. In Wilhelm’s view,
Socialists, Catholics, Jews and Freemasons
were all enemies of the State
As well as a growing recognition of the
problem in his own country, there was
strong suspicion in western European
capitals of his mental state. Lord Salisbury
- British Prime Minister in the 1890s believed that Wilhelm was ‘not quite
normal’, and Asquith in 1911 said he
was ‘tempted to discern the workings of
a disordered brain.’ Sir Edward Grey, the
Liberal Foreign Secretary, thought that
Wilhelm was ‘not quite sane’ and could
well ‘cause a catastrophe’ one day.
Living in the days when distinctions
between various kinds of mental illness
were beginning to be made, the Princess
may have realised that some of her son’s
peculiarities could be interpreted as
signs of mania, a state of mind which,
following the death of his father in 1888,
became exaggerated on his accession to
the German throne. After only two years
in power, Wilhelm dismissed the wily and
vastly experienced Bismarck, inspiring
the famous Punch cartoon ‘Dropping the
Pilot’. This Kaiser wanted to rule alone
and believed - like Charles I - that he had
a divine right to do so. But his staff found
him totally unpredictable and some quietly
questioned his megalomaniac mental
state. With personal rule, his outbursts
became more and more outrageous and
he was prone to telling inexplicable lies.
Biographers have tended to view him as a
manic-depressive.
Can we link this Kaiser’s long-standing
mental condition and his obsession with
military and naval expansion to birth
injury? The literature on the relationship
of mental disorder in adult life to this
type of trauma, and in particular to
complicated breech delivery, is sparse but
suggestive. A further factor is that at high
clinical concentrations, modern volatile
anaesthetics have been shown to aggravate
regional cerebral ischaemia in animal
models, but it is unknown whether this
effect extends to chloroform.
From
historians’
and
biographers’
descriptions of his character in childhood
and adult life, we can get a feeling for the
Kaiser’s mind-set, and it is not difficult to
imagine the effect of the useless arm alone
in a man who glorified his army, rapidly
enlarged his navy and had a fascination for
uniforms. His early attempts, on coming
to his throne in 1888, to appear a benign
liberal autocrat were belied in practice by
his desperation to be the autocratic head
of a world power capable of tackling and
beating Great Britain or Russia – or both
together. In this he was ably spurred on
by the powerful German military clique of
the time. Once war became inevitable,
he appeared, quite unsuccessfully, to
distance himself and his empire from the
Anaesthesia News June 2009 Issue 263 impending conflict, but a reactionary,
militaristic, Anglophobic temperament in
an unbalanced ruler with absolute power
must surely bear substantial responsibility
for the catastrophic holocaust of 1914-18.
If the introduction of anaesthesia to the
world had been delayed by fifteen years
it is unlikely that either the neonate who
became Kaiser Wilhelm II, or his mother,
would have survived this complex birth.
The discovery of chloroform may well have
played a more significant role in the history
of Europe than we realise.
Frank E Bennetts
Retired Consultant Anaesthetist
References and further reading
Bennett D. Vicky. Princess Royal of England
& German Empress. London: Book Club
Associates, 1973; 4-85
Clark J. to Queen Victoria. Letters of 27 and
31 January 1859 in the Royal Archive refs
Z63/107 and 117, quoted in Röhl p 829
Fasbender H.. Geschichte der Geburtshülfe.
Jena: Gustav Fischer, 1906; 281
MacDonogh G. The Last Kaiser. The Life of
Wilhelm II. New York: St Martin’s Griffin,
2000
Marx R. The birth of an emperor. Surgery,
Gynecology and Obstetrics 1949; 89, 366369
Ober W. Obstetrical events that shaped
Western European history. The Yale Journal of
Biology and Medicine 1992; 65, 208-9
Pakula H. An Uncommon Woman. The
Empress Frederick. London: Phoenix Press,
1996
Palmer A. The Kaiser: Warlord of the Second
Reich. London: Phoenix Giant, 1997
Röhl JC. Young William; the Kaiser’s Early
Life 1859-1888. Cambridge University Press,
1998; 4, 7-14, 274-278, 826-827
Tisdall EE. She Made World Chaos. London:
Stanley Paul, 1940; 102-103
Sinclair A. The Other Victoria. London:
Weidenfeld & Nicholson, 1981; 366
Transactions of the Obstetrical Society of
London XVIII 1876. London: Longman
Green, 1877; 60-61
17 Competency Testing
at the GMC
– on the Receiving End!
J Robert Sneyd
Professor of Anaesthesia
Peninsula College of Medicine
and Dentistry
Following an email asking for volunteers, I
agreed to act as a guinea pig at a prototype
GMC competence assessment centre.
Having blithely agreed to do this I felt an
increasing sense of apprehension as the
days counted down towards my trip to
Regent’s Place (the home of the GMC).
With revalidation looming and gradually
increasing numbers of doctors reported to
the GMC, there is a need for robust and
defensible methods for assessing a doctor’s
competence. Of course, you can end up
at the GMC for three principal reasons
– conduct, health or competence. This
exercise is primarily aimed at the latter,
however elements of conduct inevitably
overlap with engagements between
clinicians and their colleagues, other
health care professions and patients, so all
of these are included in the competence
assessments.
The tests of competence are run for the
GMC under contract by ACME, The
Academic Centre for Medical Education
at University College London.
Since
anaesthetists practise as specialists, we
require specialist assessment tools and
these in turn need validation if they are to
be applied fairly. One possible outcome of
a competence assessment is failure and all
its consequences, which may be profound.
The whole thing is therefore truly “high
stakes”. To ensure that the instruments
(questions and other assessments) are fair,
valid and reliable they are being tested on
a cohort of 120 volunteers.
18 Part of the mounting pressure prior to the
assessment was the background worry of
what might happen to us if we performed
badly on the day. The blurb sent to us
was only partly reassuring because the
bottom line is if you are truly terrible
they reserve the right to refer you to the
GMC… Having worried about this briefly
I then came to the conclusion that if I was
really that bad it was probably a good thing
to be referred so I decided to forget about it
and get on and try to enjoy the whole thing!
The first part of the test is actually finding
the GMC building on Euston Road; no
mean feat despite written instructions.
Once we’d arrived a robust security process
kept us in the lobby until identities had
been checked, passes issued etc. Within
the GMC facility there is strict visitor
control with a quaint system of coloured
lanyards used to confine punters to specific
parts of the building and prohibit us from
wandering into other (presumably more
secure) areas.
Our session began with a briefing and
a bit of question and answer. After that it
was eyes down for a two-hour multiple
choice examination (MCQ). If that wasn’t
bad enough the exam was conducted in a
new format (single best answer) which is
different from the traditional five part true/
false MCQ with negative marking which
most of us will have been accustomed to.
Actually, single best answer is perfectly
straightforward and a key tip is to stick a
bit of paper sideways across the script
obscuring the potential answers so you
Anaesthesia News June 2009 Issue 263
Current Topics – Liverpool RCoA
17–19 June 2009 (code: A32)
The Radisson SAS Hotel, Liverpool
read the question, have a serious think about what the answer
might be and only then give yourself the choices – this avoids your
ideas being over influenced by some other distractor suggestions
that you may be offered.
The standard of the MCQ was fairly high with a number of questions
on therapeutic areas with which I have not engaged for many years;
nevertheless there was a strong clinical emphasis throughout and
where there was basic science it was always couched in clinical
terms. We had 114 questions and I only just managed to finish
them in the 120 minutes available.
2009
Registration fee: £430
Approved for 15 CPD Points
Day 1
❚❚
❚❚
❚❚
❚❚
Day 2
Revalidation Issues
❚❚
NIV in Critical Illness:
an update
❚❚
A new approach to
reversal
Therapeutic
hypothermia
❚❚
CPX testing: an
update
The management of
chronic neuropathic
pain
Radiology for
anaesthetists
Day 3
❚❚
❚❚
A new model for
predicting difficult
Intubations
Anaesthetic
management of
the gravitationally
challenged
❚❚ Surgery and obesity
Straight out of the MCQ, a quick lunch and then into the Objective
❚❚ The Mental Capacity
❚❚ Evidence based
Act
and
anaesthesia
❚❚ USS in the acutely ill
Structured Clinical Examination (OSCE). This was a surreal and
medicine – paper to
and anaesthesia
❚
❚
bedside
OSA
and
anaesthesia
slightly spooky experience. We were ushered into a special
❚❚ Update on paediatric
❚
❚
❚
❚
Early
warning
scores
Anaesthesia
for
examinations suite with ranks of small white rooms each with
anaesthesia
carotid artery surgery in obstetrics
a door off a central corridor. We were lined up, given numbers
❚❚ Cardiology for
❚❚ The future of day
❚❚ An update on
from 1 to 12 and then marched in sequence and made to stand
anaesthetists: what’s
surgery
cardiothoracic
new?
in front of our doors. After a brief pause a disembodied voice
anaesthesia
❚❚ Local blocks in
children
❚❚ Decision making
from a tannoy told us we had 60 seconds to read a few lines on a
Meeting organiser:
and critical thinking: Dr E Shearer
piece of paper then a further announcement ordered us to enter.
errors and safety
It looked like a cross between something from the Matrix and
2001 – A Space Odyssey, with the candidates playing the roles
Further information: [email protected]
of astronauts or cyber-travellers . . . Inside the room we faced a
7-minute scenario ranging from clinical skills, communication and
consent, to resuscitation and more besides. I cannot remember if
AN_June.indd 2
7/4/09 17:32:50
we were sworn to secrecy but it doesn’t seem appropriate to list
all the details here. Suffice to say that all the stations included
things that a “general” consultant might reasonably be expected
to do and although the whole thing felt pretty pressurised, none
of it seemed unfair. One minute before the end the disembodied
voice told us to hurry up and finish and then we were straight into
the next cycle moving along to the next room. By the time I had
done 12 and met 12 examiners, multiple actors and sundry bits of
equipment I was exhausted and glad to finish.
Overall I had a clear impression of an efficient, fair and well-run
process with the staff doing their best to put you at ease. Of course
if you are facing loss of role or even the sack then no amount
of reassurance is really going to help and doing it for real will
definitely be a scary experience.
To conclude, doing this as a volunteer was very worthwhile. I
have a much better insight into how we are going to manage
clinicians with competence issues and I am reassured that a wellfound process is in place. Anybody being judged by this will have
their performance compared with the 120 of us who took it as
volunteers and can therefore be confident that they are not being
measured with something untried or experimental. ACME is still
looking for volunteers for the assessment centre and if you are
interested, have a look on the UCL Medical School website for
details of additional sessions.
Oh – and in case you are interested, I passed!
Anaesthesia News June 2009 Issue 263
19 Cambridge Anaesthesia
Courses 2009
Cambridge University Hospitals NHS Trust,
Cambridge
Final FRCA VIVA DAY
12 June & 27 November 2009
Consultant-led, intensive VIVA preparation course giving trainees
Extensive VIVA practice for the exam
The aim of the day is to provide candidates with at least 8 hours VIVA practice to give the required preparation and
confidence to pass the exams.
“A very good course with lots of exposure to all aspects of finals exam”
Registration Fee: £200.00
For further information, please contact: Miss Lucy Bailey,
Postgraduate Medical Centre, Box 111, Addenbrooke’s Hospital, Cambridge CB2 0SP;
Tel: 01223 217059; Email: [email protected]
Addenbrooke’s Simulation Centre
Cambridge Airways Course
24th June / 6th October 2009
A full-day course for Anaesthetists to refresh and update skills in managing patients with difficult airway
Registration fee: £125.00
Anaesthetic Emergencies for ST1s/SHOs
8th May / 22nd July / 6th November 2009
A simulation-based teaching course using scenarios and video debriefing by experienced anaesthetic faculty in a
non-judgmental, friendly environment
Registration fee: £150.00
Obstetric Crisis Resource Management
9th March / 13th May / 17th November 2009
Learn how to manage obstetric emergencies using a high-fidelity computerised medical simulator
The course is suitable for all grades of
Obstetrician, Anaesthetist and Midwife
Registration fee: £150.00
For further information on Simulation Centre courses, please contact: Miss Debbie Clapham,
Postgraduate Medical Centre, Box 111, Addenbrooke’s Hospital, Cambridge CB2 0SP;
Tel: 01223 348100; Email: [email protected]
20 Anaesthesia News June 2009 Issue 263
AAGBI members
develop Paediatric
Anaesthetic Drug
Dosage Calculator
Whilst on-call during a quiet night your
bleep goes off with a paediatric crash.
When you arrive in the ED you find a 4
year old with a severe head injury needing
intubation. You try to pull from your hazy
memory paediatric drug doses, which are
then hastily written down on to a piece
of tissue paper. If you manage to find the
only, out-of-date copy of the children’s BNF
in the department, you spend the next 15
minutes frantically searching through it,
wondering if your calculations are right….
If this scenario sounds familiar, you may
be interested to look at a website and
free downloadable program that we have
written at www.paediatriccalculator.com.
The calculator is designed for doctors who
may not regularly anaesthetise and stabilise
children. It will calculate all that you need
until the retrieval team arrive.
Once you have entered the age (down to one
month) or weight of the child, it calculates
dosages for drugs used in anaesthesia,
analgesia, ICU and resuscitation. The age/
weight formula is based on an updated
calculation of (age x3)+7) to account for
children getting heavier for their age1,2.
Alongside the dose, the calculator will
also tell you what volume of drug to give
for a standard drug concentration. It also
calculates sizes and lengths of airways, as
well as fluid requirements and boluses. It
is designed to run on desktop or laptop
computers, PDAs and Smart-phones and it
can be viewed either as a web page or as a
Microsoft Excel file, both of which can be
printed out.
Anaesthesia News June 2009 Issue 263
Figure 1 A screenshot from the web
format paediatric anaesthetic drug dosage
calculator
Dr Marc Davison, Consultant Anaesthetist
Buckinghamshire Hospitals NHS Trust
Dr Benjamin Attwood, SpR in Anaesthesia
Buckinghamshire Hospitals NHS Trust
References
1)Weight estimation in resuscitation: is
the current formula still valid? Archives
of Disease in Childhood 2007;92:412415 Mark Luscombe, Ben Owens
2)Can age-based estimates of weight
be safely used when resuscitating
children? Emergency Medicine Journal
2009;26:43-47 J M Sandell, S C
Charman
Evelyn Baker
Medal
An award for clinical
competence
The Evelyn Baker award was instigated
by Dr Margaret Branthwaite in 1998,
dedicated to the memory of one of her
former patients at the Royal Brompton
Hospital. The award is made for
outstanding clinical competence,
recognising the ‘unsung heroes’ of
clinical anaesthesia and related practice.
The defining characteristics of clinical
competence are deemed to be technical
proficiency, consistently reliable clinical
judgement and wisdom and skill in
communicating with patients, their relatives
and colleagues. The ability to train and
enthuse trainee colleagues is seen as
an integral part of communication skill,
extending beyond formal teaching of
academic presentation.
Dr John Cole (Sheffield) was the first
winner of the Evelyn Baker medal in 1998,
followed by Dr Meena Choksi (Pontypridd)
in 1999, Dr Neil Schofield (Oxford) in
2000, Dr Brian Steer (Eastbourne) in 2001,
Dr Mark Crosse (Southampton) in 2002, Dr
Paul Monks (London) in 2003, Dr Margo
Lewis (Birmingham) in 2004, Dr Douglas
Turner (Leicester) in 2005, Dr Martin
Coates (Plymouth) in 2006, Dr Gareth
Charlton (Southampton) in 2007 and Dr
Neville Robinson (London) in 2008.
Nominations are now invited for the
award to be presented at WSM London in
January 2010 and may be made by any
member of the Association to any practising
anaesthetist who is also a member of the
Association.
The nomination, accompanied by a citation
of up to 1000 words, should be sent to the
Honorary Secretary Dr Les Gemmell at
[email protected] by
Friday 2 October 2009.
21 Resilience
AND SAFETY
Andrew Hartle
Chairman, AAGBI Safety
Committee
I suspect most readers would consider
themselves resilient; we wouldn’t be doing
the jobs we do without being able to cope
in the face of adversity. But how resilient
are our systems, particularly when things go
wrong that are beyond our control?
We had a fairly spectacular power failure
last year. Theatres weren’t affected too
badly. By chance no patients were on
the table, it was a Saturday, the affected
theatres all had windows, but up in the
Paediatric ICU it was not a happy time.
Although no patient suffered lasting harm,
it was a close-run thing. Neither sites had
an Uninterruptible Power Supply (UPS).
Thankfully the Adult ICU did, as it was full
and the doctor to patient ratio there was not
as fortuitous as in PICU.
Since then one of our sister ICUs has had
power problems, and several incidents
have been reported to the NPSA of power
failure affecting departments or individual
anaesthetic machines.
I’m old enough to remember when a power
failure would have had limited effect on
the average anaesthetic; a Boyle’s machine,
Manley ventilator, finger-on-the-pulse and
von Recklinghausen’s oscillotonometer
would have just carried on working.
With the development of increasingly
22 sophisticated anaesthesia workstations,
monitoring, vapourisers etc, we are almost
entirely dependent on mains power. Some
but not all departments will have UPS. Does
yours? Does it supply everything, or just
certain power points, and do you and other
members of staff know which ones they are?
Will it allow you to complete the case, or
do you still need to make arrangements to
finish and move to a place of safety?
Most new anaesthesia workstations are
electronic, mains powered, and with an
integral battery to provide backup in the
event of mains failure, but the battery life
varies. More importantly the battery life “as
advertised” when the machines are supplied
new will deteriorate over time, particularly
if the power packs are not serviced regularly,
and allowed to discharge completely. Many
of us will be familiar with this phenomenon
from the batteries on mobile phones, and
almost any other rechargeable device. Is
the servicing contract on your machines
up-to-date? Is there a regular maintenance
programme for the power packs? The
same applies to monitors and machines in
anaesthetic rooms (where natural light may
be rarer), and in the Emergency Department
or Intensive Care Unit.
Finding the answers to some of these
questions may make the difference to a
Anaesthesia News June 2009 Issue 263
power failure being a minor irritation or
an overwhelming catastrophe. Make sure
that your department has a plan for power
failures, as I’m sure you do for major
incidents and fires. Don’t forget the really
basic provision such as torches (preferably
with working batteries and bulbs) and
an alternative manual form of ventilation
(already part of the AAGBI anaesthetic
checklist).
Other steps which may help avoid disaster
include ensuring that any proposed work
on essential power supplies (or medical
gases, suction equipment etc.) is planned
appropriately, and there is a Permission to
Work certificate. Make sure everyone who
should know does so and that there are
clear lines of communication between any
critical care area and those controlling the
works; it’s no use if the Clinical Director
and Managers know about the plans, but
are at home during the weekend (when
such things are almost always planned)
leaving the poor on call team in the dark
(sometimes literally). All of this may seem
so obvious (at least I hope it does) but I’m
aware of instances where simple steps have
been forgotten.
Resilience and continuity planning has
received much greater attention from
national and local government recently, in
response mainly to major acts of terrorism.
Certainly most organisations working in
central London, as I do, will have resilience
plans. These don’t always work as well as
expected; no-one questioned the placement
of the major IT back up adjacent to the oil
storage depot at Buncefield until after it
went bang!
There are other aspects to resilience
planning that we may be all more familiar
with, although we may not have categorised
it as such. Problems with the “sudden”
unavailability of drugs, laryngeal masks,
local anaesthetics at times are all too
common. All too often the ODP’s “What
do you want for the next case?” question is
better answered with “What do we have?”
Some items are rather more crucial than
others; if one had to pick a single drug whose
shortage could almost paralyse (apologies,
pun intended) the work of an anaesthetic
department it would be neostigmine and
glycopyrrolate “pre-mix”, and yet it’s not
that long ago that some departments woke
up to find they had only about a week’s
supply left, and everyone else in the country
was after it.
Financial pressures on Trusts have meant
for many a move to “lean” stocking, with
sophisticated (or not!) ordering systems
based on barcodes and predicted usage,
and the interface between purchasing,
stores, pharmacy and the anaesthetic coalface may not be all it could be. The first you
may know of an item running low may be
when it’s not there. My department drew
up a plan for prioritisation of neostigmineglycopyrrolate to certain areas, whilst
attempting to maintain a minimum supply
for emergency uses. When supplies were
restored, we also reviewed the minimum
holdings of certainly operationally-critical
(sorry, another pun, perhaps anaestheticallycritical?) drugs so we weren’t plunged into a
crisis overnight.
We’re used to planning for emergencies
such as Major Incidents, and problems with
the supply of blood products (do you know
about your Emergency Blood management
Plan? Your Trust is required to have one), but
there are other shortages or external failings
that can seriously affect our ability to get
on with our daily work. We’re all under
the usual constant pressures to streamline patient journeys, reduce waiting lists,
improve theatre efficiency, increase day
case rates, reduce cancellations, be naked
below the elbow, appraise, re-license and
revalidate (I’m sure I’ve missed one or
two) that finding time to step back and ask
“What would I do if….” may be beyond
us. But all or experience and knowledge
of dealing with emergencies teaches us that
we do better, and patients do better, if we’ve
thought about it in advance. From difficult
airway algorithms to failed intubation drills,
anaphylaxis and local anaesthetic toxicity
guidelines (many published by AAGBI!) or
knowing where the nearest exit is on your
flight, prior preparation prevents (pretty)
poor performance.
So spend a little time asking a few “What
if…” questions. Even better, if you’re a Lead
Clinician, Clinical Director or similar, get
colleagues to ask one each, particularly the
ones who may look a little thin on the SPA
part of their job plan, or who could with
something else on their Excellence Award
application. And once you’ve done it, and
come up with a plan, don’t keep it a secret.
Anaesthetists are pretty good at planning
for the unexpected, so share what you’ve
learned; I’ll bet few of our other colleagues
have thought much about things like this.
If you had experiences of these or similar
incidents, particularly if you found
innovative solutions email me at enquiries@
aagbi.org with “Safety” in the subject line,
or even better, write to Anaesthesia News
and let everyone know!
Andrew Hartle
Chairman, AAGBI Safety Committee
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 secretariat@
aagbi.org and you will be put in contact with an appropriate advisor.
*The doctor advisor scheme is not a 24 hour service
Anaesthesia News June 2009 Issue 263
23 Dear Editor…
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News, AAGBI,
21 Portland Place, London W1B 1PY
or email: [email protected]
SASM – a response
Thank you for allowing us to reply to Dr Kestin’s letter published in the March 2009 Anaesthesia News.
The Scottish Audit of Surgical Mortality (SASM) understands that occasionally, due to the nature of its work, individuals will be critical of its
process. We welcome constructive criticism and regularly reorganise the review process. While we are disappointed in the negative slant in Dr
Kestin’s letter and normally would ignore it, there are inaccuracies which need correcting.
SASM is primarily a voluntary, confidential educational process for the profession by the profession, to allow them to reflect and if necessary
correct identified problems. It relies on the opinion of one’s peers. It never uses the term culprit and indeed, in the vast majority of cases, the
problem is considered to be due to a faulty system or process such as poor communication or delays, so-called non-technical skills. So in fact
SASM does consider the full organisational and system factors that may lead to a patient’s death.
With respect to trainees, Dr Kestin has clearly not read the latest annual report where in only 4 surgical cases and 5 anaesthetic cases was there
an area of concern or for consideration with respect to the seniority of the trainee.
As with all retrospective reviews SASM does suffer from hindsight bias but there is a lot to learn from this type of assessment. If not, there
would be no morbidity or mortality meetings, nor indeed national investigation boards for the maritime and airline industries. Failure to learn is
inexcusable.
Dr Kestin states that there is only one expert reviewer. This is not correct. There can be up to four per specialty. Furthermore, any case in which
it was considered an area of concern caused the patient’s death is also anonymously reviewed by the whole management committee. A robust
process of appeal also means that this number may be even higher, including referral to NCEPOD. Many of the forms are completed following
local discussion at an M & M meeting; indeed, SASM strongly supports the view that this local peer review is fundamental to learning and
rectifying faulty systems. While it would be inappropriate for an anaesthetist to comment on the surgical techniques employed, they can and
indeed should comment on the non- technical aspects mentioned earlier. There are two training meetings every year for the assessors when
particularly difficult cases are discussed and debated.
We are very disturbed that Dr Kestin believes newsletter 3 made vague threats to inform chief executives. Indeed, this is the main reason for
this response. The newsletter was an attempt to answer questions about how the Scottish Freedom of Information Commissioner would assess a
request to release confidential medical data held by the audit. The point was that a request under FOI to release the names of non-participants
would legally have to be complied with. Protection from such disclosure would be obtained by participation in the audit. Disclosure of an
individual’s confidential report, however, would not be allowed provided SASM had a robust clinical governance process and there were
sufficient participants in the audit. Both of these satisfied the Commissioner.
Interestingly Dr Kestin states that the SASM methodology is redundant. The SASM process is well established in Western Australia (WAASM) and
there have been recent requests from other parts of Australia, New Zealand, Northern Ireland, Ireland, parts of England and the independent
sector to discuss our process, copy it and thus undertake
similar reviews. In addition, in Scotland, the renal physicians,
interventional radiologists and cardiothoracic surgeons have
Getting serious about reverification
recently adopted its methodology.
Recently, in his latest annual report, the English Chief Medical
Officer asked why a similar project was not being undertaken
in England while Professor Vincent, in an article in the British
Medical Journal (1), used the SASM process as an example of
how the quality of care can be improved.
We rest our case.
Dr Nick Pace, Clinical Director
Mr John Orr, Chairman of The Board
SASM, Abbotsinch, Paisley
Reference
1. Vincent C et al. Is health care getting safer? BMJ
2008;337:a2428.
24 I wish it were possible to draw some comfort from the fact that William
Harrop-Griffiths' article on reverification is published in the April edition
of Anaesthesia News. However, since the GMC has already communicated
explaining the position to me I fear he writes no more than the truth. It causes
me a particular difficulty: what I should do if called upon to exercise my
particular skills in an emergency? Post-traumatic tension pneumothorax is
an obvious example. If the patient dies I might find myself facing a charge of
manslaughter if I do intervene, or opprobrium if I don't. The trouble is you see
that, like many others, I am retired with no chance of being reverified. It isn't
difficult to envisage a type of registration that would get round this problem
but those responsible for devising the brave new order have evidently
overlooked that they, too, will one day be in the same position.
Alan Seymour
Retired anaesthetist
Anaesthesia News June 2009 Issue 263
Is it time to stop pre-preparing drugs? A case of
frozen thiopentone.
I wish to present a case involving delayed induction of general
anaesthesia in a multiparous patient during emergency caesarean
for foetal distress. A 31 year old lady was brought to theatre due to a
persistent foetal bradycardia despite fluid resuscitation and maintenance
of the left lateral position. There was no epidural in situ and the decision
was made to perform an emergency caesarean section under general
anaesthesia.
The previously drawn-up drugs were retrieved from the fridge within the
operating theatre. The patient was given sodium citrate 30ml (0.3molar
concentration) as a premedication and preoxygenated. Thiopentone 2.5%
was injected into a 16G cannula. Resistance to injection was high and so
injection stopped after 50mg (2ml). The cannula was flushed with saline
from the drip but resistance was again high. A new cannula was promptly
inserted without problem, but further injection of thiopentone was still
difficult. A keen-eyed ODP noticed that the thiopentone in the syringe
had separated into two clear states, a liquid form at the top of the syringe
and a solid form occupying about 10 millilitres. The thiopentone had
partially frozen. 140mg of propofol was promptly drawn up and given
and the remainder of the induction, anaesthesia and operation concluded
without event. I estimate that the time delay was about 90-120 seconds.
Both mother and baby recovered well and the mother had no explicit
recall of intubation.
After the case the fridge
temperature was checked
and found to be -10 degrees
Celsius (see fig 1) with a large
range showing on the min/
max readings. The fridge
temperature record had been
completed at the beginning of
the shift (12 hours previously)
Figure 1 Thermometer on fridge
and documented as 2 degrees
Celsius. The fridge was reported and removed for repair.
There have now been a number of case reports on problems with freezing
of pre-prepared drugs, including suxamethonium (1) and thiopentone (2,3
and 4) as well as precipitation of thiopentone within normal temperature
range (5).
Yet it is still common practice to draw up emergency drugs in advance
and store them in a fridge (6).
As always in anaesthesia there is no substitute for checking the drug
yourself prior to injection – vigilance which can be overlooked in an
emergency.
Daniel Bailey
Specialist Registrar in Anaesthesia
University Hospital Birmingham
References
1) Harrison C, Hilton P. Frozen Drugs. Anaesthesia 1985; 8: 825
2) Emmons S, Abeyewardene L, Ramakrishnan U. Case of frozen Thiopental.
Anesth Analg. 1998; 3: 748.
3) Gadiyar V. Frozen thiopentone? Int J Obstet Anesth. 1994; 4: 238.
4) Cross MH. Freezing of Thiopentone solution. Anaesthesia. 1991; 7: 602.
5) Thickett MA. A problem with thiopentone solution. Anaesthesia 1991; 1 :74
6) Bryden D, Kenworthy J, Johnson T. The use of obstetric emergency drug
trays: room for improvement? Anaesthesia 1996; 7:709-710
Anaesthesia News June 2009 Issue 263
Intensive Primary FRCA viva course.
11th and 12th September 2009.
Western General Hospital, Edinburgh.
Building on 10 years of success…
Candidates will be examined in small groups and in
paired vivas by tutors from our very successful local
course, now available to all.
For more information and an application form contact:
[email protected]
Or ‘phone Keith Kelly 0131 537 1652
Fee £280- includes lunches, refreshments
and course dinner.
Early application recommended.
Vascular Anaesthesia Society
Of Great Britain and Ireland
ANNUAL SCIENTIFIC MEETING
17th AND 18th SEPTEMBER 2009
ACTONS HOTEL, KINSALE, IRELAND
CALL FOR ABSTRACTS
• RESEARCH
• AUDIT
• CASE REPORTS
Have you performed any research or audit, or do you have
an interesting case report that you would be interested in
presenting?
This would also be an ideal opportunity for your trainees to get
involved.
There is a prize of £200 for the best verbal
presentation and £100 for the best poster
presentation.
For further information please contact:Dr Andy Lumb, Chairman of the Education Committee, Consultant Anaesthetist,
St James University Hospital, Beckett Street, Leeds, LS9 7TF
Tel: 0113 2065789
E-mail: [email protected]
Closing Date: Friday 10 July 2009
25 One of
those
days…
We all get those days when nothing seems
to go according to plan and we wonder how
and why we escape having a major disaster.
Can I, for a moment, imagine the events
described below have happened and see
what anybody could have done about it?
On a Monday morning, I arrive at the hospital
with morning blues after a lovely weekend
with the family. The morning session is a
major orthopedic list and the surgeon does
not even bother to say hello. We do get them
every now and then. The only case on the
list is ‘revision of a hip replacement’ on a
cardiopath aged seventy-five. The patient is
fine after three hours surgery in spite of...
The afternoon session is a day case general
surgery session with six quick fire rounds
of lumps and bumps and no time to spare
between cases. Then follows the evening
trauma list of orthopedic cases, ill prepared,
with a slow registrar and the day at last
finishes at ten at night. One feels completely
exhausted. I go to sleep wishing I was off
the following day. However, the anaesthetic
secretary has requested me to do an extra
ENT list in the morning. I have not learnt to
say ‘no’ yet and the extra money is always
handy.
The following day I start at quarter past
seven in the morning to be on time for an
26 eight thirty start. It is twenty minutes run to
Hospital. I pick up the operating list from
theatres and head off to children’s ward
to see the three patients posted for adenotonsillectomies.
potentially
difficult
and
yet
avoidable
It is a shame that I do not get to see patients
the day before. They are pre-operatively
assessed and hence arrive on the day of
operation. I do not think that it is good for
the patients or nurses or even anaesthetists.
This may improve bed utilisation but causes
unnecessary inconvenience to staff and
undue anxiety to patients.The first child
presents with a runny nose, pyrexia and
an acutely inflammed tonsils. Operation is
deferred and mother is obviously upset. The
child was seen the day before and the trainee
missed the diagnosis. Assessment did not
serve the purpose.
reception. Nurses are waiting for surgeons to
problems. The third child had no apparent
problem.
I later visit the patients in the adult wards.
Ten past eight. Patients are still waiting in the
do rounds and discharge patients. Patients
might have been pre-assessed, but what
about pre-operative preparation of patients?
I do my assessment in the treatment room
and drag myself to operating theaters in time
to commence the list at 8.30.
Where are the surgeons, what about consent
forms, and indeed what about beds?! There
is no surgeon in sight. The trainee surgeon
finally arrives at 9 and wonders why first
patient is still not in theatre. Does he not
really know what is happening? I wonder.
Come on.
The next child is six year old, rather obese
and is extremely nervous. EMLA cream
is applied on both hands where there are
no obvious veins. How easily it could be
a difficult induction if venepuncture was
impossible and if I had to do a gas induction
on a nervous obese child without a cannula
in a vein. It is a high-risk strategy. I apply
EMLA cream at the appropriate places.
How very important it is for the anaesthetist
concerned to visit the patient and avoid
Right, the fun starts. I manage to do
venepuncture successfully on the nervous
obese boy, first on the list, induce and
intubate. I find some resistance to inflation
of lungs and the chest does not move. I look
for obvious causes and find none. When in
doubt, take it out. Re-intubate the patient
and there is no problem this time. Nurse
points out the thick plug of green sputum
stuck at the end of endo-tracheal tube.
Anaesthesia News June 2009 Issue 263
Imagine what one could easily have done. Vigorously inflate the lungs and somehow
dislodge the mucous plug into bronchi or possibly cause barotrauma? Anything
could have happened resulting in the wrong assumption and inappropriate
treatment. It’s the sort of thing that can happen when you’re under pressure.
Once the patient is stablised I get ready to take the patient inside operating theatre.
As the trolley moves the ECG monitor off the wall drops on to the floor. Oh!...my
God. Luckily it only falls on to the floor and thankfully no harm is done to the
patient or other personnel. How about the monitor?! Not an immediate concern.
The operation is carried out successfully and the patient goes to recovery. The
capnograph catheter was entangled in the side frame of the trolley. And the monitor
was pulled down as the trolley was dragged. These things can happen even with
all the care in the world.
The next patient’s operation is fairly uneventful except for the fact that I discover a
swab left in the mouth after surgery during suction.
The consultant surgeon arrives, unaware of what has gone on so far. How could
he come so late? Then he whispers into my ears that he has an addition to the list.
Apparently the patient has been fasting all night. Why and how was it allowed to
happen? It is a total failure of communication. How unfair will it be if I could not
accommodate the patient in the morning session? If the patient has been fasting for
more than twelve hours- should it be taken lightly?
The adult patient eventually gets a bed. He is due for nasal polypectomy according
to the operating list. The consultant surgeon looks through the notes and decides to
check ears and larynx. What is the point of publishing an operating list and taking
consent if the patient has a totally different operation?
It is already nearing twelve noon, with only half an hour left of the session. I send
for the last patient – the one who was added on whom I did not get to see, but I had
asked the very obliging on call anesthetist to see him. I was informed that it was a
short operation on the nose. Ten minutes pass. I inquire and the anaesthetic nurse
insists that patient is being sent for. Another ten minutes pass by. There is no sign
of patient. I ring the ward. The ward nurse is waiting for a call for the patient from
theatres. It is yet another communication disaster.
The patient arrives. He is for septorhinoplasty! It is at least a 45 minute operation,
even for a quick surgeon. What can anyone do about these? Humanity and
professionalism prevents me from taking any firm steps. Should I cancel the
operation and shout at the surgeon? What will it do for my relations with surgeon?
And what about the poor patient who has already fasted for more than twelve
hours?
Did I mention that the orthopaedic SHO had informed me when I arrived in theatre
that yesterday’s revision of hip patient was moved to CCU with a possible MI? That
was all I needed before I started the list. It later transpired that it was angina and
the patient would be transferred back to the orthopaedic ward.
Is it one of those days? How much can I control? Every little incident has the
potential for a major disaster. I am late going home and will face the fireworks
from my wife. Half of my half day is already gone. I am not in the mood to go to
the gym any more.
Are they dropping off or picking up?
Submitted by David Bogod
Cycle ride in aid
of OAF
Anna Janowicz, a CT1 trainee in Barts and The London
School of Anaesthesia, is planning to cycle 500km from
London to Paris in aid of the Overseas Anaesrhesia Fund
which provides training, textbooks and equipment for
anaesthetists in developing countries.
“Why am I doing it?
· To support patients and anaesthetists in developing
countries
· Because I think that every child and adult in every
country in the world has the right to have safe surgery
· Because I like challenges !”
How you can help?
To donate go to www.justgiving.com and type in Anna
Janowicz.
Does this ever happen to you, and if it does what do you do?
Ramana Alladi, SAS Anaesthetist
Anaesthesia News June 2009 Issue 263
27 MERSEY NOTICE
For the Attention of those who intend sitting
The Final FRCA Examination
in or beyond
September 2010.
In anticipation of the intended change to the Final MCQ Paper currently scheduled for September
2010 or later, the MSA is to establish a
SINGLE BEST ANSWER
(SBA)
FACULTY
Trainees who are to face the challenge of the SBA are invited to join
The SBA Faculty.
Members of the Faculty will be expected to draft SBA Questions from Final FRCA Examination
Fodder as provided by the MSA and to submit the Answers and appropriate Explanations to
those Answers.
All Communication will be Anonymised & Conducted by Electronic Mail
Ultimately, the SBAs submitted, once refined as necessary, together with their Answers and
Explanations, will be used in an
Private SBA Weekend Course
14.00 Friday – 16.00 Sunday
August 2010
This course will only be available to those members of the Faculty who have contributed in
accord with the Rules of the Faculty.
There will be a
Registration Fee of £100
to join the Faculty and to show Commitment.
This fee will also cover the cost of attending
The Private SBA Weekend Course.
For further Details, Faculty Rules & Regulations and Application Form
msoa.org.uk – sba faculty
28 Anaesthesia News June 2009 Issue 263
2009 AAGBI
Annual Congress
Art Exhibition,
Liverpool
Three really good reasons for giving your
support
As usual, the Association will be supporting an
Art Exhibition at Annual Congress in September.
This is a fantastic opportunity for members to
exhibit their artistic skills, and to enjoy some
of the amazing talent we have amongst us that
would otherwise go unappreciated. In recent
years the exhibition has been expanded to
include all manner of art and craft other than
the mainstays, painting and photography. We
have had jewellery, needlework, beading,
sculpture, pots - there seems to be no end to the
creativity of anaesthetists and their families! As
a very amateur painter myself I can testify to the
joy of exhibiting some of my work in a proper
exhibition and getting positive feedback. In fact
I would never have started to paint at all if it
had not been for this exhibition. Assisting John
Edwards, the exhibition’s founder, in hanging
some of his wonderful watercolours some
years ago in Belfast, I repeatedly remarked on
how much I would love to be able to paint.
Eventually he turned to me and, in his usual
gruff manner told me to stop moaning and just
get on and do it. ‘But I’ve got no training’ I
cried, to which he replied that I needed nothing
other than some paints, brushes and a canvas.
He was right! Without that encounter I would
never have got started. There is a hidden artist
inside all of us I suspect, and I am hoping that
this year there will be new work from members
who have never contributed before – who
possibly have always wanted to have a go but
have never got round to it. Take John Edwards’
advice: don’t worry about training. All you need
is the materials and the will to create.
There are however, two other non-aesthetic,
really good reasons for supporting the Art
Exhibition and they are both charities well
worth your backing.
The AAGBI Overseas Anaesthesia Fund
(OAF)
The OAF was set up some years ago by the
International Relation Committee (IRC) to
enable members to donate directly to the
provision of assistance for anaesthetists in the
developing world, and initiatives have included
provision of books, equipment and funding
for training of personnel. Last year the OAF
provided over £35,000 in financial support,
over and above the regular IRC funding of travel
grants, CD-ROMs, and journals for developing
countries.
Winning entries from previous years
Anaesthesia News June 2009 Issue 263
29 The Royal Medical Benevolent Fund
(RMBF)
The Royal Medical Benevolent Fund offers
help to colleagues and their families in need.
Widows, orphans and families can benefit
from financial support and/or specialist
advice. Not only the elderly or very young
occasionally need a helping hand, young
doctors and their families can be vulnerable
in the first few years of NHS practice,
particularly if they have been working for
relief agencies in the Third World. They have
little to fall back on if they are unable to
work due to chronic illness or accident.
The RMBF is particularly good at offering
practical help designed to get colleagues or
family back on their feet whenever possible,
enabling them to retain their independence.
The Fund also provides support for refugee
doctors retraining to practise medicine in the
UK.
During the course of the Exhibition, donated
artwork and greetings cards are on sale and
there is a raffle. The proceeds go to these very
worthwhile charities. Moreover, the official
AAGBI Christmas card design is chosen from
the exhibits, and the proceeds of sales later
that year all go to the OAF.
So please come along and support the Art
Exhibition in Liverpool in September. You
can do this in so many ways. You can:
The art exhibition.
• Contribute by exhibiting some of your art
or craft
• Donate for sale any you can bear to part
with
• Buy a stunning work of art created by a
colleague for a fraction of the market cost
• Vote for your favourite – prizes are
awarded at the end of conference
• Buy lots of raffle tickets in a prize draw for
these two very good causes
• Buy beautiful greetings cards
• Just simply visit and enjoy the talents of
your colleagues
This year, Diana Dickson and I will be
taking over from Anne Sutcliffe who has
made such a success of the Exhibition in
recent years. Please help us continue that
Autumn Meeting
2009
success. Your work can be delivered to and
transported from Portland Place, or by either
of us if you get it to us in time; or you can
bring it along yourself at the beginning of
Congress. It would greatly assist us if you
register your work in advance regardless
of transport method as it will enable us to
plan the exhibition and provide a catalogue
of contributors for visitors’ use during the
exhibition.
You will find an application form on the
AAGBI website with Congress details.
If you have any queries, contact AAGBI
membership secretary, Julie Gallagher
([email protected]). We look forward
to seeing you and your work in Liverpool!
Stephanie Greenwell
De Vere Herons Reach Hotel
Blackpool, UK
Thursday 5th November
Thoracic Day
5 CEPD Points
Organised by Dr Jonathan B. Kendall
Liverpool Heart and Chest Hospital NHS Trust
• One Lung Ventilation in the Difficult Airway
• Complications of Thoracic Epidurals
• Paravertebral Block Versus Thoracic Epidural
• Lung Resection after Pneumonectomy
• Carinal Resections
• Lung Transplantation
Faculty Includes;
• Prof Peter D Slinger, University of Toronto, Canada
• Dr David Counsell, The 3rd National Audit Project,
The Royal College of Anaesthetists, UK
• Prof Jonathan Richardson, Bradford Royal Infirmary, Bradford
Consultants:
Others:
Friday 6th November
Cardiac Day
5 CEPD Points
Organised by Dr Christopher Rozario
Lancashire Cardiac Centre
• Cerebral Oximetry
• Safety in Cardiac Surgery
• New Drugs / New Targets
• Trans Apical Aortic Valve Replacement
• Update on Aprotinin / Anti-Fibrinolytics
Faculty Includes;
• Prof Hilary P Grocott, University of Manitoba, Canada
• Dr Thomas Hemmerling,McGill University, Montreal, Canada
• Dr Elizabeth Martinez, John HopkinsHospital, Baltimore, USA
• Dr David Royston, Royal Brompton and Harefield, UK
• Prof Samuel V. Lichtenstein Vancouver , Canada
One Day Both Days
£125
£200
£75
£120
For further details and application form please visit: www.actablackpool2009.nhs.uk
Or contact [email protected] Tel: 01253 657789 Fax: 01253 657134
30 Anaesthesia News June 2009 Issue 263
SAS Travel Grant 2009
The Association of Anaesthetists of Great Britain and Ireland invites
applications for the SAS Travel Grant for 2009. This is a new grant
(up to a maximum of £2000) exclusively given for SAS doctors to
visit a place of excellence of their choice for two weeks. This is
not meant for attending a meeting or a conference. Entries will be
judged by the SAS Committee of the AAGBI. All SAS doctors who
are members of the AAGBI are eligible to apply for the grant.
Applicants should complete an application form and return it to
the AAGBI. The successful applicant will be expected to submit a
report of the visit which may be published in Anaesthesia News.
If alternative funding becomes available for a project already
supported by the AAGBI, the AAGBI should be notified
immediately.
Please contact Chloë Hoy (020 7631 8807 or chloehoy@aagbi.
org) for an application form, or visit www.aagbi.org/sas.htm. The
closing date for applications is Friday 23rd October 2009.
Call the booking line on
0 1 6 1 6 0 3 4 7 1 9 or visit www.ebpom.org
The 8th International
Conference on Evidence
Based Peri-Operative
Medicine
The IET, London, 29th June - 3rd July
10
C
Po PD
ints
!
5C
Po PD
ints
!
29th & 30th June 2009
Cardio Pulmonary Exercise
Testing Course
1st July 2009
The 2nd National
CPET Meeting
ONLY 32
delegate
places
available!
Delegate
places
will be
limited!
Secure upto 15 CDP points!
EBPOM 2009 is fast approaching,
so don’t miss out!
Ap
CP
D
pro
The 8th Evidence Based Peri-Operative Medicine Conference will again
take place in London at the IET confirmed for 2nd and 3rd July 2009,
with associated events and workshops at the same venue on Monday
29th,Tuesday 30th June and Wednesday 1st July.
ved
2nd & 3rd July 2009
8th EBPOM Conference
Delegate
places
will be
limited!
Visit the website for the full
programme for each event
www.ebpom.org
Anaesthesia News June 2009 Issue 263
31 T
A
CAMBRIDGE
1-3 JULY
2009
Corn Exchange, Cambridge
GROUP OF ANAESTHETISTS IN TRAINING
ANNUAL SCIENTIFIC MEETING
The Trainee Anaesthetist Conference of the year
www.aagbi.org/events/gatasm.htm
Not to be missed for its highly topical and educational scientific programme
•Keynote Speakers – Prof David Spiegelhalter &
Ms Elizabeth-Anne Gumbel QC
•New parallel session - three streams of career focused
lectures aimed at ST’s, SpR’s and SAS grade doctors
•Workshops
•Coroners Court dramatisation
•Annual Dinner at Kings College
Register
y!
a
d
o
t
E
ONLIN
Registration Fees
Early Booking
Rate*
Late Booking
Rate*
Non
Members
One day
£160
£210
£300
Two days
£230
£280
£370
Three days
£280
£330
£430
* (members booking up to 04/05/09) ** (members booking after 04/05/09)
These rates apply to both GAT and SAS doctors.
For more information: [email protected] Tel. 020 7631 8804