No. 168 July 2001
ISSN 0959-2962
Anaesthesia News
The Newsletter of the Association of Anaesthetists of Great Britain and Ireland
Contents
1–2
Giving ourselves a fair chance
3
Editorial
4–5
Letters to the Editor
6
It couldn’t happen here
7
From the Museum
8
GAT page
10
Something to be proud of
15
Gas Flo
Keep up to date
16
Tales from the back line
The Association of Anaesthetists of
Great Britain and Ireland
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Anaesthesia News
Editor: John Ballance
Deputy Editor: Stephanie Greenwell
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Copyright 2001 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.
Giving ourselves a fair
chance
by Mike Harmer
A
previous leading article in Anaesthesia News by Dr Mike Ward
raised the topic of the proposed changes
to the Merit Award system. Although the
document is still out for consultation, the
gist of the proposals is that trusts will be
given a role in the determination of the
awards, up to a value of £30,000, with
awards above this being decided by a
national committee. Thus, there is a further extension of discretionary points
such that a trust is able to award up to a
sum similar to the current ‘B’ award. With
greater emphasis being placed on the
trust in the determination of such awards,
it is not unreasonable to assume that the
criteria upon which people are judged
will be particularly aimed at involvement
in management.
The national committee proposed to
oversee the higher awards (equivalent of
current A and A+) will have less medical
representation and is expected to ensure
that contribution to the NHS receives
appropriate recognition alongside excellence in academic spheres. It is also intimated that current inequalities between
specialities and other groupings should
be taken into account in the determination of such higher awards. Although
these changes are currently proposals,
the pattern of the past decade would suggest that such a system is likely to be introduced.
Will such changes help our quest for
an increase in the number of awards
commensurate with our numbers? Whilst
some might argue that we should receive
an equal proportion of awards to any
other speciality, it is unrealistic to think
that a fairy godmother is going to arrange
that for us (despite any assurances regarding inequalities) and, if things are to
change, we first need to ensure that we
are doing the best we can for ourselves.
We all know that anaesthetists are hard
working people who are often heavily
involved in management and are recognised as vital to the functioning of any
trust but we seem to have difficulty at
times in convincing others.
In an anaesthetic utopia, discretionary
points and distinction awards might be
given out on a pro-rata basis to all specialities and each person’s appropriateness
for such an award could then be judged
in a fair manner by his/her peers. But life
is not like that, it is a competitive world
Mike Harmer
Anaesthesia News
July 2001
out there and, whatever changes are introduced, it is almost
certain that we shall still have to compete in an open system
where meritorious attributes may not be as readily apparent to
others as they are to us. So how can we seek to ensure that
those making the decisions are made aware of our suitability
for consideration for an award?
Just as we are likely to remain in a system for awards that is
not dramatically different to that currently in use, we are also
unlikely to see any major changes in the method by which we
inform others of our appropriateness for consideration. Be it
for trust discretionary points or for a distinction award, some
form of curriculum vitae questionnaire (CVQ) is inevitable.
Given that outside one’s sphere of practice, the only way that
a committee can assess a person is by what is in the CVQ, it is
astonishing how some people choose to tackle its completion.
One should look at the CVQ in the same light as one would a
full curriculum vitae (CV) when applying for a job. Unless the
CV provides sufficient appropriate information for a specific
post, one would not expect to be shortlisted for that post.
Most full CVs are comprehensive records of qualifications,
achievements and contributions, yet when a similar document
is requested for the purposes of discretionary points or a merit
award, many seem to take a far less serious view of its completion. Anyone involved in the assessment of these documents,
be it at trust, speciality, regional or national level, will agree
that many of us do not do ourselves any favours. Having viewed
a large number of these forms, I believe there are lessons to be
learned regarding their completion and a forthcoming article
will hopefully give some useful advice.
If we want to have more of a look in at the award stakes, we
need to give ourselves a chance!
Mike Harmer
Head of Academic Department of Anaesthesia
University of Wales College of Medicine , Cardiff
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Anaesthesia News
July 2001
Editorial
Flaming June?
W
hat an eventful month June was! We have a new (old)
government, run by New (not old) Labour. The majority is largely unchanged, as is the Health Secretary and the
unchanged head of the British Medical Association has
presented the new government with a ‘wish list’.
The ‘doctors’ trade union’ (the media love that expression as it
puts us on a level with other ‘workers’) has decided to
approach our masters with demands for many more general
practitioners, amongst other things. What we are waiting for
from Dr Bogle (I bet he loves being thought of as a trade union
leader!) is some information on the negotiations for the new
consultant contract.
Meanwhile the Anaesthesia News postbag is bursting with
correspondence about style and image. One correspondent is
alone in thinking that dress is unimportant in impressing
patients and others of our status and the Editor has been taken
to task over his dress style but has taken steps to remedy this
(see above).
CENTRE FOR ANAESTHESIA
OESOPHAGEAL
DOPPLER TRAINING
Basic and advanced courses
Lectures series on
The oesophageal doppler machine • validation and
comparison • physiology of cardiac output • waveform
interpretation • clinical applications • critical review of
the literature • cost effectiveness and outcome
Extensive Practical sessions
Insertion and focusing • case histories
Places strictly limited
For further details contact:
Dr Mark Hamilton
Dr Monty Mythen
Supported by an
Centre for Anaesthesia
educational grant from:
Room 103, 1st Floor Crosspiece
Middlesex Hospital, London W1T 3AA
Tel
020 7380 9477
Fax 020 7580 6423
Email [email protected]
CME/CPD applied for
Professor Mike Harmer, in this
issue, wonders how anaesthetists can climb the ladder in the
Merit Awards table and shows
us how, much more than
previously, management in
individual trusts is influential
in who gets what. Anaesthetists have, of course, been low down on the scale long before
management took a hand – or is this not the case?
Have style and presentation got anything to do with our lack
of recognition? Does the image of the surgeon as a godlike
figure with a retinue of acolytes, an expensive car and a
burgeoning private practice inspire managers to encourage the
heaping of awards upon these colleagues? Does the humble
anaesthetist miss out because of (a) humility, (b) appearance
or (c) lack of voice in the corridors of power? Perhaps, as John
Burnell implies (page 5), we’re all working too darn hard, with
fewer trainees available, to get anywhere near these corridors.
Mike Vickers (page 10) suggests that our anaesthetic service is
in pretty good shape, unlike another country (guess where)
and his ex-professor colleague appears to have had a less than
satisfactory anaesthetic experience. So, awards and decent pay
may not be the answer?
Not that all trust management is involved in assessing the
medical staff for awards. Gas Flo’s lot are seeking out body
parts. I think our department has been checked for missing
bits and all we have is a plastic skeleton as, fortunately, my
poor law hospital couldn’t afford a real one, unlike a senior
member of the Association who has discovered that the
assumed plastic skull which has been on his desk for years is
real! Now, presumably, some manager has to find the
relatives.
An area where style, image and body parts have little, if any
relevance to the daily grind is Africa. Sadly, Paul Fenton is
hanging up his laryngoscope after many years in that
continent. Readers of Anaesthesia News will miss his words of
wisdom, after his last contribution in August.
Thanks, Paul, for keeping us sane in a ‘first world’ gone mad.
John Ballance
3
Anaesthesia News
July 2001
Letters to the Editor
The Arms of the Association
and the downward-burning
torch
When referring to the many and varied skills of anaesthetists, I
have often pointed to the Arms of the Association and said
facetiously that it takes an anaesthetist to make flames burn
downwards. However, on a recent visit to the Museum of
London, I learned that the Romans in the first centuries BC
and AD also had this skill and there is a carved statue
displayed that proves it. Alas, to them the downward-pointing
torch was a symbol of darkness and death; light and life were
signified by pointing it upwards in the usual way. I hope that,
today, there are not too many Roman citizens amongst our
patients as this is an unfortunate message for us to be giving.
I suppose it is much too late to change it?
Dr Aileen Adams, Cambridge
No worries
My first reaction on reading Frankie Dormon’s letter
(Anaesthesia News, May 2001) was to agree but, on
reflection, it seemed that the anonymous anaesthetist who
used the expression had some merit. We talk about
“going to sleep” and “waking up” as though this were
some trivial process, not a coma induced by the administration of potentially lethal poisons. We thus reduce our
image in the eyes of the public. I think I shall use this
phrase to the next patient who says, light-heartedly,
“There’s no risk from this, is there?” or, worse still, asks
“Are you a qualified doctor?”
Charles Davies, Calgary, Canada
Self-awareness
The suggestion that a suit and tie are commensurate with
professionalism is as odious as the traditional notion that the
successful doctor must drive an expensive car to demonstrate
to patients their excellence via their financial success.
I believe that the essence of professionalism is the satisfaction one takes in one’s own work, regardless of anyone else’s
opinion. By implication, therefore, I couldn’t care less whether
my patients think I am a doctor or not. I know that I am.
James H Carter, consultant anaesthetist
Sunderland
4
What, no tie?
Appropriate professional attire has recently been the subject
of lively discussion in both these pages and the Newsletter of
the American Society of Anesthesiologists (ASA). In the ASA
publication, however, all of the contributors, including the
editor, dress conservatively and wear a tie for their photographs.
In the May ‘News’, John Zorab advocates the wearing of a
coat and tie. In the same edition the Editor advocates improving our image and concludes with the hope that ‘.... John Zorab
would be proud....’. Would his message have been more
forceful, and Dr Zorab’s pride a little greater, if the Editor’s
photograph had included a coat and tie?
I request Anaesthesia News to join its US colleagues as
leaders in maintaining a professional image by wearing
appropriate clothes for their photographs.
Alan W Grogono, MD, FRCA, South Carolina
Editor’s note. The Editor is suitably chastened but protests that
the photograph for Anaesthesia News was taken without
patients around. However, after seeing the Annual Report for
1999, with the Editor also tieless, Professor Rajinder Mirakhur
kindly donated a splendid tie. It will be removed from the
cupboard and worn.
Behaving like a doctor
May I offer a reflection on the ongoing discourse concerning
our ‘image’? Some years ago the ‘Prof’ – WW Mushin –
responded to a registrar who was concerned that some of his
surgical colleagues treated him ‘like a technician’ with the
reply “My boy, if you behave like a doctor they’ll treat you like
a doctor”.
Words of wisdom, indeed. I have repeated this suggestion
often to junior staff down the years. It seems that it is relevant
still.
David D Imrie, FRCA, FRCPC, Halifax,Nova Scotia
Name badge also
Referring to Dr SM Zorab’s letter (Anaesthesia News, May
2001), much seems to be being made of our professional
image.
It is important to bear in mind that the wearing of a name
badge is also an important part of presentation and thus
image.
Douglas Duncan, FRCA
Anaesthesia News
July 2001
Letters to the Editor
We are highly trained
Referring to Dr Dormon’s experience (Anaesthesia News, May
2001), surely it is better to explain that anaesthesia is – potentially – extremely dangerous but rendered safe by virtue of the
fact that it is administered by a highly trained DOCTOR. One
does not need to be alarmist to do this.
Given that surveys of public perception tend to show that a
large percentage of our patients do not realise that we are a)
medically qualified and b) specialists in our field, minimising
the risks of anaesthesia can only add to the idea that we ‘give
an injection and walk away’.
Frances O’Donovan, FFARCSI, Dublin
Over and above?
Michael Ward gives an interesting insight into the awarding of
Merit Awards, with his inside knowledge of the Higher Awards
Committee (HAC). Obviously, many anaesthetists have inferior CVs. Why should this be?
First, we do not have our own firm, so it is from a limited
shared pool of trainees that our sessions have to be covered.
Secondly, if we cancel lists all hell is let loose, with the offended surgeon bringing the wrath of the Chief Executive to
bear upon us, as “waiting lists will increase” etc. Surgeons,
however, will happily cancel lists so that they can do other
things and the CE does not seem to worry. It is therefore easier
for a surgeon or physician with the firm to cover the work, to
get involved in examining, regional committees etc., than it is
for an anaesthetist.
As I understand it, Merit Awards are given for performance
‘over and above’ the standard consultant job. If consultants
are away examining, or chairing regional or national committees etc., and most of these occur during the working day, where
does the ‘over and above’ bit come in? Isn’t it ‘instead of’ (and
the trainee laps up the opportunity to do some clinical work
by him/herself), rather than ‘over and above’? Does the HAC
stop to think about that?
John Burnell, consultant anaesthetist,
Kettering General Hospital
Keeping abreast
In the May edition of Anaesthesia News, it is mentioned that
Dr Bowley from Nottingham reads Cosmopolitan “to keep
abreast with developments in modern soaps..”. While at medical school, I was advised to read that journal by a consultant
gynaecologist, in order to know one’s enemy.
Life is not risk free –
the sequel
Following on from the letter under this title from Dr Chris Frerck,
I have a short story to tell.
A child aged six had an adenotonsillectomy with the singleuse instruments we must now employ. All went well until the
very end when all credit is due to the vigilance of the surgeon.
The rather narrow tracheal tube (size 5 RAE as I reall –- rather
smaller than I would normally use for a six year old but this
was the largest comfortable fit) was snagged in the blade of the
tongue depressor part of the gag, to the extent that it was not
possible to remove the gag without extubating the child.
A plan of action was formulated and acted upon. The surgery now complete and the pharynx cleared of all debris, the
child was to be placed on the side. Removal of the gag and
tube would occur and a deep extubation was planned. All
went well and there was never any departure from normality.
On removal of the gag and tube it was seen that the tube had
been securely snagged by the wire loop at the distal end of the
tongue depressor plate. It could only be removed once out of
the mouth with an action that would destroy the tube. It would
have been quite impossible to separate them while still in the
mouth.
The scope for injury and disaster was appreciable. Had the
fact that the tube had ensnared itself on the gag not been
appreciated, movement of the gag may have resulted in
inadvertent extubation at any time. The consquences of this
action would have varied according to the depth of anaesthesia and whether or not the child was paralysed and ventilated
or breathing spontaneously at the time.
It seems ridiculous that we are ‘protecting’ children from
the (in all probability) non-existent presence of a prion but
seriously and tangibly risking asphyxiating them instead.
Ken Ruiz, consultant anaesthetist
Rotherham General Hospital
PLEASE SEND YOUR LETTERS TO
The Editor, Anaesthesia News, AAGBI,
9 Bedford Square, London WC1B 3RE
or email [email protected]
Dr Matthew Roberts, FRCA, Health Sciences Center,
University of Colorado
5
Anaesthesia News
July 2001
It couldn’t happen here?
A recent report into a scandal involving cricket
players caused one Anaesthesia News
correspondent to reflect on the relevance to us.
2. If ‘other major events’ translates to ‘private practice’, the
earnings differential of surgeons and other specialists is an exact equivalent.
The Condon Report – on Doctors?
3. Who hasn’t accepted ‘hospitality’, from sandwiches and biros
at the lunchtime drug do, to free travel and hotel accommodation?
Cricket has been knocked for six by the recent inquiry into
corruption in the game by Lord Condon. Those of us on
cricket’s fringes have been amazed to learn how much and
how many are involved. But are there some lessons here for
doctors? The report lists a number of reasons why, in Lord
Condon’s view, cricketers have been especially vulnerable to
corruption.
1. International cricketers are paid less than other top
sportsmen and are therefore more vulnerable to corrupt
approaches.
2. During the last World Cup and other major events, the cricketers received a low single figure percentage of the proceeds
from the event and resent the distribution of profits elsewhere.
3. Cricketers can take money from potential corruptors in
return for innocuous information and yet refuse to fix matches.
4. Whistleblowing and informing on malpractice was ignored
or penalised rather than encouraged.
5. Some administrators either turn a blind eye or are themselves involved in malpractice.
6. Cricketers have little say or stake in the running of the sport
and limited recognition of their representative bodies, where
they exist.
7. There was no structure in place to receive allegations about
corruption.
8. Cricketers have relatively short and uncertain playing
careers, often without contracts and some seek to supplement
their official earnings with money from corrupt practices.
9. Cricketers play a high number of One Day Internationals
and nothing is really at stake in terms of national pride or
selection in some of these matches.
10. Cricketers were coerced into malpractice because of threats
to them and their families.
11. It was just too easy.
If you replace the word ‘cricketer’ with ‘doctor’, at least half of
these become all too familiar:
1. No need to look internationally. Most doctors are paid less
than other professionals.
6
4. Events in Bristol and elsewhere are all too fresh in the
memory.
5. How did Dr.Shipman get away with it? Not through
‘malpractice’, but to have so many sudden deaths unnoticed
must indicate that the system is inattentive?
Many might feel that the structure and function of the GMC
has, at least in the past, been reflected in Condon’s items 6
and 7 as well. Certainly, his last is true – it is all too easy to
allow standards to slip.
If doctors have half as many vulnerabilities to corruption as
cricketers, don’t we need our own Condon Report?
JR Davies, Lancaster
Final FRCA Examination
Intensive Preparation Course
The Bristol Crammer
Monday 24 September –
Friday 28 September 2001
This five day course will include sessions on examination
technique, intensive therapy, new drugs, current topics and
practical subjects (viz. ECGs, X-rays and equipment)
conducted by national and local experts. It will include mock
examinations, performance analyses and will be held at
Burwalls Conference Centre, Bristol.
For further details, please contact:
The Secretary, Department of Anaesthesia,
Bristol Royal Infirmary, Marlborough Street,
Bristol BS2 8HW.
Telephone: 0117 928 2163 (Direct Line).
Course Director: Dr S Underwood FRCA.
Some accommodation available.
Course Fee £395
Includes coffee, lunch and tea.
Anaesthesia News
July 2001
From the Museum
Taking the pressure
Every schoolboy, as Macaulay would have said had the
occasion arisen, knows that Stephen Hales, in about
1712, measured directly the blood pressure of a mare
and published an account in his Haemastaticks in 1733;
and most doctors know that Riva-Rocci invented and
described, in 1896, the non-invasive method still in use.
W
hat is less well known is that attempts to measure the
blood pressure indirectly date back to 1834, when Jules
Herisson invented the sphygmometer. This was a graduated
glass tube with an expanded lower end covered by an elastic
membrane. When placed over the radial artery at the wrist, it
displayed the pulse beat and, if pressed on the artery until the
pulse could not be felt distally, the mercury level gave an
indication of the systolic blood pressure. Although it was
displaced by much more complicated apparatuses during the
1840s and 1850s, all of which depended on the principle of
loading a beam with weights to obliterate the pulse and which
developed into the sphygmograph, of which Dudgeon’s is the
best known example, Herisson’s simple idea persisted and a
modification by Hill and Barnard of the London Hospital, dating
from about 1890, is to be seen in the present exhibition on
monitoring in the Association’s Museum. This sphygmometer
was still in the instrument catalogues of 1910, although much
more accurate methods had by then been described.
The 1880s saw increasing interest in the measurement of
arterial blood pressure and the invention by SS von Basch
(1837–1905) of an instrument to which, in 1883, he gave the
name sphygmomanometer. His work is said to mark the
beginning of clinical sphygmomanometry and, almost
immediately, other apparatus began to be produced, the most
interesting of which was Gärtner’s tonometer. This was
described by the Austrian physician Gustav Gärtner (1855–
1937) in 1899 and used an inflatable finger cuff, an idea which
was re-introduced some sixty years later in the original version
of the Sonopulse apparatus. Gärtner’s tonometer was used by
Crile during his early researches into the mechanism of surgical
shock. A complete Gärtner tonometer and part of a von Basch
apparatus, on loan from the Science Museum, can be seen in
the exhibition.
In 1903, Cushing, on a visit to Italy, saw a version of
Riva-Rocci’s sphygmomanometer in use, introduced it to Crile
and gave it such publicity that other apparatuses were swept
from memory. However, in 1897, quite independently, Leonard
Erskine Hill (1866–1952) and Harold Leslie Barnard (1868–
1908), lecturers at The London Hospital, described in the British
Medical Journal a very similar apparatus which consisted of
an inflatable armlet, an aneroid manometer and a pump. A
copy of their paper is on display and their version of the
sphygmomanometer was listed in instrument makers’
catalogues for some years.
As late as 1924, CG Douglas and JG Priestley, in their
textbook Human Physiology, a Practical Course, observed that
clinical measurements of the blood pressure ‘have been made
possible by the introduction by Riva-Rocci and Leonard Hill
of the armlet method.’ Hill did pioneering work on the
measurement of intracranial pressure, researched blood
pressure changes during sleep and was elected FRS in 1896;
he was knighted in 1930. In his later years he worked for the
MRC, studying health and the environment. If there were any
justice, he would be receiving credit equally with Riva-Rocci
for the introduction of the non-invasive method of measuring
the blood pressure currently in use. In fact, he was the first to
measure the blood pressure during anaesthesia, as Dr NH Naqvi
has pointed out (Who was the first to monitor blood pressure
during anaesthesia? European Journal of Anaesthesiology 1998,
15, 255–259).
David Zuck
ST MARY’S HOSPITAL
LONDON W2
(SCCM Approved)
FCCS Course
19 – 20 July 2001
£175 including lunch
Enquiries and Registration:
Dorothy Walsh
Academic Department of Anaesthetics
Tel: 020 7886 1681
Fax: 020 7886 6425
E-mail: [email protected]
7
Anaesthesia News
July 2001
GAT Page
ORBIS
W
orking as a doctor in developing countries was something I
had always wanted to do. When I was a medical student, I
thought it was something I would spend a lot of time doing. In reality,
I got caught up in the rat-race of exams, training schemes and
research and I found myself repeatedly putting off volunteering, in
case I fell behind in the competition at home. Eventually, I made the
decision and organised leave from my SpR scheme before it was all
too late. I have not regretted it for one minute. If I live to be ninety
years old, it will still be one of the best things I have ever done.
Working with ORBIS
I joined ORBIS for two missions, one in Uzbekistan and one in Peru.
ORBIS is a flying eye hospital, founded in 1982, which travels around
the world in a DC-10 jet. The inside of the jet has been converted to
a fully equipped, modern ophthalmic surgery theatre, with a recovery room and a lecture theatre, connected to the operating room via
a live audiovisual link.
ORBIS flies into each country for an average of three, sometimes
six, weeks; there, they are joined by ophthalmology consultants from
around the world who perform up-to-date surgery on a range of
conditions. For the lucky patients who are selected, this is a dream
come true; however, ORBIS tries to avoid the scenario of performing
just a handful of miracles and flying away again, leaving a lot of other
people disappointed. They aim to teach intensively and to provide
the local doctors with up-to-date skills and techniques, so that they
can provide a service in their local hospital. This was not available
before.
I was the only anaesthesiologist – there was also a nurse anaesthetist from the USA. The crew – approximately 30 people in total – also
consisted of ophthalmologists, nurses, engineers, media, administration and flight staff. Some of them were long-term; others, like me,
were just there for a few weeks. Countries from literally all over the
world were represented on the crew, many of whom had developed
close friendships.
The patients were all day cases. Most were done under local anaesthetic, although the children received general anaesthesia. I was
also expected to look after the general health of the crew and to be
responsible for stocking of drugs and equipment. The plane had its
own oxygen generator which was maintained by the biomedical
engineer. Everything was fully up-to-date and in plentiful supply.
ORBIS has a very efficient public relations machine which generates regular funding and they provide a first-class service to the
centres they visit. I ended up on the front pages of newspapers in
Ireland and in Peru! During each mission, all expenses were paid
and we stayed in hotels which were provided to ORBIS by the host
countries at much reduced cost. We travelled each day to the airport,
to operate and teach on the ’plane.
At the start of each mission, we went to the local hospital, with
translators, to screen patients for suitability for surgery. Hundreds
turned up. Of the two countries, Uzbekistan appeared to be the worst
off, from a medical point of view. The local anaesthesiologists were
well educated and motivated but desperately short of equipment, drugs
and journals. Most surgery, general as well as ophthalmic, is done
using ketamine and diazepam. They rarely have volatile agents and
the anaesthetic machines are often old and in poor condition. Mor-
8
phine is used cautiously, as oxygen supplies are unreliable and pulse
oximeters are not always available. The hospitals are always short of
fresh needles, cannulae and tracheal tubes. Because of this, many of
the anaesthesiologists have become de-skilled and are not good at
intubating patients, or even maintaining an airway. Where possible,
everything is done under local or regional anaesthesia. This is a country
where children have their tonsils removed while they are awake!
Despite all this, the patients we met did not seem to be unduly
traumatised by previous trips to hospitals and most types of surgery
appear to be performed safely enough.
The patients were all absolutely desperate for themselves, or their
children, to have the eye surgery they needed. I have never seen such
desperation in Ireland or the UK, where medical treatment is largely
taken for granted. Some of them falsely denied having conditions
such as diabetes or hypertension, in case they would be turned away.
We would catch them out easily enough, by measuring their blood
pressure, as it was often dangerously uncontrolled. Since they could
not afford to take antihypertensives every day, they tended to save
their tablets until they felt their pressure becoming very high, as evidenced by black-outs, severe headaches or spots in front of their eyes.
Then, they would take the tablets for a few days, until the symptoms
went away. I have become as cynical and unsentimental as most
people in medicine but the pleading in the faces of those people on
that first day in Uzbekistan moved me quite considerably. It was terrible to have to choose only a few and turn the others away, many of
whom had travelled for hundreds of miles to see us. I hope that the
hospital may have been able to help some of them, after we had gone.
It is, in fact, surprisingly difficult to find a voluntary post as a
doctor abroad in the developing world. Aid agencies filter out
uncommitted volunteers by making it a real effort to get accepted.
Finding suitable agencies takes time and applications tend to be
processed rather slowly. A significant time commitment (about a year)
is often expected and one must be extremely flexible about when
travel will be possible. It is not a way to earn easy money, either, as
many agencies expect some contribution from volunteers. However,
in my case the hard work reaped dividends in terms of personal
satisfaction, as well as useful clinical experience. I cannot recommend it highly enough.
Carla Glynn, Dublin
Carla Glynn
Anaesthesia News
July 2001
Nuffield Department
of Anaesthetics
University of Oxford
3rd Regional Anaesthesia
for Carotid Surgery Course
Monday 8 October 2001,
9am to 4:30pm
Details:
Dr Mark Stoneham, Nuffield Department of
Anaesthetics, John Radcliffe Hospital, Oxford.
Tel 01865 221590, fax 01865 220027
Email: [email protected]
Website www.nda.ox.ac.uk
S
CATA
OCIETY for COMPUTING and TECHNOLOGY in ANESTHESIA
Autumn Meeting of The Society for
Computing and Technology in
Anaesthesia in association with
The Northern Schools of Anaesthesia
“Training and Technology”
Wednesday November 7 to Friday November 9, 2001
At the Britannia Airport Hotel, Newcastle upon Tyne
As well as topics of general interest to SCATA members, this
meeting will have a main theme of the role of technology in
relation to training and re-accreditation.
Sessions will include:
• Simulation, including demonstrations of the new “SIMman”
from Laerdal
• Logbooks and their relationship to RITA
• Technology and education
• Learning to Manage Health Information
• The European Computer Driving Licence
• Free paper sessions, with cash prizes for the best trainee entries
For details, please contact:
Dr Gary Enever or Ms Barbara Sladdin,
Northern Schools of Anaesthesia,
Anaesthetic Training Department,
Royal Victoria Infirmary,
Newcastle upon Tyne NE1 4LP
Tel: 0191 282 5081
For more information
Northern Schools of anaesthesia website on
www.ncl.ac.uk/nsa
SCATA website on www.scata.org.uk
9
Anaesthesia News
July 2001
Something to be proud of
Rather similar in scope to Murphy’s law is The Law
of Unintended Consequences. Although well known to
many, it has lacked, so far, an eponym. Before anyone
else lays claim to it, I should like to do so. It must be
great to go down in history attached to a universal and
timeless truth. Not much likelihood, I fear, but nothing
ventured etc, so here goes. Vickers’ first law (you never
know) states that whenever action is taken to change
behaviour en masse, something (usually the opposite)
occurs. For those of scientific bent, it is the sociological
equivalent of Le Chatalier’s principle – the Law of Pure
Cussedness.
I
ncreasing the duty on cigarettes increased smuggling, for
example, rather than reducing smoking or increasing
revenue. Another good example is the wearing of helmets by
cyclists, on which there was an article in the last Christmas
issue of the BMJ [1]. This showed how the campaign to
encourage the wearing of helmets, in the belief that it would
reduce head injuries and therefore be ‘safer,’ has had the
following consequences: the number of deaths of cyclists has
increased whilst the number of people cycling has reduced,
thus reducing the public health benefit of this activity and
worsening road congestion. Yet, until this concern for ‘safety’
was promoted, it was one of the safest of activities. Recently,
there has been a paper on the effect of introducing on-line
computers into A & E departments and the admission ward so
that investigation results would be available to staff at the
earliest possible moment and also reduce staff time spent ’phoning through results. About 20% of results were not actually
seen until between one and three hours of becoming available
and 3% were never seen at all.
I would like to recount another example of the power of
regulation to worsen matters in our own field. To avoid
embarrassment, let us suppose that it happened in a mythical
country elsewhere in this continent of advanced medical
practice. It happened to a retired professor of anaesthesia, in
his day the most distinguished such, honoured also in other
countries. Some few years ago the Ministry of Health made it
a binding requirement that all inpatients should be seen by an
anaesthetist pre-operatively. This is obviously desirable: it has
been promoted as good practice by our College as far back as
I can remember although we recognise that lapses are occasionally unavoidable. However, making the desirable compulsory has not had the beneficial effect expected.
Apparently, there had been complaints that operations were
sometimes cancelled by anaesthetists at short notice because
patients were found to be unfit or some investigation had not
been done. To make sure this didn’t happen a law was passed
which stipulated that an assessment by an anaesthetist must
10
take place twice: at least one week before the operation and
the day before the operation. Apparently, the Ministry officials
assumed that it would be the same anaesthetist both times and
the quality of anaesthetic care must therefore be improved.
The Ministry of Health took no advice from any official body
involving anaesthetists. Indeed, it is difficult to believe that
they took advice from anyone with the remotest knowledge of
how surgical services operate.
Many of you will be ahead of me by now. Anyone who has
tried to set up pre-anaesthetic assessment clinics will have
discovered that trying to cover every patient gives rise to
organisational problems and having the relevant anaesthetists
seeing even the majority of their own patients on such a timetable is frankly impossible. However, the National Society did
not feel moved to put up any opposition: rather the reverse. As
it is an insurance based medical system with remuneration for
item of service, it was obvious to the leaders of the speciality
that this would provide an opportunity to be paid twice for the
same task. In fact, as there was already a requirement that the
anaesthetist who gave the anaesthetic was responsible for the
patient’s medical care for 10 days postoperatively, there was
the possibility of three different anaesthetic fees.
And so, a few years on, to the actualité. The eminent
ex-professor needed a general anaesthetic for his intended
operation and so would have had to make an extra visit to the
hospital for his assessment – no mean undertaking when you
are 80++ years old and have selected a surgical colleague in
your old hospital, which is 400 miles away from your retirement home. An element of commonsense intruded: the
surgeon managed to get him seen by an anaesthetist on the
same day as the outpatient surgical consultation. He needed
pre-operative therapy and was very pleased to be told by the
nice lady anaesthetist (after consulting her diary and schedule) that she would be giving his anaesthetic.
However, on the day before operation he was seen by a
different anaesthetist and re-examined. He did not ask but
assumed that this was whom he would see the next day. But
no: on arrival in theatre (unpremedicated) he was greeted by a
total stranger who announced himself as his anaesthetist. He
knew nothing about the ex- and his reputation, his previous
illnesses, disabilities (numerous) or operations. When he had
fully recovered (a process complicated by prolonged sedation
by intra-operative midazolam leading to retention of urine and
traumatic catheterisation by a nurse) he asked to see ‘his anaesthetist.’ This gentleman admitted that he wasn’t very interested
in Anaesthesia: his only medical interest was the effect of diet
on inducing illness. He firmly believed that every ailment was
caused by taking an incorrect diet which needed to be individualised for each person. However, he had been unable to
find any gainful employment in which to practice his speciality.
However, the consequential shortage of anaesthetists following
the change in the law meant that he could earn a living as an
anaesthetist without too much effort on a case-by-case basis,
whilst following his real interest in the rest of his time.
Subsequently, the professor has discovered that his experi-
Anaesthesia News
ence of current anaesthetic practice in that country was not
unusual. The law has been obeyed but anyone who supposes
that the quality of anaesthetic practice has therefore been
improved knows nothing of the reality. As predicted by Vickers’
first law, it has got worse. And this is a country that maintains
that it is more cultured than any of its neighbours.
The apparent paradox remains that, in Britain, where there
is no such law, the great majority of patients are seen preoperatively by the anaesthetist who will be personally responsible for their care and, by the application of a little
commonsense, few patients are cancelled by an anaesthetist
at the last minute. Seen through that professor’s eyes, we have
an enviable system which is much better for patients than theirs.
And, for what it is worth, the ‘image’ of their anaesthetists has
greatly deteriorated and is now much worse than many anaesthetists in this country seem to think is the case in Britain. A
corollary of the first law is that those who take the easy money
always pay for it. The British way of delivering anaesthetic
services is really something to be proud of, even though most
of us do not appreciate it. I wonder if our masters do?
Michael Vickers
References
1. Wardlaw MJ. Three lessons for a better cycling future. BMJ
2000; 321:1582–1585.
2. Kilpatrick ES, Holding S. Use of computer terminals on
wards to access emergency test results: a retrospective
audit. BMJ 2001; 322:1101–1103.
July 2001
PAIN CLINIC PROCEDURES
COURSE
Dr S J Dolin, St Richard’s Hospital, Chichester
Dr N Padfield, St Thomas’ Hospital, London
A ONE DAY COURSE FOR THOSE WHO WOULD
LIKE A CONCENTRATED BRIEF EXPOSURE TO PAIN
CLINIC PROCEDURES
Small groups (maximum of eight participants)
Classroom-based teaching of indications, complications and
evidence base of commonly performed pain clinic procedures.
Practical demonstrations of a selection of:
• radiofrequency lumbar facet denervation
• radiofrequency cervical facet denervation
• radiofrequency trigeminal ganglion lesion
• sympathectomy (RF/Chemical) • coeliac plexus blocks
• cervical epidural • nerve root injection • thoracic epidural
• stellate ganglion block
Five CME points
PRICE: £125 TO INCLUDE LUNCH AND REFRESHMENTS.
DATE: THURSDAY, 4 OCTOBER, 2001.
LOCATION: DAY SURGERY UNIT, ST RICHARD’S HOSPITAL,
CHICHESTER.
Contact: Pain Relief Department 01243 831475 or
email [email protected]
THE ASSOCIATION OF ANAESTHETISTS
THE ASSOCIATION OF ANAESTHETISTS
of Great Britain and Ireland
of Great Britain and Ireland
SEMINARS AT 9 BEDFORD SQUARE
SEMINARS AT 9 BEDFORD SQUARE
Anaesthesia for
Interventional Radiology
Anaesthesia and Sedation for
Magnetic Resonance Imaging
Monday 15 October 2001
Thursday 25 October 2001
Organiser: Dr Peter Farling
Registration fee: Members £80, Non-members £160
Organiser: Dr Peter Farling
Registration fee: Members £80, Non-members £160
Open to all anaesthetists but priority is given to
members of the Association of Anaesthetists. Places
are limited, so early application is advisable. We
regret we cannot accept telephone bookings.
Open to all anaesthetists but priority is given to
members of the Association of Anaesthetists. Places
are limited, so early application is advisable. We
regret we cannot accept telephone bookings.
For more information, contact Nicola Heard at the
AAGBI on 020 7631 8805, fax on 020 7631 4352 or
email [email protected]
For more information, contact Nicola Heard at the
AAGBI on 020 7631 8805, fax on 020 7631 4352 or
email [email protected]
11
Anaesthesia News
July 2001
MERSEY SCHOOL OF ANAESTHESIA AND PERI-OPERATIVE MEDICINE
PRIMARY FRCA EXAMINATION WINTER 2001
THE MERSEY SELECTIVE
(formerly the Primary Eclectic Course)
A designer course specifically for candidates sitting the Primary Exam this coming winter, UK or Eire.
This five-day course has been designed following extensive consultation with trainees who have recently had to
face the challenge of the Primary Examination. As a result, the course will cover only those areas of the syllabus
which are considered to require special attention and elucidation.
The format is to be one of discussion, didactic or interactive, as judged appropriate, the aim being to explain and to
simplify. However, some rudimentary insight will be presumed and thus the organisers are confident the course will
only be of real benefit to trainees who are seriously approaching the threshold of the examination.
(Availability limited to 30)
SEPTEMBER 3–7 £300
For further information, please contact:
The Secretary, MSAPM, Postgraduate Centre, Broadgreen Hospital, Liverpool L14 3LB
Tel: 0151 282 6609, Fax: 0151 282 6935, Email: [email protected]
Writing for
Anaesthesia News
Anaesthesia News is always happy to receive copy of
articles, reports, travel stories and opinions. Most will be
accepted although some editorial revision or abbreviation
may be necessary. Letters to the Editor are particularly
welcome. There are several ways of sending your work to
your Newsletter and it should arrive at least four weeks
12
before the intended publication date. A Word file, posted on
a disk or sent attached to an email is best, although
typescript may be scanned. Please send photographs, of
reasonable size and in colour, either as a jpg file attached to
an email, or as ‘hard copy’.
Our contact details are: 9 Bedford Square, London
WC1B 3RE. Telephone 020 7631 1650. Fax 020 7631
4352. Email [email protected]
Anaesthesia News
Dingle 2001
Dingle 2001
3rd Current
Controversies in
Anaesthesia and
Peri-operative Medicine
Skellig Hotel, Dingle, Co. Kerry, Ireland
3–7 October 2001
(Dingle 2002: 2 – 6 October 2002)
(Dingle 2003: 1 – 5 October 2003)
For Details of Registration and Abstract Guidelines:
Dr Monty Mythen, Centre for Anaesthesia, UCL,
Room 103,1st Floor Crosspiece, Middlesex Hospital,
Mortimer Street, London W1N 8AA, UK. Secretary:
+44 (0)20 7380 9477 / Fax: +44 (0)20 7580 6423
[email protected]
Centre for Anaesthesia
July 2001
THE NEWCASTLE UPON TYNE HOSPITALS NHS TRUST
Department of Anaesthesia
THE FREEMAN HOSPITAL
Department of Anatomy
UNIVERSITY OF NEWCASTLE UPON TYNE
Biannual Workshops on the techniques and
practical application of peripheral nerve blocks
for upper and lower limb surgery
September 3, 4 & 5, 2001
Numbers to be restricted to 8 to allow hands-on experience.
Suitable for Consultants, Staff Grade, 4th & 5th year SpRs.
Workshops include: dissections of the relevant anatomy.
Use of nerve stimulators as an aid to performing
peripheral nerve blocks.
Demonstrations and hands on experience of nerve blocks and
catheter techniques.
Video and course tutorial provided.
Course fee £350
Contact: Sister L Smith, Department of Anaesthesia,
Level 4, Freeman Hospital, High Heaton,
Newcastle-upon-Tyne NE7 7 DN.
Telephone: 0191 223 1049 Fax: 0191 223 1180
Email [email protected]
British Ophthalmic Anaesthesia Society
3rd Annual Conference
Thursday 30 and Friday 31 August 2001
Will be held at Tall Trees Hotel, Yarm, Middlesbrough, Cleveland, UK
WORKSHOPS, LECTURES, NATIONAL AND INTERNATIONAL
SPEAKERS, DINNER AND ENTERTAINMENT
Last date for submission of free papers, posters, video and
registration: 15 Aug 2001
For further information, please contact:
Mrs Pat McSorley, Conference Administrator, Cleveland
School of Anaesthesia, James Cook University Hospital,
Middlesbrough TS4 3BW, UK. Tel: 01642 854601,
Fax: 01642 854246, Email: [email protected] or visit
our BOAS Website www.boas.org
Jointly hosted by Cleveland School of Anaesthesia,
Middlesbrough and Department of Ophthalmology; North Riding
Infirmary, Middlesbrough
Conference Organiser
Dr Chandra M Kumar, Consultant Anaesthetist,
James Cook University Hospital, Middlesbrough, TS4 3BW, UK
Email: [email protected]
13
THE ASSOCIATION OF ANAESTHETISTS
of Great Britain & Ireland
Annual Scientific
Meeting 2001
Belfast Waterfront Hall
13–14 September
Book here or contact
Jo Barnes, Association of Anaesthetists, 9 Bedford Square, London WC1B 3RE
Telephone +44 (0)20 7631 8802/3 • Fax +44 (0)20 7631 4352
• Email [email protected]
Details available on the Association website - www.aagbi.org
Anaesthesia News
Gas Flo
Notes from a Small Hospital
A Tale of Everyday Folk in the North
The men in white coats are coming. Not to take me away,
which might please some people, but to search our department for – wait for it – BODY PARTS! Three A4 pages of explanation have just arrived in the internal mail, including a declaration for me to sign to the effect that we are not harbouring
anything nasty and a reassurance that they will not search my
office. Well that’s all right then – phew!
The search party is to be made up of a consultant pathologist, his general manager and the Director of Personnel (who
wouldn’t recognise a body part if it hit her in the face). Now
when you consider that pathology is currently undergoing a
major trust-wide review and that we managed to appoint a
consultant recently and employ him for fifteen months before
it was discovered he had been erased from the General Medical Register, you can see that these people might be better
employed attending to their usual business.
I read in today’s newspaper that there are 165 specimens at
large in our trust that may have been taken without permission. This is, on the face of it, quite worrying. Our head of
pathology, however, is a very astute person and I am perfectly
sure that anything dodgy would have been disposed of thoroughly months ago. In fact, come to think of it, there was a
Keep up to date
Profligate over-ordering of shellfish is suggestive of which
physical sign? Answer on page 16
July 2001
large skip outside the path. lab. for weeks last summer. Apart
from the underlying sad reason for it all, the real tragedy is that
this search is, almost certainly, a complete waste of everyone’s
time.
I fear I may have committed a grave error in flippantly declaring on my form that there is nothing to find in our department apart from an ancient Spam sandwich in the fridge and a
cactus that closely resembles an intimate part of a man’s
anatomy but is, in fact, just a cactus. The search party, it would
seem, is running short on humour. Perhaps it was the Cabbage
Patch doll in the pickle jar that they found in Maternity or the
glass eye in a drug fridge. Rumour has it that a nurse in a neighbouring hospital was on the point of suspension until she was
able to convince them the steak and kidney in the staff room
was in fact destined for her family’s dinner and not yet another
decoy. The whole business is so completely surreal; however,
the temptation to plant something in every cupboard is understandably irresistible.
To the best of my knowledge, the only genuine anatomical
specimen we have in the surgical department is Archie, the
skeleton who lives in the orthopaedic seminar room. He was
originally in theatre but someone dressed him up as an anaesthetist and labelled him ‘Waiting for the End of the Trauma
List’. The orthopods didn’t think this was at all funny and removed him to a place of serious study and science. Anyway,
no doubt Archie’s relatives will have to be traced and perhaps
we will have to put him in a box and post him back home to
give them an opportunity to arrange a decent burial, grieve
and achieve what the Americans like to call ‘closure’.
This is just a small district general. I can only imagine the
pandemonium occurring in university hospitals with museums.
Why do we always have to have the costly, ill thought out,
knee-jerk reaction to any perceived problem that occurs in
public life? Whatever happened to good sound British
commonsense? I feel duty bound to warn you all. They will be
coming to a theatre near you soon, if they haven’t been already. Better be prepared and make sure all your particular
skeletons are well locked up in the cupboard or, better still,
someone else’s. After all, why take the blame?
Have fun!
Gas Flo
a
A
E-mail: [email protected]
Web: www.TheAnaesthetistsAgency.com
15
Anaesthesia News
July 2001
Tales from the
back line
I
was watching a second screening of the three part documentary from the 1980s called The Africans – A Triple
Heritage by the Kenyan Ali Mazrui, on South African
television. It presents the African perspective of the Development History of Africa. Resentment is the general theme.
Recently, one of the hospital staff said to me “Ah,
doctor, now we are having development brought to this
country”. This simple statement was just meant to be a polite
conversation piece but it said more about the development
dilemma in Africa than three hours of Mr. Mazrui and helps
one understand why development in health is just not
happening here.
To most Africans there is only one History of Africa. It is
an uncomplicated sequence:
Stage I. (Prehistory to 1000 AD) Africans were on their
continent, minding their own business, right in the middle
of the world. Everything was going on nicely.
Stage II. (1000–1960) Things started going wrong:
Arabs came from the East and whites from all directions.
Both brought slavery and war (neither of which existed
before) and the latter divided up the continent arbitrarily
and stayed on as colonialists. They wanted the minerals
and to contain the indigenous people in convenient plots,
irrespective of tribal or cultural factors.
Stage III. (1960–1989) Independence. New African leaders started out OK but valiant efforts were scuppered by
outsiders, resulting in bankruptcy at the end of stage III.
Keep up to date
What is the condition illustrated on page 15?
Muscle wasting
Smart IT person wanted!
The GAT committee is in dire need of an update on its IT skills.
A trainee with the appropriate knowledge would be warmly
welcomed and could be co-opted onto the committee.
Please reply to Sarah Harris at Bedford Square, 020 7631
1650, fax 020 7631 4352 or email [email protected]
The copy deadline for the September 2001 edition
of Anaesthesia News is 18 July
16
Stage IVa. (Today) The world has
turned its back on Africa and, from
starting out in the middle, it has gone
to the edge of the global scene.
Stage IVb. Africa gets Development
Aid from the West to compensate for
IVa. If this process is going wrong, it
is only because not enough is being
given. Tight-fisted azungu are hanging on to it somewhere.
End of the story so far. In the next
episode: Globalisation (=Western greed) looks set to make
things worse. The bottom line: The West owes, Big Time.
Development is seen as A THING, probably of divine
origin, with Man the passive vehicle for its dissemination
to other men. Widespread religious culture assists this
perspective. Like numeracy and literacy, which evolved as
man himself developed his thinking somewhere in Mesopotamia, Development is without ownership or history. As
far as the Africans are concerned, there are no human
patents or intellectual property rights on Development. Thus
we can read that the latest electronic technological developments, like computers, will enable Africa to ‘leapfrog’
(over the traditional development sequences normally
lasting several hundreds of years) into the 21st century.
Clearly, this perspective of being the passive recipient
of manna from heaven is at odds with the current global
market trends that seem to be here to stay.
Paul Fenton
Direct line telephone numbers
Public Affairs: Metin Enver 020 7631 8808
Meetings: Joanne Barnes 020 7631 8802
Seminars: Karen Grigg 020 7631 8803
Membership: James Kirton 020 7631 8801
Finance: Liz Keegan 020 7631 8815
Heritage and Museum: Trish Willis 020 7631 8806
House Management: Paul Berncastle 020 7631 8810
Committees: Nancy Dobson 020 7631 8807
Chief Executive: Kevin Horlock 020 7631 8811
For general enquiries, continue to use 020 7631 1650
and the fax number is still the same – 020 7631 4352.