2011 Spring

spring 2011
ISSN 0265-9212
The Society of Anaesthetists of the South Western Region
President
Dr Peter Ritchie
Cheltenham
President – Elect
Dr Kerri Houghton Torbay
Honorary Secretary
Dr Chris Monk UHBristol
Honorary Treasurer
Dr Bill Harvey
Truro
Trainee Representatives
Dr Katie Holmes
Dr Dominic Hurford
Editorial committee
Dr Fiona Donald
Dr Vanessa Purday
Administrator
Website Manager
South West School
Bristol School
Editor, Southmead, NBT
Assistant Editor, Exeter
Kate Prys-Roberts
UHBristol
Dr Ben Howes
UHBristol
www.saswr.org.uk
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Anaesthesia Points West
Contents
Vol 44. No.1
Spring 2011
1
Committee members
Contents
Editorial
Future Meetings of the Society
News of the West
Examination Successes and Honours
Report of the Spring Scientific Meeting of the Society
Basic Training in Anaesthesia – the Effect of a
Run-through Programme in the Bristol School
of Anaesthesia
Follow-up Study to Assess the Accuracy of Visually
Estimated Blood Loss in Obstetric Haemorrhage
Audit of Training in the Use of a Lighted Intubating
Stylet (TrachlightTM) for Blind Tracheal Intubation
Emergency Caesarean Section in a Patient with
Presumed Pre-eclampsia and Undiagnosed Thrombotic
Thrombocytopenic Purpura; A Case Report
Severn Ultrasound Regional Foundation (SURF) Course
African Anaesthetic Adventures
Anaesthesia in Taunton 1959/60 - a Different World!
Poem
The Wine Column
Crossword
Prizes and Bursaries
Notice to Contributors
2
Page
2
Fiona Donald
3
Linkmen of the Region
5
4
18
Chris Monk
19
Catherine Bryant, A Gray
& Tracey Appleyard
34
Lorna Burrows, Tim Hooper,
Claire Hommers, Andy
McIndoe & Su Underwood
26
Johanna Angell, Usha
Devadoss & Khaled Moaz
39
Elspeth Hulse & David
Elliott
43
Henry Murdoch, Tom Martin
& Chris Thompson
48
John Powell
57
Nigel Hollister
52
Robin Forward
63
Tom Perris
Brian Perris
64
66
67
69
Editorial
He who does not economize will have to agonize.
Confucius
At the time of writing this editorial I am
enchanted by the arrival of Spring. The sun
is shining and it’s almost warm enough to
dispense with scarf and gloves. All of this is
timely as we seem to need something to cheer
us up. The news from our correspondents
in the west is somewhat more gloomy than
usual with all departments starting to feel the
financial pinch. Having said that, one of the
major preoccupations does still seem to be
car parking so maybe things aren’t quite as
different, or as bad, as I thought!
To cheer us further, we have a fine selection of
articles in this edition including a fascinating
insight into life as a junior anaesthetist (and
some information about the life of a consultant)
in 1960 in Taunton. I particularly enjoyed the
description of general anaesthesia for caesarean
section and the concept of a subapnoeic dose
of muscle relaxant in spontaneously breathing
patients. It is amazing to see how much
things have changed in just 50 years. John
Powell brings his usual humour to bear in this
entertaining article but it is clear that life was
tough and leisure time was scarce. It is salutary
to remember why it was necessary to reform
junior doctors’ hours when these days we are
apt to complain about the lack of time they
spend in hospital. Indeed, the article by Lorna
Burrows et al., looking at the effect of runthrough training on clinical experience amongst
junior anaesthetists, complements Dr Powell’s
recollections very well. Whilst it is clear that
more cases are undertaken if more time is spent
in training, the question of whether clinical
expertise has been compromised by reducing
training time is more difficult to answer. We
will probably need to wait at least 10 years to
find out. I for one am keen to know the answer,
as I am likely to be a consumer by then!
Nigel Hollister was awarded the Ross Davis
bursary to help fund anaesthetic adventures
in Africa. Many of us will be envious of
the obvious efficiency of the system aboard
the Mercy Ship. Why is it that our hospitals
cannot work like this? There are, of course,
many reasons and even more excuses. Maybe
rather than pondering the question too much
we should concentrate on what is perhaps the
most telling line in Dr Hollister’s article: “lives
really are changed”. Too often, as we become
bogged down in all the annoying trivia of the
NHS, we lose sight of this aspect of the work
we are privileged to be able to do.
We have another case report in this edition, to
follow on from that published in Spring 2010.
As I mentioned at the time, case reports have
not been part of our usual fare and I would
like to say that the publication of this one is
in response to overwhelming support for the
last. Unfortunately, I would be lying if I did,
as letters to the editor are few and far between.
Even informal feedback is rare, but I generally
work on the principle that no news is good
news so case reports will contine to be gladly
received.
I am sure you are all looking forward to the
Spring SASWR meeting in Taunton. We are
now becoming accustomed to a high level
of intellectual rigour and entertainment at
our meetings, and Taunton promises not to
disappoint on either front. Although unable
to attend myself, I am sure that the Cricket
Ground will be home to as much jollity as
when I last attended – to watch Ian Botham
play for Somerset. Does that date me?
Fiona Donald
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Future Meetings of the Society
Spring 2011
Somerset Cricket Ground,
Taunton May 19th and 20th 2011
Autumn 2011
Bath Assembly Rooms,
December 1st and 2nd 2011
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Spring 2012
Torbay, May 2012
Autumn 2012
Bristol, (Frenchay) November 2012
News of the West
This is where you are kept up-to-date on all the news and gossip from each department in the
South Western region. The name of the correspondent appears at the end of each contribution
and he/she is also the SASWR LINKPERSON for that department. Anyone wishing to find
out more about SASWR, or wishing to join, should search out the local linkperson, who will
readily supply details and an application form. In addition to other benefits, each member
will receive the twice-yearly edition of APW – free!
Barnstaple
Greetings from North Devon. Well after what
seem like years of stability, we appear to be
on the threshold of ringing a few changes. No
reference to the somewhat uncertain future of
the wider NHS but to the turnover of permanent
staff in our department.
Firstly, another almost nearly, but not quite
yet, retirement. After sterling service well past
the traditional retirement age, Ken Barron has
withdrawn from full-time anaesthetic practice, but
he continues to deliver the chronic pain service. He
will be joined in a year or so by Gareth Sowden,
followed shortly thereafter by yours truly.
This month we are delighted to welcome Cecily
Don to the consultant ranks. She has an interest
in obstetric anaesthesia, and replaces Henry
Bastiaenen. We hope that she will have a long
and happy career here in this corner of glorious
Devon. Welcome too to Katy Gregg who
began her anaesthetic career as a trainee with us
some years ago, and now returns as a part-time
consultant to make up the sessions released by
Ken. We hope it will be a happy return.
We say arrivederci to Christina Opranescu who
has been with us for the last few months and
has been happy to cover as either consultant
or middle tier on-call according to service
demands. Thank you Christina and our very
best wishes for your forthcoming marriage.
Our middle tier has now been boosted by the
appointments of Balazs Bartos and his wife
Monika Hanko, Balazs Itzes, Amin Rahat and
Mala Jayaweera, as well as our longer-term
locums, Sri Malampalli and Sylvia Herczog.
Another recent arrival has been baby Kurup,
shortly after proud new father Shinoy joined the
department. Congratulations to Mum and Dad.
Good news on the exam scene: Danielle
Franklin, Seb Knudsen, Ben Murrin & Jo
Riddell have all passed their Primary FRCA.
Congratulations to all of them. A welldeserved reward for their hard work. Lance
Holman has but one hurdle yet to jump and we
are sure that success is not very far off. They
are a great bunch and will undoubtedly be
assets to whichever departments they complete
their training in.
Tony Laycock is fresh back from India where
he spent 2 weeks working with Operation
Smile. We have yet to receive formal feedback
but by all accounts it was a stimulating and
exciting experience. Charlie Collins has been
back to Nepal but this time taking Joe Riddell
with him. We expect Laurie Marks back from
his 3-month sojourn in Zimbabwe imminently,
so perhaps more about that in the next issue.
David Hurrell
Bath
Can it be 6 months since the last missive from
the Royal United? All has been trolling along
well here with a relatively stable period of
calm. We were very sad to see some of our
most excellent trainees leave us for more senior
posts. We wish Chris Bordeaux, Carole Streets
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and Natasha Clark every success and thank
them for their very sterling efforts. We were all
delighted to welcome back Tracey Christmas
and she continues where she left off.
We have survived swine flu, norovirus and even
coped fairly well with Elspeth being away for
a couple of weeks but all has been brought to a
halt by the new car parking regime. Although
after a number of weeks of online chaos even
this outrageous action has been rescinded.
This was not due to any action from the
department of anaesthesia, who were too busy
with the day job, but as ever our well lunched
physician colleagues managed to sort out this
latest on line fiasco. Talking of on line events
the hospital is looking forward with nervous
anxiety to the rolling out of “Millennium”. We
have no doubt it will bring boundless joy to all
our lives not least by seeing our orthopaedic
brethren explode and decry any modern
technology, harping on about the days when
they had secretaries to do all the menial tasks.
Sporting endeavours have been relatively
limited with a few half marathons barely worthy
of mention, I am not aware of anyone climbing
Everest or swimming across the Atlantic this
term and will apologize in advance if anyone
feels they have been missed out.
Special mention must go to a few of my
colleagues. Firstly after many years service
as our CD Monica Baird has relinquished
her role and handed over to the ever youthful
Alex Goodwin who is having a second term
of office. We thank Monica and wonder what
she will do with herself once the MBA from
Bath University is completed!! Surely great
things are in store. Jerry Nolan has been voted
onto the Council of the RCOA where I am sure
he will be a voice of reason and practicality.
On the side he has also taken over from Kim
Gupta for a second term as lead clinician for
ICU. Also I am sure it will not come as a
great surprise that Tim Craft has become the
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Medical Director of the Trust. We wish him
well in sorting out the PCTs while they are still
in existence.
Finally we wish Tim Cook well with the
launch of NAP 4. We all know how hard he
has worked over this and hopefully the whole
anaesthetic community will benefit from his
work, plus he might be on the telly.
I will end my ramblings at this point and hope
I am not too late for the deadline.
Tom Simpson
Cheltenham
And so to Cheltenham…cottage hospital to
the Cotswolds…well nearly but not quite yet.
The beginning of January saw the move of
maternity from CGH to Gloucester’s sparkly
new women’s unit, leaving a midwife led birth
unit in Cheltenham and a wee bit of space
for “reconfiguration” and amalgamation of
services...watch this space.
To begin with hatches and matches,
congratulations to Raj Shivanna on the birth
of his daughter, and Helen Crispin who returns
to us after the birth of her daughter last year welcome back Helen. Gemma Mathews has
got herself engaged as well as passing her
MRCP - clever girl! Gemma has moved on to
a slot in ED at Cheltenham but hopefully will
be back in anaesthetics before we know it.
Other exam successes include Richard Edwards
passing his MCQ and Jeannine Stone who
has completed her Primary. Our two fantastic
medical trainees who contributed hugely to our
critical care unit in the past 6 months, Barny
Hole and Francesca Jones, both gained their
MRCP during their time with us…obviously we
weren’t working them hard enough but maybe
we also imparted a bit of wisdom and knowledge
along the way, so well done us! We say goodbye
also to Megan Dangerfield (budding EDist), and
Matthew Roe (budding anaesthetist, currently
doing time on ACUC in Cheltenham).
We’ve gained a few new faces; Nick Preston,
Abigail Lind, Dan Taylor, Ross Hodson, and
Alan Radford and we welcome them all.
Many congratulations to Martina Nejdlova,
one of our most treasured staff grades, who’s
got a job as a locum consultant in Heartlands
in Birmingham. Good luck in your new job
Martina, we are truly going to miss you.
Finally, I’d like to mention Betty Green one
of our lovely long serving departmental
secretaries. Betty has been poorly and absent
from work for several months now, we all miss
her and wish her a speedy and full recovery.
TTFN
Yvonne Marney
Exeter
I must start by apologising for the absence of
news from Exeter in the last edition of Points
West. I thought I had submitted it at the eleventh
hour, but it clearly was the half past eleventh or
even midnight hour. This time, I will send it in
(and indeed write it) a whole lot earlier.
So, I have almost a year to catch up on. By
now, last year’s CT2s must be well established
across the length and breadth of the country.
Hopefully they are a credit to us, their formative
hospital. Our new crop of CT1s are settling
in well, and starting to become useful on the
rota. If only James Pittman hadn’t devised
such a fiendishly detailed competence book for
them. So many DOPS, CBD, CEX (as a result
of which I now know that Teabag can’t wear
boxers, and therefore always wears briefs), and
now the ALMAT, which I think was a Chuck
Berry song. Where will it all end?
Welcome back to Suzy Baldwin, from a year of
maternity leave – mildly calmer, but no quieter.
Matt Rucklidge is due back soon from a year in
Perth. We are looking forward to seeing him,
and I’m sure he’s missing Exeter too. Harry
Pugh is currently guffawing his way through
military service in Afghanistan. We wish him
a safe time there, and look forward to seeing
him again in April. In Harry’s place we
temporarily welcome Richard Hughes. Hearty
congratulations to Nij, on his consultant post in
Durham, and to Richard Eve and Mike Spivey,
who both have ITU jobs at the BRI. They have
all served us well, and will be missed every
time there’s a tricky list to cover on the rota.
Good luck to all 3 of you. Good luck to Dave
Pappin, who has moved on, and welcome to
Will Key, the new block fellow, Paul Margetts,
Nigel Hollister and Simon Rolin.
There have been a number of babies since I
last wrote. Congratulations to Vanessa and Jon
Purday on the birth of Caroline, to Suzy on the
birth of Ellie, and to Richard Eve, Mike Spivey
and Mark Davidson on their new arrivals.
Also congrats to Rachel and Kris, two of our
secretaries, on the births of their daughters.
Biggest congrats to Nij, whose wife managed
to go into labour 3 weeks early, while Nij was
on call, leaving Fred Roberts resident on call
for obstetrics for the night. Finally we wish
matrimonial bliss to Hayley Stevens and
Suzanne Coulter who tied the knot this year.
Alasdair Dow has celebrated a big birthday.
Sheena organised a surprise party, complete
with a full complement of candles. Her
reward was a complete fire crew storming the
department, to Sheena’s great delight. Roland
Black has finally finished writing a book –
something to do with ITU, which he would
commend to you all as probably the best book
ever written.
We have had a fair amount of exam success,
with Patriczia Jonetzko, Karen Hayes, Paul
Stevens and Louise Finch passing the Primary
OSCE, and Hannah Dodwell passing the MCQ.
The social life of the department is a bit
lacking. The summer BBQ, once again
skilfully organised by Bruce McC and no
longer running at a financial loss, was again
held at the Turf Locks in the pouring rain. For
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once I wasn’t there, but I am assured by my
sources (Lauren and Emma, both of whom
cannot be relied upon to stay sober enough to
have accurate recall of events) that there was
no hurricane this year, nobody fell off their
bike, no mishaps in the estuary, and even Dom
wasn’t sick. Very boring, and I’m glad I missed
it. The Christmas Do was held once again at
the Clarence. It was lovely to see Pete Ford
there – his first public engagement since his
welcoming party, several years ago. In a break
with tradition, both trainees of the year were
not on call and were at the party. Well done to
Louise Finch, on winning the Jim Poulos SHO
prize, and to Hannah Dodwell for winning the
ITU OSCAR, then drinking until she almost
but didn’t quite fall over. Alex declined to
give a speech, probably on the good advice
of his wife, but did have his tequila monster
head on. Aided by Dom, the only consultant
young enough (or perhaps foolish enough) to
go clubbing after the party, he rounded up a
bunch of trainees, dragged them to a night club
and force fed them tequila. Emma molested
Matt Grayling on the dance floor, and a good
time was had by all. The evening also saw
the premier of “The Apprentice”, written and
directed by Fiona Martin. It featured Lady
Emma Hartsugar, myself as Margaret, and
Quentin as the bloke in a suit, with 8 hapless
trainees competing for a 5-figure salary and
the opportunity to work almost every weekend
for a year. It was so expertly produced by her
(BBC employee) dad that it almost looked like
we could act.
And finally, to the Mid Life Crisis sweeping
our department. I expect that by the next
instalment of Points West there will be more
cases, as it is apparently spreading. Clearly we
have had the obligatory quota of sweaty, lycra
clad boys, and Emma, prowling the corridors
at either end of the day, for years. However,
now Teabag, our former and never knowingly
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PC leader, a man heard to spit at the mention
of a bicycle, when clearly driving would be
superior in every way, has succumbed. He has
lycra, he has fluorescence, he has a bike, and
he’s not afraid to use it – sometimes to cycle to
work and back twice in the same day. It might
actually be quicker than driving after all. Ed
Hammond, always a delight to behold in his
variety of lycra, has taken his cycling to new
depths. Cycling to Tiverton, for a morning
list (not along the M5 although it would be
quicker), then back to Exeter for an afternoon
list. Who else would be so pleased to have
a list in Sidmouth, just so they can get up at
6am to cycle there? (Colin Berry, I think is
one answer). And then there is Lauren, who
is taking her MLC to new extremes. On a
general background of too much exercise for
a normal person, she undertook to cycle from
Bideford to Sidmouth. 10 hours later, Lauren
arrived. Two days later Lauren was able to
sit down. The following week she took part
in a 5-mile swim along the river Dart. This
time it only took 2 or so hours, but it was only
13 degrees. Now the Grizzly beckons – the
name is enough, I don’t need details. And not
to be outdone, Myn successfully completed
the Athens marathon, and was even seen
wearing his medal at work (presumably until
he was dealt with by infection control). I wish
Mark Daugherty good luck for his impending
3-day bike race in South Africa - researching
and buying the right bike is no substitute for
actually training.
So, that’s it, except for congratulating Iain
Wilson on taking up the position of President
of the Association of Anaesthetists. Now
that’s a medal that would be worth a fight with
infection control.
Pippa Dix
Frenchay
Much excitement at Frenchay as the winners
of the lottery for a new parking permit are
announced. The allocation process remains
shrouded in mystery, except that working in
Trust management seemed to guarantee a
permit, but being a Consultant Surgeon seemed
to count against. Cue angry emails, and a dropoff in productivity all round.
Hearing that one’s in-laws are selling their ski
chalet to move closer to their grandchildren
can be distressing, and all the more so if you
discover the news during a relaxing read of
the ‘Home’ section of the Sunday Times,
as David Lockey did. To be fair, it must be
disconcerting having a son-in-law who looks
the spitting image of Bruno Tonioli, of ‘Strictly
Come Dancing’ fame. Come to think of it, I’ve
never seen them in a room together, and David
is away an awful lot...
Departments around the region may be
interested to hear of an innovation devised by
Ben Walton, the Anaesthetic Fight Club. All
you need is a copy of the rota, and an ad hoc
committee to decide which consultant would
beat which in a fight. For example, Ben is tall
so has a long reach, but Gareth Greenslade
looks like he packs a punch, if he could catch
you. Judith Dunnet is Scottish, which counts
for a lot, and James Rogers has three older
sisters, which doesn’t. To cut a long story short,
the final consisted of Alex Manara (Maltese,
probably carries a knife) and Nuala Dunne. I
can’t tell you who won, but she keeps horses.
Rhys Davies was mortified to go out to Ruth
Spencer, unanimous decision by the judges.
Congratulations to Matt Thomas on being
appointed as an ITU consultant, but we are
losing Charlotte Steeds as she jumps ship to the
BRI, presumambly for some sort of bet.
James Rogers, Rebecca Leslie and Reston
Smith successfully completed a 450 km charity
bike ride across Kenya, raising money for an
orphanage run by Rebecca. On the subject of
endurance, whoever said it was advisable never
to exercise so hard that speech became difficult
obviously hadn’t bargained on Sarah Martindale
taking up triathlons. In fact, if she does stop
talking, initiate CPR at once. To prove the world
has gone completely exercise-mad, Samantha
Shinde is training for a half-marathon.
Congratulations to Stefan Krassnitzer and Vera
on the birth of Paul Ian, to Scott and Sarah
Grier on the arrival of Erin Sophia, and lastly to
Keiron and Sarah Rooney on the birth of Alice.
We were very sorry to say goodbye to Michael
Bishop, who spent a year as a neuroanaesthetic
fellow, also finding time to unleash his freakish
knowledge of physiology on the trainees in
tutorials. Michael is returning to what’s left
of his native Brisbane. Michael was also the
recipient of the Wilton award, along with Henry
Murdoch. The Wilton award is now challenged
by the ‘Walton award’, which is an accolade
bestowed by Ben Walton on the departing
trainee, generally female, who bakes the best
cake. Points are awarded, Olympics style, on
level of difficulty, execution and presentation.
Special mentions go to Jo Collins’ Victoria
Sponge, Anoushka Winton’s Lemon Drizzle
(don’t get me started), Abbie Lind’s Rock
Cakes and Liz Hayward’s Chocolate Tiffin.
Other departures included Louise Sherman,
who emigrated to New Zealand with her family,
and Esther Flavell, who is returning to Wales.
Congratulations to Jo Collins on her
engagement to Neil, and rumours that Kate
Crewdson had been cornered by a bull whilst
walking her dog were confirmed by the
announcement of her engagement to Neil
Bradbury, a Bath orthopaedic surgeon. Helen
Turnham found a way to help the chronic pain
patients forget their troubles by wearing a black
leather mini-skirt during her Pain attachment.
Sartorial problems were also encountered by
Sophie MacDougall when anaesthetising a
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plastics patient while on-call. Walking into
theatre mixing some antibiotics in a syringe,
she experienced a wardrobe malfunction
involving the loss of her trousers, revealing big
pink pants. Her squeak of distress alerted the
four operating surgeons, who all looked round
and regarded her for a second, then, as a man
(moot point as plastic surgeons) turned back
to their work. Perhaps surgical loops magnify
in an unflattering way, but oh, the shame, the
ignimony of it all. Sophie quickly got over this
episode by travelling to the Artic Circle as an
expedition doctor, where she was issued with a
rifle to take pot-shots at polar bears with. Nice.
New arrivals include Lorna Burrows, Alia
Darweish, Katie Howells and Thom Petty, all
whom have ‘previous’ at Frenchay. Ingenues
are Claire Newton Dunn, Clintin Lobo, Alastair
Keith, Ben Gupta, Hannah Wilson and Charlie
Heldreich, Welcome.
Richard Dell
Gloucester
Spring already and lots of news to report from
Gloucester. In short, a wedding, several babies
(including a royal delivery), a new clinical
director, a few parties, a large national meeting
and an obstetric union with Cheltenham.
Gloucester and Cheltenham hosted the Difficult
Airway Society meeting at the end of last year.
It was a really successful meeting and was well
attended. We had a large organising committee
from both hospitals who were led by Richard
Vanner. One of my roles was organising the
IT component of the meeting – interesting
considering my total lack of expertise in that
field!!! Fortunately help was on hand from the
Cheltenham Racecourse team - the academic
meeting was held there and it was fantastic. The
rooms overlooked the racecourse, and the only
disappointment was that there wasn’t a race
meet on at the time! The gala dinner was at the
Pittville Pump Rooms which again was a great
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venue - the evening kicked off with champagne
and a string quartet, followed by opera singers
during dinner and we finished with a band and
dancing. All in all a fantastic meeting.
Just before Christmas the snow turned our
county into something that resembled Narnia,
even our Christmas party had to be postponed!
This is almost unheard of for our department
which loves to party. Fortunately we managed
to make up for it and had a great evening out in
January. Tom Perris and Ian Godfrey organised
an evening with a huge excess of fine wines
and great food.
In January our new Obstetric Wing opened.
Unfortunately it wasn’t ready in time for the
delivery of the Queen’s first great grandchild
who was born in Gloucester Hospital at the
end of December but we will be ready for
the next one.
Cheltenham obstetricians,
anaesthetists and midwives have been brave
enough to cross to our side of the motorway
and have joined forces with Gloucester to
form one large obstetric unit. There has been
quite a lot of reconfiguration across the county
with obstetrics, gynaecology, ENT, max fax,
dentals and most of the paediatrics coming to
Gloucester and urology moving to Cheltenham.
We have a new general manager called Emily
Morgan who has obviously been very involved
in the logistics of these cross county changes.
There will shortly be a speciality director who
will be the anaesthetic lead for Gloucester and
Cheltenham. There is, of course, a lot of rumour
flying around as to who will apply, the current
word is that there will not be many applicants.
Whoever is successful will undoubtedly have
the tricky / impossible task of managing the
anaesthetists at Gloucester and Cheltenham
and trying to keep the management happy!!!
Alistair McCririck stood down as our Clinical
Director and Richard Vanner has stepped in
to take up the role for a second time. Chris
Finch our lovely secretary is back which is
great. As well as sorting out an enormous
amount of things for the department, more
importantly she has organised another girls spa
day at Calcot Manor. Kay Chidley is also back
after a sabbatical in Tasmania, which sounded
fabulous. Charles Rodriguez and Sue Jenkins
are getting married this month, which is really
exciting. Although they have been together for
several years they decided to put themselves
under pressure and arrange a wedding within
six weeks - most impressive. I have no doubt
that it will be a fabulous a day; I am currently
in training to ensure that my alcohol tolerance
is appropriately high!
David and Amy Hamilton have recently had a
little girl, Allanah. Pete Sanderson and Sarah
Muddle are expecting a baby in April. Amelia
Pickard is expecting her second baby; she was
with us for a few weeks having returned from a
year in Vancouver. Mark Wigginton’s wife has
just had a baby and Harpreet Bhangoo is also
expecting.
Roger Eltringham is still going strong and now
commutes from Sussex each week. He still
leads the very popular Wednesday morning
M and M meeting - not only are they very
informative, they are great fun. It has however
been rumoured that he managed to persuade a
registrar to complete his e-learning mandatory
training (on fire safety etc) for him, apparently
scoring 80%.
We have had some exam success –Andrew
Bartlett, Annabel Pearson and Marcin Pachuki
have passed the Primary exam and Lucy
Marshall and Naomi Tate have passed the
Primary MCQ.
Well, that’s about all for now, more news in the
autumn.
Claire Gleeson
Southmead
Still here, still a building site but noticeable
progress and from one end of urology theatres
one can get a great view of the new hospital
as it grows ever upwards. Panoramic view
of legions of industrious builders – should be
even better in the summer when they get their
shirts off…
Car parking has again been a major bone of
contention and, along with staff restaurants,
was the issue that finally got enough people
to turn up for MAC to make it quorate.
Interestingly, I believe that these are the same
issues that are most important to patients when
they are surveyed about their hospital – take
note those who can influence these things.
What else…..well, the usual ebb and flow of
trainees has seen the departure of Dom Hurford
to Bath and Laura Hamilton to Swindon – well
done to Laura for passing the Primary MCQ
too, there is something to be said for spending
all day in urology theatres with Mark Dirnhuber
after all…. Well done indeed to Malinka for
passing Primary after great perseverance!
Yeli Horswill and Katy Konrad went off to
have babies. Congratulations to both – Yeli
has Hope and Katy has also had a baby –
don’t know the name but perhaps not the
latest names coming from CDS at The ‘Mead
which are “Shantaleezay” and “Shardonnay –
spelt the posh way”! More will be on the way
soon as at least 3 trainees are pregnant - we
are looking for someone to blame for this burst
of procreation, which plays havoc with the
rota, but haven’t found a scapegoat yet. Also
leaving us to have a baby is Katy Jepp who has
done sterling work as a locum consultant with
us; she will be much missed by all when she
goes off to Yorkshire.
Trainees arriving are Lucy Kirkham, Tessa
Bailey, Ben Burrows and back with us are
Cerys Scarr and Kate Nickells - welcome all.
Louise Sherman has also left us to live the good
life in New Zealand; fortunately for her she is
a long way from Christchurch but has already
felt the effect of transfers into their region. We
11
wish her, Jez and the girls well.
We welcomed Chris Thompson, Carole Streets
and Simon Webster as locum consultants in
the New Year and within weeks they were
competing for the new substantive consultant
post – it was a very close run contest –
congratulations to Chris, we wish we could
have appointed them all.
The autumn SASWR meeting at Brasserie
Blanc was a great event – wine, women and
song and the usual oldest swingers in town still
going strong at the end of the night. Thanks
to all who made this a top do, particularly Kay
Spooner, Nicky Weale, Jo Angell and Malinka
Vrabtcheva. The other social event of the
season was the joint Christmas party for North
Bristol hosted by David and Judith, the only
people with a house big enough to fit us all
in, or brave enough to do it. A very convivial
evening was had by all and we were well fed
largely by a variety of venison dishes cooked
by all and sundry using David’s roadkill – no
really it was great!!
And finally, Karine has, Samson like, had all
her locks cut off and as the photo shows has
generously donated them to Stevie for his hair
transplant.
Jill Homewood
12
Swindon
Your scribe turns first to our academic highlight,
hosting the Wessex Society of Ultrasound
and Regional Anaesthesia (WSURA) Annual
Meeting at the prestigious Stanton House Hotel
on 19th November. It’s easy to forget how
much time and effort goes into organising a do
like this. You turn up on the day, lounge about,
make a few notes, maybe risk humiliation with
a (stupid) question, get fed and watered and go
home. Tony Allan and Jill Dale did a fantastic
job putting it all together and providing us
with an excellent programme. Life does love
a googly – and for the WSURA delegates
and organisers it was to be the failure of the
heating system, and this on a prequel day for
temperatures to come. The first lecture was
delivered in a haze of breathy condensation,
lecturer’s jaw and neck cocooned in a generous
scarf, to an audience similarly attired. No
chance of anyone falling asleep – if they
wanted to live. Thank god I had my balaclava
with me.
No ‘News of the West’ report can be complete
without mentioning the weather. Well, it
did get a bit parky. I saw -110 on my car
thermometer. But for an old reptile whose
preferred environment is an NHS backwater,
the disruption to services at GWH was
disappointingly small. We started late the first
Monday of the cold snap because the air con/
heating units on the roof had frozen. They
were, in my view, sorted far too quickly. Time
only for a cup of tea and a scan through Yahoo,
and it was back to administering to the sick.
Job planning, private practice, pensions, CEA
brownie points. Yes, they are all favourite
conversation topics for the jobbing anaesthetist;
but there is an issue that outranks all of these:
a cause of frustration, fury, bitterness and
resentment – your scribe refers, of course, to
car parking. If only Trust Management, in
their infinite wisdom, could appreciate how a
polished plaque ‘Dr Smith only’, adjacent to
the main entrance portico, would reap a rich
harvest. Your scribe digresses; the new version
of the GWH parking policy is out, 42 pages.
Having done a risk assessment, I decided
to read it. Glossary/Definitions, Purpose,
Scope, Regulatory Position,… getting there…
Equality Impact Statement, Special Cases,
Comments, References & Further Reading,
Policy. Arrived. I’ll summarise - 42 pages
down to 2 lines - cars may be brought on site
3 days a week. The other days? Stay away,
or pay £35. Going live in May. Your scribe,
provided reporting restrictions have been
lifted, will report on progress of this exciting
development in the next issue. There may be
blood.
Arrivals and departures. In the last issue,
your scribe reported on the close of one of the
longest consultant tenancies of the modern era,
the retirement of Dr Mark Jackson. Sadly, he
now reports on one of the shortest. Dr Mala
Mani started with us in April 2010 and left in
December. Nothing sinister. Her husband’s
work took him to Cardiff and it made sense for
Mala and the rest of the family to follow. Mala
was a popular member of the team, we were
sorry to loose her and we wish her well in her
new appointment in Cardiff. Trainees? Another
name on the rota I don’t recognise? February
saw Kat Mattheus, Ben Burrows, Kat Ng and
Alia Darweish head up the M4 in a westerly
direction; while Robbie Pongratz headed back
to the dreaming spires via the A420. Kat Ng
and Alia hadn’t been here 5 minutes. Trainee
comings and goings; a thing of wonder and
mystery.
And finally, congratulations to Toby Jacobs
and Gary Devine on passing Primary. Well
done chaps!
Doug Smith
Taunton
Greetings to all from Taunton. Since last
writing things have been a bit quieter here.
Only a few comings and goings to report this
time.
The legend that is Peter Ravenscroft will
be retired by the next edition. He has been
a backbone of the department for years
and is responsible for the infamous ‘Pub
Cyclopuffathons’, renowned on the SW
anaesthetic trainee circuit (amongst many
other department institutions!). The winter
cyclothon held towards the end of January
this year proved a very popular cycle ‘finale’
for Pete, with more than 40 people navigating
breakfast fry up, extreme cold, Somerset levels,
ice, beer, canals, beer, extreme cold, punctures,
beer, beer – you get the drift. This year we had
no hedge-meet-cyclist or near water mishaps
… two colleagues are being held to their
(drunken but witnessed) promises to carry on
the great tradition. Bradley Browne received
a department send off the other week having
already had an ITU one. It was (by his own
admission) very apt that an artist commissioned
picture of him in scrubs, portrayed him
hammer in hand, ‘mending’ a laptop. We will
all miss his larger than life presence and the
computer graveyard that was his desk space!
Paul Wong has started and James Sidney will
join us later this year – both consultants on the
critical care rota. I suspect they will be the
last substantive appointments for a while, now
the belt tightening starts in earnest around the
southwest.
The only birth to announce is Bethan (to myself
and Sally) – not content with deliveries to date,
we thought we’d add unplanned precipitous
home delivery to the list (garden ties are fab
for umbilical cords by the way).
On the trainee front we said farewells to James
Cockcroft, Julie Lewis (again) and Fran Smith
– all will be missed. We kept most of our
13
trainees (for a change) and said hellos to Nila
Cota and Dave Pappin. Sam and Jo continue
to pin the department/office up and weather
the regular list alterations that are thrown at
us. Mike and Justin remain surprisingly sane
at the helm (or hide it well) and Dave Creasey
continues to bridge all manner of rota issues
and last minute leave requests we all still give
him, despite the ‘6 week rule’ and our computer
rota which quite literally ‘says no!’.
Some of us are busy finishing plans for the
SASWR Spring Meeting to be held on May
19/20th at the Somerset Cricket Club – I for
one look forward to the preliminary wine
tasting…Until next time.
Joe Silsby
Torbay
First off, it’s farewell to Ian Norley, after what
can only be described as a substantial term in
office and an amazingly prolonged departure,
challenging that of any current (or recently
removed) North African political leader. Ian has
finally handed over the last of his departmental
responsibilities, as the author of 15 years of
SASWR Torbay updates. I now pen the first
of my 15-year term. Ian’s updates have been
witty and entertaining. ‘Norley humour’ (you
may have heard of it) will be missed.
There is also change at the top. After a
successful 3 years at the crease, our captain
and opening batsman, Jon Ingham steps down
as Clinical Director. After the clamour to
replace him finally dimmed, one candidate
stood alone so Nuala Campbell will step up
from department Chairman to lead our struggle
against dwindling SPA time, reduced numbers
of trainees, the largest financial constraints
the NHS has ever seen, massive changes to
commissioning and competition, revalidation
and most importantly the continuing struggle
to stop the management taking our milk away.
The latter, I think, already lost. The vacant
14
Chairman position has been filled by Tas Ali,
hence creating a formidable all girl team at the
top; we wait with some excitement to see what
changes lie ahead.
In obstetrics Jeremy Ackers has completed a
formidable stint as lead, in fact he’s been lead
as long as anyone can remember - he now
passes the batten to me. A fair challenge ahead,
but with Jeremy representing possibly one of
the largest obstetric reference books this side
of the Zambezi there is a steadying hand on the
tiller, or rather handle bars (Jeremy is rarely
seen far from his bicycle and trouser clips).
Once again the ever energetic, resourceful
and hard working Kerri Jones (previously
Houghton) fresh from another medical trip to
Kenya, finds herself in the position of SASWR
President-Elect, for which we, in our quiet
little part of sleepy South Devon are very
proud. Well done Kerri! But our fortunes do
not end there, we are pleased to welcome back
to the department Todd Guest, a rising star as a
trainee at Torbay...now taking up a consultant
post in ICU.
As for the trainees, through the revolving
doors we say goodbye to Paul Warman, David
Adams, Claire Blandford and Zoe Brown. We
welcome our new registrars Nikki Freeman,
Andrew McEwan, Allie Pigott, and our two
military gunmen, Abiola Ledele and Richard
Reed. At CT1 we welcome Ian Davies,
William Rutherford and Baha Mohammad;
FRCA Primary for Katie Patton, FRCA Final
for Susie Davis and Nikki Freeman; Rob
Horsley becomes a dad with the arrival of Seb
- splendid work all round!
As for the Trust, I guess you could say we
muddle through. Day surgery and orthopaedics
are perhaps our biggest assets. The hospital, of
course, is falling down but there are rumours
of a new obstetric theatre and even a new
intensive care unit, the latter I would say being
of some urgency as even the duct tape holding
up the ceiling is now itself being held up by
further duct tape.
Despite all the changes, the actual delivery
of anaesthesia continues to be remarkably
unchanged.
Rachael Blackshaw working
quietly yet ever efficiently has helped introduce
our new ‘rapid NOF’ pathway, shortening the
waiting time for surgery from 36 to 16 hours
and the average inpatient stay from 10 to 6 days!
Also buoyed on by a noticeable increase in the
number of registrars with a solid grounding in
regional anaesthesia (many thanks goes to those
who set up the Peninsula regional anaesthesia
‘fellowship’ and to SOWRA) we have set up
our own in house regional anaesthesia courses.
I would imagine within a few years Torbay’s
legendary stockpile of propofol will be replaced
by gleaming ampoules of levobupivacaine.
On the social front, the summer BBQ was
once again hosted by Mary Stocker and Tony
Matthews - a beautiful day culminating in a
massive children’s sports day with a dads race
planned for next year. We said goodbye to
Peter Ballance, who will be sorely missed, with
a knees up at the Seven Stars Hotel in Totnes.
The department Christmas party was held at
Dartington Country Park and was a fantastic
hit, with dancing, most of it appalling, going
on long into the night. The evening’s quiz,
hosted by John Thorn, was won by the trainee
table, although controversy still surrounds the
legitimacy of the win with iPhone use being
strongly suspected (by me anyway - sore
loser!).
Most importantly summer is coming and happy
days lie ahead.
James Griffin
Truro
A new year and we are still here and still
functioning, albeit at a higher degree of
entropy. Our Day Case Unit closed and the
cases have been distributed with varying
degrees of success. The facility will reopen
next month with two theatres for the Head and
Neck Directorate and a new endovascular suite
for Radiology. Their two current theatres in the
current Hot Hub will close and be reincarnated
as general surgery theatres. Theatre direct is
beginning to work well in the Trelawney wing,
but still suffers from overload and inappropriate
case-mix in the old tower block. Unified preassessment is coming up to speed with slots
for all patients; however, engagement by
some surgeons is still a problem. It has been a
difficult winter with a big increase in medical
admissions, which has had a negative impact
on the financial balance. Staff have been run
ragged on the wards and bed-management has
been a nightmare. Things are settling down but
morale is low because the rebanding exercise
on the nursing grades is in full swing. All in all
the hospital is not a happy place to work, and it
is going to be a tough year. We anaesthetists are
embarking on another round of job planning,
which will doubtless involve more chipping
away at what we are credited for, in an effort to
shave more expense off the divisional budget.
Foundation status in two years still looks like
a pipedream and I have no doubt that Lansley
will be encouraging the predators to circle.
On the bright side we have been granted an
anaesthetic staff coffee room opposite the
Trelawney wing theatres, as a small temporary
replacement for our previous department. Our
theatre information system is showing the
benefits of its upgrade. We can now look at
exactly where delays occur on an individual
basis. So there is no facility for blarney and
whitewash any more, and no hiding place for
the dilatory and the self-deluded!
However we are still productive! Jonathan
Cheung has fathered a boy. Jules Berry has
become the proud father of twin girls. Andy
Lee has a new daughter as have Dave Elliott
and Clare Moser. We had a farewell party
15
for John Griffiths, which provided a tonic to
banish the winter blues. Exams have also gone
well. Duncan Tarry and Chris Bauchmuller
nailed the Primary. Congratulations especially
to Chris who also gained the medal for top
score. Katie Gregg is leaving us to take up a
locum consultant post in North Devon. Our
loss is your gain, and we will sorely miss her
contribution to our department.
We have welcomed John Searle as new
Consultant with the Pain Team. Our trainees
have remained unchanged. ACCS trainees
Dr Bell and Dr Davidson have rotated into
anaesthetics and are rapidly finding their feet.
So we start a new year with new incarnations
of familiar problems and new rules for the
great game. We live in interesting times.
Bill Harvey
University Hospitals Bristol
Thanks go to Rachel Craven for her valued
contributions to this column, and for handing
the honour to me. I have a suspicion she
capitalised on an opportunity to share her
SPA load with a ‘noob’ (newcomer, in internet
forums) in the department. To kick off, I’d like
to plug the SASWR website, http://www.saswr.
org.uk which has recently been re-designed.
As your webmaster (sounds like some sort of
official spider) I’d be delighted to receive your
articles, suggestions and pictures to publish,
as well as suggestions and corrections – thank
you, Neville.
The Big News from UHBNHSFT – what an
acronym - is recruitment. With 8 consultants
coming into the department for the loss of one,
you would have thought the anaesthesia service
would be sitting pretty. Not necessarily. The
Trust has recently added Neil Muchatuta, Claire
Dowse, Ben Howes, Charlotte Steeds, Chris
Bourdeaux, Sanjoy Shah, Richard Eve and
Adrian Wagstaff to the consultant ranks. Many
congratulations to them on their appointments.
16
The traditional ‘Dining In’ party for some
of these new recruits was also attended by a
small, furry rodent who had apparently found
his way into the scallops and eaten the bottom
half of them....
Despite recruitment, the general on-call crisis
continues with consultants heroically covering
a depleted tier of trainees and desperately
hoping the Trust’s recruitment drive bears fruit.
The Trust is trying to make things easier for us
however: at 2.30am Mike Kinsella discovered
the 2nd on call room in the condemned
Dolphin House was provided with a resident
orthopaedic student.
In January Sally Masey retired. Sally is very
well known in the region as one of the world’s
few doctors who has a licence to provide
paediatric cardiac anaesthesia and pilot hot
air balloons. She started at Bristol Royal
Infirmary in the mid 1980s and revolutionised
the paediatric cardiac service. Sally taught
the majority of consultants and trainees in the
Bristol School, and contributed significantly to
the ethics committee. She plans to retire with
Pete to their cottage in France, and we all wish
them very well.
UHB has a new Chief Exec and our new
Medical Director is Dr Sean O’Kelly. Dr
O’Kelly is an anaesthetist and will also have a
clinical role at the Children’s Hospital.
Work has just started on demolishing the
buildings at the back of the BRI to make
room for the new ward block. By 2014, this
will replace the aptly named ‘Old Building’
(c.1735); it will provide an acute assessment
unit, wards, and a bigger, badder ITU. More
exciting plans to tart-up the Queens building
with a glass front, new foyer and helipad have,
of course, been shelved as the promised cash
dries up. One wonders whether the BRI could
earn a Heritage Trust Award for the nation’s
ugliest hospital. The Trust seems to be getting
the message about working more closely with
North Bristol, with the announcement of the
Joint Partnership Programme. For now, the
‘partnership’ bit doesn’t involve sharing out
the winter burden of medical patients, which
has caused BRI theatres to temporarily grind
to a halt.
Winter is in full swing and the emergency
theatres’ white board is wearing out. ITU
was nobbled with swine-flu cases just before
a planned refurbishment and creation of 4
additional beds. They are currently camping
out upstairs, planning world domination and
nonchalantly batting off timid requests for
post-op beds. The Physician’s Assistants for
Anaesthesia - Alison and Claire - are doing a
great job supporting us in our endeavour to
prevent the good ship UHB from sinking. The
glamorous anaesthetic secretaries have been
vital in somehow plugging holes in covering
the ever-expanding workload. Our trainees and
SAS doctors have also been crucial in getting
through the busy period, many going beyond
the call of duty. Congratulations to those who
recently passed exams, had babies or other life
events!
We’ve long passed the shortest day now, so
summer is definitely on the way. Speaking of
which, the demise of ‘Anaesthesia Reloaded’
has been grossly overstated - 2010 was merely
a fallow year. Watch out for ‘Reloaded –
reloaded’ early this September.
Ben Howes
Weston General Hospital
As I survey the setting sun on the horizon I
can see storm clouds around. On a number of
occasions we have been summoned on to the
deck by our Captain, or Chief Executive, to
be warned to brace ourselves for troublesome
times ahead, turbulent waters and possible
damage to our vessel. Here in the department,
however, it has been a quiet six months and all
remains calm - perhaps this is the lull before
the storm?
Crew members remain largely the same
although we have had the addition of a new
Specialty Doctor, Vinay Marulasidappa, who
has worked with us before and whom we are
delighted to see again.
Changes within the hospital include the
imminent opening of a new emergency
department which, externally at least, looks
very smart and has, like our MRI unit, the
seemingly obligatory green roof. The other
change anticipated in the near future is the
second attempt to introduce car-parking
charges for staff – we are, I think, the only Trust
in the Southwest that doesn’t at present do this.
Judging by the e-mail correspondence that this
proposal has produced, one might think that the
storm has already arrived but I fear that this is
just a light breeze in comparison with the gale
force winds that seem to be out on the horizon.
I’d better help batten down the hatches and get
down below.
John Dixon
17
Examination Successes and Honours
Bristol School of Anaesthesia
Primary FRCA Jeannine StoneCheltenham
Liz HaywardFrenchay
Annabel PearsonGloucester
Andrew BartlettGloucester
Marcin PachukiGloucester
Malinka VrabtchevaSouthmead
Toby JacobsSwindon
Gary DevineSwindon
Final FRCA Steve Cantellow
Bristol School
Reston SmithBristol School
Alex MiddleditchBristol School
Dave WindsorBristol School
Lorna BurrowsBristol School
Katie HowellsBristol School
Rob AxeBristol School
Kaj KamalanathanBristol School
Alice BragaBristol School
Thom PettyBristol School
Southwest School of Anaesthesia
Primary FRCADanielle FranklinBarnstaple
Seb KnudsenBarnstaple
Ben MurrinBarnstaple
Jo RiddellBarnstaple
Katie PattonTorbay
Duncan TarryTruro
Chris BauchmullerTruro
Alex KennedyTaunton
Dan GrocottTaunton
Final FRCASusie DavisTorbay
Nikki FreemanTorbay
Society of Anaesthetists of the South Western Region Prizes
Trainee Prize
President’s Prize
Poster Prize
Dr Dominic Janssen & Dr Subbu Halder
Dr Dominic Hurford
Dr Catherine Bryant
Other Awards
Ross Davis Bursary
Dr Patrycja Jonetzko
Please accept the apologies of the editorial team if your success has not been mentioned above.
We can only print the names supplied by the college tutors and linkmen around the region.
18
Anaesthesia Points West Vol 44 No.1
Meeting Report
The Society of Anaesthetists of the South Western Region
Autumn Scientific Meeting
The Friary Building, Cabot Circus, Bristol
4th-5th November 2010
Dr Chris Monk, Honorary Secretary, SASWR
The autumn meeting was hosted by the
committee from Southmead Hospital at
Baker’s & Cutler’s Halls, part of Raymond
Blanc’s restaurant complex. The local team of
Kay Spooner, Nicky Weale, Ronelle Mouton
and Malinka Vrabtcheva organised a superb
meeting with support from Jas Soar who
helped arrange the scientific programme. The
decision to use a new venue was well made and
the Society congratulates the committee on a
meeting which built on recent successes.
The organising committee contemplate escape
routes
Dr Stephen Mather, the incumbent President,
welcomed everyone to the AGM and remarked
that SASWR had enjoyed a good year with
increased membership, greater interest by
the trainees and a solid financial position
established.
He thanked the supporting
committee for all their hard work and
particularly Dom Hurford and Ben Howes for
their efforts to encourage the next generation
of trainees to support and join the Society.
The Honorary Secretary reported on the
success of the meetings held at Exeter and in
Rome. Both had received positive feedback
from the delegates about the science, venues
and entertainment. In the audience was Dr
Claudio Melloni who received special thanks,
for his role in supporting the meeting in Rome,
which was critical to its success. The Hon Sec
then looked forward to the Bristol meeting
which had an interesting scientific programme
and had obtained strong trade support.
The Honorary Treasurer’s report was given by
Dr Bill Harvey. He reported that the Society
had recouped the deficit of two years ago with
a surplus income of £13000 being achieved;
he planned to rebuild the reserve fund over
the next year to provide security against any
unplanned loss incurred at future meetings.
Bill told the AGM that the Ross Davis Fund
had been transferred to the Royal College
of Anaesthetists for ongoing administration
therefore any donations should be made to the
Financial Controller at the College.
Dr Fiona Donald, the Anaesthesia Points West
editor, thanked Jason Crane of BluePrint for
the high quality of reproduction of the journal
and then considered the issue of copyright.
The importance of acknowledging that an
article had been previously published in APW
was underlined and that failure to do so was a
matter of probity, which could not be ignored.
The AGM was informed that the Portrait of the
President would be moved to coincide with
the start of the presidency rather than in the
19
APW issue published midway through their
term. Fiona announced she is stepping down
as Editor at the end of 2011; her leadership has
ensured the quality of the journal has remained
high, the Society is grateful for her skill and
attention to detail. Vanessa Purday is stepping
into Fiona’s place so the hunt for an assistant
editor to start in 2013 is on; all those with latent
journalistic skills should make contact.
The AGM was then asked to agree the next
President Elect. Dr Kerri Houghton has
been a stalwart of the Society and has made
a major contribution to improving the quality
of patient care, both in the Southwest and
nationally through her work with the Institute
for Innovation and Improvement. She was
proposed and to warm applause seconded
by those present. The Society’s prizes were
then awarded with Dr Mather presenting the
President’s Prize to Dom Hurford. This was
given in recognition of his contribution to
SASWR in promoting the Society to the trainees
across the region. The award of the Ross Davis
Adventure Bursary to Dr Patrycja Jonetzko
was announced; she is the first core trainee
to receive this bursary which helps trainees
complete the adventures of their dreams. To
win the SASWR Intersurgical trainee prize is
a significant achievement and the Society was
pleased to learn that Mark Ellis had agreed to
continue with this long term relationship and
sponsor this prize which has helped build up
the trainee support of the meetings.
To conclude the AGM it was confirmed that
the annual subscriptions for retired members
would remain at £40 and that future planned
meetings would be: Spring 2011 in Taunton;
Autumn 2011 in Bath with Torbay and Bristol
planned for 2012. Under any other business
the President led a debate concerning who
could submit work for the trainee prize and the
origins of the data. Following an exchange of
ideas the AGM asked the committee to clarify
20
The President with Mark Ellis of Intersurgical
the qualification rules around the proportion
of work undertaken by the trainee and whether
the trainee should be working in the South
Western Region.
The installation of the new President, Dr Peter
Ritchie, concluded the AGM. Wearing the
splendid SASWR medal he thanked both the
outgoing President for his leadership during the
year and Kate Prys-Roberts for her unstinting
efforts to maintain the Society in good health.
He then opened the scientific meeting and
looked forward to the next two days of science
and education.
Handover of power
Dr Ed Morris chaired the first session which
considered how the quality of care could be
improved, with the first speakers explaining
how human factors are essential in achieving
safe, effective patient care. Dr Carol Peden,
back from her Master’s programme at Harvard,
reflected on the experience of Dom Berwick in
the USA in trying to improve quality across
the American healthcare system.
Using
the experiences and knowledge she gained
at Harvard Carol has launched a series of
simple measures as part of the South West’s
patient safety campaign. These have already
reduced mortality and misadventure. Dr
Ben Howes further developed this theme
by explaining how situational awareness
in critical anaesthetic situations can be
improved.
Using the locally developed
airways training programme he demonstrated
how immediate feedback on decision making
and team leadership, in a simulated situation,
improves outcome. As with the patient safety
programme the message is that large gains can
be made by simple education and rehearsal to
improve performance. The last lecture of the
session linked well as Ms Pamela Murison,
from the Langford Veterinary School, asked
the audience to reflect on their airway skills
as she challenged our definition of a “difficult
airway”. Using examples from the wide
range of species she anaesthetises, the same
principles of airway access, visualisation and
maintenance were seen with a new emphasis.
It seems that the pug and bulldog airways need
a new Cormack-Lehane classification of five
due to the absence of a nose, long palate and
a hypoplastic trachea, particularly considering
the potential consequences of a lack of
cooperation with an awake intubation.
The afternoon session was chaired by Dr
Nicky Weale after Raymond Blanc provided
lunch, perhaps not in person and unfortunately
without the chilled white wine as the modern
NHS does have its limits. Stopping the postprandial attention-dip were Drs Chris Johnson,
Fiona Donald and Jas Soar. Chris presented
on how we could prove our worth to our
medical school, deanery or college depending
on the stage of our career. He considered how
the attributes of empathy and sensitivity or
moral sense are tested, to select the best career
anaesthetists. As yet no single solution has
been defined. This is perhaps unsurprising,
as he stated that 2500 competencies are now
needed to be an anaesthetist. Fiona continued
the theme by presenting on the ISIS research
project and how the use of simulation can
improve safety. The lecture’s clear message
was that to improve performance the
learning should include both personal and
administrative objectives. She concluded that
simulation training is here to stay and we must
learn to use it to the advantage of the people
we are teaching. Jas completed the second
session with a comprehensive update on the
ever-changing resuscitation guidelines. After
reflecting on the influence of Peter Baskett and
Bristol on the whole science of resuscitation,
he emphasised how improved performance
and better outcomes can only be achieved if
clinicians measure the effect and outcome of
new techniques. To the listener it seemed that
for a good outcome, a patient should chose
ventricular fibrillation in preference to a nonVF arrest whilst the medic should change their
chest compression technique to fast and deep
and switch the defibrillator to maximum. This
concluded an excellent start to the afternoon.
The SASWR Intersurgical Prize session
followed and the first of the three shortlisted
presentations was given by the duo of Drs
Dominic Janssen and Subbu Halder. They
presented a snapshot of out of theatre emergency
intubation and proposed that its safety could be
enhanced with improved monitoring and the
use of team checklists. The battle for the prize
continued with Dr Ben Huntley describing a
web based portal he had designed. The concept
was to form a network across the region
21
allowing trainees to coordinate research and
audit ideas between different hospitals. As the
projects could be effectively passed from one
trainee to another it could avoid the difficulties
and failures encountered when projects take
longer to complete then the time spent in a
hospital by an individual trainee.
The judges decide
The SASWR Intersurgical Prize contenders
The final presentation, given by Dr Stephen
Tolchard, showed new research using exercise
testing to characterise the recovery from
major surgery. The data on the impact of
renal transplantation defined how dramatic
the improvement in the quality of life and
physical capabilities is in the recipient. He
also characterised the impact on the donor’s
well being. Although transitory, the loss of
physical fitness is severe enough for many to
carefully consider the implications of making
a live donation.
The judges had a difficult task and whilst the
delegates visited the trade exhibition, Drs
Mouton, Peden and Mather had to balance the
merits of quite different pieces of work before
concluding that the first presentation had
taken the prize by a narrow margin. Before
the final session of the day Drs Janssen and
Halder received the Intersurgical prize (£1000)
and many congratulations on delivering an
excellent presentation.
Dr Katie Holmes then gave the Ross Davis
Bursary to Dr Jonetzko whose adventures
at supporting successful ascents of Everest
and Kilimanjaro perfectly illustrate why the
bursary maintains the memory of Ross.
Well deserved congratulations
22
As always, the first day closed with the Sir
Humphry Davy lecture, which has a heritage
of providing talks on leading edge science.
Professor Martin Birchall enhanced this
reputation by describing his work in developing
an artificial trachea for transplantation.
had prepared well.
The President rehearses his first joke
Professor Birchall
entertained
keeps
the
audience
Although the audience was aware of the
headline grabbing operation, the story
of innovation, careful development and
cooperation between multiple centres kept
them entranced. Few surgeons have an interest
so key to the anaesthetist, perhaps his talk
should have been recorded to become part of
the SASWR website. Without doubt Martin
lived up to the expectations of the eponymous
lecture.
The President’s reception that evening was held
in the Cutler’s Hall at Raymond Blanc’s, with
Ben Howes’ band playing gentle jazz whilst
the President met the guests. Dinner was then
served with everyone enjoying the convivial
atmosphere and good company. After the
loyal toast the Society’s new President thanked
the organising committee for their successful
meeting and choice of an excellent venue.
He then entertained all the diners with some
carefully selected stories, as always Dr Ritchie
Mr David Mitchell then replied on behalf of
the guests. It is always a time of concern when
a local surgeon is given an opportunity to tell
some home truths to an anaesthetic dinner
audience; a number of Southmead anaesthetic
secrets were leaked to the amusement of all but,
disappointingly, the subjects cannot be named
without prejudice. As always the Society
danced and chatted to the end of the evening
before concluding an excellent day.
Bonfire day started with Fiona Donald showing
her multitasking skills. Now chairing the
first session, our editor introduced Mr David
Mitchell who spoke on quality improvement in
aortic surgery. His lecture discussed the best
evidence on how to improve patient outcome
and echoed the talks given in the meeting’s first
session on improving quality of care. David
demonstrated that dramatic improvements
can be made by reducing variability in patient
care though the introduction of standardised
operating procedures, decision-making using
multidisciplinary teams and ensuring that
surgical teams achieve minimal standards of
volume and outcome. The message was that
the anaesthetist has an important role to ensure
that UK practice can match the best outcomes
of other countries. Continuing the theme
of improved outcome Dr Ronelle Mouton
23
discussed how the deleterious effects of
ischaemia can be modified by preconditioning
using a planned period of ischaemia before
surgery. Although the experimental evidence
is good she explained the difficulties of
transferring the concept into improving
outcome in a clinical setting. More research
is required. Perhaps the secret for better
post-operative survival also lies in the choice
of patient and Dr John Carlisle updated the
audience on his work to understand the impact
of pre-existing disease and the benefit of CPEX
testing on outcome following complex surgery.
Using his systems patients can be fully
educated to what the impact of the operation is
and what effect it will have on their subsequent
health and survival; this may mean patients
declining an invasive operation. As the level
of background fitness can alter outcome, his
talk did much to improve gym membership
but, as yet, he had no recommendation to
minimise the other confounder of advancing
age. Quite a worrying thought for some parts
of the audience.
The final scientific session of the meeting was
chaired by Dr Kathryn Holder. She introduced
Professor Paul Dieppe who considered the
impact of placebo versus nocebo on patient
outcomes following treatment. His novel
evidence showed how negative conditioning
through words or behaviour can lead to a
worse outcome, perhaps giving an insight
as to why some anaesthetists have a better
reputation then others, even when they give
similar anaesthetics. A lively debate ensued
as the audience questioned how this theory fits
with the concept of fully informed consent;
informing patients of a 5% mortality or serious
complication seemed to be a definite nocebo
event. Professor Ashley Bloom and Dr Mark
Pyke then considered the different aspects
of how outcomes could be improved for
orthopaedic patients. The Professor outlined
24
the importance of including patient satisfaction
in outcome trials, most results measure
outcome in terms of range of movement,
longevity and infection rates. Surprisingly
almost 10% of people would not recommend a
major joint replacement after undergoing such
a procedure. Therefore, to improve outcomes
he recommended that medicine should move
towards patient based trials. Throughout his
talk mysterious slides of him and Mark Pyke
enjoying an African adventure were screened.
A notable slide was Mark eating Impala
testicles, the author reflects that it must be
rare experience to lecture after such a picture.
Unsurprisingly Mark was unruffled and gave
an excellent talk on the role of anaesthesia
in developing a fast track joint replacement
service. The take home message being that
ultrasound and local blocks by experts is the
key success factor if the NHS mantra of a
shorter length of stay is to be delivered.
After this session it was a pleasure for Peter
Ritchie to announce the winner of the poster
prize. Each meeting now has a prize of £250
for this type of presentation and 16 posters
were submitted, for consideration by Drs
Ritchie, Soar and Monk. Dr Catherine Bryant
was the winner with her work on improving the
estimation of blood loss in obstetrics.
The meeting’s afternoon session included the
members’ partners and the lecture room was
filled to capacity to listen first to Dr Neville
Goodman and then Dr Ed Coats. Neville is
known for his encyclopaedic knowledge of
the English language and any trainee who
worked with him will have benefited from his
advice on writing; perhaps this author should
have listened more intently. He recounted his
experiences with English from his early days
as editor for Manchester Grammar’s school
publication through to modern day scientific
writing. In a superb lecture not a single word
or breath was wasted, but this merely fulfilled
our expectations. As always, many thanks to
Neville for setting a high standard that we can
aim at.
Ed Coats is known to most as the man chosen
to accompany Ben Fogel and James Cracknell
on the race to the South Pole.
Was it worse pulling a sled to the South Pole or
speaking to an audience of anaesthetists?
The audience listened attentively as the story
unfolded of the arduous selection process
and the survival training necessary to prepare
physically and mentally for one of the world’s
greatest races. Everyone knew what an
adventure this was, to hear the man speak in
front of the pictures of real hardship was a
superb way of finishing an excellent two day
meeting. For a local medic to ski across the
Antarctic snow for 770km in 18 days and to
take second place to a team of Norwegian polar
experts, was recognised as an achievement that
none listening could hope to emulate.
The President then closed the meeting observing
how successful it had been and thanking the
local committee for their organisational flare
and the production of an excellent scientific
programme. Dr Ritchie also reported that the
social programme had been well attended and
a success since his spies, aka Mrs Ritchie and
Monk, had been able to report back to him. So,
until the next time....
25
Anaesthesia Points West Vol 44 No.1
Article
Basic Training in Anaesthesia – the Effect of a Run-through
Programme in the Bristol School of Anaesthesia.
Dr Lorna Burrows, Dr Tim Hooper, and Dr Claire Hommers, Registrars in Anaesthesia, Dr
Andy McIndoe and Dr Su Underwood, Consultants in Anaesthesia.
University Hospitals Bristol
Summary
A new seven year run-through anaesthetic
training programme was introduced in 2007.
We set out to assess whether these changes
had reduced clinical training and experience
amongst anaesthetists who were entering their
first registrar year (ST3). Logbook data was
collected from the new trainees in the runthrough programme (ST group) and the last
group of registrars to train in the old system
(SHO group). The logbook data was compared
retrospectively between the 2 groups, to assess
experience in anaesthesia during their basic
training years. Median annual case numbers
were 523 in the ST group and 525 in the SHO
group. The median total number of cases
during basic training was 1050 (ST group)
and 1383 (SHO group). The average number
of months spent in basic training was 26 (ST
group) and 33 (SHO group). The total number
of cases performed before becoming a registrar
was reduced in the ST group due to a reduction
in training time prior to registrar appointment.
Introduction
August 2007 marked the start of new
programmes for training in accordance with
Modernising Medical Careers (MMC) [1] as
well as further implementation of the European
Working Time Directive (EWTD, now called
Working Time Regulations) for junior doctors
[2]. The initial introduction of the EWTD for
doctors in training in 2004 resulted in total
weekly hours being reduced to a maximum of
58 as well as imposing specified rest periods.
From August 2007 this was reduced to 56
26
hours and to 48 hours a week by August 2009.
The new run-through training programme
implemented in 2007 provided trainees with a
continuous seven year programme from their
first anaesthetic year. This took the trainee
through basic, intermediate and higher training
to the receipt of a Certificate of Completion
of Training (CCT).
Previously, trainees
completed pre-registration house officer
(PRHO) posts for one year, then may have
worked in posts outside anaesthesia, before
spending a minimum of 2 years at senior house
officer (SHO) level and then applying for
specialist registrar (SpR) training (see figure
1 in appendix). The new specialty trainees
(ST) started their anaesthesia training after
completing two Foundation years (FY1 and 2).
Following the first two basic training years in
anaesthesia (ST1 and ST2), they went directly
into ST3, equivalent to the old specialist
registrar year 1 (SpR1). This occurred without
any further selection procedure or extra training
time, often reducing the actual length of basic
training in anaesthesia.
We were keen to ascertain in what way
these changes affected clinical training and
experience for anaesthetists within the Bristol
School of Anaesthesia. We compared case
numbers in logbooks to assess the impact of
the new run-through system on the experience
of first year registrars when compared to the
previous system.
Methods
We compared the experience of the final group
of new registrars to train completely in the
SHO programme (entering ST3 in 2007) within
the Bristol School of Anaesthesia, against
the experience of the new cohort of trainees
entering the run-through training programme
(entering ST1 in 2007). We used electronic
logbook data to examine the pattern of training,
supervision and clinical experience that these
two groups of trainees received before entering
the equivalent of ST3.
Trainee groupings
For the 2007 run-thorough group, we report the
activity of specialty trainees (ST1 and ST2).
Pre-2007 we report the activity of senior house
officers (SHO). The SHO group underwent 2
years of recognised training before obtaining
their Completion of Senior House Officer
Training (CSHOT) certificate. They remained
in SHO posts after this period until they
obtained a national training number (NTN)
and become specialist registrars (figure 1 in
appendix), which for our cohort was August
2007. The first 2 years as an SHO are matched
to the ST1 and 2 years. The basic training
years include all anaesthetic experience prior
to entering ST3.
Data Collection
All anaesthetic specialty trainees from years
3 (ST Group) and 5 (SHO Group) within the
Bristol School of Anaesthesia were approached
in August 2009 and agreed to submit an
electronic copy of their Royal College of
Anaesthetists (RCOA) approved logbook [3].
They were also asked to submit a copy of their
employment history to date. All logbook data
is compiled individually by the trainee and is a
personal record of their theatre experience. It
is a training requirement of the College that all
anaesthetists keep a logbook [4] on paper or in
electronic form.
Data Analysis
The downloaded logbook information was
imported into a modified copy of the RCOA
Electronic Logbook version 7.0 (Hammond/
McIndoe) [3].
All cases performed, as
recorded in the trainees’ logbooks (in
accordance with the RCOA guidelines [4])
are included in the data analysis. The logbook
data was cross referenced with each individual
trainee’s employment history to establish
the dates of SHO or ST posts (2 year period)
in anaesthesia, as well as any additional
anaesthetic experience at basic training level. A
retrospective analysis of the logbook data was
then performed. We compared total caseload,
case mix, level of supervision, American
Society of Anaesthesiologists (ASA) grade of
the patients, urgency of operations and outof-hours caseload of trainees from the SHO
and the ST groups. The logbooks of less than
full time trainees or incomplete data sets were
excluded.
Definition of supervision
Direct supervision of a trainee is defined as
the trainee working with a supervisor senior
to them who is present in the same operating
theatre. Trainees working solo in theatre remain
under the indirect supervision of a nominated
consultant, in accordance with RCOA
guidelines [4], whether they are elsewhere in
the hospital or at home. Consultants are on
the Specialist Register held by the UK General
Medical Council.
Ethical Approval
The project was discussed with the chairman
of the regional research ethics committee, who
deemed that formal ethical approval was not
necessary.
Results
Of the trainees within the Bristol School of
Anaesthesia during August 2009, 20 trainees
were at ST5 level (SHO group) and 8 at ST3
level (ST group). We obtained a total of 26
logbooks, 18 from the SHO group and 8 from
the ST group. Five were excluded due to part
time training or incomplete data sets. One
27
trainee in the ST group was excluded because
she was not trained within the Bristol School
of Anaesthesia.
We examined 20 logbooks, 13 from the SHO
group and 7 from the ST group (table 1 in
appendix). Theoretically all trainees entering
the new run-through programme could have
come directly from the Foundation years.
However, 2 trainees had additional anaesthetic
experience, 3 trainees had Membership of the
Royal College of Physicians and only 2 came
directly from the Foundation programme. The
mean number of months spent in basic training
was 26 for the ST group, 33 for the SHO group.
All trainees undertook their basic training after
2004, but before August 2009, and therefore
we assume their weekly working hours to be
between 56-58 hours per week.
The median annual caseload during the first 2
years of basic training was 523 cases per year
for the ST group and 525 cases per year for the
SHO group (table 1 in appendix). The median
total caseload during basic training was 31%
higher in the SHO group (SHO group 1383
cases vs. ST group 1050 cases). The number of
solo cases reduced from 43% to 31% of all the
cases performed by the trainees. The average
case mix during basic training years is shown
in figure 2 in the appendix. The proportion
of obstetric cases increased from 14% in the
SHO group to 21% in the ST group. However,
the number of caesarean sections performed
under general anaesthesia was reduced in the
ST group; median 7 vs. 9 cases per trainee.
The proportion of ophthalmic, general,
neurosurgery, plastics and paediatric cases was
reduced whilst the proportion of gynaecology,
urology, ENT and orthopaedic cases increased.
The number of directly supervised cases
increased from 57% in the SHO group to
69% in the ST group (figure 3 in appendix).
All trainees in our study classified over 80%
of their cases as ASA 1 or 2. The number of
28
ASA 3 and 4 cases a trainee was exposed to
was reduced to 10% in the ST group compared
to 16% in the SHO group. However, 4% of
logbook cases for the ST group did not have
an ASA status recorded. The proportion of
elective work done (routine and day cases) was
higher in the ST group (71%) when compared
to the SHO group (58%) and the percentage of
cases performed out of hours was lower (ST
group 17% vs. SHO group 25%).
Discussion
We analysed a total of 20 logbooks (13 SHO
group and 7 ST group) out of a possible
28. The number of trainees in the ST group
differs from the SHO group because of the
introduction of the Acute Care Common
Stem (ACCS) programme, which many of
our trainees follow. We did not include these
trainees in our analysis because they had not
completed basic training by 2009. We were
able to analyse more logbooks than previous
studies into anaesthetic training [5], which
may reflect the more diligent recording of
cases by today’s trainees who are very familiar
with electronic applications and the logbooks
available through the RCOA. However, it is
interesting to note that even in 2009 it was
not possible to collect a full set of electronic
logbooks from a cohort of trainees.
The median annual caseload during the basic
training years is similar in both groups, but
there is a wide range of case numbers performed
during the basic training years. There has
always been variation in case numbers and
some trainees are exposed to many more cases
than others for a variety of reasons; the list
turnover varies between specialties and on call
workload varies daily and between hospitals.
The quality of the cases being undertaken
cannot be assessed by a logbook review. The
variation in case numbers between trainees
is of concern because we do not know its
significance to training. If we compare median
annual case numbers in our study for the two
groups (ST group 523, SHO group 525), they
are greater than the mean annual number of
cases for trainees doing different shift patterns
(441 and 448 cases) recorded by Al-Rawi and
Spargo [6] and mean annual SHO cases (496,
449 and 400 cases) recorded by our group in
2005 [7]. This could suggest an improvement
in the training programme as adjustments are
made to accommodate the changes that have
been required by the EWTD and MMC. This
is in contrast to the suggestion by Sim et al
that the numbers of cases done per week by
SHOs has been reduced by the introduction of
the EWTD [5]. However, our previous review
analysed a single teaching hospital practice,
whereas this study considers multiple hospitals
within the Bristol School of Anaesthesia.
Pre-2007 it was unusual within our region to
do only 2 years training in anaesthesia before
achieving an NTN for a specialist registrar
post (33 months training in SHO group). This
additional time, and the cases done during it,
added to the caseload during the basic training
years of the SHO group. The case numbers were
therefore higher when entering the registrar
years than could be achieved by run-through
training alone. The SHO group had a median
total caseload of 1383 cases on entering their
registrar years in comparison to 1050 cases in
the ST group entering ST3 in 2009, showing
that the SHO group entered their registrar years
with greater clinical experience (31% higher
case numbers in the SHO group). Although we
assessed the case number, we do not know if
this translates into the current registrars within
our School of Anaesthesia being less competent
than their predecessors, when taking up their
posts.
The level of supervision of trainees, by
consultants, increased within our School (57%
in SHO group and 69% in ST group) and
remains above the requirement of the RCOA
[4]. Our level of supervision is higher than
in previous studies [6-8] and this is likely to
be beneficial to training. The opportunity to
gain further experience is lost with a shortened
training programme and may reduce the
readiness for more independent working in
the intermediate years. This should be taken
into consideration by trainers and organisers of
service provision.
The case mix of specialties is similar for trainees
pre and post-2007 in our study. Comparing the
case mix with our study from 2000 [8], which
used theatre system data and is therefore not
directly comparable, the percentage of the
caseload appears to have increased greatly in
obstetrics and urology, but declined in general,
gynaecology and ophthalmology. All other
specialties have remained approximately the
same. The reduction in the percentage of the
caseload in ophthalmic, paediatrics, plastics
and neurosurgical cases may reflect the fact
that basic training within our region now
takes place away from the two large teaching
hospitals within Bristol and is generally based
in the District General Hospitals, to allow
subspecialty training to be concentrated in the
intermediate years. The number of theatre
based obstetric cases within this region remains
consistent with our previous study [7] and
the number of caesarean sections done under
general anaesthesia remains low. The lower
percentage of paediatric cases experienced
during basic training in this School reflects the
distribution of paediatric services, which are
centralised around the Bristol Royal Hospital
for Children. This reduces the exposure of
trainees to paediatrics when working in District
General Hospitals and this may exacerbate
existing concerns about reduced paediatric
experience due to changes in working patterns
[9].
The majority of cases that a junior trainee
29
anaesthetises are in ASA grade 1 and 2
categories. This is consistently over 80% for all
trainees in our study. It is appropriate during the
basic training years to learn how to anaesthetise
less complex patients. However, less than 10%
of cases performed by new specialty trainees
are ASA 3 or above, reducing their exposure to
higher risk patients. Unfortunately 4% of cases
performed by the ST group did not have an
ASA grade recorded, which may have skewed
the data and is an example of inconsistency in
data collection between individuals. The ST
group gave anaesthetics to fewer emergency
and urgent cases when compared to the SHO
group and performed fewer cases out of
hours. This is a reduction in emergency and
urgent cases in comparison to our previously
reported 45% in a teaching hospital [7]. Our
data implies that the ST group are gaining a
solid grounding in well supervised, ASA 1 or
2 elective cases during normal working hours.
However, it also suggests that there has been
a reduction in experience for those in the ST
group in dealing with emergency cases, which
tend to be in more complex and higher risk
patients. This may have implications both for
their training and for service commitment in
the intermediate training years.
The RCOA requires trainees to keep a logbook
but it is important to note that this does not
include all aspects of the work or training done
by an individual. It is only possible to measure
quantity, there is no measure of the quality of
training or of an individual’s competency in the
logbook data [10]. Having said this there is
some evidence that the number of procedures
undertaken may be important in training [11].
The logbook data is only a marker of theatre
activity and may not include clinical sessions
outside theatre in pre-operative assessment,
pain management, or non-clinical sessions
in research, administration and meetings.
These play an important part in the training
30
programme of anaesthetists. Logbooks do
not accurately reflect the duration of the cases
being undertaken, nor the precise skills learnt.
It is difficult to compare logbook data, even
when it is inserted into a standardised format
application, because it depends on the data
an individual anaesthetist records and their
diligence in doing so.
Our study only focuses on the impact that
MMC has had on the Bristol School of
Anaesthesia and we do not know if our findings
are consistent with those of other Schools of
Anaesthesia around the country. We have
also not assessed how trainees felt about the
reduction in case numbers or how their trainers
felt it had affected the competence of new
registrars.
The aim of a training programme is to produce
excellent anaesthetists, who are highly skilled,
competent, confident and safe, and to do so in
an efficient and timely manner. The anaesthetic
logbook is not a measure of competence or
ability and clinical experience is only one
element of the overall progress towards the
Certificate of Completion of Training (CCT).
The data we have shown indicate that annual
case numbers were maintained when runthrough training began. The reduction in the
total number of cases which our ST trainees
completed during basic training, seems to be
related to the shortened duration of training
rather than the reduction in weekly working
hours. This suggests that it was run-through
training, rather than the EWTD which resulted
in less experienced registrars at ST3 level.
In 2008 the RCOA uncoupled their training
programme [12] so that trainees who started
in August 2008 completed 2 years of basic
training (now called Core Training) before
applying in open competition for ST3 posts.
Declaration of interests: None
References
1. Modernising Medical Careers : http://
www.mmc.nhs.uk (accessed 03/07/2010)
2. Statutory Instrument 2003 No. 1684: The
Working Time (Amendment) Regulations
2003. Regulation 7 (http://www.opsi.gov.
uk/si/si2003/20031684.htm
(accessed
03/07/2010))
3. http://www.logbook.org.uk
(accessed
03/07/2010)
4. The Royal College of Anaesthetists. CCT
in Anaesthetics I: General Principles
London: First edition Jan 2007,
Amendment 2, April 2009
5. Sim DJ, Wrigley SR and Harris S. Effects
of the European Working Time Directive
on anaesthetic training in the United
Kingdom. Anaesthesia 2004; 59: 781-784
6. Al-Rawi S, Spargo P. A retrospective
study of anaesthetic caseload of Specialist
Registrars following the introduction
of new working patterns in the Wessex
region. Anaesthesia 2009; 64: 297-300
7. Underwood SM, McIndoe AK. Influence
of changing work patterns on training in
8.
9.
10.
11.
12.
anaesthesia: an analysis of activity in a UK
teaching hospital from 1996 to 2004. Br J
Anaesth 2005; 95: 616-21
McIndoe AK, Underwood SM. The
Current State of Anaesthetic Training
– a detailed analysis of activity in a UK
teaching hospital. Br J Anaesth 2000;
84(5): 591-5
Fernandez E, Williams DG. Training and
the European Working Time Directive:
a 7 year review of paediatric anaesthetic
trainee caseload data. Br J Anaesth 2009;
103: 566-9.
Nixon MC. The anaesthetic logbook – a
survey. Anaesthesia 2000; 55: 1076-1080
De Oliveira Filho GR, The construction
of learning curves for basic skills in
anaesthetic procedures: An application for
the cumulative sum method. Anesth Analg
2002; 95: 411-6.
The Gold Guide: A reference guide for
post-graduate specialty training in the UK.
June 2008. 2nd Edition. (http://www.rcoa.
ac.uk/docs/GoldGuide-supplement.pdf
(accessed 03/07/2010))
Appendix:
1996
-2007
PRH
O
SHO
*
SHO
SHO
SHO
**
SpR
1
SpR
2
SpR
3
SpR
4
SpR
5
2007
runthrough
F1
F2
ST1
ST2
ST3
ST4
ST5
ST6
ST7
CCT
Training
Foundation
Basic
Intermediate
Advanced
CCT
CCT
Competitive entry
*
Option for non-anaesthetic SHO jobs
** Additional basic training (anaesthetic SHO jobs)
Figure 1: Training programme pre and post 2007
31
Groups
Number
of
Trainees
Number
of
suitable
logbooks
Number
of cases
analysed
Median total
caseload
during basic
training (IQR
[range])
Number
of cases
analysed from
first 2 years
basic training
ST
8
7
SHO
20
Total
28
Median Annual
Caseload (IQR
[range])
7,907
1050 (9941236 [9601436])
7,337
523 (432-646
[396-911])
13
18,122
1383 (11751560 [7942269])
14,423
525 (497-539
[480-591])
20
26,029
21,760
Table 1: Trainee annual caseload and total caseload during basic training years.
S T G ro up C a s e Mix
Uro lo gy
9%
P la sti cs
0%
S HO G r oup C a s e Mi x
V a scu la r
2%
Va scula r
1%
O the r
2%
U rol og y
6%
E NT
6%
O the r
3%
Pl astics
2%
P ae di atri cs
4%
G en era l
15 %
P a ed iatr ics
O the r
7%
E NT
ENT
3%
Ge ne ra l
1 9%
G en er al
G yna e
ICU
Ma x- Fax
Ne ur o
O rth op ae dic s
25 %
O rth op ae di cs
19 %
G yn ae
14 %
O bste tr ics
O ph tha lm ics
G yn ae
9%
O rth op ae di cs
P ae di atri cs
P la sti cs
ICU
2%
Ur olo gy
ICU
2%
O p htha lm ics
0%
O bstetr ics
21 %
Neu ro
0%
M ax- Fax
1%
V ascu lar
O p hth al mi cs
3%
Ma x-F ax
1%
O bste tr ics
23 %
Ne uro
1%
Figure 2: Subspecialty case mix.
32
AS A C ategories
L evel of S upervis ion
100%
100%
80%
80%
60%
Indirect
Direct
40%
Percentage
20%
Donor
5
60%
4
40%
Percentage
20%
3
2
1
0%
0%
ST
ST
SHO
SHO
G ro u p
G roup
L evel of P riority
Out of Hours Work
100%
100%
80%
Emergency
80%
60%
Urgent
60%
Out of Hours
40%
Day case
40%
Normal
Routine
Percentage
20%
0%
Percentage
20%
0%
ST
SHO
G ro u p
ST
SHO
G ro u p
Figure 3: Percentage of workload according to ASA category, supervision, priority and time of day.
33
Anaesthesia Points West Vol 44 No.1
Article
Follow-up Study to Assess the Accuracy of Visually Estimated
Blood Loss in Obstetric Haemorrhage
Catherine Bryant CT2 Anaesthesia, A. Gray ST3 Obstetrics & Gynaecology & Tracey
Appleyard, Consultant Obstetrics and Gynaecology
Southmead Hospital, Bristol
Introduction
Obstetric haemorrhage can occur rapidly and
unpredictably and is an important cause of
maternal mortality, accounting for 11% of
maternal deaths worldwide [1]. The 20035 Confidential Enquiry into Maternal and
Child Health (CEMACH) report for England
and Wales, showed that 17 maternal deaths
resulted directly from haemorrhage, and it
was a complicating factor in a further 9 [2]. In
addition, in 10 of the 17 direct maternal deaths,
care was assessed as substandard. In the acute
situation, an accurate visual assessment of
estimated blood loss is a very important tool
and can forewarn of impending haemorrhagic
shock. It permits early identification of an
evolving obstetric emergency, allowing timely
intervention including the declaration of a ‘code
red’ haemorrhage, calling for senior anaesthetic
and obstetric assistance, the appropriate use of
blood products and cell salvage, and recognition
of clotting derangements. However, previous
studies have shown visual estimation of blood
loss to be inaccurate and of limited clinical use
[3].
In order to address this problem, we used a
previously trialled study format [4,5] to assess
the accuracy of estimation of blood volumes by
the multidisciplinary team in our obstetric unit.
The objectives of the study were to:
1) Assess the accuracy of visually
estimated blood loss
2) Compare these results to those of
a similar previous study within the
region [5]
3) Provide training to improve accuracy
34
of estimation and give the opportunity
for self directed learning.
Methods
An observational study was conducted in the
obstetric unit of our hospital. Participants,
including obstetricians, anaesthetists, midwives,
nurses, theatre staff and healthcare assistants,
were invited to attend. 15 objective structured
clinical evaluation (OSCE)-style stations were
set up to simulate varying degrees of obstetric
haemorrhage, using measured volumes of red
cells and equipment commonly found on labour
ward. Packed red cells past their expiry date
were obtained from the hospital transfusion
service and diluted to a normal haematocrit with
0.9% sodium chloride.
EBL Aide Memoire
Small swab:
50ml
Medium swab:
100ml
Large swab:
350ml
Sanitary towel:
Inco sheet:
100ml
250ml
Kidney bowl:
Bedpan:
Vomit bowl:
Floor spills:
PPH:
600ml
500ml
300ml
50x50cm (500ml)
75x75cm (1000ml)
100x100cm (1500ml)
On bed
only(1000ml)
Spilling to
floor(2000ml)
Fig 1 – Aide Memoire of estimated blood loss
(EBL) and pictorial representation of some of the
15 OSCE – style stations included in the study
Stations included in the study afternoon were
as given below (see also aide memoire – fig 1):
1. Stained maternity pad
2. Saturated maternity pad
3. Floor spill (small) – 50cm x 50cm
4. Floor spill (medium) – 75cm x 75cm
5. Floor spill (large) – 100cm x 100cm
6. Floor bowl (low runner)
7. Kidney dish
8. Stained incontinence sheet
9. Bedpan
10. Vomit bowl
11. Saturated surgical swab (small)
12. Saturated surgical swab (medium)
13. Saturated surgical swab (large)
14. Manikin on bed
15. Manikin on chair
Participants visited each station in turn,
visually estimated the blood loss and recorded
their results on a pre-designed answer sheet.
Following completion of the 15 stations,
they were then given a correct answer sheet
and invited to re-visit stations to facilitate
individual learning. The total error between the
estimated blood loss (EBL) and actual blood
loss (ABL) was calculated for each individual,
along with the average EBL and average
error for each station and professional group.
Statistical analysis, using the Wilcoxon Signed
Rank Test, was performed on the estimated and
actual blood loss values for:
• each participant and professional group
• comparison between stations
• comparison between results from our
sample and a previous identical study at
Bath RUH
The study afternoon was completed in
agreement with local guidelines and all
contaminated material disposed of according
to Trust policy.
Results
43 participants from seven groups of healthcare
professionals attended the study afternoon. A
wide range of values was seen in the estimation
of blood loss across all 15 stations (table 1).
The most accurate participating individual was
an ST1 obstetrician (total error = 2180mls),
whilst the most accurate group of participants
were the nurses (average total error = 3268mls).
However, no significant difference in accuracy
between the professional groups was observed
(table 2 – see end).
Regarding the individual stations, strongly
significant
underestimation
(p<0.0001)
occurred between the average EBL and the
ABL at five stations (labelled * in table 1).
These were the floor bowl (representing the
average blood loss at normal vaginal delivery),
the large surgical swab and the three floor
spills. This echoed findings from the previous
study at Bath RUH, where the blood loss in
the three floor spills was also significantly
underestimated. In none of the stations in
our study was the blood loss significantly
overestimated.
35
Station
Range
(mls)
Average
(mls)
Actual loss
(mls)
Stained maternity pad
Saturated maternity pad
Floor spill (50x50cm)*
Floor spill (75x75cm)*
Floor spill (100x100cm)*
Floor bowl with bag*
Kidney dish
Stained Inco sheet
Bedpan
Vomit bowl
Surgical swab small
Surgical swab medium
Surgical swab large *
Manikin on bed
Manikin on chair
5-150
10-400
50-900
80-1500
80-2000
70-1000
300-1500
20-750
200-800
60-900
5-150
15-400
25-750
175-2500
70-2000
48
115
252
478
524
274
548
248
449
287
51
107
196
949
711
30
100
500
1000
1500
400
600
250
500
300
50
100
350
1000
550
Table 1 – Actual blood loss, average estimated blood loss and range of observations obtained for each of the
15 stations. Those marked * showed a significant difference between the average EBL and ABL (p<0.0001)
Discussion
Accurate visual estimation of blood loss
can be a very important clinical tool in the
identification and management of obstetric
haemorrhage but previous studies have shown
this to be inaccurate [3,4,5]. At vaginal
delivery, studies have shown blood loss to
be underestimated by 35% (EBL = 260ml v
ABL = 401mls) [3], and this underestimation
may be greater at caesarean section. Both
underestimation and overestimation of blood
loss can have significant clinical consequences.
Therefore, identification of the degree of
inaccuracy of estimation of blood loss, and
attempts to improve this clinical skill in
obstetric haemorrhage, are of great value.
The results of our study day support previous
findings that visual estimation of blood loss
is inaccurate. There was a wide range of
36
estimates across all 15 stations, indicating
significant individual error in blood loss
estimation. However, with the exception of
the stations involving the floor bowl, the large
surgical swab, and the three differently-sized
floor spills, the average EBL for stations was
not statistically significant from the ABL.
This leads to the suggestion that estimating
blood loss at obstetric haemorrhage might be
more accurate if “group” estimation is used
at delivery. When considering those stations
that were statistically underestimated, it is
important to note that, as in previous studies
[4,5], the three floor spillages showed the
greatest errors. This could be overcome by
measuring the diameter of the spill using a tape
measure (cheap, disposable and available in all
delivery rooms) and approximating the blood
loss within the spill using the Aide Memoire
shown in Fig. 1 (50x50cm = 500ml, 75x75cm
= 1000ml, 100x100cm = 1500ml).
There was no significant difference in
accuracy of estimation of blood loss between
the professional groups, as indicated by the
total average error in EBL compared with
ABL. Although our study sample was too
small to allow us to draw firm conclusions,
it reproduces the findings of the previous
study in Bath [5] where no difference was
found between specialties in a study group
comprising 114 volunteer participants. This
would indicate that all healthcare professionals
tend to overestimate or underestimate by
approximately the same amount. Of interest,
the nurses were the best estimators of blood
loss, with theatre staff being the least accurate.
A previous study found anaesthetists to be the
most accurate estimators of blood loss [4], citing
factors such as their responsibility for planning
routine postoperative fluid management and
fluid management in emergency resuscitations
as contributing to their ‘estimating’ skills.
However, this finding has not been confirmed
either by our study or the one from Bath [5].
Our training afternoon was well organized,
easy to run and well received with 100%
positive feedback. All equipment used to stage
the clinical scenarios was routinely found on
delivery suite and was therefore easy to acquire.
Blood products were obtained via the hospital
transfusion service without complication,
although this is likely to differ across individual
hospitals and healthcare trusts. The study took
approximately 1 hour to set up, and around
20 minutes for participants to complete. It
provides a valuable tool for improving the
ability of healthcare professionals routinely
working on delivery suite to accurately
estimate blood loss in obstetric haemorrhage
but the study design is also reproducible in any
specialty, notably trauma. The pictorial Aide
Memoire produced following the study in Bath
[5] is now being used in clinical areas including
the sluice, theatres, and on the post-partum
haemorrhage (PPH) emergency box. After
we presented these results at the departmental
audit meeting, North Bristol NHS Trust is
considering including this study session in its
multidisciplinary intrapartum study day.
References
1) Ronsmans C, Graham WJ. Maternal Mortality:
Who, when and why. Lancet 2006 Sep 30; 368
(9542): 1189-200.
2) Confidential Enquiry into Maternal and Child
Health. Saving Mothers’ Lives. 2003-2005.
3) Duthie SJ, Ven D, Yung GL, Guang DZ, Chan
SY, Ma HK. Discrepancy between laboratory
determination and visual estimation of blood loss
during normal delivery. Eur J Obstet Gynaecol
Reprod Biol 1991; 38: 119-24.
4) Bose P, Regan F, Paterson-Brown S. Improving
the accuracy of estimated blood loss at obstetric
haemorrhage using clinical reconstructions. Brit J
Obstet & Gynaecol. 2006; 113(8): 919-924.
5) Appleyard T & Thomas M. A study to assess
the accuracy of visually estimated blood loss. 2003
Unpublished.
37
Station
Obstetricians
(n = 14)
Anaesthetists
(n = 4)
Midwives
(n = 6)
Nurses
(n = 5)
HCAs
(n = 6)
Theatre
Staff
(n = 4)
Other
(n = 3)
Stained maternity pad
30mls
48 (20)
38 (18)
78 (48)
38 (18)
44 (33)
38 (25)
49 (41)
Saturated maternity
pad 100mls
113 (30)
85 (15)
171 (79)
114
(46)
108
(93)
88 (48)
110 (115)
Floor bowl with bag
400mls
246 (254)
230 (270)
275 (358)
260
(240)
229
(288)
175
(325)
356
(269)
Floor spill (50x50cm)
500mls
490 (539)
513 (488)
492 (608)
526
(474)
370
(630)
313
(688)
645
(605)
Floor spill (75x75cm)
1000mls
681 (820)
463 (988)
552 (948)
514
(986)
269
(1231)
330
(1170)
550
(950)
Floor spill
(100x100cm) 1500mls
246 (168)
195 (205)
321 (179)
260
(160)
398
(202)
175
(225)
31 (88)
Kidney dish
600mls
536 (264)
550 (100)
567 (100)
498
(254)
562
(228)
425
(175)
601
(261)
Stained Inco sheet
250mls
266 (123)
233 (93)
317 (100)
298
(140)
130
(120)
144
(106)
306
(169)
Bedpan
500mls
418 (154)
575 (225)
550 (167)
388
(112)
448
(168)
338
(163)
468
(183)
Vomit bowl
300mls
289 (96)
325 (125)
275 (25)
256
(68)
278
(38)
190
(135)
413
(238)
Surgical swab small
50mls
40 (21)
26 (24)
68 (33)
72 (34)
56 (28)
25 (25)
88 (50)
Surgical swab medium
100mls
94 (42)
53 (48)
144 (73)
146
(82)
106
(48)
66 (34)
169 (94)
Surgical swab large
350mls
194 (163)
138 (213)
252 (115)
286
(224)
156
(194)
124
(226)
275
(200)
Manikin on bed
1000mls
1171 (471)
1325 (675)
975 (292)
840
(280)
580
(487)
506
(494)
888
(613)
Manikin on chair
550mls
954 (468)
520 (255)
900 (450)
540
(150)
518
(298)
730
(545)
500
(275)
Total Average Error
mls
3633
3742
3575
3268
4086
4384
4151
Table 2: Average estimated blood loss and average error ( ) for grouped participants across each of the 15
stations. The total average error in observations for each group is shown, and was not statistically significant
38
Anaesthesia Points West Vol 44 No.1
Article
Audit of Training in the Use of a Lighted Intubating Stylet
(TrachlightTM) for Blind Tracheal Intubation
Dr Johanna Angell, PA(A), Dr Usha Devadoss, Anaesthetic Specialty Doctor and Dr Khaled
Moaz, Consultant Anaesthetist
Southmead Hospital, Bristol
Summary
Many different methods of blind intubation
have been described. Some have been shown
to be useful in cases of predicted difficult
intubation but also as rescue techniques in
cases of unanticipated difficulties.
We found that those trainees who had
previously used the lighted intubating stylet
(TrachlightTM), whether on a manikin or a
patient, were more likely to achieve a quick,
uncomplicated intubation with success at the
first attempt, than those who were complete
novices in the technique. A small number of
complications related to the use of the stylet
were recorded during the audit but without
comparison to a direct larygoscopy group it is
difficult to assess the significance of these.
Our audit showed that the TrachlightTM is safe
and easy to use. We recommend that training in
its use be included in our in-house airway skills
training package and that all trainee anaesthetists
should be given the opportunity to attend.
Introduction
The use of lighted intubating stylets as a
method of blind intubation has been described
in the literature since 1959 and relies upon
trans-illumination of the neck tissues in order
to demonstrate correct placement of the
endotracheal tube [1].
Many authors have highlighted the value
of its use pre-emptively in those with high
Mallampati scores, cervical spine trauma,
maxillofacial injuries or limited neck extension
[2,5,8]. In addition, direct laryngoscopy is
associated with haemodynamic variations, and
it is thought that this type of blind intubation is a
more cardiovascularly stable way of achieving
endotracheal intubation as it does not rely
on direct visualisation of the oropharynx [2]
although this has yet to be proven [3, 4].
As with any technique, there are disadvantages
associated with the use of the lighted stylet. An
increased risk of trauma has been described in the
past and in early prototypes the light source was
known to cause burns to surrounding tissues [1].
The TrachlightTM lighted intubating stylet, first
described in 1995 by Hung et al,[5] has been
shown to have a success rate of over 99% in
experienced hands (i.e. intubation within three
attempts) with various studies having shown an
average time to intubation of between 15 and
37 seconds [1,2,5]. This compares favourably
to the time to intubation for direct largngoscopy
[2,5]. In order to overcome the problem with
burns to local tissues, the TrachlightTM has been
designed with an inbuilt safety mechanism that
causes the light to flash after 30 seconds as a
reminder to the anaesthetist to withdraw the
device and prepare for another attempt [5].
The aim of this audit was to assess current
training in the use of the lighted intubating stylet
in our hospital and to identify any complications
that occur in relation to its use. We also hoped
to set a standard for future training.
Methods
Local clinical effectiveness committee consent
was obtained. All patients were verbally
consented on the morning of surgery. Forty-seven
ASA grade 1 and 2 patients undergoing elective
39
ENT procedures were audited over a period of
6 months. Standard monitoring was used (noninvasive blood pressure measurement, pulse
oximetry, electrocardiogram and capnograpy)
and all patients were induced with propofol
and fentanyl. Mivacurium was used for muscle
relaxation. Easy bag and mask ventilation
was ensured before intubation was attempted.
Trainees attempted tracheal intubation using the
TrachlightTM device under direct supervision of
a consultant anaesthetist experienced in its use
(KM). Each trainee was allowed a maximum of
two attempts using the TrachlightTM before the
supervising consultant took over the airway.
A data collection form for each patient was
completed by the trainee. Data collected included:
• Previous experience in the use of the
device on both patients and manikins
• Number of attempts at intubation
• Total time taken to intubate
• Complications associated with the
intubation
Results
No patient had oxygen saturations of less
than 95% at any time during the attempts at
intubation. The rate of successful intubation
was 95.6% with 55% of patients being intubated
successfully on the first attempt (figure 1).
A further 19% were intubated on the second attempt
leaving the remaining patients to be intubated by
the trainer. If a trainee had used the TrachlightTM
before, whether on a manikin or patient, they had
a 67% chance of intubating on their first attempt
(figure 1). In contrast, those trainees who were
novices in the use of the device had only a 33%
success rate on their first attempt, with the trainer
finally intubating over 50% of these cases (figure
1). There were two cases of failed intubation where
direct laryngoscopy was used as an alternative;
these patients’ airways were found to be Cormack
and Lehane grade 1 and 2 respectively.
40
70
60
50
40
Prev. training
No prev. training
30
Percentage occurance
20
10
0
1st attempt 2nd attempt
Trainer Abandoned
intubated trachilight
Figure 1: The number of attempts needed to
intubate divided into those trainees who had received
previous training and those who had not. Those with
training were more likely to intubate on the 1st or
2nd attempt than those with none. Two cases were
abandoned and conventional laryngoscopy used.
The average time to intubation was 34.3 seconds
with a range of 12 to 74 seconds. Thirteen
complications were seen in 10 cases, giving a
complication rate of 21.2%. Problems recorded
included minor haemorrhage, coughing, a small
lip laceration and difficulties in seeing the light
source due to the high BMI of the patient (table 1).
Complications
Difficult to railroad tube
Coughing
Bleeding
Sore throat
Lip laceration
Difficult to see light due to patient
obesity
Failure to intubate
Total
1
3
2
3
1
1
2
13
Table 1: The complications associated with the use
of the TrachlightTM in this audit. The 13 complications
occurred in only 10 of the cases audited.
Three cases of sore throat were recorded,
but 2 of these were in tonsillectomy patients.
Complications were seen in 50% of patients
dealt with by anaesthetists who were new to
the technique, but in only 18% of patients dealt
with by anaesthetists who had some experience
of it (figure 2).
20
18
16
14
No comps.
12
10
Frequency
8
Minor comps.
6
4
2
0
Used on
Manikin
Used on
patient
Used on
both
Never used
Figure 2: Frequency of complications grouped by
experience of practitioner
Discussion
Previous studies investigating the effectiveness
of the TrachlightTM device have shown the rate
of successful intubation within three attempts
to be 99% [5]. However, the rate of successful
intubation in our study was 96%. This slightly
lower figure may not be significant and as our
study numbers were low in comparison to
other work, a larger study may show success
rates that are comparable.
There were only 2 failures to intubate with
the TrachlightTM in the 47 patients audited in
this study. However, the significance of this
is not clear as not enough information was
collected to allow us to say why the failures
occured, but it was noted that intubation using
direct laryngoscopy was easy in both cases.
The study by Hung et al.[5], compared all
aspects of intubation using the TrachlightTM
and direct laryngoscopy and showed that when
the TrachlightTM failed, direct larynscopy was
effective and vice versa, suggesting that a
combination of the techniques would give a
successful intubation rate of 100%.
The average time taken to intubate was similar to
that in a previous study by Aikins et al.[6], who
also studied the success of doctors new to the
technique, but was unsurprisingly longer than in
other studies where the intubation was carried
out by those who were competent in the use
of the TrachlightTM [2, 5]. Interestingly, other
work comparing direct laryngoscopy with this
technique have shown little difference in time
taken to intubate [3] and it would be interesting
to repeat the work carried out in this audit with a
direct laryngoscopy group as control.
Two-thirds of patients were intubated on the first
attempt if the anaesthetist had used the device
previously, either on a patient or manikin.
This dropped to only a third of patients if the
anaesthetist was new to the technique. The
number of complications in patients intubated
at the second or third attempt was higher than
in those patients that were intubated on the first
attempt. This supports the need for training
and practice in the use of the device if it is to
be included in difficult airway algorithms.
The complication rate in this study (21.2%)
is similar to that in the work by Hung et
al.[5], who showed a rate of 25%. They also
compared their results with a group of patients
who had undergone direct laryngscopy and
showed a complication rate of 43% in the latter
group. This is in contrast to a study by Siddiqui
et al.[4], who found that direct laryngoscopy
caused fewer complications than the use of
the TrachlightTM. The most frequent problems
associated with the TrachlightTM in our study
were coughing and sore throat but again,
without comparision to a direct laryngosopy
group, it is difficult to assess the significance of
41
this. Rates of sore throat post intubation have
been shown be as high as 45.5% [7].
One interesting complication in our study was in a
patient with a high body mass index (BMI), where
it proved very difficult to see the trans-illumination
of the neck tissues, thus making it impossible to
assess whether the endotracheal tube was correctly
placed. It has been suggested by Hung et al.[5]
that the TrachlightTM can be used in obese patients
when the airway is suspected to be difficult, but
in a similar study to ours, Aikins et al. [6] studied
the use of the TrachlightTM by junior anaesthetists
in patients with a high BMI and recorded a rate
of successful intubation of only 20% with an
average time to intubation of 95 seconds. Wong
et al.[8] concluded that the lighted stylet method
significantly increased the time to intubation
in patients with high BMIs when compared to
direct laryngoscopy. Our finding tends to support
the latter viewpoint but as we did not record the
BMIs of all our patients we cannot really draw any
conclusions.
The results from this short audit indicate
that experience and training in the use of the
TrachlightTM, whether on a manikin or a patient,
increases the likelihood of a quick, successful
and uncomplicated intubation. If the use of such
an airway device is going to be considered in the
face of a difficult or failed intubation, we feel it
is important to learn how to use it in a safe, non
emergency situation. We suggest that if a trainee
has never used the device before they should be
limited to one attempt per patient in order to
minimise the likelihood of complications. As a
result of this audit, we have now introduced training
for all trainees in the use of the TrachlightTM device
as part of their routine airway training.
An audit in patients with predicted difficult airways
is currently in progress.
The work from this audit has previously been
presented in poster format at the Difficult
Airway Society meeting, November 2009 and
42
the SASWR Winter Meeting, 2009.
Conflict of Interest: None declared
References
1.
Ellis ET, Jakymec A, Kaplan RM, et al. Guided
orotracheal intubation in the operating room
using a lighted stylet: a comparison with direct
laryngoscopic technique. Anesthesiology 1986,
64: 827-6.
2.
Ka-young R, Jeong-rim L, Jinhee K,
Sanghyon P, Won-Kyong S. and SungHee H.
A comparison of lighted stylet (Surch-Lite)
and direct laryngoscopic intubation of patients
with high mallampati scores. Anesthesia and
Analgesia 2009; 108: 1215-1219.
3.
Hirabayshi, Y., Hiruta, M., Kawakami, T.,
Inoue, S., Fukuda, H., Saitoh, K. and Shimizu,
R. Effects of lightwand (Trachlight) compared
with direct laryngoscopy on circulatory
responses to tracheal intubation. British
Journal of Anaesthesia 1998; 81 (2): 253-255.
4.
Siddiqui, N. Katznelson, R, Friedman, Z.
Heart rate/blood pressure response and airway
morbidity following tracheal intubation
with direct laryngoscopy, GlideScope and
Trachlight: a randomized control trial.
European Journal of Anaesthesiology 2009;
26(9): 740-5.
5.
Hung, O.R., Pytka, S., Morris, I., Murphy,
M., Launcelott, G., Stevens, S., MacKay W.,
Stewart, R.D. Clinical trial of a new lightwand
device (Trachlight) to intubate the trachea.
Anesthesiology 1995; 83(3):509-14.
6.
Aikins, N.L., Ganesh, R., Springmann, K.E.,
Lunn, J.J., and Solis-Keus, J. Difficult
airway management and the novice physician.
J Emerg Trauma Shock 2010; 3(1): 9-12.
7.
Higgins, P.P, Chung, F., and Mezei, G.
Postoperative sore throat after ambulatory
surgery. British Journal of Anaesthesia 2002;
88 (4): 582-582.
8.
Wong SY, Coskunfirat ND, Hee HI, Li JY, Chen
C and Teseng CH. Factors influencing time of
intubation with a lightwand device in patients
without known airway abnormality. Journal of
Clinical Anaesthesia 2001; 16: 326-331.
Anaesthesia Points West Vol 44 No.1
Case Report
A Case Report of an Emergency Caesarean Section in a Patient
with Presumed Pre-eclampsia and Undiagnosed Thrombotic
Thrombocytopenic Purpura
Dr Elspeth Hulse, ST4 Anaesthetics1, Dr David Elliott, Locum Consultant Anaesthetist2
1
Derriford Hospital Plymouth, 2Royal Cornwall Hospital, Truro
Abstract
We describe the management of a 20 year
old primigravida at 38 weeks gestation, with
presumed pre-eclampsia and undiagnosed
thrombotic
thrombocytopenic
purpura,
requiring an emergency caesarean section for
foetal distress. This case report describes the
actions taken by the medical team, the clinical
outcome, a discussion of current literature and
how management of the patient could have
been improved. We conclude that patients with
thrombotic thrombocytopenic purpura can
be transfused with platelets and fresh frozen
plasma for emergency caesarean section and
advise early plasma exchange with involvement
of both haematology and renal specialists.
Introduction
Thrombotic thrombocytopenic purpura (TTP)
is a rare, life threatening condition found more
commonly in women than in men and which can
be triggered by pregnancy.1 It is characterised
by microangiopathic haemolytic anaemia
(MAHA) and consumptive thrombocytopenia
leading to disseminated microvascular
thrombosis. It has been described by some
researchers as looking for the ‘proverbial
needle in the haystack’2 and is estimated
to affect 1 in 100,000 pregnancies with an
untreated maternal mortality rate of up to 60%,
with a foetal loss rate of 80%.3 However, with
the advent of plasma therapy, it has become a
curable illness.4
We describe the management of a 20-yearold primigravida at 38 weeks gestation with
presumed pre-eclampsia and undiagnosed TTP
requiring an emergency caesarean section for
foetal distress.
Case Report
A previously well 20 year old primigravida at
38 weeks gestation, presented to the obstetric
department with a four day history of feeling
unwell with vomiting.
On examination,
abnormalities found included a blood pressure
of 155/96mmHg, heavy proteinuria on urinary
dipstix, with loss of variability and late
decelerations on the cardiotocograph (lowest
heart rate 80bpm). It was decided to proceed
with an emergency caesarean section5, but
to await a full blood count, because of the
presumed diagnosis of pre-eclampsia and
potentially low platelet levels.
The patient was taken to the operating theatre,
placed on her left side and given oxygen to
breathe whilst intravenous access was obtained.
Blood results were as follows: haemoglobin
level 5.9g/dl (normal 11.5-16g/dl), platelets
27,000/mm3 (normal 150-400,000/mm3),
prothrombin time (PT) 13.9 seconds (normal
11-16 seconds) and the activated partial
thromboplastin time (APTT) 23 seconds
(normal 25-39 seconds). One unit of red
cells and one pool of platelets (100ml) were
transfused prior to surgery to reduce the
likelihood of major haemorrhage.
The patient was treated for her pre-eclamptic
symptoms with a loading dose and infusion of
intravenous magnesium sulphate. Intravenous
alfentanil (2mg) was given on induction of
43
general anaesthesia to obtund the pressor
response to laryngoscopy. Spinal anaesthesia
was not performed due to the perceived risk of
haematoma formation.
The patient underwent an uneventful lower
segment caesarean section under general
anaesthesia. The baby was delivered with Apgar
scores of 1 at two minutes and 10 at ten minutes
and transferred to the neonatal intensive care
unit for a short course of continuous positive
airways pressure (CPAP) and antibiotics. The
estimated surgical blood loss was 200-300mls.
Intra-operatively a further two units of red
cells, but no fresh frozen plasma (FFP), were
administered.
Post-operatively the patient had a central
venous catheter and an arterial line inserted
and was observed on the maternity high
dependency unit (HDU) overnight. Her blood
pressure was controlled initially with an ongoing magnesium infusion later supplemented
with oral felodipine as is normal practice
in our unit. She later required a labetalol
infusion for more precise control. There was
evidence of renal dysfunction, but this did not
require haemodiafiltration. Liver function was
altered with alanine aminotransaminase (ALT)
levels elevated at 109U/l (normal 7-56U/l),
but coagulation studies remained normal
throughout.
Over the next 48 hours the patient developed
worsening neurological symptoms including
visual disturbance, confusion and clonus; she
also had jaundice and a swollen abdomen.
A CT scan of the head was normal but a
CT abdomen showed ascites. A blood film
showed microangiopathic haemolytic anaemia
(MAHA) in the presence of thrombocytopenia
indicative of TTP.
A haematology opinion was sought and, on
their advice, the patient was transferred to the
intensive care unit (ICU) for an emergency
single plasma exchange. She was discharged
44
from hospital 2 weeks later on oral labetolol
for hypertension. A definitive diagnosis of
TTP was made by finding low plasma levels
(<5%) of ADAMTS 13 (A disintegrin and
metalloprotease with thrombospondin type 1
motif, member 13) enzyme. The baby was in
the neonatal intensive care unit for one night
but was discharged home well.
Discussion
TTP used to be diagnosed by the finding of a
pentad of clinical symptoms: thrombocytopenia,
Coombs negative MAHA, neurological and
renal abnormalities with a fever. However, this
presentation was found to occur in only 40% of
patients.6
When plasma exchange was introduced for
the treatment of TTP, the diagnostic criteria
were abridged to include just MAHA and
thrombocytopenia in the absence of other
identifiable causes.7 8 This definition does
not distinguish between haemolytic uraemic
syndrome (HUS) and TTP and is thus
sometimes classified as TTP-HUS.9 The
patient may or may not also have associated
elevated blood pressure and proteinuria.2
Martin et al found in a review of 166 pregnant
patients diagnosed with TTP, that 17.5% had
concurrent pre-eclampsia / eclampsia / HELLP
syndrome (haemolysis, elevated liver enzymes
and low platelets) which significantly increased
maternal mortality.10
From research in the last decade it is understood
that TTP is caused by low levels of an enzyme;
von Willebrand factor-cleaving metalloprotease
known as ADAMTS 13 (A disintegrin and
metalloprotease with thrombospondin type 1
motif, member 13).11 12 This enzyme deficiency
prevents normal processing of large Von
Willebrand factor multimers that are secreted
from endothelial cells and platelets.13 This
leads to platelet clumping and microvascular
platelet thrombi, which often result in platelet
counts below 20,000/mm³.14 The thrombi are
localised to terminal arterioles and capillaries
mainly in the renal and cerebral circulations,
with impairment of the fibrinolytic system.3 7 8 9
TTP is thought to be either congenital,
through mutations of the ADAMTS 13 gene,
or acquired through autoimmune inhibitors
against the ADAMTS 13 enzyme.7 12 13 Levels
of ADAMTS 13 have been found to be severely
deficient in 70-100% of patients with TTP, but
normal in patients with HUS.12 ADAMTS 13
levels can also fall during pregnancy and in
HELLP syndrome.3 Other known precipitants
of TTP are drugs, autoimmune disease,
malignancy, infection (E. Coli 0157) and
Human Immunodeficiency Virus (HIV).8
For both acquired and congenital forms the
time of greatest risk for development of TTP
in pregnancy is near term and during the
post-partum period.2 This condition is often
confused with other obstetric diagnoses such
as severe pre-eclampsia, HELLP syndrome,
eclampsia, acute fatty liver of pregnancy,
antiphospholipid antibody syndrome and
disseminated
intravascular
coagulation
3 4
(DIC).
TTP must be differentiated from
pre-eclampsia and HELLP syndrome because
delivery is the treatment of choice for the latter,
and not recommended as first line therapy for
TTP.7
Investigation of symptomatic patients should
include a full blood count, urea and electrolytes,
liver function tests, coagulation screen, lactate
dehydrogenase (LDH) level, direct antiglobulin test, a peripheral blood smear and
urine dipstix.4 8
If all other causes of thrombocytopenia have
been eliminated, in the presence of a raised
LDH and Coombs negative haemolytic
anaemia, then TTP should be considered
and plasma exchange instigated.3 8 15 If the
patient’s symptoms and laboratory findings do
not resolve within 48 hours of delivery of the
placenta, then TTP should also be suspected
and treated.3 The value of measurements of
ADAMTS 13 activity and inhibitors remains
uncertain.14
Treatment
The management of TTP in pregnancy has
improved through early recognition, aggressive
treatment with plasma transfusions and
exchanges in consultation with haematologists,
nephrologists and critical care physicians.3 4 15
FFP and cryosupernatant contain the deficient
metalloprotease, ADAMTS 13.
The pioneering study by Rock et al in 1991
showed that treatment with FFP alone gave a 6
month survival rate of 63% and this improved
to 78% with plasma exchange.9 Other studies
have similarly found improved survival
when plasma infusion, plasma exchange, or a
combination of both was utilised.11 15 Plasma
exchange is thought to restore ADAMTS
13 activity and remove auto-antibodies to
ADAMTS 13.14 16
The British Committee for Standards in
Haematology recommends that plasma
exchange continue for two days after
platelet levels normalise.8
Those who
do not respond to plasma exchange may
benefit from immunosuppressive therapy or
splenectomy.4 7 Current research is focussing
on immunosuppressive agents such as
monoclonal antibodies, which may be able to
target ADAMTS 13 autoantibody and therefore
have the potential to speed up treatment and
reduce relapses.17
Platelet transfusions in patients with TTP
were believed to increase the risk of micro
vascular thrombosis leading to neurological
deterioration and death. This led to the
practice of platelets being transfused only for
the management of life-threatening bleeding.16
Swisher et al found that the evidence for harm
45
was inconclusive, and that platelet transfusions
should not be withheld from patients who have
appropriate indications for management of
overt bleeding, surgery, or invasive procedures
in the presence of severe thrombocytopenia.18
The rarity of this condition and the emergency
setting highlighted some questions and
observations.
Firstly, the authors are happy that platelets
were transfused as the patient required an
emergency caesarean section, but this may
have inadvertently fuelled the disease process
of TTP.8 16 19
Secondly, no FFP was transfused as her
coagulation screen was normal, which is
typical for TTP 3 14. In hindsight the authors
think that an FFP transfusion may have been
beneficial, as shown by Rock’s research.9 11 A
recent case report highlighted the usefulness of
an FFP transfusion in a patient suffering from
TTP allowing them to have a caesarean section
under spinal anaesthesia, although this was an
elective procedure.19
Thirdly, the initial assumption was that the patient
was suffering from pre-eclampsia and/or HELLP
syndrome so she was treated accordingly. It was
not until she developed neurological symptoms at
the same time as having an abnormal blood smear,
that TTP was considered the likely diagnosis.
The authors recommend that haematologists and
renal teams be consulted early when faced with
such a haematological conundrum. The British
Guidelines for TTP state that plasma exchange
should commence within 24 hours of presentation
for optimum effect.8 However, current consensus
is that this is a rare disease with a non-specific
presentation and so remains difficult to recognise
and to treat in a timely fashion.
Written informed consent was obtained from the
patient for the publication of this case report.
Conflicts of interest: none declared
46
References
1. George JN. The association of pregnancy with
thrombotic thrombocytopenic purpura-haemolytic uraemic syndrome. Curr Opin Hematol
2003;10:39-344
2. Stella CL, Dacus J, Guzman E, Dhillon P,
Coppage K, How H, Sibai B. The diagnostic
dilemma of thrombotic thrombocytopenic
purpura/haemolytic uremic syndrome in the
obstetric triage and emergency department:
lessons from 4 tertiary hospitals. Am J Obstet
Gynecol.2009;200:381-e6
3. Sibai BM. Imitators of severe preeclampsia.
Obstet gynecol 2007;109:956-66
4. George JN. How I treat patients with thrombotic thrombocytopenic purpura-hemolytic
uremic syndrome. Blood 2000;96:1223-1229
5. Lucas DN, Yentis SM, Kinsella SM, Holdcroft
A, May AE, Wee M, et al. Urgency of caesarean section: a new classification. J R Soc Med
2000;93:346–50.
6. Rock G, Porta C, Bobbio-Pallavicini E.
Thrombotic thrombocytopenic purpura
treatment in year 2000. Haematologica.
2000;85:410-419
7. British Committee for Standards in Haematology. Guidelines on the diagnosis and
management of the thrombotic microangiopathic haemolytic anaemias. Br J Haematol
2003;120:556-73
8. Rock GA, Shumak KH, Buskard NA, et al.
Comparison of plasma exchange with plasma
infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis
Study Group. N Engl J Med 1991;325:393-7
9. Vesely SK, Li X, Mcminn JR, Terrell DR,
George JN. Pregnancy outcomes after recovery from thrombotic thrombocytopenic purpu-
ra-haemolytic uremic syndrome. Transfusion
2004;44:1149-58
10. Martin J, Bailey AP, Rehberg JF et
al.Thrombotic thrombocytopenic purpura in
166 pregnancies:1955-2006. Am J Obstet Gynecol 2008;199(2):98-104
11. George JN, Vesely SK. Thrombotic Thrombocytopenic Purpura: From the Bench to the
Bedside, but Not Yet to the Community. Ann
Intern Med. 2003;138:152-153
12. Tsai HM. Pathophysiology of thrombotic
thrombocytopenic purpura. Int J Hematol
2010;91:1
13. Moake JL. Thrombotic Microangiopathies;
Mechanisms of Disease. N Engl J Med
2002;347(8):589-600
16. George JN. The thrombotic thrombocytopenic purpura and haemolytic uremic syndromes: evaluation, management, and long
term outcomes experience of the Oklahoma
TTP-HUS Registry, 1989-2007. Kidney Int
2009;75(112):552-554
17. Kiss JE. Thrombotic thrombocytopenic purpura: recognition and management.
Int J Hematol 2010;91:36
18. Swisher KK, Terrell DR, Vesely SK et al.
Clinical outcomes after platelet transfusions
in patients with thrombotic thrombocytopenic
purpura. Transfusion 2009;49:873-887
19. Kato R, Shinohara A, Sato J. Case Report
ADAMTS13 deficiency, an important cause
of thrombocytopenia during pregnancy. IJOA
2009;18:73-77
14. George JN. Thrombotic Thrombocytopenic
Purpura. N Engl J Med 2006;354:1927-37
15. Egerman RS, Witlin AG, Freidman SA, Sibai
BM. Thrombotic thrombocytopenic purpura
and haemolytic uraemic syndrome in pregnancy: review of 11 cases. Am J Obstet Gynecol
1996;175:950-6
47
Anaesthesia Points West Vol 44 No.1
Article
Severn Ultrasound Regional Foundation (SURF) Course
Targeted Introductory Training in Ultrasound Guided Regional Anaesthesia
Dr Henry Murdoch1, Dr Tom Martin1 & Dr Chris Thompson2
Southmead Hospital, Bristol
1
Specialty Registrar in Anaesthesia. 2Consultant Anaesthetist
(Winning trainee presentation at WSURA Annual Scientific Meeting, November 2010)
Why do we need an introductory
sonoanatomy course?
The use of ultrasound in anaesthetic clinical
practice has come to prominence over the
last decade. This has been due in part to
the development of ultrasound technology,
but also to an increasing recognition that
ultrasound is an important aid to clinical
practice, providing the benefits of increased
procedure safety and success. Having initially
set out recommendations for ultrasound use
in central venous cannulation [1] almost ten
years ago, the National Institute for Health
and Clinical Excellence (NICE), have more
recently published recommendations on the
use of ultrasound in epidural placement [2]
and regional nerve blockade [3] highlighting
the benefits of improved safety and quality
of regional anaesthesia. The caveat to these
recommendations is that ultrasound should
be used only by those with formal training
and experience in ultrasound guided regional
anaesthesia (UGRA).
In recognition of the need for formal training a
joint committee of the American and European
Societies of Regional Anaesthesia (ASRA
and ESRA), as well as the Royal College of
Radiologists, produced recommendations on
teaching these skills [4,5]. In the UK UGRA
is now included in the core curriculum for
CCT in Anaesthesia 2010 [6]. At the end
of 2010, a joint committee from the Royal
College of Anaesthetists, the Association of
Anaesthetists of Great Britain and Ireland
and the Intensive Care Society also produced
48
draft guidance on training in ultrasound skills.
[7]. However, opportunities for acquiring and
consolidating skills in clinical practice seem
limited. We sought to determine whether there
was a paucity of training opportunities in the
hospitals in our region and, if so, to address the
problem by providing formalised introductory
training.
Is there a demand amongst trainees?
We surveyed all the trainees in the Severn
Deanery to establish their exposure to training
opportunities in UGRA and their views on
formal introductory training. This allowed us
to determine the demand for a course and to
identify a possible primary target group for it.
We had a 54% (69 of 128 trainees) response
rate to our survey with a good spread of level
of trainee across the School of Anaesthesia.
From this we were able to identify 225
individual training episodes showing when and
where UGRA training occurs in our region.
Different patterns in UGRA exposure were
found between basic, intermediate and higher
level trainees. Displayed graphically (table
1) the responses show a trend toward greater
exposure to UGRA during clinical placements
in those hospitals with more senior trainees
(Southmead, Bath, Swindon, Gloucester &
Cheltenham).
We also found variations in the types of blocks
performed throughout training. Of concern,
77% of intermediate (ST3/4) trainees reported
performing fewer than ten blocks during these
two years and more than half of higher trainees
(ST5-7) reported limited experience in upper limb
This correlates with earlier findings that most
exposure to UGRA training occurs in the
higher years in our Deanery. However, with
the introduction of UGRA to the anaesthetic
curriculum, we may be about to see an increase
in demand for structured introductory training.
Performing this pre-course survey helped
acknowledge the increasing demand for
training and identify a primary target group of
trainees who would benefit the most from it.
Table 1
blockade. Irrespective of grade, all trainees cited
lack of clinical exposure and adequate ultrasound
machines as reasons for lack of UGRA experience.
When asked if attending an introductory UGRA
course prior to clinical placements would be
helpful, 82% of trainees agreed that it would.
However, when analysed by grade of trainee only
65% felt it would be useful prior to basic and
intermediate training compared to 95% of higher
trainees (table 2).
Table 2: Most positive results were obtained
from those hospitals with more senior trainees
– Southmead, Bath, Swindon, Gloucester and
Cheltenham.
Designing and planning the course:
Having demonstrated that there is limited
exposure to UGRA, and an appetite for formal
training, we designed a course that would add
value to limited clinical training opportunities.
UGRA is difficult to teach and learn in the clinical
setting. In addition to a sound knowledge of
regional anatomy (and sonoanatomy), UGRA
requires skill in acquisition and interpretation
of ultrasound images as well as dexterity in
manipulating an ultrasound probe and needle
simultaneously.
While many will have
used real-time ultrasound to guide central
venous cannulation, using this application to
guide injection around peripheral nerves is
considerably more complex and requires greater
knowledge, discrimination, and caution. The
universal time pressures of clinical practice
and limited case numbers mean that honing
these skills from scratch in a clinical setting
may limit the value of training opportunities.
However, much of the knowledge and many of
the skills required for safe and effective UGRA
may be gained without a patient. The aim of
our course was to provide an environment
where this could be achieved such that when
trainees were subsequently faced with a
clinical training opportunity, this could be used
to ‘polish’ rather than ‘practice’ their skills.
In March 2010, we ran a successful pilot
course (BiSON) from which the subsequent
course (SURF) has evolved. The course was
49
designed with clearly defined aims, which were
to simulate as much as possible away from the
patient, to develop confidence in using the
ultrasound machine to produce a ‘target’ image
and thus to allow trainees to maximise their
experience during clinical episodes. The oneday course consists of an introductory lecture
on the physics and principles of the ultrasound
machine and how to manipulate the machine
to optimize the image. The rest of the day is
divided into four sections to cover upper limb,
lower limb, trunk, and central blocks. Each
section follows the same format; a short lecture
followed by a practical workshop. During the
lecture, the anatomy is demonstrated using
schematic diagrams that are projected alongside
‘perfect’ ultrasound images with simultaneous
video demonstration. The workshops allow
all participants the opportunity to scan
their colleagues under the supervision of an
experienced facilitator. Using scanners brought
in by an external company has the benefit of
using reliable, top of the range equipment
without taking the anaesthetic department
machines out of clinical use. It also avoids the
restriction of choosing a venue on the basis of
scanner availability.
Venue choice has been largely determined by
cost. The facilities available to us at Southmead
Hospital provide us with the venue at no cost.
There is also the added benefit of double
ceiling projectors. During demonstrations this
allows us to project the image from the scanner
direct onto one white board whilst PowerPoint
slides displaying the sonoanatomy image we
are trying to obtain is projected onto the other
board.
The course faculty is almost entirely made
up of consultants experienced in UGRA,
two of whom have the European Diploma of
Regional Anaesthesia. Having faculty with the
European diploma is one of ESRA’s
requirements for course accreditation,
50
something we hope to achieve at a later date.
Are we getting it right?
Feedback is an essential for development and
improvement of any course. We were keen to
use feedback to quantify learning outcomes
and establish the primary target group who
would benefit the most from this course. All
participants on the SURF course are required
to complete a self-assessment questionnaire on
their UGRA skills. They are asked questions
about their confidence in using UGRA,
knowledge of specific block sonoanatomy
and confidence using the scanner to obtain
different images. They score themselves on a
scale of 1-10. This is done before the course,
again at the end of the day and is repeated at
two months. To date we have trained twentyone candidates on the course; nineteen trainees
and two consultants. Self-assessment scores
showed a median improvement of 2 in scores
for candidates’ confidence in UGRA and
specific sonoanatomy knowledge. However, in
the two month follow up questionnaires, skills
were only retained by those regularly using
UGRA (table 3).
catheters. http://guidance.nice.org.uk/TA49/
Guidance/pdf/English. Accessed Jan 20th 2011.
2. National Institute for Health and Clinical
Excellence IPG 249 Ultrasound guided
catheterisation of the epidural space.
Updated
March
2010
http://guidance.
nice.org.uk/IPG249/Guidance/pdf/
English.
Accessed
Jan
20th
2011.
Table 3
Due to the structure of clinical placements in
our deanery these tended to be higher trainees.
Identifying and reaching our target
audience:
Our introductory course has successfully helped
all twenty-one participants acquire UGRA skills
and confidence. However, as skill retention at two
months is better in those regularly using UGRA,
we feel that those trainees about to commence
clinical attachments where UGRA skills can be
consolidated should be the primary target group
for introductory UGRA training. Currently, our
course seems best targeted at higher trainees;
however, as these skills are now included in the
core anaesthetic curriculum for all grades of
trainee, our target group may change.
Courses are currently being run twice a year,
usually in March and June. Anyone interested
in attending should contact us at SURFcourse@
hotmail.co.uk
Conflict of interest: none declared
References:
1. National Institute for Health and Clinical
Excellence. Guidance on the use of ultrasound
locating devices for placing central venous
3. National Institute for Health and Clinical
Excellence IPG 285: Ultrasound-guided regional
nerve block. Updated March 2010. http://
guidance.nice.org.uk/IPG285/NICEGuidance/
pdf/English. Accessed Jan 20th 2011
4. Sites BD, Chan VW, Neal JM, et al. The
American Society of Regional Anesthesia
and Pain Medicine and the European
Society of Regional Anaesthesia and Pain
Therapy joint committee recommendations
for education and training in ultrasoundguided
regional
anesthesia.
Regional
anesthesia and Pain Medicine 2009; 34: 40-6.
5. Royal College of Radiologists. Ultrasound
Training Recommendations for Medical
and Surgical Specialties. http://www.rcr.
ac.uk/publications.aspx?PageID=310&Pu
blicationID=209. Accessed Jan 20th 2011.
6. CCT in Anaesthetics (2010 Curriculum)
h t t p : / / w w w. r c o a . a c . u k / i n d e x .
asp?PageID=1479. Accessed Jan 20th 2011
7. Ultrasound
in
Intensive Care A
Anaesthesia
and
Guide to Training
8. A guidance document produced by a joint
working party of the Association of Anaesthetists of Great Britain & Ireland, the Royal
College of Anaesthetists and the Intensive Care
Society.
http://www.aagbi.org/publications/
guidelines/docs/ultrasound_draft_for_website.
pdf Accessed Jan 20th 20
51
Anaesthesia Points West Vol 44 No.1
Ross Davis Adventure Bursary Report
African Anaesthetic Adventures
Dr Nigel Hollister, Anaesthetic SpR
Peninsula School of Anaesthesia
The Ross Davis adventure bursary is available
to anyone participating in exciting endeavours
in anaesthesia. With Ross’ inspiration and this
bursary I was able to undertake two projects in
developing world anaesthesia.
The first trip was with Mercy Ships to Benin,
West Africa for two weeks in May 2009. Mercy
Ships is a Christian charity whose vision is to
bring hope and healing to the poorer countries
of the world by providing free medical and
surgical care, using developed world equipment
and resources. Types of surgery offered include
ophthalmic, orthopaedic, gynaecological,
plastic, maxillo-facial, ENT and general. Mercy
Ships also offers non-surgical health care in
the areas of dentistry, mental health, palliative
care and physiotherapy. Many local Beninese
medical professionals receive training with the
aim of improving sustainability and delivery
of healthcare in the long term. In addition to
the healthcare offered on board there are also
various projects in areas such as agriculture,
sanitation and church ministry.
Africa Mercy is the flagship for Mercy Ships.
It is a 16,700 tonne ship that has been converted
into a floating hospital. It houses six operating
theatres, a five bedded intensive care unit, an
x-ray department, CT scanner, laboratory and
four wards with fifteen to twenty beds on each.
It even has its own walking blood bank (the
52
Africa Mercy
staff!). It has accommodation for over 400
staff, a Starbucks coffee shop and a swimming
pool on the top deck.
Africa Mercy is probably the most pleasant
and efficient “hospital” that I have ever worked
in. Firstly, the morale is very high. No one is
there for the pay as no one gets paid. Every
one of the 400 crew, from the cleaners to the
captain, is working voluntarily. No one can
be late as all staff live on board so there is
no commute! Theatre lists are ready the day
before surgery and pre-operative visits are
efficient as all patients are on board the night
before, on the same ward and in consecutive
beds. Occasionally some patients get cancelled
due to malaria but the majority of operations
go ahead as scheduled. Failure to attend is
unusual despite patients travelling for days
with no calendar, diary or watch.
Each of the theatres is well equipped with new
machines and all the latest difficult intubation
aids. Anaesthetic agents used are the same as
in the UK, apart from the lack of remifentanil
and Desflurane. Oxygen is supplied via an air
compressor to two oxygen concentrators. On
the upper deck, ten size H cylinders act as a
cylinder manifold and are maintained by the
ship’s engineer. Each theatre has an E and
a further H size cylinder. Mercy Ships is an
international organisation so oxygen cylinders
come in many different colours. Some are as in
the UK (black body with white shoulders) but
I also saw blue cylinders with white shoulders
(Norwegian), green body and shoulder
cylinders (USA) and grey body and green
shoulder cylinders (USA) and all contained
oxygen!
During my two week attachment, I anaesthetised
for thirty three cases. These included cleft lip
repairs, mandibulectomies, maxillary and facial
tumour excisions, thyroidectomies, hernias and
orthopaedic work. My anaesthetic skills were
pushed to the limit with many difficult airways
and paediatric cases. Occasionally extra skill
was required as ship movement provided us
with moving targets.
Work starts at 07:30 when machines are checked,
drugs drawn up and theatre staff meet for a safety
briefing and prayer for the patients. The first
patient arrives at 08:00. There are no portering
delays and interpreters are available at all stages
apart from emergence of anaesthesia. Although
there are many helpful theatre assistants, it is
rare to have an ODP and this necessitates being
prepared, organised and self sufficient. The
sterilising department is just down the corridor
so fibreoptic bronchoscopes are always available
and the laboratory is just up the corridor so
any serology, blood film or cross matching
requests are easily processed and reported. The
radiology department is conveniently placed
next door. All staff are pleasant, receptive and
keen to help. The close working relationships
and team approach are immediately visible and
there is an amazing feeling that everyone and
everything is to hand. Post-operative visits are
also easy, and lists finish by 5pm, giving you the
opportunity for a quick swim or game of table
tennis before dinner.
Lives really are changed. One particular case I
recall was Odo, an eight year old boy born with
cleft lip. He and his parents were told it was
a curse. He therefore spent his life as a cow
herder away from his community and away
from social interaction. A family friend heard
of Mercy Ships and organised for him to get
to the ship, many hours from his home. On
arrival, Odo was petrified, not understanding
why he was being taken to the coast onto a ship.
On my first encounter with him he was hiding
his face and mouth with his hand and when I
approached him he cried. The last person he
saw with a stethoscope examined his face and
performed venepuncture, so understandably he
was frightened of me. We took him around the
ward to see other children with cleft lip. He
was amazed to see that there were children just
like him and excited to see that his cleft lip
could be repaired. Seeing the change in him
both physically and emotionally after surgery
and seeing him smile and relate to other people
will be a memory that I carry for life.
At the weekends there were opportunities to
explore the country or join a trip to a local
school, clinic, orphanage or trip to a local
market, swimming pool or beach.
Thousands queue at screening day Cotonou Benin
Any grade of anaesthetist from experienced SHO
to consultant can apply to join Mercy Ships and the
53
minimum time on board is two weeks. Volunteers
have to pay for their food, board and flight. The
ship spends ten months of each year docked in
a different country. In 2009 it was in Benin, in
2010 in Togo and in 2011 will be in Sierra Leone.
Screening days are held during the month of
February where thousands of patients attend for
assessment, preparation and booking for theatre for
the following ten months. For more information
please look at the website www.mercyships.co.uk,
or on You Tube for promotional material. You may
find it very inspiring.
For our second “anaesthetic adventure” my
wife and I organised a year out of programme
experience (OOPE) from our registrar training,
to work in a government hospital in South
Africa.
South Africa is a beautiful country with a
varied and diverse culture and heritage. It is
still however sadly ravaged by poverty, and an
oppressive history of colonisation and apartheid.
Of the eight Millenium Development Goals
set out by the United Nations in 2000, South
Africa had seen either insufficient progress,
no progress or reversal of progress with most
of the goals by 2009. Anyone planning on
working there would benefit from reading
a series of papers published in the Lancet in
September 2009. The series highlights the
issues facing South African healthcare.
Failure to address HIV has had far reaching
consequences. HIV prevalence in antenatal
women in Kwazulu Natal is approximately
40%. The number of people diagnosed with
TB has risen by 350% since 1995. Birth rates
are decreasing and death rates are increasing.
Life expectancy at birth is dropping and is
currently estimated at 47 years. Maternal
mortality rates are alarming. The maternal
mortality rate among HIV positive women is
400/100,000 live births. For comparison, in the
UK, maternal mortality rate was 8.2/100,000
live births in 2008. Infant mortality rates are
54
69/1,000 births for South Africa and 6/1,000
births in the UK.
Extremely high levels of violence with over
18,500 murders per year and road traffic
collisions at eight times the international
average add further strain to the health service.
The challenges are great and morale of doctors
and other health care workers is low. Only
10% of medical graduates end up working
for the South African Government, the rest
migrate abroad or choose to work in the private
sector. 16% of nurses have HIV, a further 40%
of nurses are due to retire in the next 5-10
years. Ineffective leadership, inexperienced
and unaccountable managers and appointments
on race, and not ability, inhibit progress. There
are clearly many challenges facing the South
African Health Service. There is however a
great deal of potential to make a difference
to people who are suffering as a result of the
problems facing the country.
I worked at two hospitals in Kwazulu Natal, both
tertiary referral hospitals with a catchment area
of just under one million people. Ngwelezane
has 555 beds, nine ICU beds and six operating
theatres performing over 7,500 operations per
year. It covers neonates, paediatrics, plastics,
thoracics, orthopaedics and trauma, vascular,
ENT, dental and general surgery. Lower
Umfolozi Women’s Hospital has 255 beds,
three operating theatres and three ICU beds
and delivers over 10,000 babies per year.
Initially, I worked as a principal medical officer
but I temporarily assumed responsibility for
running the anaesthetic department when the
chief specialist relinquished his post following
‘burn out’.
The workload was initially
overwhelming. I took on both clinical and non
clinical duties and was on call as a consultant
for both hospitals on a one in three rota, and
oversaw teaching and supervision for the
anaesthetic department. My log book exceeded
1,500 cases but didn’t include all the additional
duties of running the department, fixing kit,
organising rotas, morbidity and mortality
reviews and risk management. The staffing
level in the department was at a critically low
level and the subsequent pressurised working
environment led to several resignations.
Essential kit was often out of stock and despite
frequent negotiations and meetings with
management, little progress was made which
was extremely frustrating.
Clinical work was always exciting.
A
memorable emergency list looked something
like this: thoracotomy for gun shot followed
by laparotomy for gun shot, laparotomy for
stab wound, fasciotomies for snake bite,
debridement and suturing for shark attack,
debridement of burns in a three month old
baby, removal of coin from the oesophagus of
a one year old and tendon repairs following a
panga chop assault.
causing great excitement on each occasion. A
power failure drill is not normally taught in the
UK but requires a self inflating bag, oxygen
cylinder, propofol boluses and alternative light
sources provided by laryngoscopes and mobile
phones.
Power failure drill
Working hazards
Medical staff must also be aware of the great
prevalence of HIV, hepatitis, tuberculosis and
sickle cell anaemia. Gloves and eye wear are
essential due to the risk of needle-stick and
splash injuries and it is important to know the
availability and immediate location of antiretroviral treatment. I nearly always wore an
N95 mask, visor and gloves. I had personal
health, possessions and travel insurance
with repatriation cover, as well as medical
indemnity insurance. Always remember travel
vaccinations and anti malarial prophylaxis.
Anaesthetising patients in the developing world
is extremely rewarding but poses risks to both
the patient and anaesthetist. The anaesthetist
must be aware of the source of the oxygen
reserves and supply as oxygen supply failure
is a real risk. Electricity supply in developing
countries is not consistent and power cuts are
commonplace. Generator failure is also a risk
and indeed occurred on both trips to Africa,
Overall the experience was amazing and
I gained far more than I gave. Although
the work was demanding, the lifestyle and
opportunities for travel definitely made up for
it. Kwazulu Natal is the perfect location for
scenic training. The Drakensberg mountains,
historic battlefields, unspoilt beaches, world
renowned safari and scuba diving are all within
the surrounding area.
55
Our jobs and visas were organized through
‘African Health Placements’, an organisation
set up to recruit healthcare workers to work for
the South African Government in rural Africa.
(www.ahp.org.za)
my awareness of global health inequalities and
equipped me with the clinical and non technical
skills necessary for prospective consultant
posts. Large doses of patience, perseverance,
a sense of humour, adventure and a smile were
all essential. Both trips to Africa have been
life changing experiences. I have witnessed
the needs of the poor and worked with people
whose lives have been devoted to serving
them. My passion is to pursue further trips
overseas in the future and to encourage others
to get involved.
An elephant drinks 120 litres of water a day
Overseas work is not possible for everyone.
I have been fortunate that the deanery,
programme director, family circumstances,
finances and personal health have allowed
me the opportunity to pursue my interest in
overseas anaesthesia. The trips have broadened
56
An adult rhino eats for 16 hours a day
Anaesthesia Points West Vol 44 No.1
Personal View
Anaesthesia in Taunton 1959/60 - a Different World!
Dr John Powell, Retired Consultant Anaesthetist
Southmead Hospital, Bristol (formerly SHO in Musgrove Park Hospital, Taunton)
The consultants, Drs Griffin, Gavin, Pitts,
and Nicholson-Lailey, taught me anaesthesia
for elective surgery, but were rarely involved
with emergency work unless it was for social
reasons, such as a colleague’s wife, or if a
patient seemed about to die on the table. It was
the registrar, Arthur Slim, who taught me about
emergencies.
Fig 1: Musgrove Park Hospital, Taunton, in the
mid-60s
‘We are quite up-to-date here,’ said Dr Gavin,
the consultant who welcomed me, his new
senior house officer (SHO), to Musgrove
Park Hospital, Taunton in September 1959,
‘we use Fluothane.’ I was suitably impressed
because although I had heard that Fluothane
(halothane) was now used quite commonly
in many hospitals throughout the country, it
was, after all, a very expensive drug. Later
he showed me the vaporizer they used. It was
a standard glass Trilene (trichloroethylene)
vaporizer with extra markings on the scale by
the lever. ‘The numbers are quite arbitrary,’
he explained, ‘but you get to know how far
to move the lever after a bit of practice. It is
difficult to tell exactly what concentration you
are giving, particularly as Fluothane gets very
cold as it evaporates, though it is easy to decide
whether you are giving too little or too much
by just watching the patient.’
The anaesthetic department at Taunton
consisted of 4 consultants, 1 registrar and 1
SHO. There were also two clinical assistants,
GPs in Minehead and Bridgwater, who
occasionally did sessions on call at Taunton.
Theatre
The main theatre (general surgery, urology and
gynaecology) had two tables in it often with two
different surgical teams working side-by-side.
There was no delay between cases because
the next patient was anaesthetised before
the previous operation was completed. The
speed of surgery was remarkable - the senior
surgeon completing two cholecystectomies
and a prostatectomy inside an hour. There was
also a theatre for ENT surgery, and another in
the maternity department. Orthopaedic and
eye surgery were done at East Reach Hospital
across the town; the casualty department was
there too.
Anaesthetists did not routinely visit their
patients preoperatively. In the theatre changing
room they took off their jackets and ties, and
put on a gown over their shirt and trousers.
Endotracheal tubes, made of red rubber, were
cut to 8 inches for women and and 83/4 inches
for men, though there were always shorter and
longer tubes to hand if needed. Nasopharyngeal
airways were particularly useful during
inhalational inductions being tolerated at lighter
levels of anaesthesia than oral airways. There
was no disposable equipment and no CSSD;
glass syringes and airway tubes were cleaned
57
Fig 3: Recovery
Fig 2: Theatre attire
and sterilised after use, as were intravenous
needles and the rubber tubing used for
intravenous infusions given from glass bottles.
If this tubing was perished there was danger
of unnoticed air embolism. There was no
automatic provision of suction in the anaesthetic
room, though it could be arranged if necessary.
At the end of the operation new tubing for the
anaesthetist was put onto the electric suction
machine the surgeon had been using. There was
no scavenging of expired gases and vapours, no
mechanical ventilators, and no recovery ward,
though patients were usually kept in the corridor
outside the theatre for a few minutes, looked
after by the nurse from the ward.
There was no crash team, no intensive care
ward and closed chest cardiac massage had not
yet been described.
Monitoring
This was largely by clinical observation. We
always looked carefully at the colour of the
blood from the first incision, often commenting
out loud about it. We judged whether breathing
58
was free and unobstructed; whether there was
a jaw jerk or tracheal tug, and we listened
continuously to the expiratory valve, which
had been deliberately tightened to produce an
audible whistle, coincidentally producing some
unintentional but perhaps beneficial positive
end expiratory pressure (PEEP). Was the
patient was warm, dry and pink? I used to score
each of these 0-2, so that 6 points meant all
was well. Was there rapid capillary refill after
pressure? Were the peripheral veins full? Blood
pressure (BP) was measured with a stethoscope
diaphragm placed over the brachial artery under
the cuff and we sometimes sniffed the gas/vapour
mixture coming from the machine to check the
concentration of the volatile anaesthetic.
Electrocardiogram (ECG) leads were only
attached to patients likely to die on the table and
although we counted the pulse and respiratory
rates these were not recorded, nor was the BP.
Premedication
Adult inpatients were usually given ‘Om &
Scop’, i.e. Omnopon gr1/3 and Scopolamine
gr1/150 (papaveretum 20mg and hyoscine
0.4mg), which came in a single ampoule so
prescribing smaller doses could be
arithmetically challenging. Children were
given Nembutal gr0.6/stone (pentobarbitone
6mg/kg), or sometimes rectal Pentothal
Fig 4: Just checking!
(thiopentone) 20mg/lb. As barbiturates have
no analgesic properties, children were often
restless post-operatively unless an opiate was
given intramuscularly towards the end of the
operation.
Anaesthesia
Minor or superficial cases: the commonest
anaesthetic technique entered in the operations
register for 1960 was ‘Pent GOT’, i.e.
Pentothal 300-600mg and N2O/O2/Trilene via
a McGill attachment. Often a “softening up”
(subapnoeic) dose of 40-60mg of the muscle
relaxant Flaxedil (gallamine) was added.
Flaxedil is fairly short-acting (20-30 minutes)
and has some atropine-like actions, which was
useful as Trilene often caused bradycardia;
any tachypnoea was controlled by pethidine.
Halothane was used instead of Trilene for big
muscular patients, or when its bronchodilator
action might be useful. It was certainly a
smoother, quicker and easier anaesthetic to
give.
Major surgery: patients were intubated using
Scoline (suxamethonium), mostly followed
by nitrous oxide/oxygen, opiates, Tubarine
(d-tubocurarine) and manual IPPR by
squeezing the reservoir bag. Tubarine was
longer acting than Flaxedil (30 to 40 minutes)
and had some gangling-blocking properties.
Its action was prolonged by acidosis.
Gynaecological surgery: for minor surgery the
anaesthetic was as above, but for major surgery
Mrs Lailey liked to add some cyclopropane to
the nitrous oxide and oxygen. That way she
could give more oxygen but still know that
the patient would remain asleep. Many of
the patients for hysterectomy were markedly
hypertensive; the policy was to proceed
with the surgery and then refer them back to
their GP for treatment. Patients for elective
surgery, of any variety, who were already on
antihypertensive drugs, had these stopped two
weeks before surgery. Those of us who did the
emergency work, where there was obviously
not time to do this, soon realised that it was
quite unnecessary anyway.
ENT surgery: tonsillectomy in children - ethyl
chloride induction followed by open ether
(figs.5,6) until deep enough to move into
theatre, insert a Boyle-Davis gag and connect
gas/oxygen/ether from the anaesthetic machine
to the tube on the tongue plate. Teenagers and
adults were usually intubated.
Fig 5: trolley prepared for giving open ether
One day after my first eight weeks I had a
critical incident: a 16-year-old boy went into
severe laryngeal spasm after extubation.
Instead of using the high flow lever for oxygen,
I mistakenly used the one for nitrous oxide.
59
Luckily the surgeon noticed that the bobbin
was at the top of the nitrous oxide flowmeter
and disaster was narrowly avoided.
Emergency cases
These were of course extremely varied,
but some seemed particularly common.
Laparotomy for perforated duodenal ulcer took
15 minutes and involved peritoneal washout,
closing the perforation with a purse-string
suture and oversewing it with some omentum.
The patient reached theatre if possible within
30 minutes of admission, having already had
a nasogastric tube inserted by the general
practitioner.
Fig 6: schimmelbusch mask in use
We also did many incisions of abscesses,
especially paronychia and ischiorectal abcesses.
Appendicectomy was particularly common
as it was believed that if at least a quarter of
cases were not lilywhite then the surgeon was
sailing too close to the wind. Prostatectomy
was ideally done for all cases of acute
retention within 12 hours. Relief of intestinal
obstruction, was occasionally complicated
by the phenomenon of ‘neostigmine resistant
curarisation’, as the role of metabolic acidosis
mentioned above, had yet to be described in
this context. Reduction of fractures, especially
of the wrist and ankle, and other trauma were
not unusual. On one memorable occasion we
60
packed ice round the thigh of an old lady to
produce anaesthesia for leg amputation in the
manner of Dominique Jean Larrey, Napoleon’s
surgeon on the retreat from Moscow.
Obstetric anaesthesia
I gave my first anaesthetic for Caesarean section
on my 10th day at Taunton. The obstetricians
wanted to perform a semi-elective EUA one
afternoon and I was sent across to do it as no
one else was available. The patient was not in
labour and had been starved all day. I started
with a simple ‘Pent GOT’ technique, only to be
told after a few minutes that the placenta was
indeed very praevia and they needed to proceed
to caesarean section at once. As the patient
was already asleep, I injected some Scoline,
remembering the advice that Dr Hopkinson
had given me a few days earlier: “...watch
closely and as soon as the lips start to twitch
you put the blade of the laryngoscope into the
mouth and quickly lift the larynx up towards
the ceiling so that if any fluid came up from the
stomach you have got the opening of the larynx
above the level of the fluid; you have to get
the tube down the trachea and the cuff blown
up before you run out of space into which the
larynx can be lifted; it is no good worrying too
much about the teeth - it is more important to
get the tube down than anything else.” There
was no mention of pre-oxygenation nor of
cricoid pressure. Luckily all went well. I
maintained anaesthesia with nitrous oxide 75%
and for muscle relaxation used intermittent
injections of suxamethonium 25mg. In due
course a healthy child was delivered.
On one occasion I watched Dr Jones from
Minehead use nitrous oxide/oxygen/ether for
caesarean section. He added sufficient carbon
dioxide to the gas mixture to make the patient
hyperventilate markedly. He explained it was
physically impossible to hyperventilate and to
vomit the same time, and that avoiding both
Pentothal and Scoline prevented the gastooesophageal sphincter from relaxing.
Nearly all forceps deliveries were done under
general anaesthesia. I did not count how
many of these I gave during my 13 months in
Taunton, but I did anaesthetise 84 ladies for
caesarean section. Overall numbers for 1960
are not available, but in 1961 there were 1065
deliveries, of which are 131 were delivered by
caesarean section (12%).
On call
From the very start I shadowed Arthur while
he tackled the emergency cases, though he
was often kind enough not to wake me in the
middle of the night. As I was a happily married
man and there were no married quarters in
the residents’ mess I had negotiated before
accepting the post that I could be on call from
a flat 11/2 miles from the hospital. By the end
of my third week I was doing some emergency
cases on my own, and by the end of the month
I was taking my full share of the work, though
still constantly asking advice from Arthur. We
were 1st and 2nd on call on alternate days, had
a half-day off most weeks, and were completely
off-duty from Saturday lunchtime to Monday
morning each third weekend. In mid-January
Arthur went away on a course for two months.
I now found myself continuously 1st on call,
both night and day, except for the day and a half
every third weekend. I was still often asked to
start and finish routine operating lists so that
a consultant could go to the private nursing
home and it was largely due to this experience
that I never did private practice at any stage
of my career. Five weeks later I arrived home
one morning at 6am and was so exhausted that
I burst into tears, explaining to Isabel that I had
to be back at the hospital by 9am to start a list
for a consultant who was going to be late. She
gave me some coffee, which tasted very bitter
despite a lot of sugar. This was not surprising
as she had opened two capsules of Nembutal
and tipped the powder into the mug. She then
put me to bed and phoned the consultant, told
him what she had done, and said that she was
not going to let me come back till I had had a
proper rest. When I went back two days later I
was told that things would be much better now
as I was going to have from 2pm to 10pm off
duty every Friday, though of course I would
have to come back to cover the night-time. It
was a great relief when Arthur came back.
Promotion
At the beginning of August 1960, now with
11 months anaesthetic experience, and two
months before I was conscripted to serve her
Majesty the Queen, I became locum registrar.
This meant I could be deployed throughout
the South Somerset Clinical Area and would
sometimes go to Bridgwater or Yeovil hospitals
to do lists. Bridgwater was a delight, but
Yeovil was a nightmare. After one in-patient
dental list, with several impacted wisdom teeth
in the bucket, I went to check on the patients
before I left, and found them at the end of a
long corridor with two closed doors between
them and the nearest nurse.
In conclusion
My time in Taunton was exciting, exhilarating
and exhausting. I used to sit down to my
Sunday lunch feeling that I had been really
useful to the world. I would not have missed it
for anything!
PS for an extended, more personal and
illustrated account of this year, visit www.
johnpowell.net and follow the link to ‘The
Taunton year’.
Acknowledgements :
Figure 1 reproduced with permission from the
61
Somerset Heritage Centre from their document,
ref no. A\CXU/1.
Figures 2 and 3 reproduced from a book
published in 1978 by the League of Friends in
Taunton, with permission from Mrs McHugh,
62
current Chair of that organisation.
Figures 4,5 and 6 reproduced with permission
from The Curator of Moving Image and Sound
at the Wellcome Library, Wellcome Trust.
Poem
Don’t Tell Me…
The cat needs feeding.
She’s too fat anyway,
keeps stealing my pens
and sits on what I’m writing.
Don’t tell me
I’m getting old.
I’m perfectly happy
being thirty five.
The grass needs cutting.
I prefer it natural
Always will be.
Don’t tell me
what needs doing
which is not the same as
what I need to do.
My hair needs cutting.
I’m going Bohemian
You want me to remove
a spider from the bath.
He may take offence.
In the next world
he could well be in charge.
That someone somewhere
is blowing a dandelion clock
that marks the end of the world
Robin Forward
63
Anaesthesia Points West Vol 44 No.1
The Wine Column: Corking or Corked
Dr Tom Perris, Consultant Anaesthetist
Gloucestershire Royal Hospital
In true British fashion, when the waiter passes
my table and enquires if “everything is OK?”,
I always mumble “fine thanks” or some other
banality, despite having not yet picked up my
cutlery or, worse still, having endured a meal
of staggering mediocrity. After all, I wouldn’t
want to make a fuss. It just isn’t done. But
this reticence doesn’t seem to extend to my
wine consumption. Is it simply because, if
I’m forced to pay the exorbitant mark up most
restaurants charge, then I want it perfect and
I don’t care if I offend the waiter? Or is it
that the waiter didn’t actually cook the food
himself so I feel churlish giving him a hard
time whereas the sommelier is fair game?
It can’t be that I care more about the wine
than the food - not from the evidence of my
waistline anyway. But it is the case that I will
not shirk from sending wine back whereas to
ask for a different meal is unthinkable. Maybe
it’s because I get to see the bottle opened but
who knows what the chef will do to my plate
in the secrecy of the kitchen!
It doesn’t happen often that a wine is bad;
somewhere between 2 and 5% are reckoned
to be tainted or “corked” but the aroma is
unmistakable when you do smell it and is the
reason why we endure the “who would like to
taste the wine?” pantomime. It is an unpleasant
mustiness that can be faint, or obvious like
the sensation of delving into a kit bag and
discovering your neglected, unwashed rugby
socks from the previous season, mouldering
within. It’s hard to enjoy your glass when the
wine is corked. This is not the same as finding
bits of cork floating in your glass, which is
simply due to clumsiness with the corkscrew.
So, if when you sniff your wine you discover
64
the telltale damp groundsheet or rotted leaves
aroma, the culprit is a substance named, by
those born romantics, the chemists, 2,4,6,
trichloroanisole or TCA for short. It is
produced by the action of fungi on cork in the
presence of chlorine. The chlorine is from the
manufacturing process after the cork bark is
stripped from the oak trees it comes from. It
is boiled, bleached using chlorine, and cut to
shape. Other sterilising agents have been tried
in an attempt to limit this tendency but chlorine
is still the most popular antimicrobial used.
This begs the question, why do we, in the
21st century, continue to use a substance that
is imperfect? If 5% of our tins of beans were
mouldy when we opened them, there’d be a riot
in Tesco’s. Well, there are several answers….
You can use sterile plastic stoppers but they
also taint the wine to some extent and allow
the sulphur dioxide preservative in most wine
to escape causing premature oxidisation. Only
about 18 months of useful sealant is possible
which is fine for cheap, quickly consumed
supermarket plonk, but not for your good stuff
which should develop slowly over a quarter of
a century or more.
It is possible to produce an absolutely airtight
seal and several have been used to close wine.
The “crown closure” familiar from bottled beer
is superbly effective over long periods, as is the
increasingly popular screw cap. Both have been
shown to effectively keep wine for up to ten
years. The problem here is two fold. No air leak
at all means that the ageing process allowed by
a very tiny and gradual ingress of oxygen past
the cork is retarded and maturation is probably
hindered. I say “probably” because they haven’t
completed the studies yet to say for definite.
The other reason is that the sheer sense of
occasion that accompanies the unwrapping of
the foil, slow spiralling of the corkscrew and
careful extraction of the cork, culminating in
the sweetest of sounds - that sublime squeak as
the bottle is breached, is lost if you can open the
thing with a flick of the wrist. I’m practically
Pavlov’s dog when I hear the pop of a cork;
trembling with anticipation and salivating like
a lunatic, I love the whole process of opening
a bottle. So what if it takes longer? I’m a cork
fan and proud.
Perris’s picks
The 2009 growing season was an absolute
classic all across France so anything from
that year will be a great example of its type.
Particular success was had in Beaujolais
which is unfairly unfashionable and thus not
overpriced. If the sun ever comes out, it is
fabulous on a nice Spring day. Why not give
it a go?
65
Crossword
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2
3
4
5
9
1
6
10
2
3
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Crossword
7
Dr Brian Perriss
6
10
14
7
8
11
15
16
12
17
18
19
13
14
20
21
15
22
16
17
24
23
18
19
25
20
21
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26
27
23
24
Dr Brian Perriss
CLUES ACROSS
11
5
13
Crossword
8
12
9
Dr Brian Perriss
25
CLUES DOWN
1. Helps but not27well. (4)
2. Blackberry taken on first brisk walk. (7)
3. Given to petty pilfering. (5-8)
4. Be secure in alternate therapy. (6)
CLUES
CLUES
DOWN DOWN
5. Precipitation
in wet Autumn. (8)
7. On this side a three wins with a flush. (7)
8. That
is
panniers
useful
1. Helps
Helps
but
not
well.
(4) for city dweller. (10)
1.
but
not
well.
(4)
11. Concern
shown
when
conditions
are
2.
taken
on on
firstfirst
brisk
walk.
(7) bad.
2. Blackberry
Blackberry
taken
brisk
walk.
(7) (13)
13. The
idea came
nine months
ago. (10)
3.
Given
to
petty
pilfering.
(5-8)
3. Given
to petty
pilfering.
(5-8)(8)
16.secure
Keep
getting
in a jam.
4.
infrom
alternate
therapy.
(6)
4. Be
Be
in
alternate
18. secure
Pant when
it has to betherapy.
slack. (7)(6)
5. Precipitation in wet Autumn. (8)
20.
Grow
old
slower
but
for
ever.
(7)
5. On
Precipitation
in wet
Autumn.
(8)
7.
this side a three
wins
with a flush.
(7)
21.
Dupe
Victor
and
Timothy.
(6)
7. On this side a three wins with a flush. (7)
26
CLUESResuscitation
ACROSS bag French politician keeps on the move. (10)
1.
6.
Fish found in small receptacle. (4)
CLUES ACROSS
9.
Beer favouredbag
by medic
with
anything. (7)
1. Resuscitation
French
politician
10.
Tooth
could
be
an
icon,
Sir.
(7)
keeps on the move. (10)
12.
Drop catch despite spreading digits. (13)
6. Fish
found in small
receptacle.
(4)keeps to
1.14.
Resuscitation
bag French
politician
onanthe
move.
Hydrocarbon
brought
Spanish
exclamation
end.
(6) (10)
9. Beer
by medic
anything.
Lostfavoured
head atincaper
but
keptwith
partnership.
(8) (7)
6.15.
Fish
found
small
receptacle.
(4)
Classification
can
bewith
found
on gyrate.co.
9.17.
Beer
favoured
by
anything.
(7) (8)
10. Tooth
could bethat
anmedic
icon,
Sir.
(7)
19.
Concerning
the
Chief.
Stay.
10.
Tooth
coulddespite
be an
icon,
Sir. (6)
(7)digits. (13)
12. Drop
catch
spreading
22.
On stair
carpet
unusually
put off.
(13)(13)
12.
Drop
catch
despite
spreading
digits.
14. Hydrocarbon
brought
Spanish
exclamation
24.
Not a 33-1 shot!
(7) Spanish
14.
Hydrocarbon
brought
exclamation to an end. (6)
toLost
an end.
(6)
25.
Three
pronged
submarine.
15.
head
at caper
but kept(7)
partnership. (8)
26.
Emperor,
wecaper
hear,
close
to partnership.
nothing.
(4) (8) (8)
15. Lost
head at
but
kept
17.
Classification
that is
can
be
found
on gyrate.co.
27.
Preacher
man?
(10)
17. Classification that can be found on gyrate.co. (8)
19.
22.19.
24.22.
25.
26.24.
27.25.
Concerning the Chief. Stay. (6)
On stair carpet
put (6)
off. (13)
Concerning
theunusually
Chief. Stay.
Not
a
33-1
shot!
(7)
On stair carpet unusually put off. (13)
Three pronged submarine. (7)
Not
a 33-1we
shot!
Emperor,
hear,(7)
is close to nothing. (4)
Three
pronged
(7)
Preacher
man? submarine.
(10)
26. Emperor, we hear, is close to nothing. (4)
27. Preacher man? (10)
Solution to Crossword in
Autumn 2010 Anaesthesia Points West
8. That is panniers useful for city dweller. (10)
23. Be
leader when
in useful
alternate
arts.
(4)
8. Concern
That
is apanniers
for
city
dweller.
(10)
11.
shown
conditions
are
bad. (13)
13.
The
idea
came
nine
months
ago.
(10) are bad. (13)
11. Concern shown when conditions
16.
from came
gettingnine
in a months
jam. (8) ago. (10)
13. Keep
The idea
18. Pant when it has to be slack. (7)
16. Grow
Keepold
from
getting
in aever.
jam.(7)(8)
20.
slower
but for
18.
Pant
when
it
has
to
be
slack.
21. Dupe Victor and Timothy. (6) (7)
20. Grow old slower but for ever. (7)
23. Be a leader in alternate arts. (4)
A
S
T
T
T
A
O
21. Dupe Victor and Timothy. (6)
23. Be a leader in alternate arts. (4)
R
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Y
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66
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O to Crossword
R
E
S
E
Solution
in N T E
R
N
M
R
Autumn 2010 Anaesthesia Points EWest
I
A
RO A
L
L
N
OR
R
A
T
N
A
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EN C
T
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AN B E L A Y T
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R
Prizes and Bursaries
Details of all prizes, rules, and entry deadlines can be found at www.saswr.org.uk
The SASWR Intersurgical Trainee Prize
This prize of £1000 is awarded annually at the November Scientific Meeting of the society. Entries of
up to 2000 words maximum in the form of an essay or short paper on any topic related to anaesthesia,
intensive care or pain medicine should be submitted electronically to the Honorary Secretary of the
Society (honsec@saswr.org.uk), by 30th September each year.
The three best entries will be presented orally at the SASWR meeting in November, and the prize
awarded at that meeting. Any entrants who do not make the shortlist will be invited to enter the
poster prize at the meeting. Please note that you must be registered for the meeting in order to present
your work, and you may not enter both this and the poster prize.
SASWR Poster Prize
The Spring and Autumn scientific meetings will have a poster prize of £250 awarded to the best
poster presentation. To enter, submit your work as an abstract or poster to the Honorary Secretary
(honsec@saswr.org.uk) by 30th September each year for the Autumn meeting and 31st March for the
Spring meeting. You will need to be registered for the meeting and be able to present your poster to
the judges during coffee.
The Ross Davis Adventure Bursary
Annual awards totalling £1000 in memory of Dr Ross Davis, are presented by his family and friends,
to trainees of ST3 or above from the Wessex, Peninsula or Bristol deaneries to support ‘exciting
endeavours in anaesthesia’. Further information can be found at www.rosswindsurf.co.uk and
applications should be directed to the Honorary Secretary of SASWR (honsec@saswr.org.uk) by
1st May each year. The successful applicant will be invited to accept their award at the following
November meeting of the society, although the award may be released before then!
The Feneley Travelling Fellowship
This cash bursary is awarded to any member of the society to support a ‘mission abroad’. Applications,
to the Honorary Secretary of SASWR (honsec@saswr.org.uk), are welcomed throughout the year.
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Notice to Contributors
All articles should be sent by e mail to the editor (see below for address). Scientific articles should be
prepared in accordance with uniform requirements for manuscripts submitted to biomedical journals
(British Medical Journal 1994; 308: 39-42) i.e. as used by Anaesthesia. Please ensure that references
are complete and correctly punctuated in the required style. The approved abbreviations will be used
for journal titles. Photographs should be sent as separate attachments.
The deadline for submissions is usually 10 weeks before the next meeting of the society.
Submission of articles to Anaesthesia Points West implies transfer of copyright to the Society of
Anaesthetists of the South Western Region. If an article has been previously published elsewhere,
permission to use the material should be sought from the editors of that journal before submission to
Anaesthesia Points West. Submissions will be acknowledged on receipt and notice of acceptance/
rejection/need for corrections will be sent as promptly as possible.
Editor
Dr Fiona Donald
Department of Anaesthesia
Southmead Hospital
North Bristol NHS Trust
Southmead Road
Bristol BS10 5NB
0117 3235114
fiona.donald@nbt.nhs.uk
donald_fiona@hotmail.com
Assistant Editor
Dr Vanessa Purday
Department of Anaesthesia
Royal Devon and Exeter Hospital (Wonford)
Barrack Road
Exeter
Devon EX2 5DW
01392 402475
Vanessa.purday@rdeft.nhs.uk
vanessahelliwell@doctors.org.uk
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