The anaesthesia workforce: problems, ideas and solutions AAGBI

Transcription

THE NEWSLETTER
OF THE
ASSOCIATION
OF ANAESTHETISTS
OF GREAT BRITAIN
AND IRELAND
Anaesthesia
News
ISSN 0959-2962
No. 302 September 2012
INSIDE THIS ISSUE:
The anaesthesia workforce:
problems, ideas and solutions
AAGBI President’s
Farewell
Anaesthesia NewsSept2012 FINAL.indd 1
31/07/2012 15:22
Editorial Contents
2012 ULTRASOUND TRAINING COURSES
06
2012 Course Dates:
Introductory Ultrasound Guided
Regional Anaesthesia
SonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of
the leading specialists in the medical industry to design a series of courses, for both novice and
experienced users, focusing on point-of-care ultrasound.
19 – 20 November
Introductory Ultrasound Guided Regional Anaesthesia
The two-day introductory course is designed to teach those who have little or no experience in the
use of ultrasound in their normal daily practice. The course comprises of didactic lectures on the physics
of ultrasound, ultrasound anatomy and regional anaesthesia techniques. The lectures and hands-on
sessions will concentrate on the brachial plexus, upper and lower limb blocks.
Ultrasound Guided Venous Access
11 October
8 November
Ultrasound Guided Chronic Pain Management
26 November
Venue: SonoSite Education Centre – Hitchin
Ultrasound Guided Critical Care
courses also available
For the full listing of SonoSite training
and education courses, dates and to
register go to:
Fees: £375 (two-day courses) includes VAT, lunch, refreshments and course materials.
£260 (one-day courses) includes VAT, lunch, refreshments and course materials.
www.sonositeeducation.co.uk
If you have any questions or should need further information please contact:
Dee Banks, SonoSite Ltd, Alexander House, 40 A Wilbury Way, Hitchin Herts, SG4 0AP
Tel: +44 (0) 1462 444800 Fax: +44 (0) 1462 444801 E-mail: education@sonosite.com
© 2012 SonoSite, Inc. All rights reserved. 03/12
2012 ULTRASOUND GUIDED REGIONAL
ANAESTHESIA – BEYOND INTROD UCTORY
These courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided
regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.
Course Dates
Location
Organisers
20 – 21 September
30 November – 1 December
Liverpool
Nottingham (A)
Dr Steve Roberts
Dr Nigel Bedforth
Faculty will vary depending on location
10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members. Cost: £400 / £500 (A) including a CD with presentations
and course notes.
Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus,
current articles of interest and MCQ’s. A pre course questionnaire will be sent 30 days before each course.
Programme
Day 1
Day 2
•
•
•
•
•
•
•
•
•
•
Ultrasound appearance of the nerves
Machine characteristics and set-up
Imaging and needling techniques
Common approaches to the brachial plexus / upper / lower limb
Workshops – using phantoms / models / cadaveric prosections (A)
Consent / training and image storage
Upper / lower limb techniques
Abdominal / thoracic techniques
Cervical plexus / spinal / epidural / pain procedures
Workshops – using phantoms / models / cadaveric prosections (A)
(A) – Anatomy based courses / with cadaveric prosections
08 Workforce Planning: The issues
12 Anaesthetic Staffing
08
– A Vision for 2020
15 Workforce: The Forth Valley Solution
18 GAT 2012: Reflections on the GAT
Men at some
time are
masters of
their fates
In this issue we focus on the anaesthesia workforce. It is
appropriate that JP Van Besouw should state the issues for two
reasons; firstly, he is in an excellent position to describe them since
he chairs the RCoA’s workforce planning group, and secondly,
this is an issue on which it is in everyone’s interests (especially
our patients) for the AAGBI and the RCoA to work together. Nancy
Redfern is my colleague both on council and in the NHS, and
we have worked together in training roles in the past. I respect
and value her views, which I find are often refreshing, and think
she makes some important points about the way forward in her
contribution to the debate. Finally, Dr Henry Robb describes the
solution that his unit in Scotland has found to these issues, which
are affecting us all. Personally, I have been expecting (dare I say
hoping?) to deliver out-of-hours care as a consultant for years –
and am personally convinced that this is the best way forward
for our patients. Nevertheless, there are undoubtedly many other
options to be explored. We (at the AAGBI and the Anaesthesia
News desk) are very keen to hear both members’ and nonmembers’ views and stories about anaesthesia workforce issues
– please do contact us.
An entirely different perspective on medical workforce issues is
given in the article on p33, about an initiative to train midwives
and nurses in the Gambia and Liberia to perform Caesarean
sections and give anaesthetics/critical care. It is valuable to be
reminded that the world is a big place.
Annual Scientific Meeting
20 Aiming higher at GAT:
Success of mentoring sessions!
25 Anaesthetics in the
12
Fast Lane - As an F1 Doctor
26 RMBF: Caring for the Medical Profession
28 Marathon Medicine
30 AAGBI Undergraduate Elective Shakespeare, Julius Caesar
Act 1 Scene 2
www.sonositeeducation.co.uk
16
Funding: Out with the old and in
with the new?
33 Critical care for newborn infants in
a new project in Africa
34 Particles
35 Victor and the Last Gasp
36 Your Letters
25
38 Anaesthesia Digested
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: anaenews@aagbi.org
Website: www.aagbi.org
Anaesthesia News
Editor: Val Bythell
Assistant Editors: Kate O’Connor (GAT), Nancy Redfern and Felicity Plaat
Address for all correspondence, advertising or submissions:
Email: anaenews@aagbi.org
Website: www.aagbi.org/publications/anaesthesia-news
Design: Christopher Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Email: chris@aagbi.org
Printing: Portland Print
Copyright 2012 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
Advertisements are accepted in good faith. Readers are reminded that Anaesthesia
News cannot be held responsible in any way for the quality or correctness of
products or services offered in advertisements.
© 2012 SonoSite, Inc. All rights reserved. 03/12
Anaesthesia News September 2012 • Issue 302
Anaesthesia NewsSept2012 FINAL.indd 2-3
16 GAT 2012: What a great meeting
For further information and to register logon to
1384_AN March 2012 Half Page Ads Split v3.indd 1
05 Anaesthesia Editorial Board
06 President’s Report
Ultrasound Guided Venous Access
This one-day course is aimed at physicians and nurses involved with line placement and comprises
didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in
ultrasound guided puncture and demonstration of ultrasound guided central venous access.
The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also
be discussed.
Ultrasound Guided Chronic Pain Management
The course is aimed at chronic pain specialists, or other interested parties practising in chronic pain
medicine who have little or no experience of musculoskeletal ultrasound and who wish to obtain an
introduction to ultrasound in chronic pain medicine skills.
03 Editorial
3
25/01/2012 15:22
31/07/2012 15:22
Editorial continued
Anaesthesia
Editorial Board
Desperately seeking Victor
I doubt that we have truly heard the last of Victor, but I for one will
Nicola Heard
miss him whilst he is resting. At risk of his considerable
wrath, IEvents Manager
Educational
have edited out many expletives, references to my own and
others’
Direct Line: +44 (0) 20 7631 8805
‘estimable organs’ and so on over the last three years, but little else I
have read has left me crying with laughter. I echo his parting21thoughts
Portland Place, London
W1B
1PY
The
Association
of Anaesthetists of Great Britain and Ireland (AAGBI)
+44 (0)and
20 7631 1650 invites applications for the SAS Research Prize. This is exclusively for
- if we stop laughing at the truly ridiculous aspects of ourT: lives
F: +44 (0) 20 7631 4352 SAS doctors to encourage them to undertake research. Entries will
start dumbly toeing the line we are sunk. If anyone is moved
to fill
E: nicolaheard@aagbi.orgbe judged by the Research and Grants Committee of the AAGBI. All
this void in our lives, please do contact us.
SAS doctors who are members of the AAGBI are eligible to apply for
SAS Research Prize 2013
w: www.aagbi.org
At our annual conference in Bournemouth later this month we will
bid farewell to one president (Iain Wilson) and welcome another
(Will Harrop-Griffiths). Iain has been a tireless advocate for
anaesthesia in general and the AAGBI in particular. Amongst his
many achievements, I would single out the Lifebox project, which he
has driven forward, and (less visible but very important) his oversight
of structural reorganisation within the Association. He leaves an
Association which is well placed to represent us in these turbulent
times, and I am sure he could have no better successor than Will.
Val Bythell
LATEST
REPORT
Research projects should have been approved by the local ethics
committee and Trust. If the project is a joint one, the names of other
contributors should be mentioned including the principal investigator.
Applicants should submit a summary of their research of no more
than 1000 words, 3 figures and 3 tables. It should be presented in
the style of the journal Anaesthesia. The winning entrant will receive a
cash prize of £100 and will have an opportunity to present their work
at a national scientific meeting held by AAGBI. Other entrants may
be asked to display a poster at the same meeting (as judged by the
Research and Grants Committee of the AAGBI). Please note that work
must not have been previously published, either as an abstract or as a
full paper in a journal or website or presented at another meeting.
Dr Steve Yentis,
Editor-in-Chief, Anaesthesia
A submission form is available on the website
www.aagbi.org/research/awards/sas-grade-anaesthetists
The AAGBI is now connecting with members through
online social networks Facebook and Twitter.
@AAGBI
ANAESTHESIA NEWS
the prize.
Please email entries along with the completed submission form to
secretariat@aagbi.org
The Editorial Board oversees the production of the
AAGBI’s journal Anaesthesia, supports and advises
the Editor-in-Chief, acts as a liaison between
AAGBI Council, the publishers and the journal, and
recommends the appointment of Editors and Editorin-Chief to Council. It meets twice a year, usually in
May and November, and reports directly to Council.
If you have any additional enquiries, please email
secretariat@aagbi.org or contact 020 7631 8812.
Closing date: Monday 07 January 2013
AAGBI1
Anaesthesia News now reaches
over 10,500 anaesthetists
every month and is a great way
of advertising your course,
meeting, seminar or product.
What were your three biggest
achievements from last year?
ents Manager
Abstracts for presentation
at WSM London 2013
+44 (0) 20 7631 8805
•
Anaesthesia News
is the official newsletter
ortland Place, London W1B 1PY
of the Association of
You are invited to submit an abstract for poster
Anaesthetists of Great
Britain & Ireland.
presentation at WSM London 2013. The deadline for
nicolaheard@aagbi.org
•
submission is midnight on Monday 17th September 2012
and full instructions, including a template abstract and
submission form, can be found on our WSM microsite:
www.wsmlondon.org and on the AAGBI website:
www.aagbi.org/education/events
Call
now for
a media
pack
What current challenges are you facing
After the deadline, a preliminary review of the abstracts received
will determine which ones are accepted for poster presentation.
For further information on advertising
Tel: 020 7631 8803
All accepted abstracts will be published in Anaesthesia in the form
of a fully referenceable online supplement. In addition, the best
ones, selected by a judging panel at the meeting, will be printed in
the hard copy version of the journal. (NB Editor-in-Chief reserves
the right to refuse publication, e.g. where there are major concerns
over ethics and/or content).
on www.draeger.com/myperseus
What are your priorities for the coming year?
More of the same, only more so
Deadline for submissions: 17 September 2012
www.aagbi.org/publications
Dr Les Gemmell
Immediate Past Honorary Secretary
21 Portland Place, London W1B 1PY
T: +44 (0)20 7631 1650
F: +44 (0)20 7631 4352
E: les.gemmell@gmail.com
W: www.aagbi.org
An increasing number of submissions and other journalrelated work for the Editorial Team, whilst having limited time
available and increasing pressure from trusts to devote time to
clinical, rather than supporting/academic, work. Plus the fact
that our readers (and potential investigators) are facing everincreasing barriers to conducting research through limited
time/resources and funding in general in the UK and Ireland
Authors of the best poster(s) will be awarded ‘Editors’ Prizes’.
If you have any queries, please contact the AAGBI Secretariat on
020 7631 8812 or secretariat@aagbi.org
or email Chris Steer:
chris@aagbi.org
•
Exceeding 100,000 downloads per month from the
Journal website
Changing to a new, fresher look whilst keeping the familiar
overall appearance of the ‘white journal’
Joining with other anaesthetic journals to identify and deal
with high-profile cases of research misconduct (for details
of which, see our website www.anaesthesia-journal.org
5
31/07/2012 15:22
PRESIDENT'S
REPORT
Firstly I would like to let members know of the death of Cyril
Dr Cyril F Scurr CBE, a Past President of the AAGBI 1976-8
and Dean of the Faculty of Anaesthetists of the Royal College
of Surgeons of England 1970-3. Countless anaesthetists
will remember the amazing Scurr and Feldman “Scientific
Foundations of Anaesthesia”.
I am hoping to meet many readers of Anaesthesia News at the
Annual Congress in Bournemouth this year. Our last conference
there was in 2002 when Ian Johnston, William Harrop-Griffiths and
I were elected to Council. It is an unusual coincidence that 10
years later I shall hand over the Presidency of the AAGBI to WHG
in the same place.
I have really enjoyed my 10 busy years working as a Council
member of the AAGBI. Countless meetings, documents and
articles to read and write, lectures to prepare and people to meet.
In later years taking responsibility for the finances of the AAGBI as
Treasurer and then for the whole organization as President. Hard
work, but never dull! Travelling has always been the hardest part,
but my journey has always been easier than many colleagues
coming from further away around the country. Of course broad
geographical representation has always been one of our aims.
Being elected as President was never anticipated, but proved an
amazing opportunity to work with a talented and diverse set of
Council members and 24 staff. Like any other leadership role,
I have been highly dependent on the expertise of others and I
have been fortunate to have been strongly supported throughout
by Andrew Hartle as Honorary Secretary, Ian Johnston and Paul
Clyburn as Honorary Treasurers and Ellen O’Sullivan and Isabeau
Walker as Honorary Membership Secretaries.
NHS. The Nicholson Challenge is to attempt to make £20b
efficiency savings in an NHS already rated as one of the most
efficient forms of national health provision. We are beginning
to see some of the impacts of these changes, particularly with
frozen salaries, reduced pension benefits, changes to clinical
excellence awards but most worrying, a reduction in the number
of consultant posts being
appointed. Most of these
Anaesthesia News Editorial discussion.
changes are impacting on
our younger members.
I cannot see that operating
theatres and anaesthetists
will be less busy in the
future, but it is possible
that other forms of health
provision will come in,
particularly if the NHS
becomes less responsive
or less comprehensive. It would be great if there was a clear
leadership involved in all of this, but decisions are all too
often political in nature, rather than for optimising clinical care.
At least we have democracy however.
Val Bythell has developed and produced Anaesthesia News with
our in house team Chris Steer and Nicole Bates. Steve Yentis
has increased the citation index of Anaesthesia with his team of
editors and Sam Shinde has done a great job with our Events.
The staff are a super bunch led by Karin Pappenheim, who took
over from Jo Silver last year. In Exeter my colleagues, including
our CD Alex Grice and secretaries Rachel and Sharon, have been
really supportive with their flexibility, advice and humour.
Seeing the Lifebox charity grow out of the AAGBI Global Oximetry
project was another highlight, as was doubling the numbers at
GAT this year and launching the AAGBI video channel - CPD on
your computer at your convenience! Revalidation here we come!
It will be a pleasure to
hand over the Presidency
to William in Bournemouth,
someone who has worked
enormously hard on behalf
of the profession over
many years. He will have
a lot on his agenda – the
Competition Commission
alone will keep the AAGBI
very busy.
The biggest political event of the last two years has been the Health
and Social Care Act, which along with the recession throughout
Europe is bringing substantial and unpredictable change to the
LAST THOUGHTS?
We are the largest clinical specialty in the NHS and working
together in our departments will keep anaesthesia great as a
career; allowing some of the changes coming along to split us up
will result in personal havoc
for many.
We have worked hard at the AAGBI during the last two years – it
was a particular pleasure to award Pask Certificates of Honour to
the Military Anaesthetists on behalf of the AAGBI in recognition of
their service in Afghanistan. Most of us know a number of those
involved and I greatly admire their courage, selflessness and
commitment to those caught up in conflict.
6
What about me?
I’m off on the bike
and then back to
theatre on Monday!
Dr Iain Wilson,
AAGBI President
7
31/07/2012 15:22
“There are known knowns; there are things we know that we know.
There are known unknowns; that is to say there are things that, we now know we don’t know.
But there are also unknown unknowns – there are things we do not know, we don’t know.”
United States Secretary of Defence, Donald Rumsfeld, 2002.
Donald Rumsfeld’s statement about the evidence for Iraq’s possession
of WMD’s accurately describes the state of NHS workforce planning.
You would think it would be easy to balance supply and demand;
figures should revolve around how many trained doctors we need,
how many are in medical school or in training and the expected
attrition rate from breaks in service, retirement etc. Given the time it
takes to produce a fully trained doctor we should be able to balance
supply and demand at a headline level. What is more challenging is
predicting manpower requirements at a service level, particularly for us
in anaesthesia, critical care and pain medicine.
Manpower planning is ultimately determined by the demands of the
service, mandated by government policies etc. Healthcare provision
is now devolved to individual UK administrations who each set service
delivery policy within their jurisdiction. In England the Health and Social
Care Act (2012) requires wide-ranging reorganisation of healthcare.
The global financial crisis triggered further financial pressures with the
£20 billion Nicholson challenge. Changing population demographics
are anticipated to increase demand on healthcare with new (potentially
expensive) ways of working (e.g. The 7 day acute services project).
Then, potential new treatments have to be considered.
In terms of who does the work there are a number of choices available:
doctors or allied health professionals, trained staff or trainees. Trained,
medically qualified staff consist of consultants, post CCT fellows,
Specialty Doctors, SAS Grades and Trust doctors. The trainee group
encompasses all pre CCT doctors be they in an established NTN post,
core training post or a Trust grade, pre-CCT fellowship. We additionally
have a small number of anaesthetic and critical care practitioners.
Table 1 – The Benefits of Consultant Delivered Care
• Rapid and appropriate decision making
• Improved outcomes
• More efficient use of resources
• GP’s access to the opinion of a fully trained doctor
• Patient expectation of access to appropriate and skilled clinicians
and information
• Benefits for the training of junior doctors.
If we continue with the current numbers of trainees in anaesthesia,
there will be around 6,100 FTE CCT holders in England by 2013, rising
to over 8,000 FTE’s by 2020. These figures are roughly in line with Royal
College of Anaesthetists’ 2010 census data, which recorded 6,849
(5,639) UK consultants and 1,843 (1,608) career grade doctors (figures
for England in brackets). Based upon population demographics and
current patterns of service delivery the DH (E) estimates that around
6,000 consultant anaesthetists will be required. This potential over
production of trained doctors looking to progress to consultant status
is not a problem confined to anaesthesia.
The Academy of Medical Royal Colleges 2012 report on the “Benefits
of consultant delivered care” lists the potential advantages of a
consultant delivered service. (Table 1), however a consultant delivered
or present service comes at a significant cost, based upon the terms
and conditions in the 2003 consultant contract.
In 2010 DH (E) commissioned the Centre for Workforce Intelligence
(CfWI) (www.cfwi.org.uk) to inform debate and decision making in
planning the medical workforce. Using DH data, they estimated that
in the next 10 years there would be a rise in consultant numbers in
England - for all specialties - from 35,100 in 2010 to 61,600 by 2020;
with an alarming increase in expenditure on consultant salaries from
£3.48 billion to £5.75 billion by 2020, without allowance for inflation etc.
Their first 2010 report identified geographical differences in numbers
of trainees in different specialties and highlighted the high number of
trainees within metropolitan areas (particularly London) compared
to other parts of the country. The report recommended short-term
changes in specialty training numbers. The second report, looking
towards 2020 again recommends only a moderate reduction in
numbers of anaesthetic trainees, with an expansion in posts for training
in critical care. It acknowledged that a drastic and sudden reduction
in trainee numbers would destabilise service delivery. A series of in
depth analyses of how services are delivered in a variety of settings
(so-called ‘deep dives’) were planned, but did not come to fruition.
In terms of our “Rumsfeldian” analysis what are the known knowns?
Data from the Department of Health in England DH(E), shows a
25% increase in the number of full time equivalent (FTE) consultant
anaesthetists since 2005.
The latest report from CfWI published in February 2012, presents
a series of scenarios about the future shape of the “consultant
workforce”, for consideration and discussion (Table 2). Some of these
can be dismissed as unworkable (e.g. consultant retirement age
A series of high profile reports over recent years, from a variety of
organisations, highlighted deficiencies in patient care provided by
under-supervised trainee doctors and emphasised the need for care to
be delivered by trained medical staff. Patients themselves now expect
to be cared for by trained professionals.
8
fixed at 60, not now possible given the current forced NHS pensions
scheme changes) and/or are likely to be unenforceable under
employment law. Scenarios 4-7 will, however, merit consideration.
The RCoA has established a workforce planning strategy group with
UK wide representation from the specialty, the AAGBI and trainees,
coupled with input from the GMC, DH and CfWI. The aims of the
group are to ensure that the specialty has the most up-to-date and
accurate statistics on the anaesthesia workforce across the UK, and
to work closely and advise the debate with the Centre for Workforce
Intelligence (CfWI) and the 4 DHs on all workforce planning initiatives,
thereby providing a structured workforce planning strategy which
meets the needs of all our stakeholders.
Table 2 – Potential Models for future workforce configuration- proposed by CfWI
Scenario
Overview
Scenario 1
Business as usual
No changes are made to current patterns of recruitment and deployment of trainees
and doctors. Trends continue as at present.
Scenario 2
Shift to General Practice
There is a shift from hospital speciality training posts to General Practice to achieve a
target 50:50 ratio.
Scenario 3
Change in retirement age
Retirement is fixed at 60 years of age.
Scenario 4
Set level of demand
The size of the consultant workforce is set using the Royal Colleges demand criteria.
Scenario 5
Training consolidation period
A consolidation period is introduced during Certificate of Completion of Training (CCT).
Scenario 6
Consultant-present service
Employers move to a service where a consultant is in the vicinity at all times (or able to
return to the hospital within a short timescale) with accountability and responsibility for
patient outcomes.
Scenario 7
Graded career structure
A multi-level career structure is introduced which recognises different levels of
expertise, competence and intensity of work.
9
31/07/2012 15:22
In our response to the latest CfWI report, we (the RCoA’s workforce
planning group) outlined a number of areas of concern requiring
further discussion and debate.
Definitions
Consultant-delivered, consultant-led and consultant-present;
definitions used by the CfWI are inappropriate for the specialty.
Without agreement on definitions it is difficult to consider the scenarios
and options .We will continue to discuss with the CfWI the requirement
to use relevant definitions.
The use of the term ‘trained doctor’ creates concern amongst trainees
as training is currently embarked upon with a tacit understanding that
a resultant CCT will enable doctors ultimately to be appointed to a
consultant post.
Data
Reliable data are scarce, which renders scenario modelling
inaccurate. Specialty worksheets are based on HES and ESR data,
neither of which produce reliable workforce numbers in anaesthetic,
pain medicine and critical care services.
Concerns regarding further work
Further work may be hampered by current uncertainties in the
healthcare environment. The establishment of Health Education
England and its future development will be crucial. We need to inform
current and future trainees about the situation, but it is difficult to
know what to say without scaremongering and making the specialty
potentially unattractive.
Employer’s organisations have also expressed their opinions on
the shape of the medical workforce. A report from NHS Employers
in 2008 set out their vision on medical training and careers; key
recommendations included:
•
•
•
•
•
Multidisciplinary workforce planning with employers fully engaged
A modular approach to postgraduate medical training built around
care pathways
A clear balance between service delivery and creating a supportive
environment for learning
A small planned oversupply in the medical workforce
Development of new non-consultant roles and structures that will
meet the needs of employers and patients with the flexibility to
adapt to local circumstances.
They went on to say
Stakeholder Engagement
The CfWI approaches the strategic objectives of leadership, intelligence
and planning generically and it seems that their primary focus is on
generic workforce issues. Whilst there is benefit in looking at wider
implications we are keen to ensure the highest quality of patient care
through the maintenance of standards in anaesthesia, critical care
and pain medicine and as such are intent on greater specialty specific
engagement with the CfWI and DH agencies involved in the process.
Most scenarios presented are neither appropriate nor workable for
our specialty.
Scenario modelling
Whilst recognising that the scenarios are examples, there is a risk
of them becoming the accepted and the only options for future
workforce planning. We would welcome the opportunity to model
specialty-specific scenarios in detail. This has been our request since
the CfWI announced their intention - now in limbo - to conduct a “deep
dive” into anaesthesia and ICM in 2011. It is vital that further work is
conducted to enable us to propose a realistic and workable strategy
to inform specialty numbers and maintain the confidence of our
Fellows and members in the future planning and delivery of services.
We have significant concerns as to how the proposed consultant
career structure will be devised, considered, communicated, funded
and implemented.
Trainee numbers
This document identified the need to address how services might be
delivered if trainee numbers were reduced. Professor John Temple’s
review and recommendations about the impact of the WTR was
widely welcomed yet there seems to be little enthusiasm to address
the issues or implement the pragmatic recommendations, both
politically and from the medical leadership. We welcome further work
on modelling Temple’s recommendations and support a policy on
their implementation.
10 Anaesthesia NewsSept2012 FINAL.indd 10-11
“Employers are clear that the future role for doctors on the specialist
register... is going to be different to the current role of consultant. They
will continue to make use of consultant roles where this reflects value
for money but the expansion expected in the number of CCT and CESR
holders cannot all be accommodated in the current consultant grade.”
The CfWI also highlighted concerns about shape, cost and
sustainability of the current medical workforce . It recognised the
need for incremental change; it supported the concept of a graded
consultant career, noting that a consultant-present or delivered
service would have a positive impact on patient safety, productivity
and quality. A recently leaked discussion paper from Trusts in the
southwest proposes a renegotiation of staff terms and conditions
of service to meet Nicholson’s austerity savings, introducing a local
market economy.
The Foundation Trust Network in their response to the CfWI reports
posed a number of questions to the evolving Local Education and
Training Boards (LETB’S), which we must also address:
•
•
•
•
•
•
•
•
What is the strategic commissioning intent for a particular service
or bundle of services?
What have local providers’ Boards and/or LETB determined would
be an appropriate response?
What options have been considered and designed by the
professions to meet providers’ service delivery requirements?
What is a consultant in the modern NHS how many are needed
and how much should they cost?
• Is the service consultant-led, consultant-present or consultantdelivered?
Is it a fair expectation for all medical specialist trainees to become
consultants?
What clinical leadership competencies are required of individuals,
teams, organisations, local health economies, networks and
beyond?
How can NHS consultant & career grade contracts be used to
better incentivise, recognise and reward service leadership;
productivity gains; and innovation?
Powered by
So the known knowns are;
1.
2.
3.
4.
5.
We face an over production of doctors in training from medical
students through to CCT.
We face major financial pressure upon publicly funded healthcare,
with ever increasing demands from many directions to reduce
the cost of medically delivered care e.g. the increasing trend in
the USA for nurse anaesthetists to provide anaesthesia without
medical supervision.
Patients have increasing expectations.
There is an urgent need to define the roles and responsibilities
of the consultant.
As a specialty we need to define what part we play as
anaesthetists, critical care and pain medicine consultants in
providing quality and safe patient care. We need to be explicit as
to how those services we provide are best delivered to support
future service developments and to remain as an environment fit
for training and research.
Saving lives through safer surgery
The known unknowns are the direction in which this agenda will
progress and who will carry the most influence in its development; if
one were to believe the mantra of Whitehall then of course it will be
patient led, there will also be financial and other pressures forcing
service reconfiguration which will also affect the supply-demand ratio,
however it is incumbent upon the profession to inform the debate with
robust evidence to support our arguments.
As for the unkown unkowns?
J-P van Besouw,
Vice President – Chair of Workforce Planning Strategy Committee
The Royal College of Anaesthetists.
Bibliography
The Benefits of Consultant Delivered Care – Academy of Medical Royal Colleges.
Jan 2012. Available at: www.aomrc.org.uk/publications/reports-a-guidance.html
Shape of the medical workforce: Starting the debate on the future consultant
workforce - Feb 2012
Employer views on the future consultant workforce: Shape of the medical
ents Manager
workforce – Feb 2012
Shape of the medical workforce: Informing medical training numbers
+44 (0) 20 7631 8805
Intensive Care Medicine: CfWI medical fact sheet and summary sheet – August 2011
Anaesthetics: CfWI medical fact sheet and summary sheet – August 2011
ortland Place, London W1B 1PY
All available at: www.cfwi.org.uk/publications
TRAVEL GRANTS/IRC FUNDING
The shape of the medical workforce
nicolaheard@aagbi.org
FTN response to the CfWI consultation on future NHS consultant numbers.
Available at: www.foundationtrustnetwork.org/influencing-and-policy/workforce/
House of Commons Health Committee - First Report
Education, training and workforce planning
Available at: www.publications.parliament.uk/pa/cm201213/cmselect/
cmhealth/6/602.htm
Medical training and careers - NHS Confederation Briefing 52.
Available at: www.nhsemployers.org/Aboutus/Publications/Pages/
MedicalTrainingAndCareers.aspx
The International Relations Committee
(IRC) offers travel grants to members who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
Please note that grants will not normally be considered for
attendance at congresses or meetings of learned societies.
Exceptionally, they may be granted for extension of travel in
association with such a post or meeting. Applicants should
indicate their level of experience and expected benefits to be
gained from their visits, over and above the educational value
to the applicants themselves.
For further information and an application form
please visit our website:
http://www.aagbi.org/international/irc-fundingtravel-grants
or email secretariat@aagbi.org
or telephone 020 7631 8807
Closing date: 30 September 2012
11 31/07/2012 15:22
Anaesthetic Staffing
– A Vision for 2020
We have a problem in the UK; if we go on recruiting
at the current rate we will apparently be producing
too many anaesthetists1.
Fully trained anaesthetists may
face unemployment; bad for
many reasons. Most obviously,
it is a waste of resource;
doctors are needed in other
disciplines. More subtle,
but perhaps more important
is its impact on the unwritten
contract in medicine. Trainees
work hard for many years to
achieve training milestones and
accept working hours that are
disruptive of social life without
complaint, in exchange for a
consultant job at the end of
training. They are the first to
know which specialties offer
good job prospects and which
are more or less competitive.
Poor consultant job prospects
lead to future recruitment
difficulties, experienced in
Obstetrics and Gynaecology2
and Histopathology.
So what should be done? Under pressure the UK culture is to
regulate. If job prospects are poor, someone in authority needs to
do something about this. There is not enough money in the NHS
and 70% of its budget is spent on salaries, so the obvious action is
to cut recruitment.
What other reactions could we have? Under pressure other cultures
innovate. Innovation happens when staff are empowered and
encouraged. A recent Kings Fund publication3 shows that NHS
organisations that engage and empower staff deliver better patient
experience, fewer errors, lower infection and mortality rates, stronger
financial management, higher staff morale and motivation and less
absenteeism and stress. It suggests that the NHS needs to break
with the command and control approach. Its ‘pace-setter’ style of
setting demanding targets, leading from the front, being reluctant
to delegate and collaborate, will not deliver the health service we
need at the price we can afford. Instead, leadership styles should
be ‘affiliative’ – creating trust and harmony – or ‘coaching’, with
leadership shared and distributed amongst teams.
This does fit with our own experience. We all know from our clinical
work that improvements in services happen when ideas are listened
to and people are given the wherewithal (time, staff, money) to
implement them. Innovation and service developments often start
when hospital doctors and GPs recognise that patient care can
be improved and are given resources to develop new services
in the organisations in which they work. If they are successful,
outcomes are disseminated through publication, presentations and
workshops. It is the enthusiasm of these innovators that engages
professional colleagues, who, in turn introduce changes in their
own working environment.
So how could we apply this to the workforce problem? One example
comes from Ireland. Here, the Minister for Health sat down with
senior trainees, explained how much money there is available and
asked them to design what they would like their future consultant
jobs to look like. Contrast this with the current UK system, which
treats trainees as subordinates passing through the department
and hence not full members of the team. The NHS builds in learned
helplessness at every stage. The Chief Executive can’t restructure
the number of hospitals for fear of the politician; the Clinical Director
can’t restructure the department for fear of the Finance Director. At
the end of this the patient doesn’t get the service he or she needs.
Yet we know that by 2020 the ageing population is likely to need
more frequent healthcare and that the ever increasing breadth
and complexity of our work requires the expertise of fully trained
anaesthetists. If I need a laparotomy in the middle of the night
when I’m over 85 I fully intend to have consultant delivered care.
We know too that the pension changes, revalidation, 24 hour
consultant delivered care all have the potential to encourage
early retirement. The work-life preferences and career intentions
of those currently in training, and the impact of a different
gender balance may also influence future availability of trained
anaesthetists. What seems the safer short term option, cutting
recruitment, could well mean that in the longer term there are
insufficient fully trained anaesthetists.
Workforce planning, recruiting and training the right numbers of
doctors to provide the right level of service 7 - 10 years hence,
is a notoriously difficult business. I remember listening to Derek
Wanless describe his investigation into how other countries plan
their medical workforce. How long in advance do you plan, he
asked? In France he was told ‘C’est difficile’, – perhaps 1 to 2
years, whereas in Sweden, they said ‘Our projections are for 30
years’. Are we right to continue with tight control of numbers
entering training?
Complex adaptive systems
Instead of trying to troubleshoot and fix things - in essence to
break down ambiguity, achieve more certainty and agreement,
complexity science suggests that it may be better to agree what
we are aiming for and let the solutions emerge4. Faced with the
potential for overproduction of anaesthetists, the NHS could set the
direction (e.g. staffing levels that can provide 24 hour consultant
delivered complex acute care), and let each department work
out how this can be achieved in their own setting. Different
solutions would emerge in different organisations, influenced by
the local culture and leadership styles. An example of just such
an approach in Forth Valley Royal Hospital is described by Henry
Robb. Gradually attention would shift towards those things that
seem to be working best.
For those making decisions (mostly in our 50s) it’s our own care
we are designing; trainees recruited now will be the consultants
of 2020, treating us in our 80s! I think we should take a ‘risk’ and
keep recruiting. We will need to explain the reasoning behind this
approach, and engage senior management. Inevitably the nature
of our jobs will change, with more evening and overnight working,
more part time posts, and more team job plans. Generation
X & Y do not have a culture in which ‘long hours are good hours’;
we need to learn from them. Perhaps we need to move away from
our tradition of coping under pressure, of providing a service to the
current patient and not cancelling lists, but instead compromising
teaching, SPA or leave requests. We will need to be more visible
as peri-operative physicians influencing care pathways and tariffs.
Training that gives people the skills to challenge ‘commandcontrol’ style managements and empower colleagues, may be
needed at all levels (consultant, staff grade and trainee), so that
we work together to retain enough trainees to deliver the service
patients rightly demand.
Nancy Redfern
AAGBI Council member
Consultant anaesthetist, Newcastle upon Tyne
References
1.
2.
3.
4.
Shape of the medical workforce: Informing medical training numbers
August 2011 Centre for workforce intelligence
Maggie Blott. Medical workforce in obstetrics and gynaecology.‘Changing
times’. Chairman’s review. RCoG 2003. Accessed at http://www.rcog.org.
uk/files/rcog-corp/uploaded-files/WF03_Chair_review.pdf on 26th April 2012
Leadership and engagement for improvement in the NHS: Together we can
2012 The King’s Fund Leadership Review
Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ
2001; 323(7313): 625–8.
13 31/07/2012 15:22
With the introduction of
Modernising Medical Careers
(MMC) we, in Forth Valley, were
concerned that reducing trainee
numbers and expecting patients
to be treated by trained doctors,
would lead to a staffing crisis.
12th Regional Anaesthesia
course organised by the John Hammond Department
of Anaesthesia, East Surrey Hospital, Redhill
South West Regional
Anaesthesia Course
26th & 27th November 2012
Derriford Hospital, Plymouth
• Popular 2 day course with experienced faculty
• Ultrasound guidance for upper & lower limb,
abdominal and neuroaxial blocks
• Sonoantomy and scanning practice on
live models
• Lectures and workshops
• Needling practice and competency assessment
• Suitable for all grades
Great transport links – only 10 mins. from Gatwick Airport
Cadaveric and RA workshops
plus Live Demos via video link from theatre
Course Director: Dr Fred Sage, Consultant Anaesthetist, East Surrey Hospital
Tue 6 Nov 2012 (OPTIONAL AFTERNOON), St George’s Hospital, London
CADAVERIC ANATOMY WORKSHOPS
Limited places available: three attendees/demonstrator.
 Head & neck  Upper Limb  Abdomen  Back  Lower Limb
Wed 7 Nov 2012, East Surrey Hospital, Redhill
REGIONAL ANAESTHESIA WORKSHOPS
Landmark and US guided techniques. Practise on live models,
simulator and phantoms, various US scanners. Choice of Workshops
for beginners and advanced practitioners. Opportunity to run through
block-related clinical scenarios on a high fidelity simulator mannequin.
Thu 8 Nov 2012, East Surrey Hospital, Redhill
LIVE INTERACTIVE DEMOS FROM THEATRE
Observe and question, live via state-of-the-art HD video link, highly
experienced Consultants performing at least ten nerve blocks in Theatre.
Cost: £250
Register early – strictly limited to 30 participants
For details & online registration visit:
www.sowra.org.uk
Or email: RAcourse@sowra.org.uk
SOBA A��
S�� M��
22�� 23�� O�� 2012
CPD approval being sought from
the Royal College of Anaesthetists
Course Fee:
£540 Days 1+2+3
£390 Days 2+3
For further information and online booking, visit
www.infomedltd.co.uk/rac or call Tel. 020 81230021
The Newcastle upon Tyne Hospitals NHS
Foundation Trust
Newcastle Ultrasound Guided
Regional Anaesthesia Course
29th & 30th November 2012
29th &
30th November 2012
Keynote lectures from international speakers
The Two day Course offers :
2012 NCEPOD report into bariatric surgery
Pro-con debate: Is the MDT essential in bariatric surgery?
Obstructive Sleep Apnoea, mechanisms, diagnosis and
treatment
Heart failure and bariatric surgery
CPEX testing in the morbidly obese
The Truth about asthma in the obese
Non-Invasive Ventilation in morbidly
obese patients
Cadaveric Anatomy of Upper and Lower limbs, Trunk and
Neuraxis
Volunteer ultrasonography
Needling Techniques on Phantoms
Performing ultrasound guided blocks on Fresh Cadavers (NSTC)
lunches & course dinner)
October 2012 (£425
thereafter)
DELEGATE FEE FOR TWO DAYS
DELEGATE FEE FOR ONE DAY
including conference dinner: £225 (Trainees £150)
22nd only - including conference dinner: £150
SOBA Members: £200 (Trainees £125)
Allied Health professionals £50 per day
SOBA Members £125
23rd only - not incl. conference dinner: £100
8 CPD points applied for
SOBA Members £100
dinner: £100
Two parallel discussions ensued. One with colleagues, many of whom
shared the wider anaesthetic community’s concerns that the status
of the specialty would be threatened if distinctions between trainee,
career grade and consultant roles were blurred. The other discussion
was with management. With our anaesthetic colleagues we could
agree that MMC would not go away; staff grades with appropriate
training were not available; recruitment from overseas was undesirable;
and the focus should be on developing a quality service that was
sustainable in the longer term. Consultants seemed the only solution
although concerns about attracting suitable candidates remained.
Management was easier to sway as it became clear that, other than
CCT holders, there was no access to high quality individuals with
appropriate training. They recognised that our proposal offered a longterm solution that would enhance the quality of care, although some
were sceptical that consultants would actually deliver the service we
described. There were challenges in creating job plans that ensured
professional satisfaction and there were concerns the generic Hospital
@ Night team would become “anaesthesia at night”. However, our
two person anaesthetic team already covered the obstetric unit, critical
care services and theatres meaning there was no opportunity for the
proposed enhanced team to lead Hospital @ Night.
When we focused on the specifics of job planning, detailed
understanding of the mathematics and intricacies of the consultant
contract was crucial. With prospective cover and planned time off in
lieu, job plans that offered meaningful supporting professional activity,
departmental engagement and focused elective commitment were
developed: but required the number of resident nights not to exceed 4
in any 6 week period. We included a small amount on non-resident oncall responsibility to make it clear that appointments were to consultant
posts with all that this role entails. These complex issues took almost
three years to work through.
Places limited to 30
Course Fees: £375 (inc.
if paid before 15th
To book your place visit www.aquaconferencemanagement.co.uk/SOBA
There appeared to be two options. Either we
should focus on recruiting staff who had failed to
complete training within MMC, or we should pursue
a high-quality, 24/7, consultant delivered service.
Approved for 3 Points (Part II) by ESRA
European Society of Regional Anaesthesia
T�� L�� R��, S�� C�� C�� C��, T�� TA1 1JT
Topics to include -
At this time we were already struggling to staff
the trainee anaesthetic rota and it was clear that
when MMC was fully established in 2012-13 this
situation would be unmanageable.
Course Organiser:
Dr M K Varma
The course is recognized for ESRA Diploma
CPD points applied for (previously 10 given)
Application
Forms & further information
from:
Mrs. Julie Angus Tel: 01912825481
Email– Julie.Angus@nuth.nhs.uk
Royal Victoria Infirmary
Queen Victoria Road
Newcastle Upon Tyne
NE1 4LP. United Kingdom
In 2010 we advertised 3 posts and appointed from a reassuringly
strong field. An additional 2 colleagues were appointed in 2011
and a further 4 will start in August this year. All interviews have been
competitive. Those appointed have been empowered to develop
and embed this aspect of the service and have allayed any fears for
subsequent applicants. In addition, we have 3 specialty doctors who
also contribute to the out-of-hours service. This allows us to cover our
overnight commitments without reliance on experienced trainees. In
our experience this development has not lead to a two tier department
and our new colleagues were immediately viewed as consultants by
both management and those in other specialties. It may seem obvious
but the benefits of consultant delivered care, now recognised by the
Academy of Royal Colleges (1), cannot be achieved unless a consultant
is present to deliver them. Our service, which we started to develop 5
years ago, offers these benefits. Specifically, we have seen the rapid
escalation of care of patients suffering critical illness; the appropriate
involvement of consultant colleagues from other specialties; improved
use of anaesthetic resources and immediate support for trainees.
This model is also beneficial for training with inexperienced trainees
involved in the care of cases they would not normally be exposed to
out-of-hours such as GA Caesarian Sections. Colleagues on both the
Intensive Care and General Rota have expanded their working day to
help meet the challenges of reduced trainees in the evenings but have
noticed a decrease in their involvement over night.
What of the cost? The most challenging work a consultant faces is
the unpredictability and complexity of unplanned care. It is in this
patient group where mortality is highest – not those undergoing routine
surgery. The cost of this development should be partly met by utilising
non-medical models of care in elective services. Further, weaknesses
in the Hospital @ Night team lie not in the use of advanced nursing
practitioners and other such non-medical roles but the lack of an
effective senior decision maker. We should be looking to expand
resident consultant roles and recruit appropriate staff to support this.
What of the future? We now have 28 Consultants, nine of whom
undertake resident activities. A tenth post will be advertised soon.
There are several outstanding issues to address:1.
2.
3.
As additional Consultants are appointed to the resident rota,
the number of Consultants on the non-resident rotas (ITU and
General-Obstetric) is falling.
What is the career pathway for those currently undertaking
resident work?
What other resident consultant roles should secondary care
services be developing?
The answers to these questions are linked and lie with those working
in and developing this role. This imaginative solution was successfully
introduced before its time despite the reservations of a conservative
establishment. Perhaps we should be more open to other potential
solutions, such as Physician Assistant roles.
Dr Henry Robb
Consultant anaesthetist, Forth Valley Royal Hospital
1.
The Benefits of Consultant deliver Care. Academy of Medical Royal Colleges 2012
15 SOBA MEMBERS £75
8C
31/07/2012 15:22
GAT 2012
What a great meeting!
The GAT ASM in Glasgow was a huge success with over 350 delegates
registered and over 170 people partying at the Dinner at the Arches. This
was a double whammy for GAT as we doubled the number of trainees
attending both events compared to 2011.
Predictably, there was double the trouble; the silver disco balls
proved too tempting for some trainees, and two delightful
GAT committee babies were smuggled into the meeting
(but made less noise than some of the snoring trainees in the
back row!)
GAT 2013 is to be held in Oxford 3-5th April. PLEASE NOTE
THE CHANGE of date. We have avoided all the FRCA exams,
major meetings, booked a central Oxford venue for the meeting
and secured en suite University accommodation so we can all
pretend that we are students again (oh dear!).
230 trainees attended workshops and thirty three people signed
up for the taster mentoring sessions with great feedback all
round. Seventeen prizes were awarded, with a high standard
of presentations and posters particularly from the younger
trainees and medical students.
Finally, well done to
all the trainees who
negotiated complex
train/taxi/coach combos
to get back South, after
3 separate landslides on
the West Coast Mainline
caused huge disruption
to the to rail network!
There was a huge buzz and energy to the meeting. The standard
of the lectures was superb and the feedback impressive.
Thanks to everyone who made it such a huge success. The
GAT ASM is definitely on the calendar of ‘meetings you must
attend in the year’! Next year promises to be bigger and better.
We have lots of interesting and innovative things planned for
you – so watch this space, I’ll keep you updated and if you
have any ideas, you know where to find me!
Roll on Oxford!
Samantha Shinde
Chair of Education
3-5 April 2013
Philips Sparq ultrasound system – new thinking
for Regional Anesthesia and Pain Medicine
Philips new Sparq ultrasound system is unique. Its sealed touch panel design is impressive. A super-intuitive user interface with
Simplicity Mode – our one-touch solution – illuminates only the scanning controls you use most often. Sparq’s advanced automation
makes imaging adjustments for you so you can focus on your patient. And Philips gold-standard image quality is the basis for
exceptional needle visualization and clear views of the target area so you confidently see
anatomy, nerve and needle. All this is packaged in a cart designed for the flexibility you
need in your unique environment. Visualize more at www.philips.com/sparq.
31/07/2012 15:22
GAT 2012
Reflections on the GAT
Annual Scientific Meeting
Having not attended a GAT scientific meeting before, what
a fantastic introduction and what a pleasure it was for us
to play host in Glasgow. A diverse scientific programme
followed by some equally enjoyable social activities
ensured a perfect balance between work and play!
Rather than talk about what a fantastic time I had (which
was undoubtedly the case) I’ve listed a few pearls of
wisdom I have taken from the superb line-up of lectures
and workshops. I’ve referenced the lecture each point
is taken from, but please don’t ascribe scientific validity
to my comments: they are purely my interpretation (or
misinterpretation) of a lecture. I would encourage you to
look online as many of these will have been uploaded to
the AAGBI’s video platform since the meeting.
1. During one-lung anaesthesia the dependent lung must be
treated with the utmost respect as it is a strong determinant
of outcome. Ventilatory practices that are developing an everstronger evidence base in intensive care medicine probably hold
true in this context. Limit tidal volumes and plateau pressure to
4ml/kg and 30cmH2O respectively, use optimal PEEP, don’t strive
for normocapnia and recruit the dependent lung in response to
hypoxaemia. [Bill McColloch).
2. The NMDA receptor is looking like one of the key culprits in
turning simple acute post-operative pain into chronic pain. The use
of ketamine (either epidurally or systemically), although not proven,
is developing an evidence base for preventing this transition and
will certainly feature more in my practice for high-risk cases. I was
reminded that this is probably the main receptor for the analgesic
effect of gabapentin. [Lesley Colvin]
The conference got off to a great start with highly informative talks
from Professor John Kinsella on the complex management issues
surrounding burn injuries, Dr Lindsay Donaldson on the challenges
faced with alcoholic liver disease patients (even if Prof did steal
the introductory joke), how to stay out of court by our legal expert
Dr Willie Frame, and an awakening account of two fatal accident
enquiries by Sheriff Linda Ruxton. Dr Kerry Litchfield offered an
interesting insight into the multidisciplinary management of the
high risk obstetric patient and Dr Sarah Hivey on some of the much
feared topics within paediatric anaesthesia. There was something
to offer everyone with workshops for senior trainees preparing for
Consultant interviews and an exam master class for the more novice
trainee preparing for the dreaded FRCA exams – I feel the pain.
3. Watch out for complex shunts in some paediatric cardiac
conditions. I hadn’t realised that in conditions with a ‘balanced
circulation’ such as hypoplastic left heart, giving 100% oxygen
can lead to cardiovascular collapse and an equilibrium must be
achieved between hypoxaemia and maintenance of systemic blood
flow – I offer a great deal of respect to any anaesthetists routinely
looking after these kinds of patients! [Sarah Hivey]
4. Two medico-legal points of note from Willie Frame’s lecture.
If a patient tells you they don’t want to know about the risks of a
procedure – don’t tell them. I’ve found myself doing this because
I felt it was my obligation. However, the GMC suggest that you
document their wishes not to be informed instead. The 30 minute
cut off for delivery in a category 1 Caesarean section has become
enshrined in law, so it really is worth documenting all the timings in
the notes, such as when you were first called. Maybe the midwives’
obsessive documentation was right all along! [William Frame]
I understand that the social events at GAT meetings are well known
for being one of the main attractions and certainly not to be missed
- this was no exception. The first night’s get together was soon
in full swing in Waxy O’Connors, an Irish bar in the city centre. It
was a good chance to catch up with old friends and colleagues,
as well as meeting new ones. A brave few continued on into the
night, but it seemed many were saving themselves for the ceilidh
and wow was it worth it - undoubtedly the highlight for me. An
unarguably elegant affair in an atmospheric setting with good food,
good company and most importantly some time to relax with a few
glasses of wine.
5. I’ve long pondered what my strategy would be for a total
nightmare airway – like a late presentation of an airway burn. There
have been several reports in the literature of the insertion of an LMA
under topical anaesthesia and then using that as a conduit for fibre-
I commend everyone for adopting the Scottish spirit (pardon
the pun) and even taking on a few locals in the ceilidh dancing,
acquiring a true taste of the Scottish culture. A good night was had
by all and there was only a minor reduction in number attending
talks the following morning. I’m sure the memories will live on for a
long time. It really was pure dead brilliant! Sorry, couldn’t resist it.
optic intubation with an exchange catheter. This sounds like the best
of an unappealing list of alternatives. [Ellen O’Sullivan]
6. Continuing the theme of major burns. Early naso-gastric feeding
really does mean early; getting the NG tube inserted and feeding
commenced in the emergency department should be the norm.
Rubbing the patients face with a clean swab will form part of my
assessment of a burns case – if there is a facial burn then intubation
is probably required and, paradoxically, in the absence of a facial
burn intubation is unlikely to be needed (unless there is another
indication such as smoke inhalation). [John Kinsella]
7. While the use of depth of anaesthesia monitors to make sure
the patient is asleep probably doesn’t carry much advantage over
vigilant routine monitoring, they may have a role in identifying
patients at higher peri-operative risk of death. The so-called ‘triple
low’ of a low MAP, a low BIS with a low MAC fraction anaesthetic
should arouse suspicion of cerebral hypoperfusion and prompt a
search for solutions (such as increasing the cardiac output or MAP).
A less positivist interpretation would be to use this observation
(after optimising the physiology) as a surrogate of increased perioperative mortality – identifying the so called ‘dead man walking’.
[Rob Sneyd]
8. Adding non-particulate steroids (such as 4mg of dexamethasone)
to an interscalene block may provide improved short and long term
pain reduction in shoulder surgery. Also nice to hear that there’s
nothing wrong with doing an interscalene block using ‘out of plane’
guidance. [Malcolm Watson]
9. I had no idea quite how strongly the mortality in sepsis is
determined by your genotype: far stronger than in cardiovascular
disease and cancer. I am reassured that some fantastically bright
individuals are working hard to seek out the specific genes
implicated (in an elevated risk of death from sepsis) with the hope
one day of finding a therapeutic target. [Kenny Baillie]
10.Finally, I was reminded what a superb group of individuals
anaesthetists are. The future of the profession is in safe hands!
I would like to thank all the contributors from across the whole of
the UK for their hard work. Special thanks for their monumental
efforts to The Scottish Airway Group under the guidance of Alastair
McNarry, The West of Scotland Regional Anaesthesia Group under
Malcolm Watson, the Advanced Ventilation group from Leeds under
Abhiram Mallick and all the events team at 21 Portland Place who
made this the most successful meeting ever.
Mike MacMahon
GAT Committee 2011/12- Education Portfolio
and organiser of the GAT ASM.
I’d like to thank all those who worked so hard to make this meeting
such a huge success. I certainly had a great time making new
friends at a variety of stages in their careers and am already looking
forward to seeing as many of you as possible next year in Oxford.
Watch this space.
Kate Slade
CT 2 Anaesthetic Trainee, Glasgow
19 31/07/2012 15:23
Aiming higher at GAT:
Success of mentoring sessions!
A team of trained mentors from East Midlands
Deanery and the Northern Deanery, led by Dr Nancy
Redfern, were invited to attend the AAGBI GAT
meeting in Glasgow. This exciting venture broke
new ground, offering trainees of all grades taster
sessions to experience the benefits that mentoring
has to offer from a trained, experienced mentor.
Mentoring is a two way relationship between a
mentee and an experienced, highly regarded,
person (the mentor)1 which helps the mentee to take
charge of their own development, to release their
potential and to achieve results that they value2.
It is a learning relationship, focused on self-development and
reflection, particularly useful at times of change. By developing and
re-examining their own ideas, learning, and experiences, mentees
identify ways to take advantage of opportunities or to overcome
problems3. This is distinctly different from coaching or patronage,
where a consultant “moulded” a junior to give them advantage in
career progression.
The team of mentors consisted of senior and trainee anaesthetists
and a surgeon, who have, between them held posts of Royal
College Tutor, Deputy and Associate Postgraduate Deans, and an
AAGBI Council member, all of whom use mentoring for themselves
as part of their own professional development. Grade is no object
and the issues covered spanned a wide area, from work and career
related issues, which featured strongly, to more personal issues.
Mentoring is equally applicable to work or personal life and is used
in business to help people achieve their full potential. Only recently
has its use been recognised in medicine with the GMC’s Good
Medical Practice 20124, stating that ‘You should seek out a mentor
during your first years as a doctor and whenever your role changes
significantly throughout your career.’ This has implications for the
new introduction of revalidation, allowing support for all undergoing
the process. In the midst of change in working circumstances,
financial insecurities and a stressful job, there is a clear need for
mentoring, confirmed by our experience at GAT.
challenging blind spots, helping the mentee to decide what they
really want or need, to set goals, develop strategies to achieve
these and to decide on a plan of action. The focus of the session is
about change, and how this can be practically achieved. Trained
mentors use frameworks and both East Midlands and Northern
schemes are based on Egan’s ‘Skilled Helper’ model5. Training
to be a mentor takes time (6 day course) and involves learning
frameworks to guide conversations as well as honing skills. This
contrasts to enthusiastic amateurs who often offer advice.
Egan’s model of mentoring
Above: Four of the seven mentoring team members at GAT, Glasgow, 2012 (left
to right: Dr Gordon French, Dr Nancy Redfern, Dr Christopher Hebbes, Dr Adzo
Apaloo. Not in photo, Mr Tim Terry, Dr Karen Naru and Dr Charlie Cooper)
The first few trainees were innovators, brave enough to have a
go at something completely new. They reported back to friends,
and as word spread there was a buzz about the conference and
demand increased. We exceeded capacity for the final day, which
was an amazing achievement and demonstrated a clear need for
mentoring at all levels of seniority and for a wide variety of issues.
A team of 7 mentors facilitated a total of 33 one-to-one mentoring
sessions lasting between 1 and 2 hours each.
Many mentees were unsure what to expect from a session, whether
it would be a “cosy chat”, counselling or a chance to “let off steam”.
These taster sessions offered the opportunity to experience what
mentoring can offer, the ability to career plan and set goals and
explore a situation with a non-judgmental, impartial colleague.
Many found the anonymity and accessibility of these sessions a
helpful opportunity to explore dilemmas, which they would not
otherwise have available. Mentees found the style of conversation
warm and friendly, and some really valued the time and space to
talk about themselves and to get clarity, but were challenged and
prompted to explore new perspectives and resolve their dilemma.
Quotes from feedback include:
‘Getting down to the ’nitty gritty’ of what I want’
‘Time to give a problem a lot more thought and
fully explore this and work out an action plan’
Mentees reported that conversations were more structured than
they were expecting, and many found this approach helpful. The
mentor provides a ‘map’, a framework which the mentor and
mentee use to guide their discussions. The mentor facilitates the
mentee in exploring the situation, gathering information and gaining
insight, reaching a decision and taking action. The mentor’s skills
are in listening carefully to everything the mentee says, empathically
Egan suggests that, when we are sorting out dilemmas and
deciding what to do about opportunities, typically we get stuck in
one of three places. Sometimes we are so embroiled in a situation
that it is hard to stand back and work out exactly what is going on.
Sometimes we know what is happening but are less clear about
what we need or want instead - what would the situation look like
if it was going well? Lastly, we may know exactly what we want to
achieve, but be less certain as to how best to go about this. Gerard
Egan’s ‘Skilled Helper’ model identifies skills and techniques that
the mentor can use to help the mentee manage the situation more
effectively, to become better at taking action and achieving what
he or she wants; to become better at helping themselves.
Using a mentor remote from the mentee’s own workplace or
deanery is clearly in demand, and something which we will be
offering at the Winter Scientific meeting and at next year’s GAT in
Oxford (3rd – 5th April 2013). We hope to also run sessions for
consultants at other events. In the future, geography will cease to
create barriers, as the East Midlands moves ahead with an exciting
project to introduce eMentoring using web based technologies.
Watch this space!
References
1.
2.
3.
4.
5.
Clutterbuck D. Everyone needs a Mentor.
Chartered Institute of Professional Development,
London 2001.
Connor, M. Pokora, J. Coaching and Mentoring
at work. Maidenhead: Open University Press,
2012
French, G. Mentoring for Self Development.
Royal College of Anaesthetists Bulletin. 2007;
44: 2225-2228
General Medical Council. Good Medical Practice
(2012). Accessed online 3/7/12 from http://www.
gmc-uk.org/Good_Medical_Practice_2012_Draft_
for_consultation.pdf_45081179.pdf
Egan G. (2010) The Skilled Helper. (9th Edn).
Belmont California: Brooks/Cole Cengage
Learning
To find a mentor in your area or to find out
more about eMentoring, visit the East Midlands
or AAGBI websites, tweet us, or email any of
the team!
Further reading
http://www.eastmidlandsmentoring.co.uk
@EMMentor (twitter)
Connor, M. Pokora, J. Coaching
and Mentoring at work. Maidenhead:
Open University Press, 2012
21 31/07/2012 15:23
SOBAUK
PORTSMOUTH AIRWAY WORKSHOPS PAWS 2012
th
7 West of England
Anaesthesia Update
7th – 11th January 2013
St Cristoph (nr St Anton), Austria
www.weauconf.com
info@weauconf.com
‘SMART’
ANAESTHESIA COURSE
Supported by
This one day course is designed for AnaesthetistODP teams. It includes interactive team training in
“Error Avoidance” strategy, non-technical skills
and their practical application in simulation and
integration with airway technical skills.
Tuesday 9th October 2012
Thursday 6th December 2012
Venue: Clinical Sciences Building
University Hospital, Coventry CV2 2DX
5 CPD points (1I02, 1I03, 1B02, 1C02, 2A01)
applied from the Royal College of Anaesthetists
Course Fee: Consultant Anaesthetist: £225 (DAS member £200),
SAS / Trainee Anaesthetist: £175 (DAS member £150),
Theatre team member: £100*
*This fee will be refunded if accompanied by an anesthetist from the same Trust
For application forms visit: www.anaesthetics.uk.com
or www.das.uk.com
Registration Enquiries
Busola Adesanya-Yusuf, Specialist Societies Manager,
Difficult Airway Society, 21 Portland Place, London, W1B 1PY
DAS@aagbi.org 020 7631 8816 Fax 020 7631 4352
K�� I�� I� A�� F�� T�� M�� O��
Royal College of Physicians, London
Thursday 6th December 2012
Friday 30th November 2012
Pitfalls and Practical Management of the Obese
Patient.
Suitable for consultants and trainees, with a highly experienced faculty. Places are
limited to allow maximum practical experience
Topics covered:
Workshops include
Fibreoptic intubation
Co-morbidities - What to watch for
NAP 4 UPDATES Jet ventilation
Based in Sporthotel, St Christoph am Arlberg
Talks cover a wide range of topics
Flights available from Bristol, Gatwick and other airports
All grades of Anaesthetist welcome Attractive prices
Society for Obesity and Bariatric Anaesthesia
Now in its 11th year the course consists of a combination of lectures, discussions
and hands on workshops covering all aspects of the management of the anticipated
and unanticipated difficult airway
THE PAEDIATRIC DIFFICULT AIRWAY 7th West of England Anaesthesia Update
SOBAUK
DAS EXTUBATION ALGORITHM Video laryngoscopy and optical stylets
Supraglottic devices
THE OBSTRUCTED AIRWAY Double lumen tubes and Bronchial Blockers
CASE DISCUSSIONS Surgical airway
LIVE FIBREOPTIC DEMONSTRATIONS Registration £175
Approved for 5 CEPD points
Pre-operative Assessment - Risk stratification
Obstructive Sleep Apnoea - Mechanisms and screening
Bariatric Surgery - Understanding the Role
Pharmacology and Dose Adjustment
The Airway and Ventilation
The Obese Parturient
Course Directors: Dr. Denise Carapiet and Dr. Matthew Turner
For further details please contact
Matt Turner, Department of Anaesthetics,Queen Alexandra Hospital, Cosham,
PO6 3LY Tel:02392 286298 or book online at www.pawscourse.co.uk
This course is kindly sponsored by
Course approved
by RCoA for
10 CPD Credits
Aimed at Anaesthetists ST3 – Consultant
5 CPD Points applied for
SOBA Members and trainees £125 Non-members £150
For registration and further information visit www.sobauk.com
Joining SOBA is just £25 per annum and gives discounted entry to
Fresenius
New Advert.pdf
all 18417
our meeti
ngs and seminars
as well as a1 host18/05/2012
of other benefi11:26
ts.
North West London Hospitals
Trust
Northwick Park & St Mark’s
THE TRANSITION COURSE
24 – 25th October 2012
Without adequate preparation the transition from a doctor in training to a consultant
can be a daunting experience.
This 2-day course is for Specialty Trainees within 15 months of CCT
and all doctors applying for NHS consultant posts
Course Fees: £150
Hospital Structures – Who does what?
The Consultant Contract & Job Plans
CV Preparation and Interview
Managing your Career
Developing and Leading a Service
Preparing a Business Case
Handling Complaints
Course Director: Dr Vino Ramachandra
For further details and registration
please contact:
Solange Micallef or Latha Kumar
Course Co-ordinators
Anaesthetic Department
Northwick Park Hospital
Harrow, Middlesex
HA1 3UJ
Team Working
Running Effective Meetings
Supervising Trainees
Managing Trainees in Difficulty
Preparing for Revalidation
Making Ethical Decisions
Supporting the Sick Doctor
All delegates will receive a copy of
‘Management Essentials for Doctors’
by Shaw, Ramachandra, Lucas and
Robinson
Tel: 0208 869 3972/3969
Email: solange.micallef@nhs.net
“Excellent Value For Money”
31/07/2012 15:23
AAGBI
INNOVATION
The Annual AAGBI Prize for Innovation
in Anaesthesia, Critical Care and Pain
The Association of Anaesthetists of Great Britain and Ireland invites applications
for the 2013 AAGBI Prize for Innovation in Anaesthesia and Critical Care. This
prize is open to all Great Britain and Ireland based anaesthetists, intensivists
and pain specialists. The emphasis is on new ideas contributing to patient
safety, high quality clinical care and improvements in the working environment.
The entries will be judged by a panel of experts in respective fields.
Applicants should complete the application form that can be found at the
AAGBI website www.aagbi.org/research/innovation. The closing date for
applications is Monday 15 October 2012.
Shortlisted entrants will be invited to present their work at the Winter Scientific
Meeting in London 16-18 January 2013 where the prize will be announced.
www.aagbi.org/research/innovation
The Association of Anaesthetists of Great Britain & Ireland
19-21 Sept 2012
ANNUAL CONGRESS
BOURNEMOUTH
Bournemouth International Centre
This year’s Annual Congress comes to one of England’s
most vibrant and cosmopolitan seaside resorts.
Bournemouth has seven miles
of beaches, award winning
gardens and a vast variety of
shops, restaurants and bars.
Lecture topics include:
• National Audits (including NAP5) • The older patient
• Pain management • Shared decision making in high risk surgical patient
• Law and Ethics • Obstetrics • Revalidation • Papers you should know about
• Wellbeing • Problem-based learning and Critical Incident case reports
• Plus sessions organised by the Association of Surgeons of Great Britain
and Ireland (ASGBI) and the British Geriatric Society
www.annualcongress.org
Scientific programme
Multiple streams of lectures
Debates
Hands-on workshops
Industry exhibition
Poster and abstract presentations
CPD approved
Foundation grade posts in
anaesthetics are not that common.
Just 4% of Foundation Year
One doctors rotated through an
anaesthetics post in 2011-121.
I have had the opportunity of being
one of these junior anaesthetists
for four months in 2012.
My role as an F1 doctor within the
anaesthetic department was not
as clearly defined as I had become
accustomed to in my previous
general medicine and surgery
rotations.
Anaesthetics in the
Fast Lane - As an F1 Doctor
My new job had no bleep, no ward round with a list of ensuing jobs
and it featured constant consultant supervision. I am also not a core
or specialty anaesthetics trainee. My clinical supervisor supported
me to tailor the role to my individual educational requirements as a
junior doctor and to learn anaesthetic principles and techniques to
support my core foundation knowledge and clinical practice.
A few consultant anaesthetists said at the beginning that they
expected my intrinsic hand muscles to ache at the end of each
day. They were not wrong; managing airways with a facemask,
chin tilt and jaw thrust in one manoeuvre proved difficult due to my
minimal exposure to acute airway skills on the ward. This is a prime
example of the patience and good practical teaching provided by
anaesthetists; after a few days my airway management progressed
onto more advanced adjuncts including endotracheal intubation.
One particular highlight in week four was successfully managing a
grade three intubation (with supervision) using a bougie. This has
given me the confidence to take my newly acquired skills to any
acute clinical scenario or crash call as an F2 doctor and beyond.
Long intra-operative periods were often filled with interesting and
animated teaching delivered by both consultant anaesthetists and
trainees. The nature of anaesthetics means that physiology, anatomy
and pharmacology are taught live in action – which is far more
memorable and fun than any textbook could ever offer.
Interestingly, anaesthetics and critical care are the most common
specialties experienced as taster opportunities by doctors in their
foundation years [1]. This reflects the popularity of anaesthetics
as a potential future specialty training post for fellow junior doctors.
Subsequent to my experience of anaesthetics, I think NHS hospital
trusts and the UK Foundation Programme Office (UKFPO), should
create more access to rotations such as the one I have enjoyed.
This would enable more foundation year trainees to enter their CT1
or ST1 training posts with the invaluable skills of advanced airway
management, enhanced knowledge of the provision of analgesia
and in the assessment of the critically ill patient.
Dr Michael Robson
Foundation Year One Doctor in Anaesthetics
Frimley Park Hospital, Surrey
References
Annual dinner and dance
At this point, as I am nearing the end of anaesthetics, I have been
challenged to collate my anaesthetic knowledge and practical skills
to give a general anaesthetic from start to finish under consultant
supervision. I soon appreciated how difficult it is as a novice to
conduct an anaesthetic as an integrated process. However, I felt a
sense of achievement when I managed a patient having a routine knee
arthroscopy from pre-operative anaesthetic assessment through to
writing up the post-operative analgesia and handing the patient over
to the nursing staff in recovery. The role of a junior anaesthetist has
enabled me to refine important practical skills, prescribing skills and
communication skills in equal measure.
1.
Foundation Programme Annual Report 2011 UK Summary. UK Foundation
Programme Office; 2011. [cited 2012 Jun 13]. Available from: URL: http://www.
foundationprogramme.nhs.uk/index.asp?page=home/keydocs
25 31/07/2012 15:23
Caring for the
Medical Profession
Royal Medical Benevolent Fund
Case Studies
The Royal Medical Benevolent Fund helps hundreds of doctors,
medical students and their families every year. Below are a few
examples of the assistance we give.
Please note all names have been changed to preserve anonymity.
This year the Royal Medical Benevolent
Fund celebrates its 175th anniversary.
RMBF President Dame Deidre Hine reflects
on the challenges and opportunities facing
the charity.
The
Royal
Medical
Benevolent
Fund (RMBF) has a long and
distinguished history of assisting
doctors and their dependants in
times of crisis and great need. For
175 years, the RMBF has provided
invaluable support to the medical
profession.
The work we do today is as vital as it was 175 years ago. In 20112012 we helped over 350 beneficiaries, from as young as six
months to 98 years old. These cases range from young parents
who’ve had to give up work to care for a sick child, to elderly
widows left unable to afford care for themselves.
Our help ranges from financial assistance in the form of grants and
interest-free loans to a telephone befriending scheme for those
who may be isolated and in need of support. The approach we
take is to provide a package of help to ensure dignity and quality
of life.
As we are all aware, the medical profession has changed
enormously over the last 175 years and continues to change
almost on a daily basis. Over the years the RMBF has evolved to
meet the changing needs of doctors and their families.
Our aim is to use our 175th anniversary to raise the profile of
the RMBF so that all those who may need our help are aware of
the support that we offer. The RMBF relies heavily on voluntary
contributions from the medical profession; without your help we
could not support our growing number of beneficiaries. We hope
that our supporters will consider making a special donation in this
important year for the RMBF.
The RMBF has many reasons to be proud of what it has
accomplished over the last 175 years, but many challenges lie
ahead. As the medical profession continues to change, we must
be ready to meet new and emerging needs.
The RMBF is committed to leading the way in providing support
and advice to members of the medical profession and their
dependants at times of crisis and serious need. Thank you for your
invaluable support.
Dame Deidre Hine DBE FFPH FRCP FLSW
President, Royal Medical Benevolent Fund
RMBF Plaster Ad A6 for Publication_v2.pdf 1 24/07/2012 10:37:21
To donate to the 175th Anniversary Appeal please visit www.rmbf.org
Because it’s not
always that simple.
In January this year, we launched a new pilot project to extend
our financial assistance to medical students in the UK who are
facing unforeseen and exceptional hardship as a result of factorsC
beyond their control. The RMBFs Medical Student Hardship Fund
provides eligible medical students with an interest-free loan to beM
repaid at such time as the beneficiary is in a position to do so. TheY
repayment of the loan will be used by the RMBF to support other
CM
students in the future. This new development will help ensure that
MY
good students are not lost to the profession and instead go on to
serve the public for the future benefit of us all.
CY
CMY
Alongside our traditional financial support we also run two
advice websites: Support4Doctors (www.support4doctors.K
org) provides access to a wide range of specialist advice
and
support
for
doctors
and
their
families;
and
Money4Medstudents
(www.money4medstudents.org)
gives
medical students advice on managing their money, how to borrow
sensibly and where to find other sources of funding.
Sometimes you need more than a plaster.
The Royal Medical Benevolent Fund is the leading UK
charity for doctors, medical students and their families.
We provide financial support, money advice and
information when it is most needed due to illness,age,
bereavement or disability.
What makes the RMBF so effective is that the majority of our Board
and our volunteers come from a medical background. This means
that as an organisation we understand the unique pressures
facing doctors on a day to day basis. Our volunteers come from all
areas in the medical profession and help ensure that the RMBF is
delivering the best support possible.
Find out more and donate
175 years at the heart
of the medical profession
Online: www.rmbf.org
Phone: 020 8540 9194
Sarah
The RMBF helped Sarah when she needed help after an operation.
She first started experiencing symptoms before she qualified. This
proved to be the result of a T1 level tumour compressing her spine.
She ended up unable to walk without a zimmer frame. I’d always
worked, from 16 onwards, ’ explained Sarah. ’Then when I really
couldn’t work, at the point when I was working at what I always
wanted to do, I found this a real shock.’
After surgery Sarah went into a rehab hospital. Her consultant
realised she was having financial problems when she was assigned
a social worker. She had been entitled to just four weeks sick pay and
that had run out while she was in hospital, leaving her dependant on
State Benefits. That’s when her consultant suggested she contact
the RMBF. Following a home visit to help assess her circumstances
the RMBF provided financial help to help tide Sarah over until she
was well enough to return to work.
Sarah has since been able to return to work full time. However, as
she says, her experience, ’Made me realise you can have money
problems even if you are a doctor.’
Paul
Sahira suffered serious head injuries in a car accident and was in a
coma for ten days.
After qualifiying at UCH she worked in London hospitals for two
years prior to taking up a short-term post in New Zealand. On her
way back to the UK to take up a post at Glasgow Royal Infirmary,
she stopped off in Bombay to visit relatives. That was when the car
accident left her in a coma.
On return to the UK, she spent an extended period in hospital but
the accident left her with severe problems more particularly with
her speech. Many years of therapy have enabled Sahira to regain
limited speech, but she was unable to resume her medical career.
The RMBF provided financial help during this difficult period. With
additional help from a specialist training organisation, she was
able to secure supported employment and now works in the sterile
services unit at a local hospital. No longer requiring regular help
from the RMBF, Sahira keeps in touch to report her progress.
Mary
Quite unexpectedly Mary found herself a single parent with three
young children to support.
Not having worked in medicine for a few years she wondered how
she could manage to practise again and also look after her family.
Fortunately the RMBF was able to help. A 12 month Back to Work
financial package was approved. This included a small weekly grant
within the Department for Work and Pensions disregard regulations
and substantial help towards childcare costs plus an additional
award to cover renewal of professional subscriptions, household
insurance and unexpected repairs.
The RMBF helped Paul when chronic illness left him unable to
continue his medical career.
The latter proved invaluable when, in the middle of a particularly
cold spell Mary’s central heating boiler was condemned and
disconnected, leaving the family without heating or hot water. Help
from the RMBF enabled a rapid replacement.
After completing his degree at UCL and House Officer duties Paul
had joined the International Red Cross. His first posting was to
Chechnya, where he worked with prisoners of war. He was then
posted to Rwanda. During his tour of duty there he noticed an
increasing number of joint pains.
Mary’s one year refresher training enabled her to return to general
practice on a part time basis, thereby providing both an income and
time to continue to look after her children.
A consultant diagnosed rheumatoid arthritis and the Occupational
Health Adviser for the Red Cross explained that he wouldn’t be able
to continue in his post. Paul realised his medical career options on
his return to the UK would be restricted but didn’t realise the full
implications until his health deteriorated further and he had to begin
to use a wheelchair.
Paul was 30 years old when a consultant suggested he contact
the RMBF, which has since helped in a number of ways. To enable
Paul to remain as independent as possible the RMBF has helped
purchase a specially adapted vehicle which he can get into and out
of without needing someone to help him. It is also providing financial
support while Paul pursues further studies to enable him to return to
paid employment.
24 King’s Road, Wimbledon, London SW19 8QN.
A charity registered with the Charity Commission of England and Wales No. 207275
A company limited by guarantee No. 00139113
Sahira
Andrew
Andrew, a recently qualified doctor, approached the RMBF due to a
diagnosis of Bipolar Affective Disorder.
This diagnosis means that he is currently unable to work. So far,
the RMBF has provided financial assistance in the form of a weekly
grant, travel costs and help with unexpected expenditure. He has
also received Money Advice, which has assisted him in getting the
interest frozen on her overdraft.
For more information about these case studies or any other aspect
of the RMBF’s work, please contact:
Josh Kubale
Development and Communications Manager
Anaesthesia News
News September
September 2012
2012 •• Issue
Issue 302
302
Anaesthesia
27 27
31/07/2012 15:23
Marathon
Medicine
Shortly after the article was published the editor of The Observer
introduced Brasher and Disley to the relevant London authorities
and after much persuasion and discussion it was agreed that the
marathon could go ahead. With a tiny budget of £75,000 and
surprise sponsorship by Gillette, the first ever London marathon
took place on 29th March 1981. More than 20,000 people entered
the race, with only 7,747 accepted.
Great Britain has seen a
boom in marathon running
over the last thirty years,
which has closely followed
that of the USA.
The first London marathon in 1981 was the vision
of Olympic athletes and Richmond based club
runners, Chris Brasher CBE and John Disley,
who in 1979 ran the New York City marathon. On
returning from New York, Brasher wrote an article
for The Observer newspaper. The following extract
was the opening to his account “To believe this
story you must believe that the human race can
be one joyous family, working together, laughing
together, achieving the impossible. Last Sunday,
11,532 men and women from 40 countries in the
world, assisted by over a million people, laughed,
cheered and suffered during the greatest folk
festival the world has seen.” Brasher concluded
his article asking the question whether London
“could stage such a festival?“ and “welcome the
world”1. The seed had been sown.
The event was so successful that the 1982 marathon received
more than 90,000 applications; 18,059 people were lucky enough
to race. Since then the London marathon has continued to grow
and is now televised in 150 countries around the world. Moreover,
to date runners have raised over £500 million for charities.
In 2007 I ran the London marathon and was exhilarated by the
atmosphere, the crowds, the world famous sights and inspirational
‘espirt de corps’ of fellow runners. Sometime later, after exams,
and job applications I started to wonder about the behind the
scenes work, that went on in order to organise such a massive
event. I wondered what happened to injured or sick runners, how
they were cared for? Were people hospitalised? I made a few
enquiries and found that a core group of doctors, nurses and
physiotherapists volunteered each year, often year in year out,
to help man 7 course stations and 2 intensive care units. Pivotal
to logistics and organisation are St Johns’ ambulance, who also
provide support volunteer cadets and medical staff.
Race Day
On the morning of the marathon I set off early to beat the crowds.
I made my way down The Embankment, choosing to walk as the
roads were closed, heading to Horse guards parade and the London
marathon finish line. As I grew closer, I saw a group of people dressed
in white waterproof jackets, just like the one I carried in my bag. I was
warmly received and pleased that I had made it on time: Most of the
doctors were local, I had travelled from South Yorkshire.
Shortly, Professor Sharma appeared from the repatriation unit (an
area where runners can be reunited with their family or friends), he
got the meeting off to a start by mentioning that the weather forecast
looked likely to be inaccurate and it could be hotter than expected
which would increase our work load. He went on to say that there
were 37,000 runners, including an octogenarian, a 38 weeks pregnant
woman and a man with a heart transplant - your every day case mix!
My nervousness increased as the briefing came to a conclusion and I
was introduced to my senior team-mates and led to ITU South.
ITU South (and North for that matter) is essentially a field hospital - a
long, white, mobile ‘tent’ that can accommodate multiple casualties.
At one end of the unit was the arrest bed, complete with defibrillator,
ventilator, induction drugs and intubation kit. Then, in descending
order of medical priority, came 4 ITU beds, 20-30 beds for those with
less urgent medical need, including beds for runners requiring the
skills of the podiatrists and physiotherapists. After a tour of the ITU,
the quiet early morning was spent watching in awe as the elite runners
crossed the finished line. ITU North received a royal visit from Prince
Harry and the teams got to know each other and became familiar with
their new ‘hospital’ environment.
The bulk of the work was treatment of cramps, blisters and general
fatigue. The podiatrist and physiotherapists were exceptionally busy
and at times I felt a bit of a spare part. However, the lead consultant
gave me some fantastic advice: he told me to quietly observe the
walking wounded, to watch them and get a feel for the ‘sick / not sick’
runner - only by doing this would I be able to start to identify a runner
that was more unwell than apparent on first glance or the runner that
despite treatment, was deteriorating. I took his advice.
The day was busy, and interesting. I treated a 50-year old woman (who
had incidentally just run a sub 4 hour marathon) with a convincing
history of cardiac-sounding chest pain and a background of multiple
previous M.I’s. She was taken to St Thomas’ where emergency
coronary angiography was negative for any obstructive lesion.
I treated shortness of breath, persistent vomiting, headaches and
helped a young type one diabetic assess his insulin requirement.
I also helped remove trainers, gave out sweets and foil blankets. On
ITU North the team was equally busy, if not more so, dealing with two
intubations and, sadly, the sudden death of a young runner. All in all,
there were almost 5,000 medical contacts and 59 hospitalisations3 a busy day indeed.
Soon the ‘2 hour 30 minute’ runners began to appear. From my running
experience, people completing the marathon in these phenomenal
times are exceptionally fit athletes, who train hard and have likely run
for many years. So when a few of these ‘super fit‘ runners started
to make their way towards ITU, I was taken aback.The first few into
ITU presented ‘collapsed‘ unable to stand, dizzy, vomiting and on
examination looked pale. Importantly, these runners were alert and
orientated. As the beds started to fill, the St John’s cadets and medics
worked tirelessly to get these runners firstly warm and then to give
them sweets, salts and fluids. As one unsteady runner approached, I
took the chance to assist him into ITU and take his history, he promptly
vomited. Once he had settled himself, his symptoms began to
sound familiar. I relaxed a little, as I gained confidence in treating the
numerous runners suffering from exercise-associated collapse.
Professor Sanjay Sharma, a world expert in sports cardiology is
the current medical director for the London marathon and it is
under his example and watchful eye that the medical team works
synergistically to ensure the safe delivery of care to marathon
runners.
© Phototograph Cate Gillon
St John Ambulance volunteer loads up countless cases of petroleum jelly
onto a trolley, in preparation for the London Marathon. St John Ambulance
volunteers will offer their services during the marathon and thousands of
runners will stop for first aid support and assistance, with the estimation of
88 lbs of petroleum jelly being used to help prevent chaffing and blistering.
At the end of the day I made my way home, and as I stood on a
packed train, full of runners, with their family and friends, I listened
to their stories of cramps at ten miles, sticky shoes due to running
through puddles of Lucozade, blisters and aches. Yet they were all
smiling and wearing red and silver medals around their necks. I’m
sure Brasher and Disley would have been proud. I overheard one
young woman ask a runner if this was her first marathon, to which
she replied ‘this is my fourth; I said ‘never again’ after the first, but I’m
hooked’. Me too, I thought as I looked out of the window, I’ve survived
my first medical marathon, I think I’ll be back again next year.
This year I was thrilled to be accepted to work as part of Professor
Sharma’s team. When I learnt that I was to work in ITU South,
(albeit with senior supervision) I was a little daunted. I am a CT2
anaesthetic trainee, and a pretty enthusiastic long distance runner
- did this qualify me to work in such a setting?
Stephanie Peate,
Anaesthetic CT2, South Yorkshire
In the weeks leading up to the London marathon I was sent a
document of important medical conditions associated with
marathon running and although vaguely familiar to me I went on
to read more in preparation for the event.
In the ITU there was a biochemist who expertly worked a device
called an iSTAT point of care analyzer, used to measure venous blood
electrolytes, specifically sodium; important in confirming exertional
hyponatraemia. There have been 15 confirmed cases between
2003-2007 and one death in 2007, all had fits or collapse2, 3. A clear
history from all collapsed runners helps identify those needing a
blood sample.
References:
1.
www.virginlondonmarathon.com
2.
Kipps C et el. Br J Sports Med 2011;45:14-19
3.
Data obtained with kind permission of Professor S Sharma
29 31/07/2012 15:23
AAGBI Undergraduate Elective Funding
11th Annual
Anaesthesia
Scientific Meeting
11th
Annual
Anaesthesia
Scientific
Organised by :BritishMeeting
Association of Indian Anaesthetists
managed with propofol followed by midazolam was re-admitted
two days post discharge with a second episode of RSE and died
whilst in ICU due to hypoxic complications whilst another patient
described chronic muscle pain.
Out with the old
and in with the new?
Thiopentone was used first line for one patient with successful
seizure termination. The loading dose was 100 mg IV with maintained
at an infusion of 5mg/kg/hr. The barbiturate was administered over
72 hours with a subsequent ICU stay of two days. One complication
noted for this patient was a fall in cardiac output. This settled within
one hour and no further treatment was required.
How an eye-opening experience of Refractory Status Epilepticus (RSE)
in Birmingham took me to India to find out more
Future outlook
Comparing what I observed in the UK with the data I collected in
India, I did not find evidence of a difference in the management
of RSE between the two countries. Further research with large
numbers of patients is needed to define the benefits of the various
anaesthetics drugs, identify complications and observe sideeffects. What is certain is that a definitive protocol needs to be made
available in each and every ICU in the UK, which could enhance our
management of RSE.
My first week on the intensive care unit (ICU) and a 23 yr old female presents with new onset prolonged seizure activity
for the last six hours with no previous history of epilepsy. Three days later and after administering five different antiepileptic drugs (AED), the seizures finally terminated. The challenge in the UK is that no definitive protocol is
available for the management of RSE, a fact reinforced by a UK national audit looking at RSE management
I subsequently completed. This audit also showed that most treatment regimes are chosen by the on
call anaesthetist with a neurologist consulted very late in the management ladder, if at all. Currently
continuous EEG monitoring in conjunction with IV anaesthetic doses of midazolam, thiopentone or
propofol infusion is preferred. The aim of my student elective was to assess the anaesthetic treatment
of RSE in India and see whether any different regimes could be applied to existing UK practice.
Mitesh Patel
Fifth year medical student, University of Birmingham
Organised by: British Association of Indian Anaesthetists
Friday, the 5th and Saturday, the 6th October 2012.
Clinical Skills Facility and Country Park Inn, Hull, East Yorkshire, UK
Friday 5th and Saturday
6th October 2012
th
Interactive
workshops
5 Oct 2012);
Venue:
Clinical
Facility,UK
HRI, Hull, HU3 2JZ:
Clinical
Skills
Facility(Friday,
and Country
Park Inn,
Hull,
EastSkills
Yorkshire,
Parallel three workshops and flexibility to do maximum 2 workshops in the day ( Mix and Match):
workshop 1:Workshops
Simulator based
patient5th
safety
Workshop
2: Trans-thoracic
Interactive
(Friday
Octworkshop:
2012); Venue:
Clinical
Skills Echo, FATE,
FAST Ultrasound;
Workshop
3: Ultrasound-guided
Regional Anaesthesia.
Facility,
HRI, Hull,
HU3 2JZ:
Three parallel workshops
and flexibility to do
maximum 2 workshops in the day (Mix and Match): Workshop 1: Simulator
based patient safety workshop:
Workshop 2: Trans-thoracic Echo, FATE,
Scientific meeting ( Saturday, 6th Oct 2012); Venue: Country Park Inn, Cliff Road, Hull, HU13 0HB:
FAST Ultrasound; Workshop 3: Ultrasound-guided Regional Anaesthesia.
Anaesthesia workforce planning, Revalidation, Enhanced Recovery Programme in Orthopaedics,
Recent updates
in Bariatrics,
Pain, 6th
and Oct
Obstetrics.
AllVenue:
lectures Country
delivered by
eminent
Scientific
Meeting
(Saturday
2012);
Park
Inn, National and
International
speakers.
Cliff
Road, Hull,
HU13 0HB: Anaesthesia workforce planning, Revalidation,
Enhanced
Recovery
Programme
in Orthopaedics,
RecentJIPMER,
updates
in
Chief Guest:
Prof. Ashok
Badhe, Professor
of Anaesthesiology,
Pondicherry,
India will
Bariatrics,
Pain,
and Obstetrics.
All lectures
delivered
by eminent National
speak about
“Developing
Patient safety
in Anaesthesia
in India”.
and International speakers.
Best Trainee
OralProf.
and Poster
presentations
Chief
Guest:
Ashok
Badhe,( 3 papers).
Professor of Anaesthesiology, JIPMER, Pondicherry, India.
Traditional
Indian
and Cultural
programme(3
onpapers).
the evening of Saturday the 6th October,
Best
Trainee
OralBanquet
and Poster
presentations
2012.
Traditional Indian Banquet and Cultural programme
on the evening of Saturday the 6th October 2012.
Workshop places are limited ( 8-12 per workshop), so register early either by contacting Dr.P.Balaji,
organising places
secretary,
department,
Hull, HU3so
2JZ;
mobile:early
07812064734 or by emailing
Workshop
areAnaesthetic
limited (8-12
per workshop),
register
to: baoia2012@gmail.com
by registering
onlinecard
via our
www.baoia.org with credit
online
at: www.baoia.orgorwith
credit or debit
orwebpage:
by emailing:
card or debit card.
baoia2012@gmail.com
Alternatively contact Dr P. Balaji, Organising Secretary, Anaesthetic
Department,
HU3
2JZ; mob:Delegate
07812 064734
Registration (Hull,
Scientific
Programme
Trainee
and Saturday Indian Banquet)
For further information, prices and registration please visit:
Snapshot of RSE
management in India
www.baoia.org
meeting
open (to
allforanaesthetists
£ 175+is
workshops
£ 110
2
£ 160 + workshops ( £110 for 2 workshops
and £ 65 for one
workand £ 65
for one workshop)
10 RCoA CPD points forworkshops
the workshops
and
meeting
(TBC)
shop)
This meeting is open to all anaesthetists and 10 RCOA CPD points for the workshops and meeting ( TBC)
Nicola Heard
Educational Events Manager
SAS Audit Prize 2013
Direct Line: +44 (0) 20 7631 8805
21 Portland Place, London
W1B
1PY
The
Association
of Anaesthetists of Great Britain and Ireland (AAGBI)
T: +44 (0) 20 7631 1650 invites applications for the SAS Audit Prize. This is exclusively for SAS
F: +44 (0) 20 7631 4352 doctors to encourage them to undertake audit. Entries will be judged
E: nicolaheard@aagbi.orgby the Research and Grants Committee of the AAGBI. All SAS doctors
w: www.aagbi.org
QEII Conference Centre, Westminster
who are members of the AAGBI are eligible to apply for the prize.
Audit projects (including departmental audits) should have been
approved by the Trust. If the project is a joint one, the names of other
contributors should be mentioned including the principal investigator.
The 2013 Winter Scientific Meeting promises to be the biggest yet!
Applicants should submit a summary of their audit of no more than
1000 words, 3 figures and 3 tables. It should be presented in the
style of the journal Anaesthesia. The winning entrant will receive a
cash prize of £100 and will have an opportunity to present their work
at a national scientific meeting held by AAGBI. Other entrants may
be asked to display a poster at the same meeting (as judged by the
Research and Grants Committee of the AAGBI). Please note that work
must not have been previously published, either as an abstract or as a
full paper in a journal or website or presented at another meeting.
POSTER
COMPETITION
CORE TOPICS
SESSIONS
SCIENTIFIC
SESSIONS
INDUSTRY
ESSENTIAL
CPD
HANDS-ON
WORKSHOPS
A submission form is available on the website
www.aagbi.org/research/awards/sas-grade-anaesthetists
Please email entries along with the completed submission form to
secretariat@aagbi.org
If you have any additional enquiries, please email
secretariat@aagbi.org or contact 020 7631 8812.
Closing date: Monday 07 January 2013
EXHIBITION
FUTURE WSM DATES:
2014 2015
15-17 January 2014
WSM2013Poster.indd 1
JournalJuly2012b.indd 3
2013
30 WSM
LONDON
The Association of Anaesthetists of Great Britain & Ireland
16-18 JAN
Interestingly, some clinicians chose to use propofol first.
However only one patient was successfully treated with
propofol alone. Of the eight patients with unsuccessful propofol
RSE termination, six patients were later changed to midazolam,
one patient switched to thiopentone and one to isoflurane.
The loading dose of propofol treatment was 3-4mg/kg and a
subsequent infusion of 3—150ug/kg/min was administered
until burst suppression was achieved. The length of stay in
ICU ranged between 2-8 days for patients initially treated with
propofol. Propofol infusion syndrome complications such as
renal failure and metabolic acidosis were observed in three
patients within 48 hours of use and were the primary known
reasons for changing to an alternative anaesthetic. One patient
£ 140 and additional fees for workshops
( £ 100 for 2 workshops and £ 60 for one
workshop)
This scientific
After 01/09/2012
I retrospectively collected data from the patient notes
of 16 adults presenting with RSE to the ICU between
2000-2010 at three government hospitals in the states
of Kerala and Gujarat. For each anaesthetic the success
of RSE termination, dose of induction and maintenance, ICU
stay and complications were determined.
Midazolam, the favoured first line AED in the UK for RSE
termination, achieved burst suppression in four patients
although one patient experienced a significant 30mmHg drop
in systolic blood pressure and required a vasopressor. Two
patients originally managed with midazolam had their treatment
subsequently changed to propofol to attain seizure cessation.
The loading dose of midazolam used was 0.2-0.3mg/kg with a
constant infusion sustained at 0.1-2mg/kg/hr. Benzodiazepine
treatment was applied for a maximum of 72 hours and all patients
were discharged from ICU within five days of admission. No
patient initially managed with midazolam experienced any short
term side effects from treatment after discharge.
£ 150 and additional fees for
workshops( £ 100 for 2 workshops
and £ 60 for one workshop)
Before 31/08/2012
14-16 January 2015
Conference App
coming soon...
www.aagbi.org
19/03/2012 10:56
09/05/2012 14:43
31/07/2012 15:23
G
co Pri et
de ma 10
AN ry %
A1 res off
2 ou ou
at rc r
th e. U FR
C
e
ch se A
ec th
ko e
ut
.*
The primary choice for
your FRCA revision
Our FRCA Primary resource provides hundreds of quality questions
written by our editorial team who have extensive experience in
question writing and exam setting. They are pitched at the appropriate
level of difficulty and mapped to the Basic Level Training Curriculum
from the Royal College of Anaesthetists. Make onExamination your
primary choice and get on the path to exam success.
UK experts will train midwives to perform obstetric
surgery and nurse anaesthetists to provide critical care
for newborn infants in a new project in Africa
Use one of our many unique features to help you achieve
exam success, including:
Group Learning – Quiz format revision tool.
AdaptForMeTM – Questions pitched to improve your learning faster.
Work Smart – Work by curriculum area to focus your efforts by topic.
Our FRCA Primary revision resource includes; over 900 MTF
questions, over 100 NEW format SBA questions, exam themes past
paper set to exam conditions, performance feedback and mobile access.
Go online and try our FREE questions today.
*Discount available until midnight GMT 31st October 2012.
onexamination.com/FRCA
in how safely to administer anaesthesia, working alongside the
midwife surgeons. These nurse anaesthetists will also be trained to
manage critically ill newborn infants. Although this innovative project
has been given the go ahead, it still needs to be fully funded.
Maternal and Childhealth Advocacy International (MCAI), The
Advanced Life Support Group (ALSG), and Mothers of Africa
(MOA), have been working in The Gambia and Liberia for 5-6
years, helping the governments of these countries to improve
emergency healthcare for pregnant women and girls (almost half of
all pregnancies occur in children under 18 years), newborn babies
and children attending national (public) health facilities. In both of
these countries, doctors and surgeons are extremely scarce, and
grossly over-worked, making it difficult to provide life saving surgery,
anaesthesia, and newborn infant care, especially in the poorest rural
areas. As a result, many women and newborn babies are dying or
experiencing preventable severe complications which affect the
quality of their lives.
Dr Barbara Phillips of ALSG says: “Our skills-based training
programme, Emergency Maternal and Newborn Health, has been
successful in driving up standards in The Gambia where it is
now sustainably taught by the Gambians themselves. It is a vital
component of our Strengthening Emergency Care programme
which will now be enhanced by this new project to train midwives
in emergency obstetric surgery and nurse anaesthetists in High
Dependency care for mothers and babies, bringing the whole range
of self-sufficient emergency care for the most vulnerable to these
West African countries”
In recognition of the need to train available health workers to
provide this essential care, in a joint project with all three charities
and ministries of health, with the support of WHO*, experienced
midwives working in the national health services of these countries
will be carefully selected to receive training from UK experts in
obstetric surgery, such as performing Caesarean sections on women
in obstructed labour. Once fully trained, these midwives will be able
to perform surgery on pregnant women in emergency situations
without delay. As it is essential for any surgery to be performed
under anaesthesia, experienced nurses will be trained by UK experts
twitter.com/onExamination
facebook.com/onExamination
32 In an innovative move to counteract the health worker brain drain,
urbanisation and loss of doctors through recent armed conflict
(in Liberia), the Ministries of Health in two sub-Saharan African
countries, Liberia and The Gambia, have given the go-ahead to
three UK based international medical charities to train midwives to
safely perform emergency obstetric surgery, such as Caesarean
sections and to train nurses to give anaesthesia and provide high
dependency care. Once trained, these health workers will work
together in rural areas to improve emergency obstetric and newborn
healthcare, and so help to save mothers’ and babies’ lives.
On behalf of MOA, Dr Tei Sheraton says: “As a consultant anaesthetist
in Aneurin Bevan Health Board in South Wales and chair of trustees
of MOA I am convinced that this partnership and project will impact
on MDG 5 and improve quality of life for families in these countries in
a sustainable way. We are actively seeking volunteers and funding.”
Professor David Southall of MCAI says: “Lack of suitably trained
Healthworkers in health facilities in poorly resourced rural areas of
Africa is, in our experience, the main obstacle to improving maternal
and neonatal healthcare. This project will be the first time that
midwives have been trained to undertake emergency surgery and
nurse anaesthetists trained to provide emergency care for newborn
infants who have life threatening illnesses.”
*This programme is supported by the Global Initiative for Emergency and Essential
Surgical Care of the World Health Organisation, Geneva, as well as by the WHO in
both countries.
For further information, please contact Professor David Southall
davids@doctors.org.uk
33 31/07/2012 15:23
Particles
Bart Van Rompaey, Monique M Elseviers, Wim Van Drom, Veroique Fromont
and Philippe G Jorens
The effect of earplugs during the night on the onset
of delirium and sleep perception: a randomized
controlled trial in intensive care patients
Frédérique Schortgen et al
Critical Care 2012; 16:R73 doi: 10.186/cc11330
Fever Control Using External Cooling in Septic
Shock, A Randomized Controlled Trial
Background
Delirium has a fluctuating course and is characterised by shifting attention,
disorganised thinking and changed level of consciousness. It has been called the
“sixth vital sign”.1 The risk factors for delirium can be subdivided into four domains:
patient characteristics and chronic pathology which are pre-existing; while
environment and acute illness are potentially modifiable.2 Patients have perceived
sleep quality to be significantly poorer on the ICU than at home.3 Acutely ill
patients on ICU have fragmented sleep with more arousal and awakenings,
resulting in decreased or absent rapid eye movement (REM) sleep. The circadian
rhythm is distorted with half of total sleep time occurring during the day. Arousals
and awakening are due to sound peaks rather than the level of background noise.4
Reduced REM can lead to psychological symptoms such as depression, confusion,
hallucinations and memory impairment. A lack of non-REM sleep reduces growth
hormone secretion; resulting in immunosuppression and slower healing.5
American Journal of Respiratory and Critical Care Medicine 2012 May
15;185(10):1088-95.
Rationale
Sepsis is a common syndrome requiring ITU admission; two-thirds of patients
have a fever (≥38.3oC). Surviving sepsis is largely dependent on the course of
cardiovascular function. While fever control in the ITU is widely used, there is
little evidence to support this intervention. External cooling decreases the time
to normothermia without exposing the patient to antipyretic drugs. Short-term
fever control decreases cardiac output and oxygen consumption while increasing
vascular tone and lactate clearance. Fever may strengthen host defences, inhibit
microorganisms and increase survival. To determine whether external cooling
is of benefit to ITU patients with early septic shock, a multicentre randomized
controlled trial (“Sepsiscool”) was conducted.
Methods
Eligible adults were those admitted to ITU with a fever, signs of infection and
who required ventilation, sedation and vasopressor (Noradrenaline / Adrenaline)
support. Central randomization assigned patients in a 1:1 ratio to external cooling
or no external cooling groups. External cooling was used for 48 hours to maintain
normothermia. Vasopressors were weaned using an algorithm to a target MAP of
≥65 mmHg. Cooling was achieved by the use of automatic cooling blankets, icecold bed sheets and ice packs, according to usual practice at each centre. Severity
of septic shock was assessed using SAPS and SOFA scores. The primary endpoint
was the number of patients with a 50% decrease in vasopressor dose after 48
hours. Secondary endpoints were assessed at 2, 12, 24, and 36 hours. Additionally
vasopressor dose increase within 48 hours, patients with shock reversal in the
ICU, change in SOFA score, and all-cause mortality on day 14 and at ITU/hospital
discharge, were reviewed.
Results
200 patients were randomised, 101 into the cooling group and 99 into the
non-cooling group, 5 were removed from the study after randomisation; 70%
had pneumonia. Vasopressor doses were similar in each group however, the
cumulative dose was higher in the non-cooled group (0.5 vs 0.65mcg/kg/min
i.e. in an 80kg patient, 2.4mg/hr vs. 3.1mg/hr). Similar requirements for adjuvant
therapy and paralysis were seen in both groups and no rebound warming was
observed. A 50% reduction in vasopressor therapy was significantly greater in the
cooled group from 12 hours (absolute difference, 34%; 95% CI 21-46%; P0.001);
but not at the primary endpoint (48 hours). Shock reversal was more common
in the cooling group (absolute difference 13%; 95% CI,2-25%).14 day mortality
was higher in the non-cooled group ( OR 0.36; 95% CI 0.16–0.76), however this
benefit was not continued until discharge.
Discussion
This study failed to show a significant shock reduction at 48 hours. Cooling seemed
to have the greatest effect in those requiring the most support. It is noted that
the post randomisation but pre-treatment baseline Adrenaline and Noradrenaline
requirements were lower in the cooled group. The early benefits seen in the
cooling group may be explained by reduced O2 consumption, reduced total
vasopressor dose or reduced exposure to another negative side effect of fever.
Failing to sustain early benefits maybe attributable to delayed side effects of
cooling, a non-significant increase in nosocomial infections was reported.
Study weaknesses
The authors note several study weaknesses; blinding was impossible, cooling was
performed using different methods and early life-supporting treatments prior to
inclusion were not documented and choice of vasopressor was not expanded.
Much of the beneficial effect of cooling may be explained by the reduced illness
severity in the cooling group prior to intervention. The majority of patients in this
study were suffering from chest sepsis; control may depend on the source and site
of infection
Sebastian Bourn
S E Scotland
By changing patients’ environment, this study attempted to answer two questions:
1. Does the use of earplugs during the night reduce the onset of delirium in
the ICU?
2. Does the use of earplugs during the night improve the quality of sleep in
the ICU?
Methods
136 intensive care patients were randomised to a placebo-controlled trial. They
were aged over 18 years, with GCS>9 and an expected ICU stay of at least 24hours.
The study group used earplugs between 22.00 and 06.00. These earplugs lower the
perception of environmental sound by 33dB (by way of scale the average noise
levels in a busy office are 70dB).3 The researchers performed daily assessments
and were blinded to the use of earplugs. Delirium was assessed with the validated
Neelon and Champagne Confusion Scale (NEECHAM) which has four grades: nondelirious, at risk, confused or delirious.6 Sleep perception was assessed with five
non-validated questions. Data was also collected on patients’ demographics, SAPS
3, SOFA, RIFLE, TISS 28 and use of SLED.
Results
The two groups were matched apart from the earplug users being more likely to
be professionally active and having their first admission to ICU. The study group
were also observed for longer because no further observations were made once a
patient was delirious. The patients wearing earplugs had lower mean NEECHAM
scores than controls (p=0.04) and more were cognitively normal (p=0.006). The
rates of delirium were similar (19% and 20% respectively), but more patients in
the control group were mildly confused. Combining delirium and mild confusion,
the rates were 60% and 35% respectively. Of those patients who developed
confusion, those who slept with earplugs became confused later than those who
didn’t (p=0.006). After the first night, more of the patients with earplugs reported a
better night’s sleep (p=0.042).
Discussion
This study points to a relation between environmental sound, sleep perception
and delirium. The majority of patients who declined to join trial were women
who wished to remain in direct contact with their environment. The incidence
of delirium in the control group is similar to that found in van Rompaey et al
2009.6 However, the proportion of patients with confusion is much higher than
in the previous study (40% v 24% respectively). The improved perception of sleep
replicates the results of Scotto et al’s study which used a validated scale.5
Conclusion
Earplugs reduced the risk of delirium or confusion by 53% (HR 0.47, CI 0.270.82). They are a cheap and easy tool to improve patient’s comfort and to prevent
confusion
Dr Lynn Fenner
ST5, Bristol School of Anaesthesia
References
1.
Van Rompaey B, Elseviers MM, Van Drom W et al.The effect of earplugs during the night
on the onset of delirium and sleep perception: a randomized controlled trial in intensive
care patients. Critical Care 2012; 16:R73.
2.
Van Rompaey, Elseviers MM, Schuurmans et al. Risk factors for delirium in intensive care
patients: a prospective cohort study. Critical Care 2009; 13:R77.
3.
Freedman NS, Kotzer N and Schwab RJ. Patient perception of sleep quality and etiology
of sleep disruption in the intensive care unit. Am J Respir Crit Care Med 1999; 159:11551162.
4.
Gabor JY, Cooper AB, Crombach SA et al. Contribution of the intensive care unit
environment to sleep disruption in mechanically ventilated patients and healthy subjects.
Am J Respir Crit Care Med 2003; 167:708-715.
5.
Scotto CJ, McClusky C, Spillan S and Kimmel J. Earplugs improve patients’ subjective
experience of sleep in critical care. Nurs Crit Care 2009; 14:180-184.
6.
Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM et al. A comparison of the
CAM-ICU and the NEECHAM confusion scale in intensive care delirium assessment: an
observational study in non-intubated patients. Critical Care 2008; 12:R16.
Victor and the Last Gasp
Brace yourself for what many readers
– I hope – will see as bad news.
This is the last outpouring of expletive-laden invective that I will offer for publication to the fragrant
editor of this estimable organ for some time. Fear not, gentle reader, this is not by occasion of ill
health, insanity or substance abuse, although our chosen specialty takes us perilously close to
all three on a regular basis. It is the indirect result of my unexpected elevation to the ranks of the
“Great and the Good”, in that I have been selected to be the next Non-Playing Captain of the
East Sheen Golf Club. The two-year term of office carries with it both rights and responsibilities.
I must therefore balance the unalloyed joy that I feel both wearing the
medal of office and seeing the framed portrait of me that will hang
evermore on the oak-panelled wall of the clubhouse, against the
restrictions placed upon me in terms of what I can and cannot say
in public print or utterance. My customary output of verbiage must
therefore be limited to matters pertaining to the game of golf in general
and to that form of the game played by the members of the East
Sheen Golf Club in particular. As the golf club feels itself not to be
competent to comment on medical matters, I am barred from saying
anything about the NHS or anaesthesia except and unless such
comments have a direct bearing on golf in South London – a highly
unlikely alignment. I hope you will therefore allow me One Last Gasp
as I deliver a short farewell sermon on the theme of the growing idiocy
of the modern NHS and its sad effects on doctors.
One of my junior consultant colleagues, a delightful young woman
with the sort of German accent usually heard only in 1960s action films
starring Robert Vaughan and Richard Burton, approached me recently
and politely told me that she needed to teach me how to wash my
hands. At first, I thought that I had misheard her, so I asked her to
repeat herself.
“I must teach you to vosh your hands”, she said, “and zen
I must teach you how to insert ein intravenous cannula”.
Although she did not actually say: “Resistance is Useless”, this was
very much implied in the tone of her voice. In the normal way of things,
she would then have been the target of a formidable salvo of Victorian
indignation and ire but, for reasons that I could not fully explain at the
time, I did not vent at her at that time. I quietly followed her into her
office and allowed myself to be subjected to “mandatory training” as
ordained by my Trust.
All was going well until we approached the part of the tutorial in which
I had to detail the procedures for which I should wear sterile gloves
and those for which I could wear non-sterile gloves. I read down the
“sterile glove” list and stopped abruptly when I found to my surprise
that these are to be considered compulsory when performing a pelvic
examination. Although I have as little as professionally possible to do
with this particular part of the human form, I am well enough aware
that the pelvic floor of even the most hygiene-orientated member of
civilised society is about as bacteriologically sterile as the gusset of a
Kalahari bushman’s leather thong after a particularly long jog across
a baking desert. At this point, something inside me snapped, and I
launched into one of my more customary tirades against my poor
young colleague. I will not go into the details of what I said, but suffice
it to say that I pointed out in no uncertain terms that I felt I did not need
teaching to do things that I had been doing with great success for
considerably longer than she had actually been alive, and that should
she at any point feel the need to tutor me in air-breathing, bottomAnaesthesia News September 2012 • Issue 302
wiping or egg-sucking, could she please first stick her head in a vat of
liquid pig’s ordure until the feeling wears off. However, I soon desisted,
struck suddenly by the awful realisation that the fault actually lay with
me, for I had for an instant actually entertained the idea of sitting
mutely while being taught how to do these perfectly simple things
of which I was already fully capable, because I had started to enter
a state that I have spent the last 10 years railing against: the dumb
acquiescence that our masters appear to seek to drive us towards
with their mandatory this, compulsory that and re-education in the
blindingly obvious. As my last gasp, I therefore implore you not to
accept the many stupidities that are being foisted upon you, of which I
will spare you all examples bar one of the legion in my files:
Bare below the elbow: how can the wearing of wristwatches be a
mortal threat to patients’ lives when wedding bands and wrist bracelets
of religious or cultural significance are permitted? Even dafter in the
face of the draconian enforcement of the bare-below-the-elbow rule is
the lack of a similar ban on the filthy name badges that dangle from the
ancient and highly septic lanyards slung around our necks. I am sure
that if you wiped the average “access permit” and the aforementioned
bushman’s gusset across a couple of agar plates, you would be hard
pressed to tell the difference between them a day later when the many
filthy colonies of bacteria coalesced over the surface of both plates.
Brothers and sisters in Anaesthesia: rise up against your oppressors
and just say ‘no’ to silly rules that are imposed without any credible
evidence to support them. Use the intelligence you were born with
and the scientific discipline you learned during your medical training
to oppose the inexplicably mandatory, the nonsensically compulsory
and the downright silly. You may be worried about the risk of the oftthreatened disciplinary action used to coerce you into toeing the party
line, but imagine the scene in court when your Chief Executive has
to explain to a learned judge why you were suspended because you
took a hot cup of coffee into an empty anaesthetic room. If this ever
happens – and I will bet you my Captain’s medal that it never does - I
strongly suspect that you will not be the one who ends up without a job
or an ounce of remaining credibility.
We may think that we live in a time in which we should worry most
about our salaries and our pensions, but mark my words when I tell
you that the thing we should fear most is our descent towards the
abject and dumb acquiescence into which it is so tempting to drift.
Once we no longer question authority and fight folly, medicine is truly
lost as a profession. But that is enough from me while I devote myself
to high office and its associated duties. I have offered the editor a
series of monthly articles on the nuances of the niblick, the wonders
of the wedge and the delights of the driver but – strangely – she has
turned me down, so you will have to do without me and my trenchant
views for a couple of years.
Keep well,
Victor
35 31/07/2012 15:23
your
Dear Editor,
Tattoos - giving spinals a bad name
Much has been written in recent years regarding the safety implications of
parturient lumbar tattoos on neuraxial anaesthesia/analgesia1-4.
Another topic, the importance of which is being increasingly recognised,
is the non-technical aspect of anaesthetic practice, including controlling
theatre environment and distracting influences – particularly during
potentially high-pressure and emotive procedures such as emergency
caesarean sections.
We would like to highlight the case of an unusual lumbar tattoo in a
parturient causing potential distraction to the anaesthetist performing
spinal anaesthesia in an emergency obstetric situation.
A 27 year-old (70kg) para 1 lady developed a footling breech presentation
and was moved to theatre with a view to immediate delivery.
After focussed discussion with the obstetric consultant, it was decided
that spinal anaesthesia in the right lateral position was appropriate (the
patient was unable to sit due to foetal lie), and vaginal delivery would be
attempted in the first instance.
After rapid transfer to the operating table, venous access, and application
of monitoring, our patient’s lumbar region was exposed to reveal a large
tattoo spelling out the (uncommon) Christian name of the anaesthetist
performing the block. We later discovered that the name also belonged to
our patient’s partner.
As is often the case with pictorial tattoos, the patient’s anatomical midline
did not correspond to the middle of the tattoo. This tattoo consisted of
five letters and the patient’s anatomical midline was located at the second
rather than the third letter.
Spinal anaesthesia was performed expediently and provided excellent
analgesia. The vaginal delivery was successful and our patient was delivered
of a healthy baby boy. She was able to leave hospital the following day.
This case illustrates two important potential safety implications for the
parturient with a name tattooed on her lower back.
Firstly, name tattoos which may appear to have an obvious midline, may
not in fact correspond to the anatomical midline, and may contribute to
needle malposition. We therefore, do not recommend using lumbar name
tattoos as a guide to the anatomical midline, as has been described in
recent literature5.
Letters
Dear Editor,
Dear Editor,
Incorrect gas delivery
Recovery bedspace number amnesia
We wish to report a problem we encountered with an anaesthetic
machine. At short notice, we were asked to take over a list that was half
way through. We started with the next case, a 68 year-old lady for a total
thyroidectomy. The patient was anaesthetised in the anaesthetic room
and taken into theatre. The patient was connected up to the breathing
circuit on a Penlon Prima SP2. IPPV with sevoflurane, oxygen and air was
commenced.
I get it, you get it, well all get it. You phone the recovery room for a bed space,
get allocated a number and set off. Half way there uncertainty descends with
‘what bed number was it? Was it 6, or 11 or did we get one at all? Did anyone
phone?’ This is Recovery bedspace number amnesia (RBNA) - an inherent,
inevitable and as yet untreatable condition that is coded in our anaesthetic
DNA. The suggested bed numbers are always wrong and no-one is immune.
It was noted that the end-tidal volatile reading was higher than expected
and end-tidal nitrous oxide was being detected.
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News at
anaenews.editor@aagbi.org
Please see instructions for authors
on the AAGBI website
Dear Editor,
Hydrogen
Stop, check, proceed
We would like to report a near miss incident caused by an unknown foreign
body found in a 5ml syringe after aspirating heavy bupivacaine.
A very fine foreign body measuring approximately 1mm in length was found
floating in a 5 ml syringe after aspirating heavy bupivacaine. The syringe
in question was part of a custom pack put together by the manufacturer
Pajunk. A 5 micron filter supplied in the pack was used to aspirate the local
anaesthetic, hence the chances of the foreign body coming from the local
anaesthetic ampoule is none. Therefore, we suspected that foreign body
must have been in the syringe per se or inside the filter.
As the syringe was thoroughly checked by the anaesthetist before injecting
intrathecally, no harm was done.
Lithium
On closer inspection it was discovered that the air and nitrous oxide
flowmeters were incorrectly labelled. This then led to the accidental
delivery of nitrous oxide instead of air. Both the air and nitrous oxide
dial were loose and presumably had both become disconnected and
reconnected incorrectly. The incorrectly- attached knobs were able to
deliver gas flow. I was surprised that this safety feature has been overlooked
in the design of the flowmeters. No harm came to the patient.
Alexandra Day,
Shikha Sarda,
ST3 Anaesthetics, Yorkshire Deanery
1. Mercier J, Bonnet M. Tattooing and various piercing: anaesthetic
considerations. Current Opinion in Anaesthesiology 2009. 22(3):436441.
4
Be
Sodium Magnesium
11
Na
12
Mg
Boron
5
B
Carbon
6
C
Nitrogen
7
N
Oxygen Fluorine
8
O
9
F
Aluminium Silicon Phosphorus Sulfur Chlorine
13
Al
14
Si
15
P
16
S
17
Cl
Neon
10
Ne
Argon
18
Ar
Consultant in Anaesthesia and Pain Medicine
Guys and St Thomas NHS Foundation Trust
Editor: Are your recovery bed spaces numbered and do you ‘book’ them?
Ours aren’t and we don’t…
NHS Uniforms and Workwear policy
References
5. Mavropoulos A, Camann W. Use of a lumbar tattoo to aid spinal
anesthesia for cesarean delivery. International Journal of Obstetric
Anesthesia 2009. 18(1):98-9.
Beryllium
Dear Editor,
Ronan Haughey
StR5 Anaesthesia
4. Kuczkowski M. Labor analgesia for the parturient with lumbar tattoos:
what does an obstetrician need to know? Archives of Gynecology &
Obstetrics 2006. 274(5):310-2.
3
Li
2
He
Dr Michael A Duncan
ST6 Anaesthetics, Yorkshire Deanery
The anaesthetist in this case (author) had recently attended a regional
non-technical skills simulator course available for anaesthetists in training,
where emphasis is placed on minimising potential distractors in stressful
clinical situations in order to reduce error and improve patient safety. This
case illustrates one type of unexpected distractor that is increasingly seen
in the obstetric setting.
3. Douglas M, Swenerton J. Epidural anesthesia in three parturients with
lumbar tattoos: a review of possible implications. Canadian Journal of
Anaesthesia 2002. 49(10):1057-60
Helium
1
H
Secondly, in the (admittedly unusual) event of the tattooed name
corresponding to the name of the operator performing the block, distraction
may be caused at a moment when focus and concentration are paramount.
2. Kuczkowski K. Controversies in labor: lumbar tattoo and labor
analgesia. Archives of Gynecology & Obstetrics 2005. 271(2):187.
However, a workable and practical solution can be implemented with great
ease and some enjoyable learning. I have taken to assigning to each bed
space the element in the periodic table of elements with the corresponding
atomic number. Hence bed 8 is the Oxygen bed, likewise 10 is Neon etc…
The number is usually less than 12 and anyone who needs to recall more
than 20 obviously works in a big foundation trust so you get no sympathy.
A surprisingly large number of ‘early’ elements are directly relevant to
anaesthesia or a specialty near you and it is this that gives the bedspace
its unforgettable unique characteristic that counters RBNA instantly and
permanently. For those that require persuading, the order from 1-20 is
hydrogen, helium, lithium, beryllium, boron, carbon, nitrogen, oxygen,
fluorine, neon, sodium, magnesium, aluminium, silicon, phosphorus, sulphur,
chlorine, argon, potassium, calcium. I have found the resistance to this new
method at the same time minimal and transient, but most importantly, futile.
It’s elementary.
The incident was reported to the MHRA and also we contacted the
manufacturer Pajunk. After an investigation Pajunk concluded that this
incident was an individual isolated event. The particle may have been cut
from a membrane or something else upon aspiring the drug. However,
Pajunk reviewed their quality control and packaging routines and found
to be adequate.
This incident reinforces the importance of vigilance in checking before we
administer any medication.
Dr Anand Jayaraman
Dr Andrew Babu
The NHS Uniforms and Workwear policy1 has had a significant impact
on the medical profession with “bare below the elbows”, becoming the
clarion call of infection control nurses whilst different departments and
professionals adhere to easily recognisable dress codes in a quest to gain
public confidence. Our trust has recently adopted the dress code of red
scrubs in the operating theatres and blue scrubs when venturing outside
the theatre complex, for example when seeing patients on the ward prior
to their operation. We wonder however if sufficient thought has been given
to the impact of such divisions on the mentality of the workforce.
Social experiments conducted by Tajfel and colleagues demonstrated that
arbitrary groups form easily despite having little in common, and once
formed the members will act in the interest of their own group, often at
the expense of the rival faction2. In the original studies, loyalties were
created over the preferences for Expressionist painters; in Stoke Mandeville
theatre coffee room, it appears that divisions are along red and blue lines.
Thankfully attempts have since been made to integrate these newfound
social groups and we remain hopeful that these now ingrained prejudices
can be gradually overcome.
Dr Phil Duggleby, Anaesthetics CT2, Stoke Mandeville Hospital
Dr Marc Davison, Anaesthetics Consultant, Stoke Mandeville Hospital
1. Uniforms and workwear: guidance on uniform and workwear policies
for NHS employers. Department of Health. March 2010
2. Experiments in intergroup discrimination. Tajfel, H. Scientific American
1970. 223; p96-102
37 31/07/2012 15:23
ad1_AnaesthesiaNews10.pdf 11/07/2012 19:29:21
Anaesthesia
Digested
Anaesthesia September 2012
Jaber S, Coisel Y, Chanques G et al.
A multicentre observational study of intra-operative
ventilatory management during general anaesthesia:
tidal volumes and relation to body weight.
Book Review
The Forgettable Girl
By Debbie D’Oyley
iSatchel Publishing, 2011
When I was editor of this publication, I wrote an editorial on
anaesthetists in literature (Anaesthesia News, May 2007),
bemoaning the fact that compared with the more “interesting”
specialties of surgery and psychiatry (among others) there were
very few anaesthetists in books. Now one of our members has
sent Anaesthesia News not one, but two completed novels
with an anaesthetist as the heroine. The first of these is The
Forgettable Girl. Our heroine is Maya, a trainee anaesthetist who
has struck up a friendship with Tina, who has been working as
the departmental secretary for about a year. One night the police
arrive to tell Maya that Tina has been found dead in a suspected
suicide, with a letter addressed to Maya in her pocket….
The novel appears to be self-published, which is a growing
industry. Particularly in the electronic self-publishing world, there
are a number of authors whose books sell well and make them
a decent income, without the hurdle of having to go through
the more traditional channels. Often these authors have been
turned down by mainstream publishers, so it is good there is
another route to take if you believe your work is worthy of a wider
audience. Presumably your first customers are family and friends,
and Dr D’Oyley’s readers must have had great fun seeing if they
could recognise any of the characters.
The down side of self-publishing is there is no editor. These are
the unsung heroes of the traditional publishing industry – their
job is to polish the author’s original ideas into a glittering gem,
and to be an objective eye on whether bits (or characters) could
be cut without losing the essence, or whether other bits may
need expansion. More prosaically, they check and correct the
grammar, spelling, and act as an extra layer of proofreading.
Dr D’Oyley’s book does betray the lack of a separate editor at
some points – confusing discrete and discreet, and wander and
wonder, for instance, but self publishing must be much harder
work for the author without the luxury of knowing an editor will
pick up these issues.
Many of us feel we have a book in us, but never manage to put in
the number of hours to actually write it. Debbie D’Oyley is to be
commended for having the imagination and determination to see
it through, rather than just having a vague idea that it might be a
good thing to do one day.
Hilary Aitken
This paper describes ventilation settings at the start of 2960 scheduled and
emergency operations. The authors consider their results in the knowledge
that patients with ARDS are killed by a tidal volume of 12 ml.kg-1 compared
with 6 ml.kg-1 predicted body mass. In the first report of the UK emergency
laparotomy network, mortality was 15% in the first postoperative month,
compared with 40% and 31% in the ARDS study. Once consultant-delivered
care and postoperative ICU admission have reduced mortality, do you think
that an RCT of intraoperative 6ml.kg-1 vs 12ml.kg-1 in 1700 emergency
laparotomies might reduce mortality from 15% to 12%? In Jaber et al.’s paper,
high tidal volumes were more common in the obese, women and patients having
laparoscopies, whilst PEEP was used in only 19% of cases.
C
M
Hudson J, Nguku SM, Sleiman J et al.
Y
Usability testing of a prototype Phone Oximeter with
healthcare providers in high- and low-medical resource
environments
The AAGBI, the WFSA and medical celebrities, such as Atul Gawande, are
working to fulfil the aim of the Lifebox charity: to provide a pulse oximeter
wherever it may save lives, supported by education, training and peer help. Why
not then have a pulse oximeter that allows you to speak with other doctors,
view training videos, or that helps your peers to help you, by streaming footage
of your current clinical conundrum? Enter the ‘Phone Oximeter’, 21st century
technology tested in the heart of Africa. Hudson et al. report on how usable
their consumers found this current iteration of an extremely promising venture.
CM
MY
CY
CMY
K
Paul RG, Bunker N, Fauvel NJ, Cox M.
The effect of the European Working Time Directive
on anaesthetic patterns and training.
“When I were a lad, I worked harder and longer than you can possibly imagine.
Trainees today – they don’t know they’re born.” I started 1999 as the equivalent
of an ST 5 and finished an ST 6. This paper assessed whether I worked more
than those of you who trained in 2009, after the EWTD. We both would have to
assume that the Chelsea and Westminster’s experience represented the hospitals
where you and I worked. Well, maybe I did work harder than you, maybe I
didn’t. I was at work more than you, in stark contrast to the SHOs in 1999 who
were always away ‘studying’. I was surprised I only did 26 solo lists in 6 months
– did you really only do 3? Supervision for trainees as a whole has increased, so
even if I did work harder and longer than you, maybe I didn’t work smarter. The
accompanying editorial puts the findings of this paper in the broader context
of a decade’s changes. Cooper & Cooper go on to describe you as “intelligent,
well-motivated and knowledgeable”, an assessment with which I agree wholeheartedly, having worked with excellent trainees in Torbay.
J.B.Carlisle,
Editor, Anaesthesia
31/07/2012 15:23
Anaesthesia NewsSept2012 FINAL.indd 40
31/07/2012 15:23

The anaesthesia workforce: problems, ideas and solutions AAGBI

Transcription

Similar documents

Pet Birds Fact Sheet - Southcrest Veterinary Centre

terapia intensiva neurochirurgica in inglese - ordine

party for a living

AoA August 05

this document

2015 Spring

State of the ART Katherine Horner, Joanna Allam, Nazril Nordin and

Anaesthesia