anaesthesia annual congress in dublin

Anaesthesia News Decemberr 2007 Issue 245 �

The Newsletter of the Association of Anaesthetists of Great Britain and Ireland. ISSN 0959-2962

21 Portland Place, London W1B 1PY, Tel: 020 7631 1650, Fax: 020 7631 4352, Email: [email protected], Website: www.aagbi.org

AnaesthesiaNews No. 245 December 2007

Annual Congress in Dublin

Adolf Baeyer’s contribution

to anaesthesia

Dr Ruxton is lost for words

� Anaesthesia News December 2007 Issue 245

Anaesthesia News December 2007 Issue 245 �

AAGBI Congress continued its tour of the constituent nations (Wales 2004, England 2005, Scotland 2006) by taking place in Dublin between 12th and 14th September 2007. Conscious of increasing pressure on study leave, Congress this year was held over three days, rather than the more traditional four.

Following opening remarks by the President, David Whitaker, we were entertained by a spirited demonstration of modern and traditional Irish dancing that left the GAT Chairman quite hot under the collar; and he was only watching from the front row!

The meeting proper commenced with the Intavent Orthofix Lecture, given this year by Professor Takashi Asai from Kansai Medical University, Japan. Tak delivered an overview of “Anaesthetic strategies for known difficult airways”. He highlighted the limitations of current methods of predicting difficult airways, the absence of evidence-based strategies for approaching them, and a reliance on “mechanisms”, and ended with a plea for large collaborative studies. The author was particularly impressed when he considered how he might have performed giving a similar lecture in Japan – in Japanese!

After lunch, and a first spin round the Industry exhibition, Congress resumed its popular “three-ring” circus format, with session on obstetrics, TIVA and OSA/Non-invasive ventilation. Members who wonder why their home town has not been chosen to host Congress may not realise that we are victims of our own success: within the UK and Ireland there are relatively few venues that can accommodate simultaneously three lectures for the numbers we now attract, plus workshops and the industry exhibition. New venues are sought constantly; if you know of one, please contact the Events team at Portland Place.

The first day concluded with a visit to the Guinness Storehouse, sponsored by GE Healthcare. Anaesthetists with their known interest in physics and pharmacology were delighted to combine both, and to enjoy unrivalled views over night-time Dublin.

It was a delight to welcome so many local delegates. Record numbers registered on the day, and the Events team worked hard to process them all – nearly 100 on day one! It was also pleasing to have so many speakers from

Annual Congress – Dublin 2007

Irish dancing at the opening ceremony

Contents

03 Annual Congress – Dublin 2007

06 President's Report

08 Editorial - Something of the night…

13 SAS Page - After the contract – where now?

14 GAT - So Your Department has got a Foundation Year One Doctor...Now what are you going to do with them?

17 Scoop - Future is CRAP for NHS trainees

18 Seminars

22 Regional Anaesthesia Fellowship in sunny Perth

24 Dear Editor…

27 The History Page - Adolf Baeyer and his contributions to local anaesthesia

30 Distinction Awards in Scotland

31 Nuffield Department of Anaesthetics 70th Anniversary

33 The ethical dilemma for International Medical Graduates

36 Dr.Ruxton

The Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: [email protected]: www.aagbi.org

Anaesthesia NewsEditor: Hilary AitkenAssistant Editors: Iain Wilson, Mike Wee and Val BythellAdvertising: Claire Elliott

Design: Amanda McCormickPips Design, Telephone: 01604 642263Printing: C.O.S Printers PTE Ltd – SingaporeEmail: [email protected]

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Professor Michel Struys presents the Draeger Medical Lecture

Royal Dublin Society

the Republic and Province, now able to enjoy the College of Anaesthetists, RCSI in Merrion Square.

Over three days there were 50 lectures, 20 workshops, 7 case discussion groups and three

main plenary lectures; something for everyone. It would be invidious to mention highlights (as well

as impossible to have attended them all!) Undoubtedly the Question Time featuring the great and the good of anaesthesia from both sides of the Irish Sea provided a popular opportunity to find out what was really going on in our specialty at the moment, and in particular President of the Royal College of Anaesthetists Judith Hulf’s insights into Modernising Medical Careers and the Tooke Inquiry were received keenly.

Congress does not “just happen”. The planning starts years in advance with groundwork by the Events Committee, led this year by Chandra Kumar. This culminates in frantic activity in the days and weeks beforehand and almost full deployment of the staff from 21 Portland Place. The Local Organising Committee, headed this year by Ellen O’Sullivan, can be justly proud of their effort. The support provided by the exhibitors from Industry, particularly those who sponsored speakers and

sessions is vital in underwriting the

costs of meetings such as this.

AAGBI is grateful to all of them, and it was good to see so many delegates touring the display stands and engaging with them.

The Annual General Meetings of the Association of Anaesthetists and the Education and Research Trust took place in series rather than parallel on Thursday afternoon, and in record time; less than 25 minutes all in!

Professor Michel Struys of Ghent University Hospital followed with the Draeger Medical Lecture entitled “Optimising drug delivery in anaesthesia. Once again the author was intimidated by the quality of someone delivering such a cogent talk not in his native tongue. His description of real-time, effect-based feedback systems to optimise anaesthesia delivery, and possibly reduce costs demonstrated how far the specialty has come from the open drop technique.

Thursday concluded with the Annual Dinner and Dance, held this year in the quite stunning setting of the Royal Hospital,

A N N UA L C O N G R E S S - D U B L I N 2 0 0 7


Kilmainham. Excellent food and company was followed by an exuberant band and dancing which may have equalled the enthusiasm of the dancers at our opening ceremony, if not quite matching their skills.

Friday saw three final sessions, with another popular closed session featuring AAGBI’s own “luvvies” (Drs Harrop-Griffiths and Aitken) in a seven act play “wot William wrote” which

gave an opportunity to discuss the problems caused by a poorly performing surgical colleague, with excellent contributions from the floor as well as comment from a panel of AAGBI “experts” (declaration of interest; the author was one of them).

Congress concluded with the Awards Ceremony, when the Association honours those who have made, and continue to make, huge contributions to our specialty. The final speaker, Dr John Hillery, President of the Medical Council of Ireland and now Chair Designate of the International Association of Medical Regulatory Authorites, presented the John Snow Lecture. His analysis of the development of self regulation, and the relative roles of the doctor, the patient and society over the last 150 years left many of us wondering “Would John Snow flourish in the 21st Century environment?”

In his closing address Professor Denis Moriarty reminded us that it was 30 years since AAGBI Congress had been in Dublin; on the basis of the previous three days we should not leave it as long to return.

Andrew HartleCouncil Member, AAGBI

Judging the posters

A N N UA L C O N G R E S S - D U B L I N 2 0 0 7

President's ReportDecember 2007


P R E S I D E N T ' S R E P O R T

It has been a busy autumn and often difficult to concentrate on the Rugby World Cup. NCEPOD launched its latest report ‘Emergency Admissions: A journey in the right direction?’1. Emergency care of patients is the primary duty of the National Health Service and so this is a particularly important report. One finding is that many consultant physicians and surgeons have up to five conflicting duties in their job plans when they are ‘on call’ and Professor Alberti, the self proclaimed ‘Trolley Czar’, said at the launch he wishes to see this corrected. Anaesthesia successfully fought this battle many years ago and for the patients’ sake we should help our colleagues to do the same.

All who attended the Annual Congress in Dublin will know what a great success it was and congratulations to all involved. Amongst the generous hospitality offered was a reception at the College of Anaesthetists, RCSI headquarters in Dublin’s Merrion Square. This is a fine Georgian building undergoing careful restoration and during the evening the College presented the AAGBI with a magnificent Waterford Crystal Rose Bowl to mark the occasion. Our next meeting, WSM London (16 -18th January 2008) promises to be equally successful.

I would encourage as many of you as possible to support the programme and attend. Any one who has never been to a WSM at the magnificent QEII Conference Centre, adjacent to Westminster Abbey and the Houses of Parliament is missing something.

The effective closing date for finalising national ACCEA application forms in many English Trusts has now passed but in the coming months many Trusts will be processing their employer-based awards. I urge every anaesthetist eligible to submit a local form and refer to the article on page 22 in November’s Anaesthesia News. A joint AAGBI / College presentation on ACCEA is available from Linkmen and on the website. The sooner you start applying the sooner you will be successful.

Our campaign on parity continues unabated and recently a number of consultants have received a letter from Netcare / BMI offering work treating NHS patients in non-contracted hours under the Extended Choice Network (ECN) in their local independent hospitals (copies available from the Honorary Secretary, AAGBI). All this NHS work will be covered by the CNST, as AAGBI have

always recommended, and Netcare are offering fees based on an equal hourly rate to both surgeons and anaesthetists. Netcare is now the largest national provider in the independent sector and for them to offer parity in this way is a very significant and welcome step. There is now absolutely no justification for any anaesthetist elsewhere to do such NHS work without parity being similarly agreed advance. The allocation of times by Netcare for some of the procedure fees mentioned is not entirely appropriate but most importantly the parity principle has been agreed and these times can be corrected. Well done to everyone who has helped convince Netcare to do the right thing and let us hope parity is now rapidly implemented by all the other outstanding providers in the country.

In the recent government spending review, it was announced the NHS budget is to increase by about 4% over the next few years. This is seen as a reduction from the 7% increases over the last 5 years designed to bring the NHS budget up to the European average. However the money available to actually spend on direct patient care (as distinct from the headline budget) should be about the same. 2% per year of the 7% increase for


P R E S I D E N T ' S R E P O R T

the last five years has only been a staged transfer of the NHS pension budget from its previous home in the Treasury into the main NHS budget. None of this was ever new money to be spent on patient care and was a purely paper exercise that is now complete. Following critical analysis the ISTC programme has even lost favour with the Department of Health (DoH) with the present wave two curtailed and wave three cancelled, so another 1-2% is similarly not required.

In 2008 a new Companies Act comes into force and there are also alterations to the charity law. Both of these will require changes to be made to the AAGBI and Education and Research Trust constitutions. Council and Executive will be working on the details of this in the coming months and will present the necessary adjustments to the membership at the appropriate time.

Sir John Tooke’s 192-page draft report ‘Aspiring to Excellence’ was published on 8th October2, and his panel have taken on board many of the comments made by

the profession and produced a thoughtful document containing much information about medical training including around the developed world. His line “good enough is not good enough” promises to be a much quoted expression in the future. The consultation period ended on 20th November and AAGBI comments are available on our website.

In October’s Anaesthesia News I referred to the Public Administration Select Committee report on the DoH and other government departments3 . Sir John has effectively taken a biopsy of the DoH and its policy-making mechanisms, accountability structures and governance and risk management processes in connection with medical training. Many of his recommendations however e.g. about piloting new proposals, using evidence, and consulting properly could equally apply to ISTCs, the Information Technology programme and the Private Finance Initiative, all of which are also now being rethought. As patients and taxpayers, let alone doctors we should

all be concerned. Modernising Medical Careers (MMC) is now such a contaminated title that it should probably be replaced; one suggest ion at recent meeting was New MMC, but perhaps not. To aid the process we have decided to offer a free AAGBI dinner voucher for WSM or Annual Congress 2008 to the member offering the best suggestion to the Honorary Secretary by 6th January 2008. ([email protected])

The AAGBI Christmas Card, based on a painting by member Aleks Bojarska and sold in aid of our charity the Overseas Anaesthesia Fund, is still available (see advert on page 11, download an order form from the AAGBI website www.aagbi.org, or just make a donation).

With the MTAS catastrophe and thousands of doctors marching on the streets in London and Glasgow crowning this year’s NHS problems, 2007 has been an Annus Horribilis for the medical profession and its patients so please accept my best wishes for a happy and peaceful Christmas and a much better 2008.

David Whitaker

References:

1. www.ncepod.org.uk

2. http://www.mmcinquiry.org.uk/draft.htm

3.http://www.parliament.uk/parliamentary_committees/public_administration_select_committee/pasc0607pn48.cfmJohn McAdoo, President, College of Anaesthetists, RCSI presents the Waterford rose

bowl to David Whitaker


E D I T O R I A L

What’s the least favourite aspect of your job? For most of us, at whatever stage in our career, it will be the nights on call. It’s so much a part of our lives I suspect most of us don’t even notice the impact it has – it’s just normal that you can’t accept any invitation until you’ve checked the rota.

For older doctors, the issue of night work can become more significant. The AAGBI, in its guideline on fatigue (Fatigue and anaesthetists, AAGBI, 2004) recommends a review of the on call duties of consultant anaesthetists over the age of 55 as they may be less tolerant of night and shift working. This has been interpreted in some quarters as giving anaesthetists in this age group “the right” to come off the rota. Sadly, no such right exists for most of us. However, a number of factors have made it easier to at least examine the possibility.

The 2003 contract, which is time sensitive, allows a fair calculation of any doctor’s hours of work. One of the thorny issues in the past was if agreement was

secured to allow a more senior colleague to come off the rota, what was it worth? One extra daytime session? Two? A reduction in pay? If so, how much? All this could increase resentment of the colleagues remaining on the rota if an arrangement was felt to be inequitable. Now it’s a straightforward diary exercise.

In addition, the increase in out of hours workload means that novel arrangements can be considered to allow senior colleagues to contribute without doing night work. My own hospital, staggering under a tidal wave of trauma for some time now, has managed to arrange daytime trauma lists on Saturday and Sunday. The five most senior consultants do a one-in-five trauma weekend, which is no sinecure, in exchange for dropping out of night work. This has made a huge difference to the weekend workload of those who remain on the main rota. My senior colleagues tell me that going home knowing you won’t be called back is wonderful – and frankly, most of us need a stiff gin after a day in trauma, which is now possible for them.

There has been a lot of chat on various website fora about this issue. I repeat, there is no recommendation by any organisation that consultants should stop doing on call after 55. In Wales, which seems to have a more civilised contract in a number of areas, there is a section which states that those in their mid-fifties may have a case for coming off on call. In practice, my mole tells me, this is only refused if the departure would leave the rota in breach of EWTD rules. If you are not in Wales, your department may be happy to simply allow this anyway – if so consider yourself lucky. It is up to individuals to discuss with their colleagues whether this can be managed, or to consider other ways in which they can contribute. Even without trauma lists, could weekends be split into shifts so that the older colleagues do the days? The consultants remaining on the rota might value some free time at the weekend before taking up duties in the evening. There has been some discussion about consultants being present for “twilight shifts” to enhance supervised training opportunities. Our contracts are pretty

Something of the night…

HELP FOR DOCTORS WITH DIFFICULTIESThe AAGBI supports the Doctors for Doctors scheme run by the BMA which provides 24 hour access to help

(www.bma.org.uk/doctorsfordoctors).

To access this scheme call 0845 920 0169 and ask for contact details for a doctor-advisor*. A number of these advisors are anaesthetists, and if you wish, you can speak to a colleague in the specialty.

If for any reason this does not address your problem, call the AAGBI during office hours on 0207 631 1650 or email [email protected] and you will be put in contact with an appropriate advisor.

*The doctor advisor scheme is not a 24 hour service


flexible now, and some lateral thinking may allow you to drop the night work without causing resentment among your younger colleagues – and remember, fatigue isn’t just an age issue. Why is a 55 year old consultant more deserving than a younger consultant with a nocturnal small child which leaves them knackered all the time? The bottom line is somebody has to cover the night work.

There has been some discussion about it being a health issue. My personal feeling is that one should be extremely careful before going down that route. If you are declared unfit to do part of your job, why are you fit to do the rest of it? In the event of a daytime catastrophe, how much mileage would a clever lawyer get out of that?

General Practitioners, of course, have famously managed to lose responsibility for providing out of hours cover. This was a concession of such jaw-dropping significance, it clearly illustrated that the negotiators on the Government side,

to quote Oscar Wilde, knew the price of everything and the value of nothing. (It’s become clear they didn’t even know the price.) It leaves the acute hospital specialties with a potential recruitment problem. I recently took part in OSCEs for third year medical students which brought home to me how much in the majority female students are. (I step onto this very thin ice with great care). Many of these will at some point wish to combine a career with raising children. Do you pick a career where you can choose to limit your out of hours work to that which suits you at a any given stage in your life, or one where you will be expected to pull your weight? Women of my generation didn’t have a choice – on call was part of virtually any medical job, so they just fudged their way through it as best they could. I am supposed to say at this stage that many male medical students may wish to make the same choices, but in the real world it’s the women who do the childrearing and have the problems of finding the balance. We’ve had a couple of female trainees within the last five

years who looked at what we have to do and decided it wasn’t for them. It’s just another factor which may make a career in an acute specialty less desirable.

The Tooke report has just appeared at the time of writing – I will leave it to others to comment more fully, but merely draw your attention to recommendation 32 – doctors in their first year of training will be known as “pre-registration doctors”. A case of back to the future? Mark my words, the senior registrar will be back before I retire!

I wish you all a very Happy Christmas, wherever you are, and may I take this opportunity to thank all of you who have contributed to Anaesthesia News in 2007. Without your contributions, there would be no newsletter, so please keep them coming in 2008!

Hilary AitkenEditor

E D I T O R I A L

�0 Anaesthesia News December 2007 Issue 245

Anaesthesia News Decemberr 2007 Issue 245 ��

AAGBI Christmas CardsSold in aid of the Overseas Anaesthesia Fund

A watercolour painting (illustrated) by Aleksandra Bojarska, an anaesthetist from Manchester, has been selected as the AAGBI 2007 Christmas card, with all profits going to the Overseas Anaesthesia Fund. Many of you will have seen the original which was exhibited in the AAGBI art exhibition in Dublin in September. Aleks painted this while working in Darfur, and it is a view of a mud hut in which anaesthesia and major surgery was performed during her time there.

The cards cost £4.95 for a pack of ten, including P&P. £1.95 will be donated to OAF for each pack sold. To order, photocopy and complete the form below. Forms can also be downloaded from the AAGBI website.

AAGBI Charity Christmas Card Purchase Form

Quantity Cost per pack £4.95

Pack x 10 cards

Additional donation to OAF

Total

Title ……………… Surname ……………………………… First name ………………………..

Address ………………………………………………………………………………………………………………………………………….

Postcode ………………… Daytime phone ………………… Email …………………………………………………..............…………

Please pay by Sterling cheque drawn on a UK bank and made payable to the Association of Anaesthetists

Credit Card (only Visa/Mastercard/Delta); or Switch.

Please debit my credit card (Visa/MasterCard/Delta) or Switch Card:

Card/Switch Number .......................................................................................................................................................................

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Cardholder’s name ……………………………….. Cardholder’s signature ……………………………… Date ……………………..

Return to: Julie Gallagher, Association of Anaesthetists, 21 Portland Place, London, W1B 1PYOr fax: Julie Gallagher 020 7631 4352 Phone: 020 7631 8801 or please email the above details to: [email protected]

The Anaesthetists Agency

safe locum anaesthesia, throughout the UK

Freephone: 0800 830 930 Tel: 01590 675 111 Fax: 01590 675 114

Freepost (SO3417), Lymington, Hampshire SO41 9ZYemail: [email protected]

Society for Education in Anaesthesia (UK) Annual Scientific Meeting

TRAINING TOMORROWS ANAESTHETISTS Monday 17 March 2008

CAVENDISH HOTEL SEAFRONT, EASTBOURNE

Submission deadline 13 February 2008 Posters welcome deadline as above Prize £50

Limited to 100 delegatesCost: £125 for members/£150 for non-members (including

one year membership)

For further details, please contact: Barbara Sladdin, Administrator, Northern School of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne. NE1 4LP Tel No: 0191 282 5081 or email: [email protected] or visit www.SEAUK.org

v Introduction to Assessment tools including the Northern Ireland Experience

v The Educational Landscapev E-Learning – will it workv DEBATE – should all

consultants have their teaching formally assessed by trainees

Plusv Workshops and Free Papers.v Abstracts invited for Free

Papers.v Trainee Prizes of £150 and

£300.

�� Anaesthesia News December 2007 Issue 245


The negotiations for an SAS contract have gone on forever; at least that is how it has felt and alas, in the end, it has come to nothing. We are back to square one. The only good thing that came out of it was that it stimulated some discussion about the SAS Grade and the job structure. What is next and what now? I do not want to dwell into reasons for failure. Life must go on.

Looking at the medical manpower situation in the NHS there seems to be so much uncertainty. MTAS, MMC and all the other initiatives that have been introduced in the NHS have changed so much. It is just not possible to predict where we are heading and what is to be expected. And I am not too sure even the authorities seem to know what is to happen. The situation is evolving all the time.

In a way I am glad that the negotiations have failed. It is better to wait till the atmosphere settles. I believe that there is a need for a non-consultant career grade job in the NHS for several reasons. What form it will take is anybody’s guess.

Trusts cannot rely on trainees and consultants to provide out of hours service as there are not enough of them and the NHS cannot afford to use consultants to fill gaps in the rota - but the service has to be maintained. Not every doctor wants to be a consultant; some prefer to work part-time whilst some are not keen on doing postgraduate exams and yet want to continue in hospital practice. It is likely that not all doctors with CCST will get consultant jobs. Some want to take time out to do research, to go abroad for further experience or to do research. In the present system there is no provision for these.

A large number of SAS doctors working now will be leaving the NHS in the next ten years because of retirement. These jobs need to be filled in some way to maintain the present level of service.

Therefore there is a need for some kind of specialist grade jobs which are not at consultant level. It is a

matter of great concern that Trusts are appointing doctors to Trust grades and research fellow posts, issuing temporary contracts which do not conform to any national terms and conditions. There does not seem to be any regulation or control on the structure of these jobs. The RCoA has no database to monitor these jobs. In addition, there are no definite plans or strategies for employing doctors getting into the ‘Yellow box’ of the MMC. It is important that there is a database for doctors that are appointed to these grades, and the RCoA with its network of clinical tutors is in a good position to obtain these figures.

I believe that there is a need for a specialist grade job similar to those found in the rest of Europe. Doctors who choose to work in hospital practice as specialists should undergo the requisite training and be allowed to practise independently. Or if they choose to get involved in training and teaching they should be allowed to gain further appropriate training to be consultants. Otherwise what is to become of these doctors?

The Association has been awaiting developments with the SAS contract, but is now going ahead with updating its SAS “glossy”. This will include guidelines on terms and conditions to protect the basic rights of SAS doctors and indicate obligations of the employers by issuing some key recommendations, and will also include some model job plans. In association with the RCoA, the AAGBI is attempting to ensure that training and teaching elements are incorporated in all jobs. Members can use these guidelines in negotiation with trusts.

The position at present is indeed confusing and appears to be totally out of control. The Association and the RCoA should try and do something to protect and support these doctors that belong to the same family.

Ramana AlladiChairman, SAS Committee

After the contract – where now?

S A S PAG E

I have recently finished my Foundation Year One (FY1, or house officer year for the non-physician) which included a four month period of anaesthetics in a district general hospital in West Wales. In addition to a suitable medical and surgical job, all FY1 doctors must complete a third block to allow them to broaden their experience, develop extra skills and help them make decisions about their future career direction. I have found my anaesthetics rotation to be hugely beneficial, and would like to share why and how.

An FY1 post in anaesthetics is highly worthwhile, both to the trainee and to the speciality as a whole. When considering career development, the mentality of current FY1 doctors is undoubtedly very different to that of our senior colleagues when they were house officers. Unless changes are introduced, we know that just a year and a half after qualification we will be expected to decide the speciality in which we may be working for the rest of our lives.

Although there is not currently a shortage of applicants for Speciality Training (ST) posts, looking forward a few years this could conceivably change. Anaesthetics seems to be considered a dark art by undergraduate course planners, and unless students take an optional study module or spend an elective period in the specialty, they may never have any contact with it. This, combined with early career decisions, could lead to a lack of talented and interested doctors applying for anaesthetics in the future.

Since rotations are now allocated in one year chunks, you will encounter FY1 doctors who are already very interested in your specialty, as well as those who have not yet even considered it and who chose their rotation because of one of the other jobs in the ‘package’. Hence this is an opportunity to interest those who have not previously considered anaesthetics, and allow those who have to confirm or change their decision.

Even if those doctors who have completed an FY1 rotation in anaesthetics do not continue in the speciality, they will still gain immeasurably from the experience. Whatever direction a doctor’s career takes, it is almost inevitable that at some point they will be responsible in a resuscitation situation. Although all juniors attend Basic Life Support training as undergraduates and an Advanced Life Support or equivalent course early in their careers, these training courses do little to develop hands-on practical skills. When starting my anaesthetics placement I was as inexperienced as most juniors in the use of the bag-valve-mask and airway adjuncts; as I finish I find myself confidently able to ventilate an unconscious patient. The large number of venous cannulations I have performed has also equipped me to deal with those more difficult patients on the ward, as well as the pressured situation of securing venous access during resuscitation.

For those who will enter other hospital specialities, time in anaesthetics allows them to develop important transferable skills and competencies. With the changes in training over

So Your Department has got a Foundation

Year One Doctor...

Now what are you going to do with them?


G AT PAG E

the past decade or so, first year doctors often get very little experience of practical procedures during other rotations. In anaesthetics, routine procedures are commonly performed and trainees will have multiple opportunities to practise them. With willing consultants I have become competent performing spinal anaesthesia - very useful for when a lumbar puncture is required during my next medical job. I have also inserted several central lines, a step along the way to that urgent pacing wire required in the middle of the night.

The final, and perhaps most important, skill which FY1 doctors can gain is confidence in the identification, assessment and initial treatment of the critically ill patient – especially when it comes to fluid management Whilst on a medical firm rotation I felt constantly concerned about patients being fluid overloaded; as an anaesthetist I found out that actually most patients require more fluids. Then there are your ‘ABCs’ - no matter how many times you hear ‘Airway, Breathing, Circulation’, you somehow never manage to put it into practice when faced with your first real emergency. Seeing it performed in practical situations with seniors bearing responsibility, but still playing a role yourself, reinforces the principles in a way lectures and courses never can.

In the modern medical education system no good learning experience exists without the need to prove it. Having FY1 doctors is no exception. The doctor will need to produce

quite large amounts of evidence about the value of their placement. The electronic NHS e-portfolio allows them to record procedures practised, document significant events and reflect on the cases they have seen and done. It is necessary to keep this documentation up to date during the placement in order to avoid a desperate last few weeks. The educational supervisor (usually the supervising consultant) will also have to organise an objectives-setting meeting or appraisal at the beginning, and an assessment at the end of the rotation. Neither of these is particularly onerous if you have been organised with your paperwork, and each should take no more than about 30 minutes.

Taking on FY1 doctors undoubtedly means more work for the department concerned. It is comparable to those first three months as a novice SHO, but with a less experienced doctor who will not be able do any independent work for the department (such as participate in on-call rotas or undertake solo lists) and who may never even work in anaesthetics again. However, by encouraging them to develop practical skills and gain experience with acutely ill patients, you are undoubtedly helping the general patient population; in addition you may even recruit some new blood into the profession.

Dr Nathan TweedFY1 Doctor, Department of Anaesthetics

West Wales General Hospital


G AT PAG E

Updated edition of “Your Career in Anaesthesia” publishedThe GAT Committee has revised and updated the booklet ‘Your Career in Anaesthesia’ in light of the recent changes to medical training. The booklet is primarily aimed at medical students and Foundation doctors considering a career in anaesthesia and/or intensive care. It includes information about the broad range of subspecialty options open to anaesthetists, what the job entails, and details on the structure and flexibility of the training programmes in the UK and Ireland. Also included are the contact details and web addresses of key stakeholders in anaesthetic training. The booklet is available as an electronic version at http://www.aagbi.org/gat/publications/docs/careersguide07.pdf. For those involved in careers fairs or similar events, please contact the AAGBI by emailing [email protected] to obtain copies to hand out.


MESSAGES FROM MERSEYWe are pleased to take this opportunity to wish all candidates of the Mersey Courses

Past – Present – Future

Very Best Wishes for the New Year

These are Hard Times for Anaesthetic Trainees, most of it precipitated by the imbroglio of MTAS and the advent of MMC.

We sincerely hope that things improve on all fronts this coming year and that, as the dust settles, the future becomes that much clearer.

In the meantime, we thank everyone for their Tolerance, Encouragement & Support over the years and trust that we will continue to merit it.

"Finally, on a personal note, a special mention of appreciation of the many trainees from overseas who have been through our courses and who now find themselves deprived of the future for which they have spent so much time, effort and money. I was

embarrassed to be in anyway associated with such a draconian remedy as that applied with so little notice and hope that those who instituted it and those affected by it will eventually get what they respectively deserve."

To All our Alumni & Friends

A Happy and Fulfilling New YearDavid Gray

Director

MERSEY SERIES & WEEKEND COURSESProspective Candidates are invited to consult

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Future is CRAP for NHS trainees

From our correspondent Scoop O’Lamine

Following the dramatic success of MTAS and MMC earlier this year, the NHS has announced that the lessons learned through the computer ranking systems used for applications would allow a new system for career selection known as Computerised Ranking Assessment Procedure.

“We are really excited about this development” explained Lead Dean Prof Otto Tutch. “Young doctors fill in the on-line application and automatically their natural career pathway is selected. The system has been tested on many of the deanery staff and I am pleased to announce that it is now fault-free, ready for August 2008 and will transform career choice and progression. The system eliminates the need for a practical assessment and also interview.”

When pressed for more details the system was explained in more detail, and Mr O’Lamine was allowed to undertake a simulated data entry session identical to the one which next August will select careers for 20,000 trainees.

The system starts by scanning the doctor’s passport photograph and then using advance matching techniques identifies the trainee. The trainee then answers 100 specialist selection questions on personality and interests. There are a wide variety of questions which determine the

underlying suitability of the doctor for certain careers. Examples include: Do you enjoy DIY? Would you like to work with small children? If a lady suddenly had a baby in front of you, would you panic? Do you get bored easily?

The computer correlates the answers, the time taken for index questions, and maps the subject personality, interests and speed of thought.

Following the questionnaire session, the subject has to perform a number of tests of hand eye coordination skills, and then undertake an interactive scenario typing answers to a student nurse’s questions. At some point during the data entry the computer simulates a crash (apparently this was the easiest part of the programme for the MTAS IT designers) and a microphone records the doctor’s reaction.

Prof Tutch explained that the mapping of career choice was performed by innovative software matching all the characteristics. “The algorithms are complex but at it simplest it could be viewed as matching rugby playing, DIY enthusiastics to orthopaedics; short, detail loving, child friendly doctors to paediatrics; those who respond to the computer crash calmly and like IT are suitable for anaesthesia; those who swore to pathology; slow detailed answers we

match to neurology; negative types to radiology. Those displaying a pompous nature to cardiology; anyone requesting a fee to complete the data entry is streamed towards general practice and slightly strange trainees with empathy and patience towards psychiatry. I asked what happened to anyone who could not be matched, and it appears that they are streamed towards education.

“Following on the successes of MTAS, we can now automatically stream doctors from their front room into their career without needing any of the previous, difficult and time consuming shortlisting and interviewing procedures. To illustrate how successful the system is, I recently sent an SHO applying for surgery in Plymouth to Grimsby to work as a neonatologist – now that is success! He does not appreciate it at present, but his Personality Interactive Specialty Score is strong for that specialty, so we are confident he will settle down.”

A DoH spokesman expressed delight and confidence at the revolutionary new system. “We are delighted – this system has been produced by the DoH following the MTAS review, tested by the DoH and will be run by the DoH – what could possibly go wrong?”


S C O O P

My anaesthetic career began six years ago and even in that short time it is hard to miss the increasing interest in and use of regional anaesthesia. With the development of improved nerve stimulator equipment, peripheral nerve catheter kits and the wider availability of ultrasound point-of-care machines combined with documented improvements in pain relief and patient satisfaction, this increase in interest seems set to continue. Therefore, a fellowship in regional anaesthesia is an excellent opportunity to develop a specialist interest and gives what one of my consultants has described as ‘added value’ to your CV. I am currently undertaking such a fellowship at Sir Charles Gairdner Hospital in Perth, Western Australia.

Sir Charles Gairdner Hospital (Charlie’s) is a 550 bed tertiary referral teaching hospital affiliated to the University of Western Australia. It carries out all adult surgical specialties (including neurosurgery, cardiothoracic surgery and liver transplants) but there is no obstetric or gynaecology service provision. The department of anaesthesia consists of 36 consultants, 23 registrars and 5 provisional fellows (PFYs). The PFY jobs are aimed at final year Australian trainees prior to becoming a consultant, and are also open to UK post-fellowship trainees. The posts are ideal for out of programme training (OOPT) within a hospital that is ANZCA accredited for training.

As a PFY at Charlie’s the normal hours are eight till six, with one half day per week and one office half day (in which to do research, reading and administration). As a PFY there is also the opportunity to undertake specific fellowships, examples of which include

• Ambulatory and Regional Anaesthesia• Simulation (at the Clinical Training and Education Centre)• Neuroanaesthesia• Cardiothoracic Anaesthesia

Clearly the aim of a fellowship is to gain more expertise, conduct research and improves one’s understanding of a specific area. During my time I have definitely improved my ultrasound skills as well as my knowledge of anatomy, the cornerstone of any regional technique. I am also much more confident in the use of continuous peripheral nerve catheters for postoperative pain relief. The department of anaesthesia runs a continual audit of all blocks placed, with a research nurse to collect data and follow up postoperative issues. This means there is a large database of information that is a great resource for research. For an appropriately qualified and motivated person, there is scope in the system to custom-design fellowships to meet specific needs (e.g. peri-operative medicine), and to be involved with current projects.

Regional Anaesthesia Fellowship in sunny Perth


Aerial view of Perth – the hospital is bottom centre

Sir Charles Gairdner Hospital


The fellowships allow one and half days per week protected theatre time to develop skills and interests. About once a month there is a Perth Regional Anaesthetic group meeting, at which the current regional fellow is expected to present current papers of interest. There are no nights on call, but you have to cover weekend days on approximately a 1 in 6 basis. All hours over 40 per week are paid at penalty rates (which is good).

Most post fellowship trainees will be very competent at regional anaesthesia but there is much more involved than just placing the block. Postoperative management of nerve blocks, follow up of complications, training and education issues are all important areas that need consideration when running a regional anaesthesia programme.

The benefit of working in a different system is invaluable, and although the conduct of anaesthesia is not that different from what we are used to in the UK (several consultants are originally UK trained or have spent time in the UK), there are logistical and organisational differences. Like the UK, patients are being admitted on the day of surgery, but unlike at home they will have been seen in a preoperative assessment clinic before turning up at hospital. Although this system is improving in the UK, in Perth it is normal practice. This means patients should have all tests at hand, with the end result of improving efficiency and throughput. From my limited exposure, this system works well. One further difference is that the private sector is very well developed and a lot of the straightforward surgery is carried out in private hospitals, leaving the public system to deal with the more complicated cases. This is probably a bonus for training but just emphasises differences in the two systems.

As a tertiary referral centre Sir Charles Gairdner Hospital allows good exposure

to other adult specialities including liver transplants and elective and emergency neurosurgery. This means that anaesthesia during non-regional time is varied and rewarding. One major difference is that junior registrars are fully supervised for their first two years of training as recommended by ANZCA, meaning the service is strongly consultant-led, even at night.

Of course this type of article requires a brief summary of Perth itself. For those who do not know Perth is the capital of Western Australia with a population of 1.5 million. Established in 1829, it is currently somewhat of a boom town due to vast mineral deposits in the desert that China requires as its economy grows. A recent survey placed Perth as the most expensive Australian city in which to buy property. There is a large expat community of British and South Africans, and it is not uncommon for everyone in theatre (including the patient) to be from the UK originally. The summers are very hot with the winters being very similar to a good English summer (without the

rain!). The beaches are sandy and clean with outstanding opportunity for all types of water sports. If you are keen enough, Perth has the best-developed cycle path system in Australia and you can easily cycle to work.

Now that training has been shortened and that OOPT time has to be prospectively approved by PMETB in order for it to count towards CCT, years spent abroad will have to be seen to be of real clinical benefit to both the trainee and the training deanery. Recognised fellowship programmes are an ideal way to meet these criteria, and the Sir Charles Gairdner regional anaesthetic fellowship is well organised, well taught within a teaching hospital environment, and will definitely be of added value to the fellow in future consultant job applications.

Nick Marshall, 4th Year SpR,

Peninsula Deanery

Dear Editor…Editor’s Choice letterCarrot and stick

With reference to David Whitaker's President's Report in Anaesthesia News, October 2007 I would like to comment on his 'ultramodern concept for excellence in service organisations'. The concept he describes is by no means 'ultramodern' but established in many successful organizations; not just service companies but also manufacturing concerns.

For years I have included the subject of motivation in my lectures on human error and risk management, citing in particular how one well-known chocolate manufacturer uses positive motivational rewards, coupled with potential negative consequences for non-compliance, to achieve excellent management/worker relations and productivity. The rules are applied equally to all employees from Chief Executive downwards. Most of the rewards are simple, low cost and transparent. Examples range from a 10% reduction in annual salary if you are late for work more than three times in a year (but the company pays 10% above the industry average!) and ensuring that all workers are treated the same when it comes to the provision of coffee, canteen facilities, grade of air travel etc.

It is disappointing, once again, to hear that our President has struggled to have these ideas introduced in the areas where he has influence. The usual argument presented to me when I suggest investing in our staff is that we are dealing with public money and there are no mechanisms for such an approach. It could be argued that the private sector also uses our (the public's) money and any method that is cost effective and improves motivation should be considered as common sense and utilised.

Francis ArnsteinConsultant AnaesthetistEdinburgh Blackwell gives AAGBI members 20% discount on textbooks ordered online – visit the website www.blackwellpublishing.com/medicine and follow the links. To claim the 20% discount enter the code AAGBI20 when prompted in step 2 of the shopping cart.

This month’s Editor’s Choice letter wins a copy of “Anesthesia for Cardiac Surgery” (3rd edition) by James DiNardo & David A. Zara, rrp £89.50, donated by Blackwell Publishing.

Recognition for Anaesthetists

No one will disagree with David Wilkinson's conclusion that the specialty of anaesthesia deserves and should receive more knighthoods1, but we do hold our own in Blue Plaques, and if the plaque that was removed from John Snow's house in Sackville Street when it was demolished were restored to the Austin Reed warehouse that replaced it, we should almost achieve parity with the surgeons.

David ZuckHistory of Anaesthesia Society

1. Wilkinson D. The knights of anaesthesia (part 2) Anaesthesia News 2007 (September); 242: 9-11Dr Zuck has kindly agreed to expand on this theme, and a full article on the blue plaques related to anaesthesia will appear in a future edition of Anaesthesia News.


SEND YOUR LETTERS TO:The Editor, Anaesthesia News, AAGBI, 21 Portland Place, London W1B 1PY or

email: [email protected]

The Editor’s Choice letter every month will win a prize.

Is it me..?

I am writing in response to Dr Stoddart’s letter regarding people’s differing perceptions of drug allergies (1). I had a similarly enlightening experience some months ago.

During my pre-assessment visits for an elective LSCS list, all the patients denied any allergies. I was therefore most perturbed when my second lady arrived in the anaesthetic room brandishing a newly acquired red allergy bracelet. On closer inspection, documented in large letters was an allergy to “anaesthetics”. When quizzed about the offending article, the woman shrugged, but the midwife helpfully chipped in, “they make her sick, doctor”. Oh I see…..

Suzi Lomax Anaesthetic SpR, Milton Keynes Hospital

1. Stoddart A. Anaesthesia News 2007 (September); 242: 26

Due To THe voLuMe of CoRReSPoNDeNCe ReCeIveD, LeTTeRS ARe NoT NoRMALLy

ACkNoWLeDGeD.

A magnetic personality

A trip to the MRI scanner can be interesting, what with stripping down to your vests and briefs to get all those metals off before you enter the scanner room. There is a picture in our hospital of a floor-buffing machine, stuck to the scanner at an impossible gravity-defying angle to remind people of the strength of the scanner’s magnetic field. I wonder how traumatised that poor cleaner would have been.

We take all precautions and care before taking patients to MRI but even then sometimes some metals slip through. I’ve heard my anaesthetic colleagues telling me about their theatre tops being pulled towards the scanner with a forgotten coin in their pockets. I take my usual precautions when I go there. I remove all my earthly possessions (wallets, phones, pens, keys, etc) and wear just the bare essentials, which include theatre top and trousers and hospital-provided theatre shoes. I don’t wear any underwired clothes (I don’t believe in cross dressing.) I have not been operated on to get any metal implants, and metallic implants these days are non-ferromagnetic anyway. So there can be no way of me ‘having a magnetic personality’.

So I trot over to the MRI scanner one day with a patient with spinal cord trauma. After having done the usual stripping down, I take the patient through for the scan. Being an anaesthetist, I am at the head end of the patient and therefore closest to the scanner. ‘On slide - ready, steady, slide’ and we transfer the patient on to the scanning table. Now who is that pulling my leg when I’m busy transferring the patient. Can’t those nurses keep their hands off me when I’m working at least? Well, hang on; there’s nobody that close at hand. They are all busy transferring the patient. I was being over-confident of my oozing masculinity there. Then who else is pulling my leg? I can’t see anyone down on their knees pulling/pushing my feet. Could there be a ghost in the machine/room? Or in my trainer shoes? Anyway, I pulled my feet away, took off my trainers when it came to transferring the patient back onto the bed and then spoke to my consultant colleague in ITU about this incident. He suggested I take an X-ray of my trainers.

Hey presto, there were the ghosts. I called up the hospital supplies department and the theatre sister who gave me the trainers to tell them that the shoes were MRI incompatible, with metallic toe caps and strips on the sole. Nowadays when I go to the MRI scanner, I’m having to go more ‘naked’. One more lesson learnt.

Dr Ahamed MalikSpR in AnaesthesiaNorthern School of Anaesthesia



SecretaryProf Ezzat Aziz

Faculty of MedicineCairo University

Cairo Egyptezzataziz2002@

hotmail.com

Scientific ChairmanProf Chandra Kumar

James Cook University HospitalMiddlesbrough, UKchandra.kumar@

stees.nhs.uk

PresidentProf Chris Dodds

James Cook University HospitalMiddlesbrough, UK

2nd World Congress of Ophthalmic Anaesthesia

28th-29th February 2008Cairo, Egypt

Organised in association withBritish Ophthalmic Anaesthesia Society

Correspondence and informationOrganising office in-charge: ICOM

Tel/Fax: +2034204849 +2034249072 Cellular: +20101224849 +20122480206

Email: [email protected]

Visit our website for registration form, full details of CPD approved scientific programme, social and other programmes

Last date for submission of abstracts for posters, free papers and case reports is 15th January 2008. Registration is essential

www.wcoa2008.com

The Association of Paediatric Anaesthetists of Great Britain and Ireland

Annual Scientific Meeting in conjunction with the British Association of Paediatric Surgeons (BAPS)

Institute of Electrical Engineers, London, 8th –10th May 2008

Thursday 8th MayJoint BAPS/APA MeetingProviding Effective Children’s ServicesChildren’s Hospital Concept and DesignInnovations in Paediatric SurgeryEmergencies in Paediatrics

Guest speakers include: Shiela Shribman (DoH), Greg Hammer (USA), George Youngson (Scotland), Agostino Pierro (London)

Friday 9-10th May Annual Scientific MeetingAcute and chronic paediatric painDifficult circulation and ventilationConsent Ethics and the LawFree Papers and Posters:Trainee prizes, Workshops

Jackson Rees LectureProfessor Ian CraftFuture Roles of the Paediatric Doctor

For further information and registration contact: APA website www.apagbi.org.uk or contact AAGBI 21 Portland Place London W1B 1PY. E-mail; [email protected] Tel 0207631-8804 or -8803

Adolf Baeyer and his contributions to local anaesthesia

Adolf Baeyer, who began work at a technical college in Berlin, was to become one of the foremost organic chemists of the second half of the 19th century. He has two connections with local anaesthesia. The first occurred in 1866 when he was seeking insight into the structure of that most fascinating of pigments and dyestuffs, indigo. He knew that oxidising it with nitric acid gave a simpler substance named isatin, and this could be reduced to oxindole, C8H7NO, but for real understanding, he needed to know not just its chemical composition but also its structural formula. He hit on the innovative idea of heating oxindole with zinc dust: at the very least it should abstract the oxygen atom and possibly yield something interesting. Indeed it did. The product from the zinc treatment was C8H7N, which he christened indole. He presumed that the, still unknown, core structure of indole would be at least similar to that in the mystery substance oxindole and even common to part of the indigo molecule – a novel and crucial insight at the time. More experiments on indole followed and three years later, in 1869, he proposed its correct structure, and by inference, aspects of the structure of its ‘parent’ compounds. Baeyer used this technique several times in his long

career, extrapolating from the structure of known fragments or derivatives of a complex molecule to give insight into the parent material.

In 1884 Carl Koller discovered that cocaine was an effective local anaesthetic for eye surgery and within 12 months it was also being used in dentistry, mainly by infiltration at the base of the tooth, but also to achieve more distant nerve blocks. A few years later it was used to produce spinal anaesthesia. Cocaine, though, had several drawbacks:1

• It was unpredictable in its action and some patients died from injections as small as 18mg, uncomfortably close to the dental infiltration dose of 10-15mg. Others, though, could withstand an injection of 1.5g without lasting ill-effects

• It was decomposed by boiling water, so traditional sterilisation was impossible

• It was addictive. This was not a problem for patients, but a number of doctors, particularly anaesthetists and surgeons (famously including the great William Halsted, who introduced regional nerve blocks), and dentists became addicted to the drug.

The question was, could chemists produce something as effective as cocaine, but without its dangers? In the second half of the 19th century, chemists were replacing many natural compounds with cheaper and more reliable synthetic agents. Just under thirty years previously, in 1856, William Perkin had produced the first commercially successful synthetic dye, Mauveine. By the time that Koller trickled cocaine solution into his eye, almost all the industrial dyes were derived from coal tar, displacing their predecessors of natural origin.

The early searches for local anaesthetics of non-natural origin were naïve: chemicals conveniently to hand were tested on animals. Claims of success were, at best, dubious as the intense pain that most of these substances caused on injection, masked the reaction to any subsequent stimulus, producing only an illusion of anaesthetic effect.2 Clearly a more insightful approach was necessary, possibly using the structure of the cocaine molecule to guide selection of promising agents. Although the full structure of the alkaloid was not known until 1898, a “half-way house” approach was possible, based on Baeyer’s method. The German schools of chemistry had established that


T H E H I S T O R Y PAG E


cocaine, ecgonine, tropine and tropane all shared the same (unknown) core structure, and were differentiated by the presence or absence of ‘attachments’ to this. Therefore determining the structure of one would give insight into the others. Albert Ladenburg chose to study the simplest of the four, tropane. In 1887 he applied the Baeyer zinc dust reaction and produced 2-ethyl pyridine. This implied that within the tropane (and cocaine) core structure there would be a six-membered ring containing five carbon atoms and one nitrogen. To this, adjacent to the N, would be fastened a chain of at least two CH2 groups (or possibly, a CH2CH3 group).

This observation provoked several conjectural structures for cocaine, some based on a piperidine ring fused to a hydrocarbon ring. The chemist Georg Merling began to synthesise piperidine ring structures linked to the ester attachments then known to form part of the cocaine molecule to see if the local anaesthesia property was dependent upon the presence of these rings.3 The Italian pharmacologist Gaetano Vinci tested the products and in 1896 found two compounds, a-Eucaine and b-Eucaine, had sufficient potential for clinical use.

The lactate salt of b-Eucaine was especially popular as the injections were supposed to be non-irritating. Its solutions could be sterilised by boiling and it could be combined with adrenaline. It was safer to administer than cocaine, non-addictive and was very popular in dentistry until about 1910. Importantly, it showed how synthetic chemistry could improve on a natural product such as cocaine and laid the way for the development of yet more effective local anaesthetics, such as Novocaine (procaine), which dominated the field for half a century from 1905.

An unknown correspondent (right) extolled the virtues of b-Eucaine in The Nursing Record in 1899: “During the operation the patient’s thoughts are usually diverted by conversation and a cup of tea. No starvation is necessary after the operation and the patient has his next meal as usual. He is quite exempt from the nausea and vomiting which so frequently follow the use of other anaesthetics…(and) the patient is able to enjoy his newspaper the same evening”.

We started this article by referring to Adolf Baeyer’s two contributions to local anaesthesia. What, then, was his second? In the early 1880s, now Professor of Chemistry at Munich, he recognised the potential of a young Tübingen chemist, Alfred Einhorn, and took him on as a post-doctoral student. After brief positions at Darmstadt and Aachen, Einhorn returned to Baeyer’s laboratory and whilst there, presumably with his mentor’s encouragement, came up with the local anaesthetic that revolutionised medical practice, Novocaine. But that is another story….

Professor Alan Dronsfield, University of Derby

Professor Pete Ellis, University of Otago (Wellington), New Zealand

References1. Dronsfield A and Ellis P. education in

Chem. In press2. Dronsfield A. Ouch, doctor, that

hurt! A by-way in early attempts to achieve local anaesthesia. Anaesthesia News 2007; 236: pp26-27

3. Sneader W. Drug discovery: a history. Chichester: John Wiley & Sons Ltd., 2005.

T H E H I S T O R Y PAG E


SOME MERSEYPLAUDITS VERBATIM“Thanks to you I have cleared my Part 1 exam in my first attempt. I had attended both your MCQ and Viva OSCE courses. Of the two courses, I can’t decide which one is better.

The MCQ course was excellent. Before I came to the course, I had read a bit but had not done any MCQs and (did) miserably in my (Opening Paper) in the course but then the course put me back on track and helped me see things in the right perspective and helped focus my knowledge onto (sic) the art of answering MCQs.

The importance given to Physics and Measurement was the best part of the course. It had a lot of hidden benefits. (Among the hidden benefits) I did not have to read my Physics and Measurement again for my viva and OSCE.

About the Viva/OSCE course, I did wonder why you were concentrating so much on (the) OSCE which is only one part of the exam rather than the viva which has two parts. But I found to my surprise my fears were totally unjustified as most topics covered in the OSCE part of the course were asked in the viva exam also. Some of the add-ons to the course like the Base of Skull and X-Ray sessions and Skills Training (were) fantastic as I was able to anticipate and answer before the examiner could finish the question.

Finally, even a person like me who is a hesitant and bad communicator got a compliment from the examiner and (the) actor who played the role after the exams regarding my performance in the Communication (OSCE). It think it was solely due to the Communication Session and the repeated OSCE practice that when I went into the station I found I could ask questions and provide answers without fear or inhibition as to what may happen or whether what I am doing is right or wrong. That I think is the ultimate achievement of this course.”

“I’m not sure you if you know but, at the risk of blowing my own trumpet, I was fortunate to be invited to the College Diplomates (sic) Day earlier in the year to collect my Nuffield Prize for the Primary exam. Three candidates from my sitting achieved the scores for the medal and, after a moment’s brainstorming, we established how we all knew each other – you can see the end coming, no doubt – we had met on the Mersey MCQ and OSCE/Oral courses. We thought we should let you know – your efforts must be working.”

“I am delighted to say I passed both the MCQs and the Clinical on my first attempt having been on the Mersey course. The OSCE/Viva week in particular was really excellent (and unexpectedly enjoyable!) preparation for the exam. Thank you very much and please pass on my thanks to the Faculty who were fantastic.”

“Well I passed the Final FRCA on Monday at the first attempt after being on the SAQ, MCQ and Viva weekend so thanks very much.

Having attended your Primary MCQ and OSCE weeks a couple of years ago, I am sure you’ll understand that returning to Aintree is something I am not planning on doing any time this decade. Plus I am broke! I have attached (photo of two young children) of a couple of people I am (now) going to spend some time with. Once again, thanks very much.”

“But I remembered your story regarding stress (which) helped me a lot to overcome the stress during my exams in Dublin and I did very well”

“You have done it again! You have helped another wandering soul to find his way back! I passed my Final!”

“I must say that, after having been grilled at your course (which incidentally I thoroughly enjoyed) my manner became much more calm and confident and ready to face the challenge of the exam. So much so that even my wife commented on this marked change in my confidence level and marvelled at how cool and collected I had become. You might consider me cheeky and presumptuous but I will say that I am not going to sit the Part 2 unless I do your courses for the same prior to it.”

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Scotland retains the merit award system previously in use throughout the United Kingdom – up to eight discretionary points awarded at a local level, and B, A, and A+ awarded nationally. Restructuring of the system has been under discussion for some time, but agreement has yet to be reached about the form a new awards system should take. As elsewhere in the UK, anaesthesia has a relative under-representation at all levels of award – some of the reasons for this are explored in this article. Discussions have taken place between the specialty and the Scottish Advisory Committee on Distinction Awards (SACDA) around ways of reducing discrepancies in award levels.

Local recognition of a consultant’s contribution to the NHS through the award of Discretionary Points is important but not essential before being considered or eligible for a national Distinction Award (B, A or A+). There is an imbalance in the current Scottish Distinction Awards system and the poor recognition of distinction in some specialties is noteworthy. Clearly, a discriminatory process related to financial reward should avoid bias in the system. The proportion of consultants in anaesthesia in Scotland holding distinction awards is 5.6% compared to 13.7% across all specialties (2006 SACDA Report). Only three “B” awards were given to consultants in anaesthesia in 2006.

The publication of the SACDA Scoring system, which was applied for the first time in 2002, was a welcome move to objectivity and openness but the criteria still appear to be heavily weighted towards academic distinction, because a derivative of the University system was used.

There are six domains in the CV which are scored:1. Professional excellence and Leadership 2. Research and Service Innovation 3. Management, administration and advisory activities 4. Contribution to clinical governance, audit and evidence

based practice 5. Teaching and training 6. Achievement of service goals

Each individual nominee is scored as a numeric sum of the score in Domain 1 plus the best four scores in the nominee’s remaining

five Domains. This ensures that a poor performance in a single domain does not adversely affect the total score.

However, high scores in domains 1, 2 and 5 may be difficult to achieve in anaesthesia.

Domain 1: Measures of "leadership" are generally “new treatment" or “disease oriented”. For example leading a managed clinical network for heart disease or cancer will score well. Anaesthesia struggles to compete, because it doesn't have an "illness" focus. There is less opportunity for anaesthetists to develop inter-specialty relationships, other than with surgeons, unless the anaesthetist has commitments to intensive care medicine. Anaesthetists do, however, contribute in a major way to NHS priorities e.g. pre-op assessment clinics, day care surgery, emergency and cancer surgery and impact on waiting lists. This contribution may often then be attributed to the surgical unit as a whole.

Domain 2: Research contributions are generally made outside the university environment due to the very small number of academic posts in anaesthesia, critical care and pain management, compared with other specialties, eg respiratory medicine. Research is generally clinically based. Modern job plans do not facilitate research and the difficulties of research bureaucracy for full time NHS clinicians are almost insurmountable. In the SACDA scoring guideline a score of 4 (maximum) is achieved in this domain only if MRC or Wellcome funding is obtained. This is one component of the university funding Research Assessment Exercise, which is criticised and has been responsible for creating a “closed shop” in research in the prestigious areas of the genome, cancer and cardiovascular disease. Research facilities available to anaesthesia are historically poor. Departments of anaesthesia rarely have substantial secretarial help, adequate laboratory or even storage space, compared with other longer-established specialties.

There is a list of “approved journals” for scoring publications. This list does not currently encompass the high impact factor journals in anaesthesia, critical care and pain medicine, so should be reviewed.

Distinction Awards in Scotland

Continuing our series of articles about the various awards systems in operation in the uk – this month, Scotland.


Distinction Awards in Scotland

Domain 5: Involvement in post-graduate examinations, especially as a Fellowship examiner at the Royal College of Anaesthetists in London, has a greater commitment compared to examiners in surgery and medicine for the local Scottish Royal Colleges, both in time and overall involvement, and there needs to be some recognition of this.

There has been considerable debate amongst consultant anaesthetists in Scotland about the serious disadvantage that our specialty suffers compared to other specialties in medicine in Scotland and indeed our own specialty in England and Wales. It cannot be due to the calibre of doctors attracted to our specialty in Scotland, because the quality of trainees attracted to the specialty has been high for many years. It is therefore very surprising that such high quality trainees go on to become low achievers as consultants, when measured by the Scottish Awards system.

Failure to recognise distinction and effort in anaesthesia, critical care and pain management will cause a problem of motivation in the specialty in the future. Senior consultants in our specialty need to provide advice to consultant anaesthetists completing CVs to the standard required by SACDA.

Clinical distinction in the specialty of anaesthesia is still poorly recognised since the introduction of the Clinical Excellence Awards System in England and Wales in 2003. The review of the Scottish Distinction Awards System and the introduction of a new system from 2009 present opportunities to be fair to all hospital specialties.

John McClureConsultant Anaesthetist, Edinburgh

Nuffield Department of Anaesthetics �0th AnniversaryThe Nuffield Department of Anaesthetics celebrated its 70th anniversary in September with a two-day meeting at St Anne’s College, Oxford. Over 150 past and present staff attended, many from Europe and Scandinavia and some from as far afield as Australasia and the USA. Over 200 members and guests attended the gala banquet. Present during the meeting were four Nuffield Professors of Anaesthetics: former heads of department Professor Sir Keith Sykes and Professor Pierre Foex and the newly appointed heads Professor Henry McQuay, Nuffield Professor of Clinical Anaesthetics and Professor Irene Tracey, Nuffield Professor of Anaesthetic Science. The lectures covered a wide range of topics from anaesthetic training, past and present practices, current trends and concepts, provision of anaesthesia and intensive cares services and ongoing research projects. The Macintosh lecture was delivered by Professor Sir Keith Sykes entitled: ‘Lord Nuffield, his benefaction and anaesthesia.’ The closing session, an open debate with Sir Peter Simpson on ‘Wither or whither, anaesthesia or perioperative medicine?’ provoked much discussion from the audience.

David ShlugmanConsultant Anaesthetist, Oxford

four Nuffield Professors and an anaesthetic machine. L-R: Professors Henry McQuay, keith Sykes,

Irene Tracey, Pierre foex


Higher Award Applicants in ScotlandThe Association will be considering submitting supporting citations for anaesthetists in Scotland who apply to SACDA for an award. Any individual who wishes to be considered for such support should send a copy of the completed SACDA application form (available online from the SACDA website) to the President by e-mail ([email protected]) by FRIDAY 4th January 2008.

It is essential that the copy submitted to AAGBI is the same as the one being submitted to SACDA. All submissions will be acknowledged but late submissions or those not on the correct SACDA form cannot be considered.

South Tees HospitalsNHS Trust

Cleveland School of Anaesthesia

The James Cook University HospitalMarton Road

Middlesbrough TS4 3BW01642 854601

Intense 3 day OSCE/Viva Course

For Primary ExamAvailable courses:

9th - 11th January 200823rd - 25th April 2008

Cost: £375.00

Description: Candidates will attend 9 vivaand 24 OSCE stations. Intense coaching in OSCE

and Viva technique via interactive tutorials.

Please contact [email protected] for an application form. Places limited

South Tees HospitalsNHS Trust

Cleveland School of Anaesthesia

The James Cook University HospitalMarton Road

Middlesbrough TS4 3BW01642 854601

Final FRCA crammer Courses

Available courses:10th – 12th March 2008 (MCQ/SAQ)

12th – 13th May 2008 (Viva)

Cost: £200- 300 (depending on course)

Description: Programme includes full mock MCQ and SAQ exam plus tutorials or intense

and realistic Viva practice and tutorials.

Please contact [email protected] for an application form. Places limited


ANAESTHETICRESEARCH SOCIETY

RESEARCH METHODOLOGY COURSE

14th-15th January 2008

Venue: Royal College of Anaesthetists,Churchill House, 35 Red Lion Square, London WC1R 4SG

This meeting aims to fulfil the RCoA requirements for research competencies for trainees, but is suitable for clinicians of all grades

interested in research.

Day 1 is devoted to tutorial teaching on: How to develop a research idea; Study design; Practical aspects of clinical trials; Ethics, COREC & research governance; Presentation skills,

How to get published.

Day 2 involves attendance at the Anaesthetic Research Society meeting (also being held at the RCoA)

with feedback from tutors.

Fee: £135.00 (includes refreshments and registration for the ARS meeting on 15th January). Places are strictly limited.

Application and registration forms available from:Dr J.G. Hardman, University Department of Anaesthesia, Queen's

Medical Centre, Nottingham NG7 2UH. email [email protected]

Much has been written, spoken and debated about ethical issues concerning recruitment by the NHS of medical staff from developing countries. These issues challenge both the NHS as an employer and doctors from developing countries who wish to work it in. To tell the truth I had never even thought about it, although it concerned me. I am a doctor from Kashmir, and I have been here for a few years now. The issue first crossed my mind when I was required to present this topic to a potential employer as part of assessment during a job application. So there it began and the issue became more interesting when I started to explore and understand the basic moral obligations of an individual and a country.

To be honest I did not even think of it when I decided to further my career in this country. My aim was an individual good – the good I can do for myself: my financial situation, my career and so on. The NHS needed more doctors, had resources to afford them, and the means to train and further educate them. India produces enough doctors merely to sustain their own demand but still they lose them in great numbers. So the question is why? Apparently, total health expenditure per capita for India is $24 compared to the UK’s $1,8351. So imagine what that difference of resources between two countries can do, and is doing.

This brings the ethical dilemma for all the parties in the process. What should India do to keep its doctors? How should the UK recruit to satisfy demand? And what should we doctors do to justify our career aspirations and pay our debts to our country?

There is no easy answer as far as I am concerned. One thing I am sure about is that if India was economically as strong as the UK and the UK not so fortunate, things would be the same, just other way round. Look at the information technology market. India has ascendancy in this field and it is taking advantage of it in any way it can. If one has an advantage in a certain field, it is human nature to benefit from it. The doctors from developing countries benefit from opportunities to come and work in the UK, they gain valuable knowledge and experience from pioneering institutes and peers. They benefit financially, and most of all they experience one of the world’s best health care system. The UK benefits by filling its job vacancies at minimal cost, because they do not spend a dime on the undergraduate education of these doctors.

The only players who lose in this game are developing countries such as India. This web is so complicated that there is little she can do to stop or reasonably influence it and still be an active participant in a global economy. I believe that there is little the UK can do to stop this process. South Africa tried to stop recruiting from other African countries because it seemed unethical to rob them of very few doctors they so desperately needed. But they were themselves losing doctors to other developed countries such as Canada and in the process created a huge shortage in their own system2. So there is no easy answer.

As far as the individual doctor is concerned I believe it is their basic right to choose where they feel is best to progress their

The ethical dilemma for

International Medical Graduates


career. I do not believe that anyone should have a right to rob them of opportunities they deserve. But I also strongly feel that an individual doctor has moral obligation to serve his/her country which allocated scarce resources to educate and train them. So I believe the real ethical dilemma is not for the countries such as the UK who recruit doctors from developing countries. They have a genuine need for doctors and resources to provide for them. The NHS is pressurised both by public and politicians to provide a state of art, timely and efficient service. By employing human resources from developing countries, they are doing justice to their own people. The dilemma is for the individual doctor who leaves his/her country to work here. Are we being opportunistic, selfish or just being fair to ourselves? I do not know. All I know is that I came because this country provided me things which my native country could not. Here, I have financial security, outstanding training, top education and above all job satisfaction. Was that enough to betray my country? It is perhaps not fair for the people back home who should benefit from my service, but is it fair for me to lose out on such opportunities?

In India I had very few choices, definite financial insecurity and above all very few opportunities to gain exposure to new technologies and research facilities. So, is it ethically and morally reasonable for me to choose to work here? I believe it is, but I am also sure that it is my moral obligation to benefit my people from what I have learnt here; maybe not now but definitely in the future. That is only way that it will be ethically possible for all parties to continue this process.

Dr Syed RazviSpR in Anaesthesia

Royal Berkshire Hospital

1. World Health Organisation, Core Health Indicators (2001). http://www3.who.int/whosis/country/compare.cfm?country=GBR&indicator=PcTotEOHinIntD&language=english.

2. Rural and Remote health, The ethics of international recruitment, http://www.regional.org.au/au/rrh/editorial/ed_14.htm

TRAVELGRANT

The Travel Grant is aimed at those undertaking visits in Great Britain and Ireland or overseas which include

teaching, research, or study. GRANTS UP TO £1,000

RULESThere is no deadline for the submission of entries and theoretically there is no limit to the number of travel grants that may be awarded. However, grants will not be considered for the purpose of taking up a post abroad, nor 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. Candidates should indicate the expected benefits to be gained from their visits, over and above the educational value to the applicants themselves.

For further information and an application formplease visit our website: www.aagbi.org

or email [email protected] or telephone 020 7631 8807.

Application forms should be forwarded to [email protected]

RESEARCH GRANT

The Research Grant is aimed at those undertaking research in Great Britain and Ireland

GRANTS UP TO £15,000RULES

Theoretically there is no limit to the number of research grants that may be awarded. Funds are available for the purchase of apparatus for specific projects and the application should enclose a precise quote from the manufacturer. The applicant must indicate why a particular make has been chosen. Such apparatus remains the property of the Association and must be labelled as such. At the end of the project, or after such interval as seems appropriate, ultimate disposal of the apparatus will be considered by E & R. It is the express wish of the Association that any equipment will continue to be used for research purposes. Salaries may be payable in the form of part-time Fellowships for doctors and salaries for technicians of other assistants. Only in exceptional circumstances will grants of more than £15,000 per annum be made to any individual department. Candidates should indicate their qualifications and experience to carry out the project. Those holding trainee appointments should have a consultant (or equivalent) as a referee, preferably the individual who will supervise the work.

For further information and an application form please visit our website: www.aagbi.org or email [email protected] or telephone 020 7631 8807.

Application forms should be forwarded to the Honorary Secretary, The Association of Anaesthetists

21 Portland Place, London W1B 1PY and [email protected]



Obstetric Anaesthetists’ Association

27 February 2008: LondonCases and Controversies in Obstetric Anaesthesia Cases: Sickle cell anaemia; A high block; twins; wandering cathetersDebates: Routine use of sitting position for spinal anaesthesia should be abandoned; Genetic variability has no practical implications for the obstetric anaesthetist; Remifentanil PCA should be routinely available for use in labour

2 March 2008: Cape Town, WCA Satellite MeetingRefresher Course in Obstetric Anaesthesia An unparalleled opportunity to hear at least twelve international experts in the field of obstetric anaesthesia drawn from four continents! Varied and topical programme. £30 only.

For further details of all meetings seewww.oaameetings.infot: +44 (0) 20 8741 1311

13th Oxford Difficult Airway Workshop

Academic Street, Level 3John Radcliffe Hospital,

Headington, Oxford OX3 9DUTuesday 5 February 2007

The Difficult Airway Workshop is for trainees and consultants wishing to refresh and update skills in managing patients with a

difficult airway.

The course aims to discuss the management of the anticipated and unanticipated difficult intubations. There are lectures, videos and interactive case discussions, and over 4.5 hours of hands-on

workshops to re-enforce the theory, and to refine manual dexterity.

The workshops cover a wide range of fibre-optic assisted techniques, ILMA and trans-tracheal access. There is a high faculty to delegate ratio (1:3) to allow maximum opportunity to interact

and interrogate the faculty.

Included in the registration fee are refreshments, a course manual, and lunch.

Course organisers - Dr Mansukh T Popat and Dr Stuart W Benham

Registration fee - £150 Recognised for 5 CEPD points

All enquiries - Marguerite Scott, Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, OX3 9DU [email protected]

Telephone 01865 221590Cheques to be made payable to ‘Oxford Difficult Airway Group’

Anaesthesia News Advertising Rates from January Issue 2008

Anaesthesia News reaches over 10,000 anaesthetists every month and is a great way of advertising your course, meeting or seminar.

Full Page - Inside Front or Back Cover One Month = £ 1607 + VAT, Two Months = £3060 + VAT

Three Months = £4392 + VAT, Six Months = £ 7277 + VATTwelve Months = £ 9663 + VAT

All prices shown are exclusive

of VAT

One Month

Two Months

(5% Discount)

Three Months(10%

Discount)

Six Months(25%

Discount)

Twelve Months(50%

Discount)

Full Page Four Colour

£ 1236 £ 2350 £ 3349 £ 5565 £ 7419

Full Page Two Colour

£ 790 £ 1501 £ 2133 £ 3555 £ 4741

Half Page Four Colour

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Half Page Two Colour

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£ 322 £ 610 £ 869 £ 1449 £1932

Qtr Page Two Colour

£ 241 £458 £ 650 £ 1082 £ 1444

Details of events and meetings will also be listed free of charge, in the Calendar of Events and International Meetings on the AAGBI website: www.aagbi.org

Contact: Claire Elliott on 020 7631 8817 or e-mail: [email protected]

Equality and Diversity are, apparently, “at the heart of the NHS strategy”. Dr.Ruxton needs those words to be explained in this context and the NHS website obliges. “Equality is about creating a fairer society in which everyone has the opportunity to fulfil their potential. Diversity is about recognising and valuing difference in its broadest sense.” Absolutely, cries Dr.Ruxton! Right on!

So why can he not ask a colleague to translate when they are native in the language of a patient who has no English? Dr.Ruxton is hideously monoglot, and although he has visited that patient’s country and took the trouble to learn some of that language, “Good morning”, “Thank you” and “Please show me the way to Lecture room 5” don’t go far in a preoperative assessment, however well received they were in that country (an American was gob-smacked by the last!).

The ward had been searching all day for someone to translate. No problem, said Dr.Ruxton! A colleague, an ODP whose native language is the same as the patient, has very kindly agreed to accompany me, and help me ask some basic questions, sufficient for assessment of an apparently fit young man. If more detailed questions of a very personal nature were required, we would try again for a translator.

“You can’t do that, Dr.Ruxton”, said the Sister, “You may not use a member of staff or even a member of the patient’s family to translate. The Equality & Diversity Manager says so.” This patient was known to lack English – it was even on the theatre list - but had the E&Q person taken on the task of solving this riddle? No, the ward staff had, at no notice at all, been seeking a qualified and registered translator, for hours, without success. Despite the known lack of a common tongue and the requirements of Equality & Diversity, the E&Q manager had done nothing to prepare for this admission, find a translator or even information documents in the patient’s language. It wasn’t as if this was an obscure language, there are hundreds of thousands of its speakers here in the UK, it was just that being qualified and registered as a senior ward nurse does not include the ability to conjure a translator out of thin air. But they had managed to extract the E&Q person from their busy schedule, not to find a translator, but to authorise the ward to use the “NHS Language Line”. Authorise, because it costs money.

Have you ever used this …. thing? It is not accessible from the phones that are so conveniently and expensively situated at every bedside. It requires the patient and their clinician to stand at the ward nurses station, to speak into the phone in a forum as public as Piccadilly and discuss their medical history. The clinician asks the phone the question, hands the phone to the patient and so on. Yes, an idea worthy of the Innovations catalogue – “End translation misery!”

Dr.Ruxton was delighted to find that his patient had a family member with them, who was enchanted by his ability to say “Good morning” in their language even though it was now afternoon, and was able to help him ask the few questions he needed to establish the fitness of his patient. The surgeon was not so lucky. Reasonably, he felt that consent could not be obtained unless the patient knew exactly what they were signing up for. So back they went to the telephone. But what about the consent form, which around here is a two page document? Should they read it to the telephone translator, line by line, wait for the patient to hear the words in their own language, and then read the next line, a work of hours? The list start-time loomed, and sensibly they explained the operation and asked if the patient would sign the consent. We started on time, my theatre colleague was on hand to reassure and explain in the anaesthetic and recovery rooms and the patient went home satisfied.

So what was “fair” about doing nothing to help a foreigner in a strange land, where the only people who bothered to help the patient overcome their lack of our language were those whose job, knowledge and skill is to provide the intricacies of surgical and anaesthesia treatment, but who are untrained in either translation or “Equality & Diversity”? How does sidelining my colleague, a professional with a specialist understanding of anaesthesia, in favour of a translator with no such knowledge, “recognise and value their difference”? Not that a useful translator was available.

Sadly Dr.Ruxton’s ethereal contacts are silent on this, as when he was alive, if your patient did not speak English, you spoke louder until they did. So may he ask his many readers around the world, what do they do with the monoglot English who are admitted to their hospitals? Of course - they speak to them in English.

Dr. Ruxtonmeets the Equaliser

D r. R U X T O N

anaesthesia annual congress in dublin

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