SPRING 2010ISSN 0265-9212

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The SocieTy of AnAeSTheTiSTS of The SouTh WeSTern region

President DrSteveMather uhBristol

President – elect DrPeterRitchie cheltenham

honorary Secretary DrChrisMonk uhBristol

honorary Treasurer DrBillHarvey Truro

Trainee representatives DrKatieHolmes South West School DrDominicHurford Bristol School editorial committee DrFionaDonald editor, Southmead, nBT DrVanessaPurday Assistant editor, exeter

Administrator KatePrys-Roberts uhBristol

www.saswr.org.uk

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Vol43.No.1 Spring2010 Page

CommitteeMembers 1Contents 2Editorial FionaDonald 3FutureMeetingsoftheSociety 4PortraitofthePresident FrancesForrest 5NewsoftheWest LinkmenoftheRegion 7ExaminationSuccessesandHonours 21ReportoftheAutumnScientificMeetingoftheSociety ChrisMonk 22ReportoftheMeetingofTheSocietyof RichardEve 28DevonIntensiveTherapistsUseofVideoBenchmarkingtoImprovetheReliabilityof GemmaCrossingham 32WorkplaceBasedAssessmentsinAnaesthesiaEmergencyCricothyroidotomy:aCaseReport NickSmallwoodand 36 EdwardBickIntroducingtheWorldHealthOrganisationSurgical TraceyChristmasand 39SafetyChecklistintoClinicalPractice SarahIngamelsDoNotResuscitateThisPC BenHowes 45GettingintoAcademicAnaesthesia TimDawesand 49 AlisdairJubbHereCometheTrainees…All12ofThem! KathrynDavies 54ATrainee’sPerspectiveoftheFirstThreeMonths CGibson 56ofAnaestheticTrainingCrashSectionsandEpidurals–ATrainee’sPerspectiveof AnoushkaWinton 57StartingObstetricAnaesthesiaTotalHipReplacement–aPersonalExperience IanGauntlett 60ThePastisaForeignCountry NevilleGoodman 63Poem RobinForward 64TheWineColumn TomPerris 65Crossword BrianPerris 67Cartoons KathyJenner& 68 JasonTrevittPrizesandbursaries 69Noticetocontributors 71

AnAeSTheSiA PoinTS WeSTContents

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editorial“Itisonlyaswedevelopothersthatwepermanentlysucceed.”

(Harvey Samuel Firestone, 1868-1938, founder of the Firestone Tyre Company.)

ThiseditionofAnaesthesiaPointsWesthasabitofatrainingtheme.Iwouldliketosaythatthiswasachievedthroughforethoughtandcarefulplanning,but in reality thephrase“moreby luck thangoodjudgement” is altogethermore apt. Be that as itmay, I think the end result is reallyquite thoughtprovoking.The issues covered include, the way in whichwe assess our trainees, howwe deal with novicetrainees,howthe traineesfeelabouthowtheyaretrained,howtogetintoacademicanaesthesia,andwhat being both a doctor and a patient can teachus.Nexttimewewilldiscusstechniquesforworlddominationandyouwillallbeset for life. Jokesaside, I hope you will enjoy this aspect of thejournal.Continuing on an educational theme, there arereports of the Autumn Scientific Meeting of theSocietyandtheOctoberMeetingoftheSocietyofDevonIntensiveTherapists.Iamnotcertainwhichgrouphadmorefun,butfunwasdefinitelyhadinbothcases.Whatishearteningistoreadaboutthequality of the scientific content at bothmeetings.Regional societiesmaywell become increasinglyimportant as providers of continuing medicaleducationanddevelopment,asstudyleavebudgetsfalltorecordlows.Ingeneraltheirmeetingscanbeprovidedatlowercostthannationalones,areeasiertogettoandmayinvolvefewerhotelbills.Ifthestandardofmaterialpresentedcanbekepthightheywillindeedprovetobeavaluableresource.ThereisaFridaynighttelevisionprogrammecalled“TheBubble”,theformatofwhichisthatcelebritiesare kept isolated from all news input for a week(i.e.theyarelockedinahousewithnonewspapersandno formof telecommunications) andare thenasked to decide which of several proposed newsstoriesaretrue.Allofwhichisaconvolutedwayof suggesting that, if you have been in a bubble

for the last few years, youmay havemissed anymentionoftheWHOsurgicalchecklist.Everyoneelsewill be all too familiarwith the concept andwill,Isuspect,havealeastawrygrin,ifnotafullblownbellylaugh,ofrecognitionwhentheyreadoftheproblemsthatUniversityHospitalsBristol(thehospitalformallyknownastheBRIetc.)havehadwiththeirimplementationplan. Is itasurprisetoanyonethatasystemdesignedtofiteveryhospitaland every surgical specialty in the world, mayneed a few tweaks before actually being of realuse? Hopefully theBristol experiencewill allowa fewother groups tomiss out someof the stepsindevelopmentoftheirownsystems.OrperhapsBristolwillbefloodedwithadvicefromthosewhoarealreadyfurtheradvanced–Iamsuretheywouldbeverygrateful.Thanks to everyone for such a great response tomy plea formore articles. I was tempted to usethe quotation “be careful what you wish for lestyou receive it” to lead this editorial but felt thatthatmightbechurlish. Wehavea fewin reservebut do please keep sending them in. There is acase report in thescientificsectionof the journal.Traditionally, case reportshavenotbeen includedinouroutputbutwewouldbedelightedtoreceivemore.AnotherfirstisafillerarticlefromourveryownNevilleGoodmanandagain,feelfreetofollowsuit.The News of theWest articles are dominated bysnow and Norovirus. One might hope that thetwo would cancel each other out but one would,unfortunately, be mistaken. Despite these dualsetbacks our correspondents still manage to findsomehumorousanecdotes toprove that lifeasananaesthetist has its rewards. We all know this ofcoursebutsometimesweneedtoberemindedofit.

fiona Donald

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future Meetings of the Society

Spring 2010Rome,Wednesday12th–Friday14thMay2010

Autumn 2010Bristol,Thursday4thandFriday5thNovember2010

Spring 2011Taunton

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Steve Mather

In 1984, as Orwellian clouds circled overthe South West, one small ray of sunshinebroke through in Bristol; a then 34 year oldStephen Mather moved from a consultantpost inBassetlawHospital,Worksop toa jobas aConsultantPaediatricAnaesthetist at theBristolChildren’sHospital.Steve’smedical career had begun in 1969 atThe London Hospital, Whitechapel, wherehe studiedmedicine. A fewyears later, afterundertaking house jobs and SHO posts inEssex (these included A&E, paediatrics andO&G),hemovedwesttoGloucesterin1976tobeginhiscareerinanaesthesia.SubsequentlyhebecameaBristol registrarmoving,aswasthecustomatthetime,toSheffieldasaseniorregistrar. It was here that he developed aninterestinpaediatricanaesthesia.Thisinteresthaspervadedhisprofessional life,and itwaswithmuchsadness(butasaconsequenceofaneedtoaddresssomehealthissues)that,inthemid1990s,hemovedoutoffulltimepaediatricanaesthesiatojointheadultanaesthesiagroup.Despite this he managed to retain his skills

andenthusiasmbycontinuingsome“practicalpaeds”atBristolEyeandDentalHospitals.Ifthis proved insufficient he could always slipawaytotheBristolMedicalSimulationCentrewherehisburgeoningprogrammeofpaediatricsimulationwouldprovidechallengesgalore.Today,SteveisourownBigBrotherintheSirHumphry Davy Department of Anaesthesia.Asourmostseniorcolleagueheisrespectedbyhispeers forhisendlessefforts insupportingandrepresentingcolleagues;o Representative and subsequent chairman

on Regional Consultants SpecialistCommittee(1996todate)

o Chairman of UHB Local NegotiatingCommittee(2006todate)

o Memberof theBMACentralConsultantsandSpecialistsCommittee(2008todate)

Yet perhaps for trainees, less familiar withthese sorts of achievements, he is in bestrenownforhisdapperdressandhisremarkablegift for making physics both interesting andunderstandable!Whataboonforpart1FRCAcandidates.Steve’scareerisunderpinnedbyaninterestin“proper” training. He has been an instructorforAPLS andALS. He was College Tutorbetween1994and1999,aCollegeexaminerforelevenyearsandhehascontributedextensivelyto teaching locally, regionally, nationally andinternationallythroughsimulation.Indeedhehas travelled widely to spread the word andchampionthesimulationcause.HecontributedtoTheSocietyofEuropeanSimulationAppliedto Medicine (SESAM) council in severalguisesandwasavisitingGovernmentSpecialAdvisorforSimulationtoSingapore.Thelistgoeson,butthewordcountmustberestricted.IhaveknownStevefor21years,allthetimeI have lived and worked in Bristol. For 10of those years (1996 – 2006) we, and many

Portrait of the President

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others,sharedaninterestinandapassionfordeveloping the Bristol Medical SimulationCentre. Having shared a beer or two after adifficult day with the manikins, I thought Iknewmuch of his medical career, but I stillfoundsomesurprisesonreadinghisCV.Ihavetoconfesstoadegreeofaweatthenumberandbreadthofhisachievements.Icanbutcoverafewinthisportrait.Steve’shandsareneveridle.WhennotatthewheelofanEtypeJagorasmalllightaircraft(heholdsaprivatepilot’slicence)hehasspenttimebuildingupasignificantbibliography:o Authorof3chapterso Co-authorof9bookso Author of 38 publications in a variety of

peerandnon-peerreviewedjournals(OnceIhadpushedmylowerjawbacktomeetmy upper, I did wonder whether writing the“Portrait of the President” might add to myownsmallnumber–pleaseadviseeditor)TherearetwoSocietiesdear toSteve’sheart.BOAS (British Ophthalmic AnaesthesiaSociety)andSASWR.Hehasbeenacouncil

memberofBOASfor6yearsandeditoroftheirjournalsince2009.HisroleswithinSASWRhave been many and varied. He was editorof Anaesthesia Points West from 1990 – 3,TreasurerofTheSocietyfrom1995–9and,ofcourse,iscurrentlyPresident.Itistraditionalfor a presidential appointee to be voted intopost beforemoving to theWhite House, butSteve did it differently. Some years ago heandhisexcellentandlongsufferingwifeCelia,alongwith one of their two children, James,movedtotheirownWhiteHouseinClevedon.Inneedof “somework” it hasbeen lovinglyrestored(muchbyStevehimself)toaresidencenow fit to receive the Obamas. Supportedby the aforementionedCelia IhavenodoubtthatStevewillcontinuetothrowhimselfintothe role of President and work tirelessly onbehalfoftheSociety.IknowthatallofusintheSirHumphryDavyDepartmentwishhimwell andcongratulatehimon thisprestigiousappointment.

frances forrest

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BarnstapleThis time last year I wrote that we hadexperienced some of the coldest weather forquitesometime.Wellthisyearweexceededthatwithtemperaturesof-10°CinBarnstapleand-16°CinthehillsofNorthDevon.Similarchaos to last year ensued with many staffmembersandpatientsbeingunable toget in,and discharged patients being unable to gethome. Wemuddledthroughandnowweareplayingcatch-up.However,therewereplentyof opportunities for the photographers so IhaveincludedoneoftheRiverTawcoveredinpack-ice–asightonlyrarelyseen.

CongratulationstoAndyHadfieldwhopassedhisPartIexams.LauraHamilton,JoeRiddeland Norfaizan Ahmad are all awaiting theirMCQresultsat the timeofgoing topress sowehopetobeabletoreportgoodnewsinthenext issue. Joe is gettingmarried to Sophie

inMay andwewish them everything of thebest.Theweddingbashisallsettotakeplacenella bellissima Italia. Wewouldall love tojoin thembut invitationshavebeencuriouslyscarce!CharlieCollinshasbeenactiveinNepalworkingwith the International Nepal Fellowship.Reporting back, he regaled us with tales offlyingtoimpossiblelocationsintheHimalayasin rickety helicopters flown by crazy pilots,but also how the team managed to perform148ENT cases (mostlymastoidectomies andmyringoplasties)in8days,withthemostbasicequipmentandfacilities.It’sastonishingwhatcanbeachievedwithamaximumofgoodwillandaminimumofredtape.Onthesametack,LaurieMarksspentaweekin Zimbabwe demonstrating and training ontheuseoftheGlostaventanaestheticmachine.Hereports:“Dr Ruth Hutchinson (originally from Poole DGH) took early retirement in the early 80’s and has spent 20 years working in Harare. She was distressed to learn of the failure of the piped medical gas system in the Parirenyatwa (Harare’s teaching hospital) and the ensuing havoc. Theatres have only just had oxygen supply restored. Ruth decided to help by donating an anaesthetic machine that would work safely and reliably without the need for piped gases. The Glostavent, built in North Devon, and working in over 20 countries in Africa, was the best option.

news of the West

This is where you are kept up-to-date on all the news and gossip from each department in the South Western Region. The name of the correspondent appears at the end of each contribution and he/she is also the SASWR LINKPERSON for that department. Anyone wishing to find out more about SASWR or wishing to join, should search out the local linkperson who will readily supply details and an application form. In addition to other benefits, members receive the twice yearly addition of APW – FREE!

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“The training of all categories of anaesthetic providers started in the classroom and ended in the operating theatres with the Glostavent being used on a wide range of patients. The simplicity of the machine with its ability to continue to function normally when all gas supplies have failed was immediately attractive to anaesthetists. There was wide interest from many other hospitals where the reliable supply of oxygen continues to hamper the normal delivery of anaesthetic services. “The decline in health care delivery in Zimbabwe over the last decade has been sad to witness. Using appropriately designed equipment is one possible way forward to help provide services while rebuilding the health service.”

We have been fortunate to have a morestable middle grade cohort of late and weare appreciative of the contributions to ourdepartment of our regular locums: BalazsBartos, Alex Smith, Geza Reusz, AkramMohammadu,GuruswamyManjunathaswamyandBalazsIttzes.OursubstantiveSASgradesareyettomoveontothenewcontract,asisthecaseinmanyTrustswhoaresuddenlyworriedbythebackpayowedinthecurrentfinancialclimate.They’veonlyhadsome2yearstosortitout!Colin Colville celebrated his big 5 with aparty in an out-of-the-way pub. Drink wastaken-mostlyalebytheyard.Iamtoldthatkaraokewasinvolvedbutthat,inColin’scaseat least, thiswasnotsomethingtocelebrate-thankfullynot a careermove. JanHanousekis approaching his big 4 but he has arrangedaproperband so at least themusicwill be aquantumleapbetter,orsowehope;althoughwedon’texpecttoseeJanwinning“Strictly”given the moves he demonstrated to Colin’scrooning.Lisa,our“bossintheoffice”hasstartedtraining

fortheGreatNorthSwimlaterthisyear. Wewere queuing up to join her but entries haveclosedalready.Onthesocialsidewehaveenjoyedthebeautyofoursurroundingsonasuccessfuldepartmentalwalk,andhadtheusualChristmaspartiesetc,but you don’t reallywant to read about that,doyou? Nor the fact that the tiresomeover-competitiveOPSbeatusupagainatdarts,poolandskittles,younameit–andwearen’tevengoingtosuggestakaraokecompetition.Haveagoodspringandsummer.

David hurrell

BathAsweawaitthefirstflushofgreenheraldingthearrivalofSpring,soweawaitthefirstsignofacleanerreturningtothedepartmentheraldingthepassingofthelatestbedcrisisaftermanyweeks. Thehospital has beengrippedby anobsessiontocontrolourfinances,ourwaitinglist targets, our 4 hour targets, and of courseourinfectioncontroltargets.RoleontheendofthefinancialyearandSpringsowecangetthe bins emptied and give the department adamngoodhoovering.However, the last six months have been fullof good news. Vaughan Martin and TriciaMcAteernodoubtfeelendlesssympathyoverthe recentplightof theRUH,butmustbesograteful to sympathise at a be-sleeved arm’slengthfromthedreaded“Noworkvirus”,nowthey are just getting the hang of retirement.VaughanhasbeensightedonhisbikebutTriciacanonlybeseenfromspaceasshecruisestheoceanswithJohn. All remain ingoodhealthbut there are signs of old age creeping intothedepartmentwithanorderlyqueueformingoutsidethePainClinicandphysiodepartments,as one degenerative disc after another seemstobepoppingout,totheextentthattherewillsoonbeadepartmentalbackpainrehabgroupmeetingonaregularbasisinsteadofaudit.

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WewereverypleasedtowelcomeFionaKellytothedepartmentasaconsultant,congratulatedSaraKeeleyonthebirthofherdaughter(andarelooking forward toher return frommaternityleaveinMay),PaulHerschonthebirthofhisdaughter, andRuthMurphyandBorysToporon thebirthsof their sons. Morebabiesareimminentlyexpectedandyouwillbeupdatedin the next bulletin. We were most gratefultoDanLowforhis stint as locumconsultantbefore headingoff to theChildren’sHospitalin Seattle, and to Clinical Fellow RajeshSrivastavaforhis3.5yearswithus.TraineesRuth Murphy, Andrea Binks, David Barnesand Ben Huntley joined us most enjoyablybut all too briefly, to be replaced by JamesSidney,Alia Darweish, Tracey Christmas (toleaveandthenreturnlaterintheyear),NatashaClarkandCaroleStreets.Iwouldparticularlylike to mention and welcome Dr SarbreetSaraowhohas joineduson theDeaneryandCollege sponsored training programme fromChandigarhinIndia,hopefullyfortwoyears.WehadwhatIbelieveiscalledalargeamountof deferred success in the Primary FRCAexams,butweareverypleasedtocongratulateBeckyBrooksonpassingher examand lookforwardtoincreasedsuccessinMay.Iamverypleased to say thatChris Seller has acceptedthebatonofCollegeTutorforthedepartment.Iwishhimwellwiththenewcurriculumandthe ever-increasing regulation of the trainingprogramme.We were also pleased to reach a settlementallowingustobecompensatedmoreaccuratelyfortheobstetricserviceprovidedbytheRUH;wecongratulateEstatesformeasuringthelandmassoftheRUHandobtainingareductionof£1mintheamountwepaytotheGovernment,plusdiscoveringthewaterleakthathascaused£100ktobewashedaway.ThesavingswillbeusefulwhenwehavetorunaSaturdayservicetocompensateforpastfailingsinmedicalbed

provisionor,whoknows,evenappointanewconsultantortwo.CarolPedenhasnowtakenup her role as Deputy Medical Director forQuality Improvement (good formanagement,bad for anaesthesia), andKimGupta isLeadClinician for Organ Donation (good fortransplants,badforanaesthesia).Currently the painters and decorators areout in force and we are undergoing a majorrefurbishment in theatres. We may haverun out of inco pads but the paint and newoperatinglightsaregoingwell–moneycomesfromadifferentpot.Theinterestingissueoverthenext fewmonthswillbe theeffectof theopeningofaverymodernandextremelyhightech circular hospital in Peasdown St Johnin addition to the 2 new ISTC’s in DevizesandEmerson’sGreen. Wherewillwe all beworkinginthefuture?–Watchthisspace.I will sign off at this point with the thoughtthatbythetimeofmynextmissive(lateagainno doubt) DrThornton’s thighs will still nothaverecoveredfromthegruelling8dayCapeEpic mountain bike ride that he is soon toundertakewithaformertraineeofthisparish,DrPaulTrumpleman–wewishthemwellandhopefullynottoomuchneedforpaddedseatsandcoolinggels.

Tom Simpson

cheltenhamThelastfourmonthshaveseenmanycomingsand goings. As with everywhere else thiswinter, the weather has intervened on manyoccasionsandmadethegoingtough.Buttwopeoplestandoutasworthyofapplause:SheilaWest for falling over, breaking herwrist andstillmanagingtodrivetoworktohaveagoatstartingherusualall-daygynaeextravanganza(akatheGornalllist)beforebeingdraggedoffto fracture clinic and put in plaster of paris,andJamesDeCourcywhofulfilledalife-longambition to ski towork and got his name in

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lights in theGloucestershireEcho forgettingthereagainstallodds(seephoto)

Snow notwithstanding, we welcome severalnewmemberstoourdepartment,manyofthemfromfarsunnierclimes:RajGiriyappa,KiranSrinivasanandManeshMittalhavecomefromIndiatojoinusasnewstaffgrades,alongwithDimu Gunasena and Vasu Devanesan fromSriLanka.WearealsodelightedtowelcomeRachel Prout, Megan Dangerfield, GemmaMatthews andMatthewRoe and towelcomeback into the foldBenHuntley.ClaireKalooand Carolyn Warr will also be returningfrom maternity leave to join the grown-upsonce again. And speaking of babies…manycongratulationstoourmanyproudnewparentsin the department: Rob Jackson (baby boy),Fran Verey (boy), Helen Crispin (girl) andTomasStankus(girl).Wesayourfondfarewellstoseveralmembersoftheteam:NaranPadhiyarwhohasgonetoJersey to take up a new staff grade position,Zehrin Nassa, Louise Carlson-Hedges, andEmma Foster. Goodbye and good luck alsotoLucyKirkham(off toTaunton)and toourdynamicduoCaroleStreetsandNatashaClarkour fantastic flexible trainees who’ve bothgone toBath, on the home straight tofinallycompletingtheirtraining.Wewishyoualltheverybest.FinallyImustmentionMrsWendyStonerourstalwart departmental secretary,manager and

magician. Wendy has retired from the NHSafter many long years of service. It’s onlysince she’s gone that we finally appreciatejust how cleverly she kept us all sorted andmanaged to jugglemany,manyballs tokeepthedepartmentservices runningsmoothly. Agreatnumberofballshavebeendroppedinherabsencebutwe’refinally getting the hangofthingswith the help of Jennifer andBetty intheoffice.P.S. Congratulations and commiserations toLeonVisser who’s taken on the role of rotacoordinatorinthedept-clearlyyoudidn’tducklowenoughwhenthatshotwasfiredLeon!ToodlePip

yvonne Marney

exeterTheRD&Eisstillinbusiness,despiterepeatedattacksofnorovirusandfreakishweather.Thewintercrisisplanswouldhaveworked,ifonlythe bed pressures this year hadn’t been evenmoreunprecedentedthanlastyear.Wardswereclosed,staffstruggledtomakeittowork,andwhentheyarrived thefewremainingpatientshadbeensnowedin.Thehospitalwentthrougharainbowofalerts,eachmorevibrantthanthelast, but less and less elective operatingwaspossible.AndsonowwearedoingextralistseverySaturday,tocatchup.Hohum.WehavesaidfarewelltoMohan(congratsongetting an ST4 in Birmingham), Rich KayeandAndyMcEwen.ShaunClarkehasreachedCCTandhasbeenalocumforafewmonths,before leaving for Oz. Matt Rucklidge hasgonetoPerthforayear–willTaniaallowhimtoreturn?Ithinkandhopeso–afterall,whatdoes Perth have to offer, that Devon lacks?TaraBoltonisleavingustomovetoGuildfordafter3yearsasalocum–thanksforallyourhardwork,andwewishyouluckinyournewjobandlife.WewillmissBillBoaden’squietpresencewhenheretiresagainafterayearas

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a locum.Andfinallywewillmiss thenot soquietpresenceofPaulMarshall,whohasbeena locumwith us for 3 years since he retired.Since retirement Paul has had a new leaseof life, taking on the role of senior registrar,enjoying the opportunity to have aweek fullofvariety.Thankyouforyourhardwork,bigsmile and very loud laugh. Fortuitously,wewelcomeHarryPugh,amanwhohasalaughasloudasPaulMarshall,asanewconsultant.WelcomealsotoDominiqueMumbyandRobPrice as new consultants. SheenaHubble isbackfromBrisbane–notsurgicallyenhanced,despite the rumours. You are perfect as youareSheena.Oratleast,it’snothingthatagoodwoollyhatwouldn’tfix.Ourtraineeshavebeenbusy. ClaireWoodallgot married earlier this year, and ratherconfusingly changed her name to Attwood.PatricziahasgotengagedtoAli,andSuzanneandHayleyareduetowedlaterthisyear(nottoeachother!).CongratsalsotoMonali,onthebirthofLisa,toSuzyBaldwinonthebirthofEleanor, and to Hannah Stewart on the birthof Jemima. Good luck toBruceMcCormickand Kate, who are due imminently, and toMarkDavidson,MikeSpiveyandMattWilsonwho are also expecting babies soon. Finallycongrats toVanessaPurdaywho is expectingbabynumber3inthesummer.Colin Berry and Jon Purday both celebratedtheir 50th birthdays recently. Well done toboth of you. Good luck also to Vanessaand Jon, Lauren and Pete Ford, in your newhomes.AndthelastofmycongratsgotoEdHammond,whowasawardedagoldmedalforthe “best online or distance learning project”at the e-learning industry awards in London.I’mnotsurewhetherthiswaswhenhemettheQueen,orifthatwasadifferentoccasion,butverywelldone,eitherway.WehostedSASWRinNovember,whichwaswell attended. Unfortunately as organiser, I

didn’t have much time to speak to anybody,butitwasgoodtoseesomanyfamiliarfaces.Imustn’ttakeallthecredit,asJamesPittmanand Quentin Milner were my trusty helpers(!!),andTarawasagreathelptoo.The Xmas do was once again held at theClarence, with a max turn out, plus waitinglist. For the first time in several years, thetraineesdida fabskit, takingoffWhoWantsto be a Millionaire/The Weakest Link, with“consultants”inkeyroles.IwasproudtobeAnne Robinson. Clearly Q should start thequestions, as he is the poshest. Luckily forAlex, it was too short notice to include theconsultant with the most risqué after dinnerspeechasacandidate.CongratstoNickBoydonwinning the trainee prize, and toAndrewFoo for winning the ITU Oscar and as istraditional,beingon-call.The Sux Pistols have been busy, playing atSASWR, the Xmas Do and at the theatremaskedball.No,JoCornes,theydonotplayLady Gaga, but Roland did think his luckwasinforamoment,atSASWR.Luckilytheknickerthrowingcontinuesunabated.

Guess who?

TheStAntonskitripclaimednocasualtiesthisyear,despiteJonPandJonShavingamidlife

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crisis,andthinkingthatitisnormalformenintheirfiftiestoclimbbarrierstoppedwithbarbedwire,andmarkedwithsignswarningofinjury,death orworse. Somehow they survived thefalldownacliff,andfoundtheperfectslopetoskidown.JonSaddlerapparentlymanagednottospendasingleEuro,mainlybecauseMarkDaughertyboughtaroundcostingapprox400Euroseachnight,butwasonly seen to smileoncewhensomebodyfellover.JamesPtookituponhimselftocureQuentinofhisalcoholallergy – imagine getting the most fearfulheadache ifyousomuchas sniff theCoqauVin. ThatwasQ, prior to theStAnton trip.Following some serious flooding/immersiontherapy,JameshasdeclaredQofficiallycured.Sadlythebeaverwasnowheretobefoundthisyear.So, that’s all from me for now. Until nexttime....

Pippa Dix

frenchayThe unexpectedly bleak winter weather wasoffsetinBristolbyaseriesofexcellentsocialevents,startingoffwithAnaesthesiaReloaded.The Frenchay contingent, notably SarahMartindale andBenGibbison, demonstratinghis famed lung capacity, could be found onstage belting out ‘Sex on Fire’ by theKingsof Leon. In generous mood and with nothought for his own safety, Ben made thegirls’ evening by dispensing goodnight hugs,andSamanthaShinde,whohasaprettygoodpairoflungsherself,becametherecipientofaparticularlycloseclinchwhichfeaturedhavingherbacksidepatted.Needlesstosay,aqueuequicklyformedatthispoint,but,tothehorrorofseveralofthegirlspresent,thishonourwasnottoberepeated.Nextupwas thebashforJohnCarter’swell-deservedretirement,heldaboardtheSSGreatBritain in its dry dock inBristol, although it

wasn’t lookingparticularlydryby theendoftheevening. Amongstother thingswe learntthat John, whilst at medical school, heldthe title of UK Universities table footballchampion,a rolehe tookseriouslyenough tosuspendhisstudiesfor.DoubtlessafullprofileofJohn’scareer,includinghisroleswithintheAssociation ofAnaesthetists, not least as theauthor of ‘TheNakedGasman’ column, willappear elsewhere. The departmentwillmisshis good humour, and also the presence of acolleaugueonecouldapproachwithany typeofproblemandbeassuredofasympatheticearandsoundadvice,unlessitwasonaMondaymorning,whichhewouldspendhidingbehindthe Isle of Wight with Tricia, in his yacht.Entertainment for the evening was providedbySuePlastow’sson’sband,theappropriatelynamed‘OpenOcean’,whowereamazingandhad everybody dancing with a particularlyrousing version of Johnny B. Goode (sic).SarahMartindalestillmaintainstheleadsingersang ‘She’s soLovely’ byScouting forGirlsdirectlyather.Incidentally,ifanyofthepartnersofthefemaleConsultants at Frenchay are wondering whathashappened toa) thecontentsof their jointaccount and b) their wives’ armpit hair, it’sallresidingatalasercentreinRedland.No,Icouldn’tbelieveiteither.

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One of the upsides of being a doctor is therelative job security we benefit from duringa recession. The downsides include havingto get intimate with the recently deceasedduringoutofhospitalcardiacarrests.JamesRogerswascalled toaidaparishionerwho’dkeeledoverduring the service, possibly aftertaking“Nearer,MyGod,toThee”alittletooliterallyandClaireJewkeswasatapartywhenadistraughtneighbourinterruptedproceedingsto say he’d stumbled across an unconsciouselderlywomanlyinginthestreet.Thevariousassembled doctors spilled out onto the streetand started administering CPR. It was leftto Claire, as the sole anaesthetist present,to perform the mouth-to-mouth breathing,while the others took turns with the chestcompressions.Perhaps it was a form of post-traumaticstress,butnot longafterwardsJames, foreverthereafterknownas‘Jimmythefinger’ in theorthopaedic department, let rip during hiscycleridetoworkwithastreamofinvective,complete with gesticulations, directed at IanHarding,oneofthespinalsurgeons,whohadhadthetemeritytotoothiscarhornathim.Hopefully not returning with post-traumaticstresswillbeDebbieHarrisandRuthSpencer,whohavejustleftfortheGazaStriptodeliversomelectures.RuthSpencer,Hamas,politicaltinderbox;whatcouldpossiblygowrong?RecentadditionstotheConsultantrankshaveonly been at the grassroots level, with thearrival of baby Gwen toAidan and HannahMarsh, and Oscar Elwyn to Ian and LisaThomas. Congratulationsalso toMiguelandAlexandraGarcia-RodriguezforthearrivalofSantiago. Other additions to the departmentincluded some familiar faces, such asLouiseSherman,JanineTalbotandYeliHorswill,andsomewhoarrivedandthendisappearedtohavebabies,suchasAliceBragaandCathyHoyer(God,IhopeI’vegotthisright). Completely

unsuspectingnewbiesincludeShailendraDeepandMichaelBishop,whoisaneuroanaestheticclinical fellow from Brisbane. He is veryexcitedashehasnever seen snowbefore,orculturepresumably.AlsoarrivedareSiobhanKing and Mark Turner. The new novicetrainees are Sophie Macdougall, Scott GrierandAlexCross.AlexisjustbackfromCampBastioninAfganistan,and,aproposofnothing,innocently made the observation that, in thearmy, staff areappreciated for their efforts atwork. HellooooNHS! Departures from thedepartment include Helen Cain (special opssocial sec), Amit Goswami, Rob Axe, EdScarth, Ali Johnstone, Nancy Boniface andEmmaBellchambers.Despiteseveralretirements,theTrustishopefulthatincreasedefficiencieswillnegatetheneedfor replacement appointments. Somewhatcounter to this was a recent edict that nofoodordrinkshouldbeconsumedwithin thetheatre complex, unless in designated eatingareas. It was pointed out that the majorityof anaesthetic lunches were consumed byanaesthetistsstandingintheanaestheticroom,peering at the monitors through the theatredoors, thus resulting in a seamless flow oftheoperating list through lunchtime,and thatthenewrulewouldstopthis.Ahastyrethinkensued,andnowthenewrulenolongerappliesto anaesthetists. Perhaps we missed a trickthere,asnowattentionhasturnedtoourSPAactivities, andwe are all filing our job plansonline. One thing is certain, as Trusts lookto work more efficiently and make savings,neverhasLampedusa’sfamousadagein‘TheLeopard’, his novel about 19th-century Italy,beenmore apt: “Ifwewant things to stay astheyare,thingswillhavetochange”.

richard Dell

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gloucesterWell, as I reflect on the last few months inthe Gloucester anaesthetic department it canprobablybesummarisedbynewappointments,exams,parties,awedding,andaspaday!Firstlynewappointments; JoCorneshas justbeenappointedasaconsultantwhichisfantasticnews.Shehasbeenworkingextremelyhardasalocumconsultantforthepastfewmonthsandthoroughlydeserveshersubstantivepost.AlexD’Agapeyeff has also joined the anaestheticdepartment as a consultant in intensive care.AlexworkedatGloucesterformanyyearsasatraineeandthedepartmentaredelightedthathehasrejoinedourteam.PaulDowniehasjuststartedasalocumconsultantinintensivecare;he trained in London and has recently beenworkinginAfrica.WewereverysorrytoseeFionaKelly leave to take up her substantivepost in Bath – she also worked as a locumconsultant on intensive care for a fewweeksanddefinitelyhadabaptismoffire,as itwasridiculouslybusywhenshewasoncall.Two new staff grades have joined ourdepartment – Dr Shetty and Dr Bansal.Welcometothem.Wehavesomegreatseniortrainees who have recently joined us – DrsThompson,Wellesley,O’ConnorandSmith.Congratulations are in order to Ian KerslakeandClintonLobowhohavebothpassedtheirPrimary FRCA and to Pete Sanderson andSarahMuddlewhotiedtheknotattheendoflastyear.As for parties –TomPerris and IanGodfreyorganisedabrilliantChristmasparty,almostallthedepartmentwerethereandwehaddeliciousfoodandcopiousquantitiesofwine.Wehavehadmany leaving parties over the years, themajorityofpeople justhaveoneeachbutEdBicksomehowmanaged three!! HehasnowleftustojoinSouthmeadwhereIbelieveheisperfectinghissurfing!A large number of the Gloucester and

Cheltenhamanaesthetistsareontheorganisingcommittee for the Difficult Airway Societyannualmeeting,undertheguidanceofRichardVanner. The meeting is going to be held atCheltenham Race Course, November 24th-26th.Itlookslikeagreatprogrammesobookyourstudyleavenow.Finally,ourgirls’spadayatCalcotSpa–ChrisFinchoursecretarywhohasbeenwithusforseventeenyearsisleavingforafewmonthssothegirlsinthedepartmentdecidedthatabitofpamperingwas inorder.Wehadawonderfuldayofrelaxingandhavedecidedtomakeitaregularouting!

claire gleeson

SouthmeadSpringcomes toSouthmeadand it’s snowingagain. We’re getting quite good at it nowandall thepatientsstillmake it insoservicecontinues almost unchecked, although yourcorrespondentchosetospendthenightoncallin thehospital’s “accommodation” remindingherwhyresidentialoncallshouldbereservedfor the young supple trainees...... Sadly thelesser-spottedspecialty traineeis increasinglyraresotherehasbeenquitealotofplayingup(sorryactingdown)goingonaroundhere, toourdelight!Enoughwhingeing,wemayevenbefullystaffedforabriefperiodsoon.SomeoftheboyswentinsearchofevenmoresnowandenlightenmentintheAlps(asiftheydidn’t see enough of each other at home??).But skiing is adangerous sport andnowoneof the department “members” appears on anX-ray:patientconfidentialitypreventsusfrompublishing this but it’s impressive (AP viewthoughMark).FionaDdidusproudatAnaesthesiaReloaded,holdingup theSouthmead stand-up slotwithgustoandprovingwhatasplendidexaminersheis.NikKoehliissteppingdownasChairmanin order to Chair the Final FRCA clinical

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sciencegroupforthecollegemakinghimevenscarierforthetrainees.Noonehasretiredforachangebutwearesadlysayinggoodbye toMedhaVanarase,whohasunderstandablytiredof the endless commuting to her family andgonetojointhembackinOxford.Wewishherwellandthankherforallherhardworkforthedepartment.We’llmissher.ChiefExecutivesalsocomeandgoandmanagementstructuresmust change. By the time this goes to presstheanaestheticdepartmentwillhaveprobablyhave been subsumed into the prestigiousdirectorateofclinicalsupport,joiningavarietyofspecialtieswhoaresomewhatlessacutethanoursbut I am surewewill continue tomakeour presence felt. Several exciting researchprojectsareunderwaywithanaesthesiaplayingaleadingpartsothiswillundoubtedlyhelp.Congratulations to Anoushka Winton onpassing the Primary and to Kathryn Jacksonfor getting a consultant post atUHB. OthertraineeswhohaveleftusareLouiseShermanand Esther Flavell and well done to MazElwishi who has secured a training post inNewcastleafterdoingtheregionalandairwayfellowshipatSouthmead.WelcometoJeremyAstin,BenFox,EdwardBick,LucyMillerandTobyEverettandwelcomebacktoPiaLieberandRajMalhotra.CerysScarrgoesofftoICUafteragreatfirst3monthsinanaesthetics.BenGibbison, Tom Martin, Steve Tolchard, MelMcDonaldandNickPrestoncontinuewithusalthoughNickisshortlytostartafellowpostinclinicalleadership–welookforwardtohisreturn asClinicalDirector in 6months! WearealsodelightedtohaveJoAdelainejoinusinasubstantivepost.BIGTHANKStoallourtrainees and specialty docs who have put inalotofhardworkcoveringsicknessandrotagapsoverthepast6months.Actually,wehavesurvived the swine flu epidemic remarkablywell,much like the rest of the country. I’msure the time taken smelling vile stuff to

check the mask fitted properly was whollyworthwhile, doubtless we can find plenty ofoccasionswherebeingunabletosmellwillbeadvantageous....Asthenewhospitalbuildingworkscontinue,parking and transport to the hospital hasbecomeatopicofhotdebateandinterminableemailexchangesbetweenfanaticaleco-cyclistsand die-hard Clarkson devotees. Our usualparking area has been the site of a huge pit.Wethoughtastherainfilleditupthatthiswastobetheswimmingpoolforthedoctorsmessbut no, once it had been pumpedout severaltimes, it turnedout tobe thesite for thenewgenerator.Notawindturbineorsolarpanelinsighteither.PlansfortheautumnSASWRmeetingarewellunderway,andafabulousprogrammeisbeingcreated,byafinelyhonedteam–itlooksgreatandIlookforwardtoseeingyouallthere!

Jill homewood

SwindonGreetings from Swindon. Your scribe lives.Swine flu did not, after all, decimate thedepartment.Itdidcometovisitthoughandnowhashopefullygoneaway.Yourcorrespondentrecallstheeveningwhenhefound3ventilatedH1N1s on ICU and thought that maybe itwasn’tallhypeafterall.Intheendwehad7ICUadmissions–2ofwhichinvolvedaperiodofECMOatLeicesterand,sadly,3deaths.Am I donewith pestilence? Noway. ThentherecametovisittheNorovirus.Fivewardsclosed. In-patients inDaySurgery,PPward,evenabayontheChildren’sward.ICU/HDUdischargingpatientsdirecttohome.‘Twasallgetting a bit silly. Trustmanagement forcedto press the nuclear button – cancel electivein-patientsfor3days.Fiveyearsoftargetsinruins.Icouldn’tsleep.OK. That really is the pestilence bit done.Now let’s talk about theweather. Ordeal by

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ice that it transpired, was the hors-d’oeuvre,for then we had ordeal by snow. What funthatwas.‘Ifyoucan’tgetin,ringthisnumberandwewillcomeandcollectyou’–theysaid.Hmm………ring, ring……ring, ring……noreply. GWHworkforce 3500. Number of 4wheeldrive‘wewillcollectyou’vehicles?Youalreadyknow,don’tyou–one.Appointments,arrivalsanddepartures.Heavytraffic on theM4 again? Yes - but not likeAugust. We said goodbye to Drs Scarfe,EverettandAstin.TheformerbacktoOxford& the latter two to Bristol. Meanwhile, wesayhellotoDrPongratzfromOxford,andDrsIqbal,Burrows&Alexanderfrom,yes,Bristol.MarkScarfewasourfirst‘green’anaesthetist.We are not talking nitrous oxide & volatileshere. I mean GREEN. We are talkingsawdustfiredcentralheating,growyourownvegandNO,repeatNO,car. Mark’sjourneyto Swindon was as follows: bicycle 3 milesfrom home, train from Charlbury, change atDidcot, on to Swindon. Bicycle 2 miles toGWH.It’sa5.30startandtwohoursdoor-to-doorifallconnectionsaremadesuccessfully.Add iceand/orsnowandyou’re talkingfour.Your scribe admires and respects Mark’scommitment–butseriousgreenisnotforthefainthearted.Consultants? It’s all one way. Wonderfulnews,youroldscribe,MatIckeringill,returnsfrom an outpost of the Empire inAugust, asdoesJulianStone.MajorBenMaxwellhasjustreturnedfromhissecondtourofAfghanistan.Benwas seconded in aUS hospital ‘facility’this time. OurAfghan correspondent reportsthattheyanksmayhaveallthekit,buttheyarenot nearly aswell organised as the limeys atCampBastion.Andlastly,Icanannouncethatwe have two new consultants starting in thespring:DrManihails fromCardiff. Aquickcheck of the ‘other interests’ part of her CV(thebitIreadfirst)tellsmethatsheisakeepfit

fan.Meanwhile,DrRidgewayhailsfromthefrozenwastesofLeeds.Sheisakeencyclistand runner. A new recruit, or possibly two,forthedeptTriathlonclub?Strangely,neithermentionedaspecialinterestinPrivatePracticein their CVs. I hope this was an accidentalomission–TheRidgewayHospitalisinurgentneedofDrsRidgeway&Mani.

Doug Smith

TorbayProbablyforthelasttime,IattendedtheWinterScientificMeetinginLondonbackinJanuary.Quitealotwassaidabouttheorganizationandlong term plans theNHS needs to assure itsfutureandmaintainstandards.Thisallseemedsomewhat undermined by another sessiondevoted to climate change and the inabilityof the planet to sustain even zero growth incarbonemissions,withseriousglobalconflictover food andwater in the next thirty years.WiththeIraqInquirytakingplaceinthesameconferencecentreatthesametimethereseemedtobeacuriousmixofmercyandmadnessallunderoneroof. Against thisbackdropInowfeeleasiershouldmyreportcontainanysmallfactualerrors.InparticularIusuallymisspellatleastonename–butyouknowwhoyouare!Wearedelightedthat thenewpostas leadinobstetrics, has been filled by James Griffin.We send to him, his wife Cathy Hoyer andtheir family our warmest best wishes andcongratulations. Richard Hughes and GerryAnderson aremostwelcome and appreciatedaslocumconsultants.Weextendourthankstothemfortheirconsiderablecontributiontothedepartment.DavidSnowhasveryeminentlycompletedhistermasChairmanoftheDepartment,andhasreturnedtotheranks,althoughhehastakenontheroleofEducationalSupervisorforCriticalCareTrainees,apostpreviouslyheldbyMattHalkes. David is succeeded asChair byDr.

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NualaCampbellwhois,ofcourse,wellknownin the region for her commitment to trainingand academia in general. Jonathan Ingham,a man of integrity, continues as our wellrespected Clinical Director. Tony MatthewsisournewCollegeTutor,andOmarIslamhastaken on the Lead in Clinical Effectiveness.MattHalkeshasbeenappointedasDirectorofClinicalEducation. Congratulationstoallontheirsuccesses.Aonedaycourseinvivatechniqueshasbeenset up by our trainees. ‘SWIPED’ (SouthWest Intensive Primary Examination Day)is held at nearby BuckfastAbbey under thedirectionofClaireBlandford,KimChishtiandDavidPappin.Atpresentthereisroomforamaximumoftendelegates,soearlybookingisadvised!Callourofficeon01803654311fordetails.Buckfasttonicwineisavailableinthevisitorshop.The Torbay Difficult Airway ManagementCoursecontinuestoflourish.Thenextonedayworkshopis takingplace inournewHorizonCentre on 3rd July and is catering forODPs,anaesthetic nurses and paramedics. Two ofown ODPs, Martin Brace and David Brownare actively involved in its organization andpresentation.MikeSwart,KerriHoughtonandRobLofthouse(Trauma and Orthopaedic Consultant) havejust returned from anotherweek inNanyuki,rural Kenya, where they have been helpingthelocalpeoplerequiringvariousorthopaedicprocedures. Theywere supported by a teamoffivenursesandODPs,allofwhomgaveuptheirtimeandmoneytoorganizeandsupportthisrewardingventure.Itislookingasifthiscouldbecomearegulartour.One of our long-serving consultants, PeterBallance, retired in January. Peter had adistinguished career including obstetric andvascular anaesthesia, and had been a verysuccessful chairman of the department. As

a gentleman anaesthetist Peter was wellrespected by colleagues, trainees and theatrestaff. Hewas, Ibelieve, theonlymemberofthe department who regularly used a properfountainpenchargedwithblackink.WegivePeter and his family our best wishes for thefuture.Congratulations to Lyn Margetts (PainManagement)andhusbandHarryonthearrivalofJohn,theirson.Allthreearewell,withLynplanningareturntoworkinthesummer.Carparkingandcoathangersremainacriticalissue,especially for thosearrivingaftereightthirtyinthemorning.Thoseinauthorityhavebeen doing a census of cars in the car parkto seewhomight be stretching their claimedhours of attendance at work on their permitapplicationforms.OnatleastoneoccasionIhave been known to arrive ridiculously early(sixthirty)tosupportmychanceofaprioritybadge. I felt rough all day. I hope Iwasn’twastingmytime.

ian norley

TruroIt is Spring, I think. There is a bitter eastwind blowing and hard frosts each night. Ithas been a difficult winter. We have had aweeks’disruptionofelectiveworkandclinicsdue to the snow. Muchworse than that, ourcommunityhassufferedwidespreadNorovirusinfectionandfor twomonthswehavefoughta running battle to keep services going. Wehavehadtobanvisitorsandemployarotaofvolunteer`bouncers’onthedoors.Asaresultwe arewell behindwith our elective surgerytargets and extra lists are appearing all overthe place,with frantic pleas for staff. Thereisonlysomuchworkthatyoucangetoutofafiniteresource!OurDivisionwasunderseverepressuretoreducecostsbutwewereallowedto appoint 4 new colleagues to address theexistinglistgap. Howeverwehavenowhad

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to increase our locum numbers to get rid ofthebacklogofwork sobye-bye cost control.IsometimesthinkI’mtrappedinafusionofa‘Carry-on’movieand‘GroundhogDay”.Since I lastwrote,we have appointed a newDirectorofOperations,(thankyouBarnstaple),anewMedicalDirector(congratulationsPaulUpton), two assistant Medical Directors anda Director of Nursing. However we havefailedto temptanyoneto takeonourHumanResources department and we have lost ourFinanceDirector toDerriford. Our surgeonsare in rebellious despair because patientadministration has been reorganised and theroleofthemedicalsecretaryhasbeenchanged,pooled typing, centralbooking;one secretarybetweentwo!ShockHorror!Fromourside,wearehoping thatwewill nowhave theatrelistswhicharebookedingoodtime,bearsomerelationtowhatisactuallygoingtohappenintheatre and accuratelydescribewhichpart ofthepatienttheyintendtooperateupon.Wehaveopenedournewanaesthetistled/nursedeliveredcentralpre-assessmentclinic.Weareabout to open our day of surgery admissionsunit in spiteof theapparentproblem that thestaffwhowill run it havenotbeen identifiedyet! Theatre rearrangement tocreateourhothub isabout torollout. Asaresultwehavelostouranaestheticdepartmentandeducationroom.Wehavebeengiventemporaryresidencein two large open plan offices with a lovelyview,ontopofthenewDentalSchoolbuilding.One is entirely given over to the division’sOperations Staff. The other is shared withthe Bookings Coordinator and the remainingsecretaries.Therearecurrentlytwocomputersand two lap-top docking bays at four deskspacesfor44consultants,andasideroomthatwillbecomethecollegetutor’soffice/interviewroom/filingroom. Wearenotallowed toputanythingonthewalls,aswearetemporary,sononoticeboards.Wehopetocommandeerthe

old orthopaedic pre-assesment room near thetheatreasasocialroom/coffeeroom,butITUwanttoreprovidetheirofficespacethere.WehavetocompetewiththerestoftheTrustforaroombigenoughtomeetinforGovernancemeetingsandteachingtrainees.Isupposeitisverymodernandwehavebecomeanelectronicentity.Eventuallyourdepartmentwillexistinvirtualrealitybutnotasaplace.Ihavenotmetthreeofmynewcolleaguesyet,inspiteofthefact that theyhavebeen inpost for amonth.Cometothinkofit,Ihaven’tseensomeofmyestablishedcolleaguesformonths! PerhapsIwillhave to joinFacebookat last just tofindoutwhattheylooklike.Ourgynaecologicalcolleaguesarebeingtaughtlaparoscopic surgery for endometriosis (andeverythingelse).Beware,takeaheadlampandagoodbookifithappenstoyou.ItremindsmeoftheearlylaparascopicgallbladdersurgeryattheBRI!On a brighter note, we have appointed DrTodGuesttoourintensivecaregroupandwehaveappointedDrsGaryMatthews,WillFoxand Jonathan Cheung to our general group.Welcome Gentlemen and catch these ‘LittleTasks”thatwewishtooff-load.We have said farewell to two of our StaffGrades.AlexSmithhasmovedupcountryoutof the region and Siva Manyan has decidedto retire. We wish her and her family well.Perhapswemayhave thehonourof teachinghersonSaratVennamifhegetsaplaceinthePeninsularmedicalschool.WehaveappointedDrKateGreggasanewStaffGrade.CongratulationstoTodGuestonthearrivalofRowanand toTonyCartwrighton thearrivalofDominic.Our Junior Staff have remained fairly stablesince the last bulletin. However, TonyCartwrighthasmovedonandtakenhisITskillswith him andDrsVanstone andWeerakkodyhavejoinedusontheiracuteservicesrotation.

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So life is very fluid here in thewest. Thereareanumberofinitiativesthatwillhopefullymakeour liveseasierandmorelogical in thenext18monthsbutbythenwemayhaveanewsetofpoliticalmasters,newdirectionsandnewrules.KeeppassinggasappropriatelyandfighttoprotectyourSPAs.Bestwishes

Bill harvey

university hospitals Bristol Likeeveryoneelsewearewaitingwithinterest(notsurethat’stherightadjective)toseewhatthenextfinancialyearwillbring.However,forthemomentweareassuredthat thenewBRIbuildwillgoaheadandwewillbeabletoclosethe Old Building - here’s hoping! The newBristolHeartInstituteopenedontimecompletewith trees in the lobby and floor to ceilingsculptures of heart valves. Unfortunatelyseveral sections of it then had to almostimmediatelyclose-oneofthecontractorshadforgottentotaketheplugoutofthesewerandpromptly flooded the basement with sewageleading to a fly infestation that took severalmeninspacesuitsafewweekstosortout.Allisnowbeautifulandfullyfunctionalagainandtheshinynewentrancehasprovideda lovelyarea for the smokers to congregate, moreshelteredfromthewindthanthemainentranceandwithmucheasieraccess to thewardsforthose smokers in wheelchairs with drips andchesttubes.WewelcometothedepartmentnewconsultantsMatMolyneux,NeilRasburn,KathrynJacksonand Richard Beringer and locum consultantsClaire Dowse, Neil Muchatuta, ChristianAlexa and Fred Oberg (from Sweden).Congratulations to Charlotte Steeds, locumconsultantwithus,whohasnowstartedapainjob at Frenchay. Congratulations to BeataourPolishclinicalfellowwhohasstartedherconsultant post in Stornoway (the pictures in

the snow looked beautiful and several of usare now plotting a visit). Theworking timedirective took its toll on us, as I imagine itdid everywhere, with at times 1st, 2nd andconsultantoncall all coveredbyconsultants,much to the shock (or possibly that shouldbe horror?) of several junior surgeons. Ourtraineeswerebrilliantathelpingoutasmuchastheywereallowedtoandwewereallrelievedand delighted to welcome to the departmentnewclinicalfellowsRiaz,VinayandWaiandcardiacfellowDanniSeddonThe department seems to have been goingthroughaveryfertilepatchandIwontattemptto list all the newbabies since I’mbound tomisssomeoutandbythetimethisispublishedtherewillhavebeensomemorearrivals.AnaesthesiaReloadedwas again held atTheBristol Marriot Hotel, with UHBristol, NBTandthisyearBath,CheltenhamandGloucesterallwellrepresented.Thenewformatoffewertalks and more socialising was declared asuccess. Thanks to Rebecca Aspinall andDianaTerryfororganisingit. Thanksalsototheaseverexcellenttraineeband,withspecialmention to the unscheduled appearance ofkaraokestarBenGibbisonandhisorthopaedicsurgeonbackinggroup.The Bristol Medical Simulation Centre hastransferred ownership from the CharitableTrustees to the Trust and is now combinedwith clinical skills. We have broadened ourscope of courses with emergency medicine,medics, surgeons, radiologists, endoscopists,paediatricians, oncologists, gynaecologists,GPs, dentists and multiple nursing groups,all now coming through the centre andnew courses starting up every few weeks itseems. MatandNeil (ourveryownAntandDec)haveproducedanewversionof theoldthoracicanaesthesiacoursewiththeironelungsimulator (developed by eviscerating a simmanwhilstAndyMcIndoe’sbackwasturned)

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andarenowaimingforworlddominancewithacourserollingoutnationally.Theyhavealsobeenbusyinrecruitment,visitinglocalschoolswithateamoftraineesandnursestoencouragestudents to consider a career in healthcare -althoughI’mnotsurewhatthisencouragementconsistsofsincethereseemstobeatleastonestudentwhofaintseachtime,mostrecentlyinfrontoftheEveningPostreporter.Onthesportingfrontithasbeenaquietyear.Mark Scrutton is apparently now trainingextrahardsincethearrivalinhisrunningclubof someone even older and faster than him.Frances Forrest has started boot camp and Iam slightly concerned shemight beplanningtomakeitpartofmandatorytraining.SofaronlyoneskiinginjurythatIknowof,although

Franisabouttoheadoffon2weeksofNordicwildernessskiing.....!Mike Kinsella and Mark Scrutton have justreturned from their annual trip to Indonesia(Ben Howes tells me he saw the air ticketsand swears theywere forThailand) teachingobstetric anaesthesia and emergencymanagement with a course that looks like itwill be rolled out across the country. Manythankstoallmycolleagueswhocoveredextralists for free to enableme togo toHaiti andsorryforreturningadaylate-myflightreallywas cancelled due to a volcano erupting inGuadeloupe,honest.CongratulationstoSteveonhisPresidencyandgoodlucktoallourtraineessittingFinal.

rachael craven

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examination Successes and honours

Bristol School of Anaesthesia

Primary frcA DrAndyHadfield Barnstaple DrBeckyBrooks Bath DrClintonLobo Gloucester DrIanKerslake Gloucester DrAnoushkaWinton Southmead

final frcA DrEdwardScarth Frenchay DrHelenCain Frenchay DrAmitGoswami Frenchay DrAndrewJacques Frenchay DrSarahSanders Frenchay

Southwest School of Anaesthesia

Primary frcA DrMelPoole Exeter DrCharlieGibson Exeter DrAdamReville Taunton DrJamesCockcroft Taunton DrNiamatAlDamluji Torbay DrLaurenWeekes Torbay

final frcA DrSuzyBaldwin Exeter DrMohanRamamoorthy Exeter DrRobertHorsey Torbay

Society of Anaesthetists of the South Western region Prizes

TraineePrize: DrGemmaCrossinghamPresident’sPrize: DrBenHowesFenelyTravellingFellowship: DrGemmaNickells

other Awards

RossDavisBursary: DrNigelHollister DrFrankSwinton

Please accept the apologies of the editorial team if your success has not been mentioned above. We can only print the names of trainees supplied by the college tutors and linkmen around the region.

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Our Autumn Scientific Meeting was hostedby the local department in Exeter in thelovelycampussettingofReedHall,atExeterUniversity, completewith garden, ponds andparking. The local team, of James Pittman,Quentin Milner and Emma Hartsilver,were capably led by Pippa Dix, and createdboth excellent scientific and super socialprogrammes. These were complementedby smooth running administration achievedby a new management technique of the“chopping hand”. Thismethod of achievingcomplete agreement, and instant action, wasdemonstratedbyPippathroughoutthemeeting.Manyobservingherprodigious talentbelieveher to be a third Dan at least. The SocietycongratulatestheExeterdepartmentonaverysuccessfulevent.The meeting was opened by the outgoingPresident,DrTriciaMcAteerwhothenchairedtheAGM. After reporting the sad deaths ofTony Bennett, Geoff Hall and Neil Harvey(past president 95/96) she warmly thankedthe outgoing Hon Sec, Ed Morris, for hishardwork, energy and success indevelopingtheSocietyover thepast threeyears. Underhis tenure the membership has grown withincreasing interest from our trainees - 19posterswere submitted for the researchprizethisyear.AnotherstalwarttothankwasJamesPittmanashesteppeddownfromhisEditorialduties.VanessaPurday,alsofromExeter,hasstepped into thepositionofDeputyEditor tosupportthepresentEditor.

One of the more pleasurable duties for thedepartingPresidentistoawardtheireponymousprize. This year BenHowes rightly steppedforward to receive the honour for the efforthe has put into the Society by promoting itwith the trainees,developing thewebsiteandreinvestingtheIntersurgicalprizewonlastyeartodeveloptheairwaytrainingprogramme.Bill Harvey reported that the Society is inbalance,thesuccessoftheCheltenhammeetingplusthenewsubscriptionleviedhasoffsetthecostsofthepreviousBristolmeeting.The new president, Dr StephenMather, wasthen installed to a warm accolade from themembers, in recognition of his unstintingsupport of the Society over many years;StephenhavingpreviouslybeenbothTreasurerandEditor.

The Society of Anaesthetists of the South Western regionAutumn Scientific Meeting

reed hall, university of exeter19-20th november 2009

Dr chris Monk, honorary Secretary, SASWr

Anaesthesia Points West Vol.43 No. 1Meeting report

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The president prepares for Rome

It was then agreed that Peter Ritchie fromCheltenham,wouldbehissuccessor.Businesswas concluded with the award of the RossDavisAdventureBursarywhich encapsulateswhat the family of anaesthesia is all about.ThemainawardwasgiventoNigelHollisterto support his electivework inAfricawhilstthe“adventure”componentof theawardwasfulfilled by helping Frank Swintonmountainbike throughBritishVancouver,byprovidingthebike!Of interest to those nearing retirement wastheunopposeddecisionforallnewretireestocontinuepayingthefullsubscription.Althoughthis clarifies the expectation it changes little,as the majority of our retirees continue tosubscribetotheSociety.The new President, resplendent in his gong,opened the scientific programme with thefirst session. The meeting proved to havean excellent programme with relevance toeveryone, raising the question whether theSASWRmeetings shouldbe advertisedmorevigorouslytoincreasenationalinterest.The first session considered life and death,opening with Dr Marina Morgan exposingthe large number of medical murderers even

beforeDrShipman took it toanew level forthepressandGMC.Whilstbeingregaledwiththedifferingtechniquestodispatchlovedoneswediscoveredmanynewfacts.Firstly,CASKisnotarestingplacefor thevictim,butCareAssociatedSocialKillingandsecondly, thereare probably 5medical serial killers runningamok in theUK. The latter did cause a fewsideways glances and knowing nods, manyconsideringthattheyworkwithsomeseriouscontenders!Thefocusof thesessionthenshifted towardslearning how anaesthetists manage not tostay alive themselves asDrAndrewMcLeodexplainedhowwehaveanincreasedincidenceofstroke,HIVandcirrhosiscomparedtootherdoctors.Heconsideredwhetherourunderlyingpersonalitytraitswerepossiblecausesforourincreaseddrugandalcohol abusebutdidnotmentionpoor short-termmemoryasa factor;observingthefunthatwashadat theSocietyDinner it appears that few remembered thewarning about cirrhosis. Thefinal lectureofthesessionchallengedusbyusingAristotle’sVirtue Theory to consider how to behavewhencaringforpatientsandpracticingtriage.Giving a talkwhich ranges fromconcepts ofbeing “best at what you are” through to theacquisitionofknowledgeandpracticalwisdomis challenging. DrAndrew Tillyard showedhowgoodhisunderstandingofthephilosophyis.Manyarestillponderingonhisthoughtsontheconceptsofwisdomandhowanaesthetistsdevelopahabitualdispositiontomaketherightchoices in complex circumstances. PerhapstheSocietyneedsafollow-uptalk.AfteradelightfullunchthemeetingreconvenedwiththeIntersurgicalsponsoredTraineePrizesession where the three shortlisted abstractswerepresentedbytheirauthors.

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Let battle commence

ChrisBordeauxreportedhisworkontheuseofaubiquitousdrug,sodiumbicarbonate, in thetreatmentofraisedintra-cranialpressure. Hegaveaclearexplanationofthephysiologybehinditsuseanddemonstrateditseffectiveness.Thesecond paper was presented byAlice Braga,on the topic of venous thromboembolism ina paediatric setting, explaining how she hadfound little evidence of protocols to providebestcare. Havingcovered the risk factors tobeawareof,theprotocolsheofferedprovideda clearway forward. The third entry for theprizewasgivenbyGemmaCrossingham,whoconsideredthestrengthsandweaknessesofthecurrent training systems based on the directobservationofprocedures. Theabilityof thetraineetochoosetheirassessorisaweaknesswhichcouldbecounteredbythe inclusionofother factors. Gemma advocated that non-technical skills should be formally assessed,suggesting that areas to be considered arecommunication, empathy and sensitivity,organisationalabilityplus themaintenanceofgooddecisionmakingunderpressure.Allthreespeakersfacedvigorousquestioningfromthejudgesandrespondedwithclearandconciseanswers.Afewminuteswereneededduring the afternoon coffee break to decidewhich was the best paper. The judges were

unanimous in applauding the quality of thepresentationsandpronouncedDrCrossinghamthe winner of the Intersurgical Prize 2009.The prize was presented at the start of thelast session byMrMarkEllis, theUKSalesManager of Intersurgicalwho, thankfully forus,hasagreedtocontinuetosponsortheprize.Their continued generosity in supporting theSocietyismuchappreciated.ThesecondafternoonsessionwaschairedbyJohnSaddlerandopenedwithProfessorTonyWatkins explaining how useful a radiologistcanbewithasetofbendystickstodeliversomerathercleverdevices.Storiesofretrievinglostwires,pluggingbleedingholesanddealingwithtraumaticandGIbleedsgrabbedtheattentionofeveryone.Withoutadoubtthesuperbtalkmadetheaudience think thatnoemergencyserviceshould be without a radiologist on hand, asmanyhoursofsqueezinginbloodandproductscould have been avoided by a simple coil ortwo.Isuspectthatitmightbealittleharderinpracticethaninthetelling.ThiswasfollowedbyDrDominiqueMumbywhogaveanupdateon obstetric anaesthesia, easily holding theattentionoftheaudienceasmanyhavenotseentheinsideofalabourwardthismillennium.Abroadvarietyofwaystoimprovetheoutcomeofpregnancywereconsideredemphasisingtherolethatanaesthesiahastoplay.Thechallengegiven was to make an impact by improvingresuscitationandincreasingtheinputofseniorclinicians. The take away message is thatsimplydevelopingmulti-professionalworkingthroughbetterteamworkandtrainingmaywellbethekeytoimprovingsuccess,somethingnotjustlimitedtotheobstetricsetting.TheSirHumphryDavylectureisalwaysgoodvalue, this year it appeared to risk puttingDavid inwith the lionswhen the lecturewasto debate whether complementary therapiesreducepain.Howmanypreconceivedopinionsabout homeopathy were there? However a

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marvelloustalkbyProfessorEdzardErnstfromthe Peninsula Medical School entranced theaudience;goodscientificevidencewasusedtoconsider the value of various complementarytreatment modalities. Acupuncture wasawarded a cautious rating as beingbeneficialbutchiropracticcaredidlesswell. Thelatterfailing,theProfessorexplained,asnopositiveevidence of benefit exists and it has evenbeen associatedwith 25 deaths. The biggestconfounderinresearchhopingtodemonstratebenefitfromcomplementarymedicineprovedto be the impact of the placebo effect.. Thechallengeherewasfortheaudiencetoconsiderhow our own pre-operative communicationsshouldbestructuredtomaximiseourplaceboimpact.ThechoiceoftheorganisingcommitteetoinviteProfessorErnsttogivetheHumphryDavylecturewasquiteinspired.The evening’s entertainment found thedelegates and guests enjoying both thePresident’sreceptionandSocietyDinner.Fewseemed to recall the earlier advice of AndyMcLeodsothevolumeofconversationrapidlygrewasthelibationsflowed.

No more food thanks – just wine

ThenewlyinstalledPresidenttooktothestageand thanked the organising committee forall theirwork inproducing sucha successful

meetingafterregalingthedinerswithadviceonhorseracing.Somanypeoplewerementionedthat the Hon Sec became quite breathlesscarryingtheflowersandchampagne. QuentinMilner replied on behalf of the guests usinghome ground advantage to tell a story closetotheknucklebut,withconsummateskill,notbeyond. The dancing to an excellent, homegrownbandcarriedonuntiltheearlyhours,asdidtheconversation.

The future of the society – and Ed

The second day of themeetingwas attendedby a large number of trainees, well done tothe Exeter Department for organising thetheatreschedules to free their time. Thefirstsession dealt ably with three topics that cancausedifficultieseveryday.DrMarkJacksonoutlinedhowtobestcareforpatientswhoareopioid dependent, distinguishing between thediffering patient behaviours when they aretolerant,addicted,havephysicaldependenceorapseudo-addictionthroughpooranalgesia.Themessagewassoclearthateveryonefeltbetterabletocopewiththeevergrowingproblemofintravenousdrugusers.Continuingthehowtodoittheme,DrAlexGricequestionedtheSouthWest’spreoccupationwithepiduralsbyaskingwhether the known side effects are balancedby thegains. Changes insurgical techniques

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allow the simple technique of a rectus sheathcatheter (RSC) block to provide excellentanalgesia. Eschewing modern IT solutions,Alex illustrated the message by exposing hisabdominalwall;veryeffectiveandonewonderswhere this ideamay lead to in the future. Theclosingmessage that theRSC technique offersgood analgesia with lower nursing costs willresonate with our managers whose mantra isto cut costs whilst maintaining quality.Followingthesetwogoodpracticaltalksprovedno problem for Dr Bruce McCormick as hediscussedhowtomanagetherecurringissues,inone lung ventilation, of hypoxia, high inflationpressuresandamisplacedtube.Thesuggestionofpushingforwardadoublelumentubewiththebronchialcuff inflatedhasnotyetbeenneededbytheauthor.Butitdoesofferanotherwayinwhichtointubatethecorrectbronchuswhentheonlysurvivingbronchoscope is in thesteriliser,yetagain.Themorning coffee breakwas spent visitinganexcellenttradeexhibitionandperusingtheabstracts. Thank you to the Trade and welldone everyone who submitted their work.Before the next session the audiencewarmlyapplauded the presentation toMikeYates byDrMichaelDobsonofacertificaterecognisinghisworktosupportworldanaesthesia.Mike,based at Plymouth, has taught in countriesaround theworldonhow tokeepanaesthetickit working, saving countless lives. He isnowusing the internet towidenaccess tohisteaching,producingtheanaestheticequivalentof the Haynes manual. His initiatives havechangedthedepressingpictureofmonitorsandmachineslyinginacornerofaremotehospitalforthesakeofasimplerepair.

Mike Yates, Mike Dobson and friend

The science then continued with Dr RichardTelford doing what he does best in taking asimpletopic,pointingouttheissuesofconcernandthenprovidingaclearpathforward.Thistime it is was bleeding and clotting; withdiscussionofthewhysandwhattodo’sfortheubiquitous drugs ofwarfarin and clopidogrelplus a newcomer, prasugrel. This lecture

Telford Tales

seamlessly morphed into Dr Peter Ford’stalk on near-patient testing of coagulation.Thromboelastograms abounded and everyonesoon really did want one to help with thatsurgicalooze,eveniftheyneverseemtowork

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at 3 am. These two lecturesworked sowelltogetherthatweknewwhattodotominimisethe risks of bleeding before anaesthesia andthen what to do when it inevitably happensanyway.The third lecture portrayed the dangers ofbeing married to the organiser. Being in amorning clinicwith a seriousman coldwereapparently not acceptable excuses, so DrRichardHaighspokeonthenewbiologicsusedinrheumatology. Notcontentwitheducatingus on treatment protocols and the importantriskassessmentofpatientswithseverecervicalspinedisease,hemadetheaudienceracktheirmemories for the song titles of some classicrock and roll quotes. Where are NevilleGoodman and his encyclopaedic knowledgewhenyouneedthem?The excellent lunchwas enjoyed by all, andthe guests and retiredmembers joined us fortheafternoonsession.Anythoughtsofapostprandial snooze disappeared as the afternoonspeakersenthralled.LaurenBarkeropenedthebatting by describing the limits of enduranceexperienced by riders in theTour de France.Fromtheearlyself-sufficientpioneersthroughto the doping of recent years, the almostincomprehensible extremes of fitness neededto win were illustrated. Colin Berry’s aptlynamed“Notwavingbutdrowning”putworlddisasters into context before delving into theproblemsofdrowning.Thenumerouspicturesofhissailingexperiencesemphasisedhispointsbut also added to the bucket list of things todo.MikeGrocotttravelledfromSouthamptonto recount the realitiesofadapting toaltitude

bypresentinghowheorganised200peopletoclimbupEverestwithexercisebikesandbloodgasmachinesandgotthemtoagreetoundergophysiological testing at ridiculous heights.WhetherthePaO

2dataorhisskillsofpersuasion

werethemoreamazingremainsamootpoint.The session was stolen however, by the lastlecturebyDrJimDownwhorecountedthesadstoryofthedeathofAlexanderLitvinenkofromtheperspectiveoftheclinicalleadfortheITU.Thesequentialstory,toldinalaconicstyle,oftheslow,“walkingghost”demiseandhowthePolonium-210poisoningwasfinallydiagnosedwas completely gripping. This final sessionreflectedtheessenceofthewholeprogrammeas it provided science, provoked thought andinterest,whilstbeingdeliveredwith skill andcarefulpreparation.The President then closed the 2 daymeetingobserving how successful it had beenand thanked the local committee for theirorganisational flare and the production of anexcellent scientific programme. Dr Matheralso noted the social programme had beenenjoyedbyallthoseabletovisitTopsham.The Society looks forward to the RomemeetinginMayandthesubsequentmeetinginBristol,thisbeingorganisedbytheSouthmeadDepartment.ThelatterwillbeheldinRaymondBlanc’s restaurant and associated rooms soI lookforward toboth. TheSociety isgoingfrom strength to strength having followedthe highly successful Cheltenham meetingwithanotherinExeter.Myadvice,planyourstudyleavenowbyfindingthedatesofallourmeetingsonthewebsite,www.saswr.org.uk.

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This year’s ever wittily acronymned Societyof Devon Intensive Therapists meeting wasseamlesslyorganisedbyDrsBradleyBrowne,Andrew Daykin, Steve Harris and RichardGibbs of Musgrove Park Hospital, Taunton.The venue was deep in the heart of sat-navcountry in North Devon and, after a fewwarningshotsfromfarmersandsomedamagedsuspensionstruts,wearrivedataverypleasanthotel with an excellent 18 hole golf course,gymandswimmingpool.Session 1 was entitled “New Tricks for OldDogs”(ofwhomthereweremany).ProfessorMonty Mythen (UCL) (who is collectingunusual acronyms and informed us that hehad just flown in from the famous “FrenchUnificationofClinicalKnowledgeinIntensiveTherapy”meeting)openedproceedingswithafascinatingdelveintothehistoryofintravenousfluids. He presented a compelling argumentas to why “Normal” Saline should reallyonly be used if the alternative is intravenousunfiltered London tap water from the 19thcenturyandrevisitedtheexcellentSAFEstudyreminding us that thismeant different thingstodifferentcontinents.Thebottomlineisthatforresuscitationalbuminisnobetterthan0.9%saline.InAustralia,albuminisfreeatthepointofcareandsoremainsapopularresuscitationfluidbut in theUKthis isnot thecaseanditisanexpensivealternative tocrystalloidoverwhichitconfersnoaddedbenefit.For anyone who takes statins David James’(Consultant Biochemist, Taunton) talk wasunmissable, if only because he revealed a

clinicalgemthathetellstomanyofhisstatin-taking patients. Statins deplete intracellularubiquinone and this is responsible for manyoftheachesandpainsuserssufferfrom.Theanswer is simple - 30mg/day of Coenzyme10 from your nearest supermarket! Statinsmayhavea role toplay in themodulationofthe systemic inflammatory response. Fewerpatients on statins seem to die from septicshock.RCT’sareawaited.SteveBreeconcludedtheopeningsessionwithatalkprovidingequalvolumesoffascinationandterrorforthelistenerregardinghisexperienceof the management of major haemorrhageduring the conflicts in Iraq andAfghanistan.Medical emergency response teams headedby consultant anaesthetists (he would preferregistrars!)are“chinooked”outtothefrontlineto pick up casualties and commence damagecontrol resuscitation, in which haemostaticresuscitationplaysapart. Atone timeStevehad 9 injured children in the helicopter andexplained that itwas hard to knowwhere tostand let alone how to begin resuscitation.Coagulopathyoftraumadoublesmortalityandthe take home point was to give blood, FFPandplatelets ina1:1:1 ratio tominimise thisriskandtousepointofcaretesting(e.g.TEGorROTEM). Healsoadvocatedtheuseofcalciumchloride, tranexamicacidandrFVIIawhich, although lacking an evidence base,still has strong support from thosewho havewitnesseditseffectinthefield.Session 2 consisted of a pro-con debate ondelirium screening in the ICU. We were

Society of Devon intensive Therapists (SoDiT) Meeting

highbullen hotel, north Devon, 1st – 2nd october 2009Dr richard eve, Specialist registrar

South West School of Anaesthesia

Anaesthesia Points West Vol 43 No. 1Meeting report

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privileged to hear Dr Valerie Page fromWatford, who is a national expert in thefield, defending the use of screening for thiscondition which is an independent predictorofmortality in the ICUandmayaffectup to80%ofourpatients.HeropponentwasColinFerguson and you could almost hear palmsbeinggleefullyrubbedtogetherashewithdrewhis tongue from its scabbard! He providedinsightful critical appraisal of the availableliterature and also argued thatwe should notworry toomuch about somethingwe can dolittleaboutwhenwearealreadyfailingtodothe thingswhichweknowmakeadifference(e.g.lungprotectiveventilationinARDS).DrPage was declared the winner but there willbesomedelegatespresentwhofeltthevotingorganisationwasslightlyMugabe-esque.Dr Anna Batchelor, former president of theIntensive Care Society and member of theCollege Council talked about quality, futuredevelopments and the new trainee. It looksas though our new curriculum for a CCT inIntensive Care Medicine is likely to closelyresemble the Competency Based TrainingProgramme in Intensive Care Medicine forEuropeandotherworldregions(CoBaTrICE)training developed in Europe. This soundedgreat: more disconcerting was the revelationthatenhancedappraisalcurrentlycontains154elementswhichwewillberequiredtoprovideevidencefor(andyouguessedit, therewon’tbeanyextratimeavailable–I’mbeginningtowishthatfarmerhadshotme).Anexitexamseemslikelyand,contrarytopreviousrumours,this is more likely to resemble the Diplomaof IntensiveCareMedicine (DICM) than theEuropeanDiplomaofIntensiveCare(EDIC).DrPeterMacNaughtonranhishighfrequencyprobeoverultrasoundtrainingforintensivists.An intensive care echo accreditation is indevelopment but for now, those interestedin thisfield can look into enrollingonFEEL

(focussed echo evaluation in life support)or FATE (focussed assessed transthoracicechocardiography)courseswhichalsoincludesomelungultrasoundcomponents.ChrisDayfromExetertalkedaboutnewwaysofstaffingtheICU.Exeterwasapilotcentrefor nurse practitioners and while they wereverywellreceiveditsoundsasthoughtherearelikelytobeongoingproblemswithrecruitmenttothisrole.Themostcapablearelikelytobeourexperiencednurseswhocanillaffordtobelostfromtheircurrentposts.

Tod was surprised that Professor Mythen was still using the old hand buzzer technique

Trainee presentations were up next and in ahighlycompetitivefieldTodGuestpickedupthe prize for his trial implementation of flupandemictriageguidelines.

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Adam Revill revels in second place

Via thegym,golfcourse, funrun,swimmingpool or bar we proceeded to dinner andthe chance to implement some of our ownresuscitative fluid ratios. 1:1:1 works wellwithwater andwine but rather falls down ifthethird“1”isJackDaniels.Day2commencedwithimportantsessionsonpaymentbyresults(PbR)andclinicalcoding,areasofeverincreasingimportanceiftheNHSisgoingtoberunmoreasanefficientbusiness.SueEve-Jones, theChair of theUKClinicalCoding Practice spoke about how it mightaffectourpaystreamsinacoupleofyearsandwhy it is best done by dedicated and trainedpersonnel–the2“GuidestoCoding”thatwerethickenoughtoputtheOldTestamenttoshamewere enough to silence most critics. KeithYoungfromtheDepartmentofHealthgaveaninsight into futurebillingbyPbR. Thegoodnewsisthatithasbeenputbackuntil2011!PaulMurphyfromLeedspresentedanupdateonOrganDonationTaskforceproposals.Thegap between donors and potential recipientscontinues to widen and the UK is a poorperformer in terms of donor numbers. Thenon heart-beating donor programme has had

some success in increasing the numbers ofavailableorgans,particularlyintheSouthwest.AnnaBatchelor told usmore about plans fora Faculty of Intensive Care Medicine whichislookingmoreandmorelikelyinthenottoodistantfuture.Thisisn’tbadconsideringICMonly achieved specialty status in 1999. WewerealsogivenaninterestinginsightintothepoliticsinthehigherechelonsoftheCollege.RichardInnesprovidedanupdatefromTauntonontheSaferPatientInitiative(SPI).TheyhaveclearlybenefitedfromtheexperienceandtheirICUmortalityisdown,althoughtheremaybeother confounding factors. What is clear isthatTauntonandtheirpartnerhospitalTorbayhave had a beneficial symbiotic relationshipasaresultoftheSPI.CriticalcarepharmacistDamian Wood spoke about new ways ofeffective medicines management usingthe Plan, Do Study Act (PDSA) processesdeveloped through SPI and showed that onecan implement timely and successful changein order to prevent prescribing errors byinexperiencedstaff.ThefinalsessionwascalledvirtualICU.TomGale talked about the role of simulation intraineeappointments in theSouthWest. ThesuccessofthisprocesshasbroughtfundingintheformofaDepartmentofHealthpilotprojectwhichhasdonemuchtoraisetheprofileoftheregion.CurtisWhittletalkedaboutsimulation,virtualrealityanditssupercedent,augmentedreality. He showed us new mannequins thathavebuilt incompressorsandwi-fi,enablingsimulationtooccurinanysetting.Thesereallyareveryportableandcontrollablefromremotelocations. Wenow justneed tofindone thatcanfillinourappraisaldocumentationforus.Kaj Kamalanathan (SpR Bristol) closed thesessionwith his prizewinning experience ofsimulation trainingwith FY1 trainees,whichis clearly very successful and will hopefullypermeatethroughouttheSouthwest.

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Taunton treated us to a thought provokingscientificprogrammeinanidyllicandremote(I’mstillnotsurewhere itwas)setting. Themeeting was a great success and cars weredrivendownroadsinNorthDevonwhichhad

not seen their like before. I wonder wherewe’llbein2010?(Apparently,TheSauntonSandsHotel 19th –20thJune)

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introductionNon-technical skills have been highlightedin the Royal College of Anaesthetists’person specification as desirable attributesinananaesthetist. Since2007wehavebeendevelopinganewselectioncentrewiththeaimofassessingtheseskills.All candidates appointed by the this methodwereconsentedtobefolloweduplongitudinally,by completing an annual, specialty specificworkplace based assessment (WBA) in ordertohelpvalidatethisnovelrecruitmentprocess.ExistingWBAs are generic and not specificto the assessment of anaesthetic practice.Directlyobservedprocedures(DOPs)andminiclinical evaluation exercises (mini-cex) havebeen reported to carry a degree of stress andartificiality,andsometraineeshaveexpressedconcerns about victimization bymulti-sourcefeedback raters.1 In addition, tools such asthe mini-cex have been shown to be poorlydiscriminatory between anaesthetic traineesand assessors have reported using lenientscoring due to the face-to-face nature of theassessment.2OurWBAtook the formofakey indexcaseperformedby the trainee in theatre. Thekeyindex case varied according to trainee grade,withanST1beingexpectedtoperformarapidsequenceinductiononanASA1or2patient,anST2toanaesthetiseapatientforafracturedneckoffemurandanST3todeliveranaesthesiaforanelectiveCaesareansection.Thesecases

were defined to ensure that the assessmentswere specialty specific and appropriate tothe level of experience of the trainee. Theoperating department practitioner (ODP) andconsultant assigned to the list independentlyscored the trainee’snon-technicalskillsusinglocallydevelopedcriterionreferencedscoringmatrices. Qualitative feedback to the traineewasencouragedbutthespecificmarksawardedwerenotrevealed.Despitepromisinginitialresultsindicatingthatourselectioncentrescoresareagoodpredictorof subsequent work place performance,3our correlations were affected by low inter-rater agreement (Scott’s Pi = 0.20) betweenconsultantsandODPswhenscoringtheWBA.Theaimofourstudywastoassesswhetherwecouldimproveinter-rateragreementbyavideobenchmarking exercise and by familiarisingconsultants and ODPs with the markingscheme.Inaddition,weintendedtoinvestigatepossiblegroupdifferencesinratingoftraineeperformancebyconsultantsandODPs.

MethodThree videos showing poor, medium andgood performances by trainees conductingrapid sequence induction in the simulator,were shown at departmental meetings in allsixAnaestheticDirectorateswithin theSouthWest Peninsula Deanery. At each of thedifferent hospitals, the films were shown inone of the six possible order permutations.

use of Video Benchmarking to improve the reliability of Workplace Based Assessments in Anaesthesia

Dr gemma crossingham, Specialist registrar,South West School of Anaesthesia

This paper is based on the winning entry for the trainee prize of the Society of Anaesthetists of the South Western Region, sponsored by Intersurgical

Anaesthesia Points West Vol 43 No.1Article

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Seventy-five consultants and ten ODPs fromvarious hospitals, independently scored thenon-technicalskillsdemonstrated in the threevideos using the same criterion referencedmatrices employed in the workplace basedassessment. Each of the three videos wasscored immediately after viewing and no re-markingwasallowed.

resultsInter-rater agreement coefficients, asdemonstratedbyScottsPi,wereexcellent:0.81fortheconsultants,0.81fortheODPsand0.79

across thewhole group.The combined valueof0.79issignificant,asthisindicatesthattheconsultantsandODPswerescoringsimilarly.Median scores for the three films stronglydifferentiated between the poor, mediumand good performances (KruskalWallis test,p<0.001) and therewas strong evidence of alearningeffect,whichwasrelatedtotheorderinwhichthefilmswereviewed.Figure 1 shows decreasing overlap of scoresbetween poor, medium and good videoperformanceswithsuccessiveviewings.

Figure 1. Distribution of Total Score by film and order of showing.

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Statistical tests reveal that themedian scoresawardedtothepoorfilmwhenviewedfirstinthesequenceweresignificantly(p<0.05)betterthanwhenitwasviewedlastinthesequence.The converse is true for the scores for thegoodfilm.Thescoresforthemediumfilmdidnot change significantly with viewing order.Thesedifferenceswerestatisticallysignificantand have obvious implications when scoringtraineesintheworkplaceorindeedatselection.Thescoresforthemediumfilmexhibitacuriouspattern which bears further investigation.When themediumfilm is viewedfirst in thesequence,nootherfilmhasbeenseenbeforeitandthescoresarerelativelycohesiveandformanormaldistribution.Whenthemediumfilmis viewed second in the sequence, the scoresare much more disparate. Two directoratessaw themediumfilm second: onegroupwillhaveseenthepoorfilmbeforeitandtheotherthe goodfilmbefore it. Those that saw thegoodfilmfirstwere scoring themediumfilmsignificantly lower than those that saw thepoor film first, who were rating the mediumperformancerelativelyhigher.Whenthemediumfilmwasviewedlastinthesequence,bothgroupshad seen thepoorandthe goodfilms in different orders. However,thisdifferenceinorderdoesnotseemtomatterasthescorestendedtore-groupcentrallyonceagain.

DiscussionOurfindingofalowinter-rateragreementwhenscoringWBAshasposedasimilarproblemtoothergroupsresearchingWBAs.Welleret al,conductedanational,computerisedevaluationofthemini-cexamongstanaesthetictraineesinNewZealandanddemonstratedmorevariationbetween raters and cases than between thetraineesthemselves.2Existingworkplacebasedassessmentsarenotspecialtyspecific,andfewformallyassessnon-

technicalskills.Ourstructuredassessmenttoollookedatanaestheticnon-technicalskillsinthetheatreenvironment,whichhavebeenshowntohaveaconsiderableinfluenceonanaesthetists’performanceandhenceonpatientsafety4.We have demonstrated that familiarisingassessorswith the scoring scheme forWBAsenables reliable judgements of workplaceperformance.Inaddition,thereisgoodinter-rateragreementbetweenconsultantsandODPswhen rating trainees’ non-technical skills,as demonstrated by our Scotts Pi value of0.79andabove.Avalueof0.8isconsidereddesirable for such an important assessment.We have therefore shown that by viewingthreevideosofsimulatedtraineeperformance,we can significantly improve the reliabilityof assessors’ judgements, a finding which issupportedbyotherresearch.5There are indications of a positive learningeffect leading assessors to become morereliablewithpractice.Therearetwopossibleexplanationsforthis:thefirstisthatassessorstend to be cautious when viewing the firstfilm in the sequence as they have nothing tobenchmark that performance against, thesecond is that assessors are unfamiliar withthe scoring scheme. Either way, there isevidenceofalearningeffectwhichresultsinareductioninscorevariationwithpractice,andonthesegroundswewouldstronglyadvocatethat assessors are trained in marking beforeintroducinganynewWBA.

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references1. CohenSN,FarrantPBJ,Taibjee

SM. Assessingtheassessments:U.K.dermatologytrainees’viewsoftheworkplaceassessmenttools.British Journal of Dermatology2009;161:34-39

2. WellerJM,JollyB,MisurMP,MerryAF,JonesA,CrossleyJGM,PedersenK,SmithK.Mini-clinicalevaluationexercise in anaesthesia training. British Journal of Anaesthesia2009;102 (5):633-641

3. Sice P, Gale T, Anderson I, Davies P,Langton J. Developing an OSCE styleinterviewprocessincludingsimulationforselectiontoanaesthesiaspecialisttraining.Anaesthesia 2008;63(8):913

4. FletcherG,FlinR,McGeorgeP,GlavinR,MaranNPatey R.Anaesthetists’ Non-Technical Skills (ANTS); evaluation ofa behavioural marker system. British Journal of Anaesthesia2003;90(5):580-588

5. GabaDM,HowardSK,FlanaganB,SmithBE,FishKJ,BotneyR.Assessmentofclinicalperformanceduringsimulatedcrisesusingbothtechnicalandbehavioralratings.Anesthesiology1998;89(1):8-18

AcknowledgementsI would like to thank the AnaesthesiaRecruitment Validation Group (ARVG) fortheirassistanceandsupportwithallaspectsofthisresearch.ThiswaspartofaDepartmentofHealthfundedpilotprojectintorecruitmentmethodologies

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AbstractWe describe the case of a 91 year old ladywhowastakingwarfarinandpresentedtotheEmergency Department following a fall athome.Retropharyngealhaematomasecondaryto odontoid peg fracture necessitated anemergency cricothyroidotomy to secure herairway pending formal tracheostomy. Itwasnoted that without prior skin incision witha scalpel, significant force was required topass the Quicktrach®. Furthermore, theQuicktrach®hadatendencytoobstructagainsttheposteriortrachealwallandrequiredregularsuctioningtopreventobstructionwithclot.

case reportA91yearoldladypresentedtotheEmergencyDepartmentatGloucestershireRoyalHospitalfollowingafallathome.Heronlysignificantpast medical history was hypertension andatrial fibrillation, for which she was treatedwith warfarin. On arrival she was tripleimmobilised to protect her cervical spine butwas haemodynamically stable and had noneurologicaldeficit.SheunderwentCTscanoftheheadandneckwhichshowedanodontoidpegfracturewithasignificantretropharyngealhaematoma(figure1).On returning to the Emergency Departmentresuscitation bay she started to complain ofdifficultybreathinganddevelopedstridor.Thisprogressed rapidly andwithin a fewminutesshewasunabletoself-ventilate.Thedecisionwas made to place a Quicktrach® (VBMMedizintechnik GmbH, Sulz, Germany) as afastandeffectivemeansofsecuringtheairwaybeforedesaturationoccurred.

The cricothyroid spacewas palpatedwithoutdifficulty and lignocaine was infiltratedsubcutaneously.Thepatientremainedconsciousas the Quicktrach® was inserted, withoutthe use of prior skin incision, immediatelyrelievingtheobstruction.Significantforcewasrequiredtopassthetrocarthroughtheskinandcrycothyroidmembrane. Whenfullyinsertedthe Quicktrach® had a tendency to obstructagainst the posterior tracheal wall requiringit to be withdrawn slightly and the externalportion to be tilted and fixed in a cephaladdirection.Inaddition,regularsuctioningwasrequiredtopreventobstructionwithbloodclotthoughoverallbloodlosswasminimaldespitethe patient’s international normalised ratio(INR)of2.4.

figure 1:Sagittal CT scan showing odontoid peg fracture (1) and significant retropharyngeal haematoma (2)

emergency cricothyroidotomy in odontoid Peg fracture complicated by retropharyngeal haematoma

Dr nicholas Smallwood, ST2 Acute Medicine, and Dr edward Bick, ST5 AnaestheticsGloucestershire Royal Hospital

Anaesthesia Points West Vol. 43 No.1case report

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The patient started to tire after an hour,highlighting the need to plan for a definitiveairwayas soonas the airway is securedwitha temporary device. She underwent anuneventful surgical tracheostomy under localanaesthetic two hours after placement of theinitialdevice.

DiscussionThereareanumberofindicationsforemergencycricothyroidotomytosecuretheairwaywhereothermethodshavefailedorarelikelytofail.1The two most commonly used emergencycricothyroidotomy techniques involve eitherwire-guidedplacement(suchastheMelker®,Cook Medical Inc, Bloomington, U.S.A.) orcatheter-over-needleplacement(Quicktrach®),although other techniques such as the rapidfour-step technique are well described.2 Inaddition, standard surgical techniques can beusedtoperformanemergencytracheostomy.Randomised evidence for the speed andeffectiveness of these various approachescomessolelyfromworkonmanikins,animalandcadavericmodels;thereisnoactualpatientdata available. The evidence suggests thatthere is little to choose between the devicesintermsofspeedofsecuringtheairway,3butthat there may be a lower complication ratewithcatheter-over-needletechniquesinanimalmodels.4 This may be particularly true inpatients such as ours who are coagulopathicwhere the absence of skin incision reducespotential blood loss. However, it has beenshown thatspeedof insertion is improvedbymakingaskinincision.6

In this case, endotracheal intubationwas notconsideredanappropriatefirst-linemanoeuvregiven the presence of upper airway swellingand the inability to extend the patient’s neckduetotheodontoidpegfracture.Therapidityoftheswellingandrespiratoryembarrassmentmeant that other techniques, such as awake

fibreopticintubation,werealsoinappropriate.As the patient was making good respiratoryeffort we used a 4mm internal diametercannulatoallowspontaneousventilation.TheDifficult Airway Society (DAS) guidelines5state thata4mmcannulamaybeused in thespontaneously breathing patient in the “can’tintubate, can’t ventilate” situation but that adefinitiveairwayshouldbesecuredasquicklyaspossible. Theincreasedworkofbreathingthrougharelativelynarrowlumennecessitatedplacementofadefinitiveairwayinourpatientwhowenttotheatreasanemergencytohavea surgical tracheostomy placed under localanaesthetic.Airway emergencies, as described here, areencountered infrequently but need to bemanaged quickly and competently. Traineesat Gloucestershire Royal Hospital undertakeregular training in and practice of difficultairway techniques. It is imperative that suchtrainingisdeliveredtoalltraineeswhomaybefacedwith airway emergencies so these vitalskillscanbemaintained.

references1 BoonJM,AbrahamsPH,MeiringJH,

WelchT. Cricothyroidotomy:AClinicalAnatomyReview.Clinical Anatomy2004;17:478–486

2 BrofeldtBT,PanacekEA,RichardsJR.AnEasyCricothyrotomyApproach:TheRapidFour-stepTechnique.Academic Emergency Medicine2008;3(11):1060-3

3 DimitriadisJCandPaoloniR.Emergencycricothyroidotomy:arandomisedcrossoverstudyoffourmethods.Anaesthesia2008;63:1204–1208

4 FikkersBG,vanVugtS,vanderHoevenJG,vandenHoogenFJ,MarresHA.Emergencycricothyrotomy:arandomisedcrossovertrialcomparingthewire-guidedandcatheter-over-needle

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techniques. Anaesthesia 2004;59(10):1008-11

5 DifficultAirwaySocietyhttp://www.das.uk.com/guidelines/cvci.html(accessed22/10/2009)

6 FreiFJ,MeierPY,LangFJ,FaselJH.CricothyrotomyusingtheQuicktrachconiotomyinstrumentset.Anaesth Intensivther Notfallmed1990;25:44–9

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introductionIn June 2008, theWorld Health Organisation(WHO) launched“SafeSurgerySavesLives”.Thisworldwideinitiativewasaimedatreducingmortalityandmorbidityassociatedwithsurgicalprocedures. A pilot study, using a 19-pointSurgical Safety Checklist in more than 3,900operationsin8hospitalsshowedthatmortalitycouldbereducedfrom1.5%to0.8%.Thiswasachieved by improving safety practices in theoperatingtheatreandpromotingteam-workingamongstthetheatrestaff.1Thehospitalschosenfor this pilot study were in both high-incomeandlow-tomiddle-incomecountries.Thoughthe difference in improvement in mortalitywasonlystatisticallysignificant in the low- tomiddle-incomecountriestherewasstillatrendtowardsimprovedmortalityinthehigh-incomecountriesfollowingintroductionofthechecklist.Bythetimethisarticlegoestopressitwillbevirtually impossible for anyone working in aUKoperatingtheatretobeunawareoftheWHOSurgicalSafetyChecklist; theNationalPatientSafetyAgency (NPSA) required its universalintroductionbyFebruary2010.2

UniversityHospitalsBristolNHSFoundationTrust(UHB)isa large teachinghospitalwithadiverserangeofsurgicalspecialties.Therearemorethan20operatingtheatresspreadoversixsites.Challengedby the Medical Director of the Trust to ensure100%up-takeoftheWHOchecklistbythetargetdate,theUHBDivisionofSurgery,Head&Neck,formedacoregroupoforganiserstointroducethechecklistacrossthehospital.Itwasanticipatedthatthe introduction of theWHOchecklistwould bechallengingnotonlybecausechangingestablishedbehaviour in healthcare systems is notoriously

difficult,3butalsobecauseofpreviousandcurrentexperience.In2006wehadfailedtosuccessfullyintroduceteambriefingsatthestartofeachtheatrelistandby2009briefingwasstillundertakenonlysporadically.Alsotherehadbeen“WHOleakage”andsomemoreenthusiastictheatreteams,withthebestofintentions,hadstartedtouseNPSAformsbutwithoutanycoordinationwiththeatremanagement.Thecoregroupidentifiedsomeinitialaims1) to distribute a questionnaire to ascertain

staffunderstandingoftheWHOchecklistandthedifferencebetweenthisandbriefinganddebriefing(appendix1)

2) toworkoutaneducationalprogrammeabout,and timeframefor, the implementationoftheatre briefing/debriefing and the WHOchecklistacrossallsites

3) tomonitorimplementationandmodifytheWHOchecklistforlocaluseapplicabletoall sites (this included cardiac, obstetric,daycase,eyesandgeneraltheatres)

first stepsThequestionnairewasdistributedinthemaintheatresuiteinJuly2009.Oneoftheauthors(SI) interviewed staff over 3 days. Some oftheresultsaresummarisedinTables1-3.Thisinformationhelpedusidentifytheeducationalissueswe had to address to dispel confusionand get “buy in” to briefing/debriefing andimplementationofthechecklist.In total, 70 staff members completed thequestionnaire including surgeons andanaesthetistsofallgrades,andtheatrenursingstaff (bands 2 to 7, including anaestheticassistants). This represented an average of33%ofthetotalofeachstaffgroup.

introducing the World health organisation Surgical Safety checklist into clinical Practice

Dr Tracey christmas, Spr Anaesthetics and Sarah ingamells, Medical StudentUniversity Hospitals Bristol NHS Foundation Trust

Anaesthesia Points West Vol. 43 No. 1Article

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Table 1:Summary of questionnaire findings prior to the launch

Staff members previously involved in a teambriefing

95%

Staffmemberspreviously involved in theWHOchecklist

46%

Staffmemberswith no knowledge of theWHOchecklist

15%

Staffwhohadfoundteambriefingsuseful >90%

Table 2:Staff knowledge of the elements of an ideal team brief prior to launch (%)

Prior to start of list

All team present

Team introductions

List order

Patient problems

equipment issues

Staffing issues

Surgeons(all grades) 50 50 8 58 42 58 0

Anaesthetic consultants 42 50 8 75 58 50 0

Anaesthetic Trainees 40 50 30 90 50 70 0

nursesBand 6&7 38 50 13 88 75 88 38

nursesBand 5 31 56 25 63 81 88 19

nursesBand 2&3 29 57 14 57 57 14 0

Table 3:Staff knowledge of the goals of the WHO checklist prior to the launch (%)

improves patient safety

reduces mistakes

Provides a standardised system

Promotes team working

Keep entire team up to date

Surgeons (all grades) 50 17 0 0 17

Anaesthetic consultants 36 36 9 0 0

Anaesthetic Trainees 40 10 20 20 10

nurses Band 6&7 63 50 13 25 0

nurses Band 5 50 19 13 6 6nurses Band 2&3 14 0 0 0 14

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These tables illustrate that most staff hadbeen exposed to the concept of team briefingand debriefing at the start and finish of lists.Understandingof the structureofa teambriefwascertainlynotuniversalnordid it conformtoaspecificpattern. KnowledgeoftheWHOchecklistwasalsopatchy.Thisinformationwasextremelyhelpfultotheteamtryingtochampionthe implementation. We set up educationalsessions for eachof the theatre sitesbasedontheresultsandwealsopreparedapresentationwhichweusedtoeducatemanystaffmembersandtoinvitediscussionacrossthehospital.BySeptember2009alltheatressitesweresupposedtobebothbriefinganddebriefingandusingtheWHOchecklistforeverycase.

Monitoring and modificationOncebriefing/debriefingandtheWHOchecklisthadbeen implemented in all areas, compliancewas monitored. Most chose to display thisinformation in their theatres. Summaryinformationwassenttothecoregrouptomonitor.Poorcompliancewasinitiallynotedinobstetric,cardiacandeyetheatres. Interestinglyall thesesiteshadbeenpredicted tohave issuesbecauseof the particular idiosyncrasies of the types ofsurgery in these areas. In obstetric theatres itbecame apparent that the clinical urgency of atruecategory1caesareansectiondidnotallowtimetocompletetheSignInandTimeOutpriorto delivery of the baby. Cardiac theatreswereconcerned that theNPSAformdidnotfit theirneedsintheorderthattheywanted.Eyetheatrestafffelt theformwascumbersomeforthefasttrack cataract cases where many of the issuesmightbeconsideredrepetitiveandirrelevantforabloodlessprocedureunderlocalanaesthesia.The core group encouraged feedback fromalltheatrestafftotryandaddresstheseissuesandto enable us tomodify the form and improvecompliance. The group still wanted a singleformacrosstheTrust’ssitestobeincorporated

into a universal peri-operative care booklet.Feedbackwasconsiderable,soadedicatedsitewas created on theTrust intranet for users toleavetheirviews.Interestinglythiswasnotuseddespite repeated requests and the core groupcontinuedtoreceiveindividualcomments.SeveraliterationsoftheoriginalNPSAformweretrialledacrosssite.ByFebruary2010whenWHOcompliancewas required to reach100%,wehadfailedtoachieveourobjectiveofbriefing/debriefingonall lists,anduseof theWHOchecklist forallpatients on all sites using an agreed single formmodifiedforUHB.Themainproblemswere:1) an inability to address the needs of the

differentsurgicalspecialties2) avoiding repetition of questions in the

briefingandthechecklist3) presenting this in a usable and succinct

format.The last iteration of the form is shown inappendix2.

current stateComplianceacrossallsitesisgenerallygood,withexceptionalperformanceinourdaycasesuiteandeyetheatres(despitetheunsuitabilityoftheformforsomeoftheircases).Emergencytheatres,likeobstetric theatres,remainachallengebecauseateambrief for thewholeday is impossibleandhas to be done case by case, and in times ofextremeemergencytheWHOchecklistcanbeanafterthought.Thestaffaremakinggreateffortstoimprove.Atthemostrecentcoregroupmeeting(lateFebruary)therewasfinalagreementthatasingleformwouldnotsuitallneeds.Thusitislikely that obstetrics will modify their form toincludethespecificobstetricchecklistshowninappendix2.Cardiactheatreswillusetheversiondevised by The Society for CardiothoracicSurgeryinGreatBritainandIrelandandapprovedbytheNPSA.4Ineyetheatres,eithertheNPSAwillproduceaspecificform,or,nowthattheatreteamsarepermittedtomodifytheformfortheir

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site,theymayundertakethisworkaspartoftheProductiveTheatresProject.Thisprocesshasbeenaconsiderableamountofworkforanumberofpeople.Astheaimistoimprovepatientsafetyitisofcoursehugelyimportant, but on reflection we feel a welldevisedandpilotednationalformmighthavebeenaneasierwayforward.

AcknowledgmentsWewish to thankDrFrancesForrest for herhelpandguidancewiththisprojectandDr Adrian Hobbs for showing us how theinitiative had been successfully implementedattheRoyalCornwallHospital,Truro.Wealsowish to thankClareEvans,ConsultantNursefor PerioperativeCare and lead for theUHBcoregroup,andallthetheatrestaffwhogave

uptheirtimetocompletethequestionnaire.

references1. HaynesAB,WeiserTG,BerryWR,LipsitzSR,

BreizatAHS, Dellinger EP, et al.A surgicalsafety checklist to reduce morbidity andmortalityinaglobalpopulation.N Engl J Med2009;360:491-499.

2. NationalPatientSafetyAgency.PatientSafetyAlertUpdate:WHOsurgical safetychecklist.(January2009).

3. National Institute for Health and ClinicalExcellence. How to change practice.http:/ /www.nice.org.uk/usingguidance/i m p l em e n t a t i o n t o o l s / h ow t o g u i d e /barrierstochange.

4. http://www.scts.org

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Who Questionnaire

Date Staffposition Grade Part 11)Whatisatheatrebriefing?

• Orderoflist• Problempatients• Equipmentissues• Other

2)Haveyoueverbeeninvolvedinateambriefing? Y N3)IfYes,inthelastweekhowmanybriefingshaveyouwitnessed? 4)Ifnoneinlastweek–whenwaslastbrief? 5)Haveyoueverleadateambrief? Y N6)IfNo,wouldyoufeelcomfortabletoleadateambrief? Y NReason (s): 7)Hastheteambriefbeenusefultoyou? Y NReason(s):

Part 2

1)WhatistheWHOSurgicalSafetyChecklist?

3components§ signin§ timeout§ debrief

LaunchinUHBmainadulttheatresSeptember2009 StandardbyFebruary2010 Foreverypatient

2)HaveyoueverparticipatedintheWHOchecklist? Y N

3)DoyouthinktheWHOchecklistisrelevanttoyou? Y NReason(s):

4)DoyouseeanyproblemsintroducingtheWHOchecklist? Y NReason(s):

Appendix 1:WHO Checklist Questionnaire

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Appendix 2:Final version of the UHB WHO Surgical Safety Checklist with obstetric amendments

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Has your computer slowed down to a snail’space?Consideringbuyinganewone?Readthis first! In this article, I aim to give youthe confidence to rejuvenate your PC. Anunderstanding of these simple concepts willhelp you maintain your computer and makeit run stronger and longer. I’m no computerexpert,butIhaveresuscitatedafewcomputers.You don’t need intimate understanding ofcomputerphysiologytotreatthem,justaswithpatients. A little knowledge and the courageto experiment can go a long way towardsgetting the best out of your computer. Thiswill improve your computing satisfaction,efficiency,andextendyourPC’sretirementagedramatically.

referral to critical careIf you understand some basic principles youcantargetyourtreatment:

1. Hardware (silicon chips, hard discetc.) is the computer’s physiologicalreserve.

2. Installed software programs, includ-ing the computer’s operating system(OS), are disease processes creatingmetabolicdemandonthehardware.Incombination, thesecan lead tomulti-organfailure.

3. Hardware newer than about 8 yearsoldshouldbeabletorunperfectlywellwithlowmetabolicdemand.Themostcommonproblemisthesoftwarecaus-ingacutecirculatoryobstruction.

4. Your files (pictures, documents etc.)takeupstoragespaceontheharddisk,

butunless it isveryfull, theyarenotresponsible for the system slowingdown.

Thebestwaytokeepyoursystemhealthyandproductive into old age is to be very sparingwiththeprogramsyouinstallandallowtorunin the background. Operating systems suchas Windows make serious demands on thehardware resources, even before adding anysoftware.

Windows Task Manager: plenty of reserve in

this one!

Diagnosiscontrol-alt-delete bringsuptheTaskManagerwhichisyourdiagnostictool.Theperformancetabgivesagraphical indicationofhowmuchthe computer’s hardware resources are beingused.Thecentralprocessingunit(CPU)isthecomputer’sheart.The‘memory’isthevascularsystemthattheheartpumpsdataaround.ThemetabolicdemandsofthesoftwarerunningcanresultincongestiveCPUfailureoroverloadofthe circulation (memory). Programs running(egWord,InternetExplorer)areshownintheapplicationstabofthetaskmanager.Running

Do not resuscitate this Pc

Dr Ben howes, Specialist registrarBristol School of Anaesthesia

Anaesthesia Points West Vol. 43 No. 1Article

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the minimum number of applications at onetime reduces the metabolic demand on thehardwareresources.

Software you probably don’t need

MSN/YahooMessengerMSNLiveGoogleDesktopMcAfee/Nortonpackages*AdobeReader*>1officesuiteWebcamsoftwareMobilephoneconnectionsoftwareAnythingcalled‘assist’,‘helper’,‘agent’or‘update’(leaveWindowsUpdatealone)

insidious Diseases Therearealsometabolicdemandsbeingmadein the background out of your view. Theprocesses tab shows you all the computingtasks that are running, and the amount ofmemorytheyareusingup.Ifyourcomputerissick,thislistisprobablylong(50+),andsomemaybeusinglargeamountsofmemory.Manyof thesewill beWindows processes (such asexplorer.exe)intrinsictotheoperatingsystem.Mostarenon-critical‘helper’partsofinstalledsoftwarewhichloadupeverytimeyoustartthecomputer. Theyruninthebackgrounddoingnot-terribly-useful thingswhilst stealing yourcomputingresources.TheyoftencomewithaniconinyourSystemTray(bottomrightcorner)thatpopsupirritatingmessages.What’smoreannoyingisthattheyseriouslyslowdownthetimeittakestostartyourcomputerandarenotalwaysremovedwhenyouuninstallaprogram.These chronic diseases need rationalisingor removing to restore your machinesphysiologicalreserve.Youcansafelyusetheend processbuttonandseewhathappens. Ifyouendaprocess(eg.svchost.exe)thatmakesyourusualWindowscontrolsstopworking,it’s

nodrama–justreboot(off&on)andallwillberestored.You’lldiscoverthatyoucanendafairfewwithoutconsequence.

Principles of Management Youcansolvethismismatchofresourcesanddemands by increasing resources (upgradeyour memory or dispatch a perfectly decentPC), or by decreasing demands (throw outunused software and streamline Windows).Hereishowtokeepthemetabolicdemandsofsoftwaretoaminimum:

1. Removeasmuchsoftwareasyoucan.

2. Neverinstallsoftwaretodosomethingthe operating system can already dofor you. Never install two programsthatdothesamething.

3. Ifyouneed software, try tochoosea‘lightweight’packagethatdoesn’thogresources.

4. Steer clear of updaters, agents, tool-bars,helpersandotherunwantedsoft-ware that are offered during installa-tionoftheprogramyouactuallywant.

5. Don’t upgrade your software unlessnecessary – demands on resourcesgrowwithdevelopment,whereasyourresourcesdonot. Keeptheoperatingsystemupdatedthough.

critical care of PcsSeriously consider a fresh re-installationof Windows if your machine is a completedisasterzone,itwillbequickerandeasierthanuninstallinglotsofsoftware. You’llneedthemanufacturer’s recovery disc, or aWindowsinstallation disc. Your files should be safewhen you do this, but back them up before you start. Yoursystemwillbe just likenew,but you’ll need to install the office software

47

you use again. Manymanufacturers includeproprietarysoftwarewiththeircomputersthatisinstalledwiththerecoverydisc.Youdidn’taskforthissoftware,sogetridofit!

Software that Microsoft gives you, whether you like it or not

MediaPlayerExplorerFirewall(XPandabove)MovieMaker(freedownload)CDburningWordPad(basicwordprocessor)Picturebrowser/viewer

Tospringcleanasystemleaving theexistingOS intact, start by removing software youdon’t use (see box for examples). Choosestart..control panel..add/remove programsandget towork. If youget the ‘file sharedwithanotherprogram’box,justsayyes.Trytoberuthlessandgominimal, it’s easy to reinstallsomething you find you wanted. Leave theWindows updates and fixes alone – keepingyour operating systemup to date is good forsecurity.

MicrobiologyNorton, McAfee, Symantec, Kapersky andothercompaniespreyonyourfearofviruses,they sell you expensive ‘bloatware’ thatseriously furs up your computer’s arteries.Catastrophic failure from viruses is rare ifyouaresensible. You’reveryunlikelytogeta virus if you don’t open undisclosed emailattachments or install software from theinternet.Butwealldoalittleofthissosomeprotection is advisable. AVG Free is a farlighteroption,andoffersplentyofprotection.OnsystemsolderthanWindowsXP,youneeda firewall too – ZoneAlarm is a sound freeoption,butotherwiseWindowsbuilt-infirewall

isadequate.Turnoffdailyvirusscanning,it’samassive resourceshog andunnecessary formost.Ithinkit’sreasonableformosttovirusscanmonthly,butonlyscanwhenyou’renotactuallyworking!So-called‘spyware’isnon-malicioussoftwarethatisinstalledwithotherpackageswithoutreallyaskingyoufirst.Itisharmless but should be removed periodicallywithSpybot.Don’tallowSpybottoscaninthebackground!

Useful Free, Lightweight Software alternatives

AVGFreeanti-virusMicrosofSecurityEssentialsFoxitPDFreader(lightalternativetoAdobeReader)Openoffice(fullyMicrosoftcompatible)Spybot/Ad-awareZoneAlarmfirewall

Waking the Patient upEven when you’ve removed unwantedsoftware, there will be processes starting upin the backgroundwhen you switch on fromcold.Thisseriouslyslowsyourbootuptime.Thisismosteasilydealtwithusing‘ccleaner’(Piriform software), a free download. Thissoftware isdesigned for editingyour registry-the computer’s record of software it hasinstalled and how to run it. Messing up theregistrycanmakeitallgowrong,butccleanerissafeandeasy touse,as longasyouopt tobackupyourregistrybeforeyoustarttweaking.The tools..startup menu in ccleaner lists allthe processes that start when you boot thecomputer.Youwantasfewaspossible.Itcanbehardtoguesswhateachoneis,butastheycan be temporarily disabled before removal,youhavefreedomtoexperiment.Now that you’re feeling brave, considercleaning the registry. This is like making

48

a large set of patient notes concise, so theinformation can be found rapidly. Backup the registrybeforeyoudoanythingthoughsoyoucanalwaysgobackifitgoespearshaped.Ccleaner will scan and fix outdated entries,whichhelpsspeedthestartup.Using ‘hibernation’ instead of ‘shut down’should help a slow-booting computer wakeup from power-off much more quickly.Hibernation saves the current session toharddisc and cuts out the need for a formal bootup at power on. The downside is shut downtakes longer, but at least this won’t impactonyourwork.Itmadelittledifferencetomydesktop,butahugetimesavingona‘netbook’.To enable:control panel..system & security...power options and navigate your own way.Youcanassignthepowerbuttontohibernateorpressshift beforeclicking in thefinal shut

down/restart/sleep window when you exitWindows.Bewarnedthatittakesacoupleofhourstogivecriticalcaretoanailingcomputer,butitisverysatisfyingtogetitallrunningnicelyagain.Youwillsavetime,moneyandtheenvironmentbykeepingyouroldmachinegoing.Theinternethasplentyoffurtherinformationavailable,butbewaryofquickfixes–theyareoftenspywareprograms themselves! Ihave to leavewithalittle disclaimer – make suitable backups ofyourfilesbeforeanytweaking,andmakesureyou have the manufacturer’s recovery discto hand in case it all goeswrong. However,there’salmostnothingyoucandofromwithinWindowstomakethecomputerunrecoverable.Bebrave,experimentandyouwillberewarded.Ifyouwanthelporadvice,contactmeviatheSASWRwebsitewww.saswr.org.uk

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introductionOne of the recommendations of the Walportreport,1 published in2005, and the aimsof theNational Institute of Academic Anaesthesia(NIAA)hasbeentheintegrationofacademicskillswithclinicaltraining. Thishasbeenreinforcedinrecentjournals2andmeetings.3 Onemethodof undertaking academic training is taking onanacademicpostwithaformalresearchperiod.Havingrecentlyappliedforandbeenappointedtoacademicposts,wefeltthatthepathwayremainsuncleartointerestedtrainees.ThisisparticularlysowithinthePeninsulawhereresearchprojectsaremorelimitedthaninlargercentres.Forthosewith an enthusiasm for pursuing research thispresentsadifficulty–howtofindoutwhatis‘outthere’andhowtogetinvolved.This article is intended to provide a shortassimilationof theopportunities thatwefound,aswellasbriefpersonalaccountsoftheprocesseswewereinvolvedin.Wehopethiscombinationisusefulforothersconsideringthisstep.ByitsnaturetheinformationhereisnotcomprehensivebuthopefullywillprovideusefulleadsforothertraineesandtheirEducationalSupervisors.

Why would i want to do this?Neitherofushasaformalresearchqualification,so where did our desire to get involved inresearch come from? Discussion betweenus, and with colleagues also pursuing thesepostssuggestedagroupofcommonqualities:an enjoyment of the investigative process(casereports/goodqualitymeaningfulaudit/studies),adesiretounderstandasubjectbetter,whetherinbasicscienceorclinicalresearch,adesiretopursueaparticulartopicinmoredetailaswellasthesatisfactiongainedinbecoming

an‘expert’inanarea.Otherbenefitsincludeanewdimensiontoyourcareer,improvingyourCVandintroducingvarietytoyourtraining.

What is out there?Firstitisworthdecidingwhetherthisgoingtobeamajorpartofyourcareer,oranadditionalexperiencethatwillaidyouinamorestandardclinicalrole.Ifyouwanttomakeasignificantcommitment,aimingatahigherdegree,thereareaseveraldifferentroutesavailable,twoofwhicharefairlystructured.1) Academic clinical fellowships (Acfs)These posts were developed in response totheWalport report into academic training inmedicine.Theyarepostsspecificallydesignedfor those in the earlier years of training toprovide an integrated entry into a mixedclinical/academic career. They are specialtyspecific and a small number are availablein anaesthesia based at University CollegeLondonandImperialCollegeatpresent.They are posts of up to 36months ofwhich9 months are dedicated to research. Duringthistimeitisexpectedthatyouwillprepareaproposalforaresearchprojectforsubmissionto a research council. If you are successfulthenyougoontocompletethisresearchasaclinicaltrainingfellow.Ifattheendof3yearsyouhavenotsecuredfundingyouswitchbacktothestandardtrainingpathway.The Peninsula Deanery offers fourACFs,4 ofwhich only one is applicable to anaesthetictrainees–itisineducation.TheSevernDeanerycurrently has no academic specialty trainees,thoughAcademicFoundationpostsexistsothismaydevelopoverthenextfewyears.5

Similar opportunities exist in Scotland via

getting involved in Academic Anaesthesia

Dr Tim Dawes and Dr Alisdair Jubb, Specialist registrarsSouth West School of Anaesthesia

Anaesthesia Points West Vol. 43 No. 1Article

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the Scottish Clinical Research ExcellenceDevelopmentScheme.6

2) The Wellcome TrustThe Wellcome Trust is a large charitablefunding organisation, which offers variousfundingopportunities.Forfurtherinformationconsult the website www.wellcome.ac.uk.However,tworouteswhichmaybepursuedare:Clinical PhD Programmes The Wellcome Trust funds 7 programmesaround the country at centres of excellencein biomedical research, for clinical traineeswishing to pursue a research career. Eachvenue has 5 posts each year, which are notspecialty specific. They vary slightly as totheir structureandentry requirementsbutaretargeted at those in earlier years of specialtytrainingandwithoutformalresearchtraining.Theyhavetwomajorstrengths:firstly,youplanyour project after joining their programme,allowing you to develop your interests andresearch training once immersed in a highcalibre research environment; secondly, theyhavefundinginplacefortheresearchdegree,assuming your proposal reaches the requiredstandard. Someof theseprogrammes(egtheEdinburgh Clinical Academic Track) absorbyourclinicaltrainingentirely,returningyoutoclinical trainingfor80%of the timeafter theresearchdegreetoallow20%timetocontinuetheresearchinterest.Wellcome also fund a smaller number ofclinical PhD posts in translational medicine- for example looking specifically at drugdevelopment-whichrunalongsimilarlines.Research Training FellowshipsThisawardisformedicalgraduateswhohavelittle or no research training, but who wishto develop a long-term career in academicmedicine.Fundingisprovidedfortwoorthreeyears to pursue a project in an appropriateinstitutionorclinical researchfacility leadingto a higher degree. It requires you (as an

anaesthetist)tohavepassedthePrimaryFRCAexamination to be eligible. It is an exampleofagrantthatisavailabletosupportthemoretraditional route (see below) into academicmedicine.3)Traditional (independent) routeAthirdpossibilityistoapplyforastand-aloneMD/PhD via direct contact with a researchgroup.Wedidnotinvestigatethispossibilityingreatdetail,althoughgoingtotheNIAAwithanideaofaresearchareawassuggested,bythoseinvolved,asareasonableplacetostart.Thelackofstructuremakesthisthemostflexibleoptionbutalsothemostarduoustosetup,particularlyifyoudonotalreadyworkneararesearchhub.Itislikelythiswouldneedamovefromtheregiontoaresearchcentre,asthereisatrendtowardsfocussingfundingongeographicalcentres.

What opportunities exist within the South West region?There is no pre-organised, funded researchtimewithin either thePeninsula school or theSevernSchool.However,traineesinvolvedinaresearchprojectmayapplyindividuallyfortimetobeallocatedtothemtopursuetheirinterest.If you have a project and supervisor thenapplyingcompetitivelyforagranttocoverthisisalwaysanoptionalthoughgettingthemoneyisobviouslynotguaranteed.Itispossiblethatmilitary-based trainees may be able to securefunding for time out to complete projects,thoughthisisnotformalisedandwouldrequireindividualapplication.Funding for small projects may be securedfrom local organisations,7 though this isaimedat coveringproject costsnot includinginvestigators’ salaries – i.e. it may coversmaller expenses such as kit, not larger onessuch as paying for your time out of clinicalwork. Trust Research and DevelopmentDepartmentsshouldbeapproachedaboutlocalorganisationsofthistype.

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Applications processIt will come as no surprise that structuredschemeshavestructuredapplicationsprocesses,andentrymaybeonlyonceayearsoitisworthchecking the deadlines some time in advance.TheWellcomeTrustClinical PhDs andACFsallhadOctober-Decemberdeadlinesin2009,and again in 2010 which were published onthe relevant websites. These schemes followastructuredformat,whichcanbefoundonlineincludingforexampleapersonspecification,ashortlistscoringsystemandanonlineapplicationprocess(seeboxes1&2forexamples).If you are pursuing a stand alone PhD, thiswoudhavetobeformalisedwiththegroupwithwhich you are applying, the host institutionandthelocaldeanery.

interviewClearly we are not in a position to providea ‘how-to’ guide to the interview process.However,amalgamationofourownexperienceanddiscussionwithcolleaguessuggeststhereare common threadsofdiscussion. Theyareworth considering for the interview, but alsobeforehand to ensure you are applying forsomethingyouactuallywanttodo.• Doyouwant to do clinical or laboratory

research?• What are you looking for from your

academicsupervisor?• Whatwillyoudoafterthispost/degree?• Howdoyouseeyourcareer(ideally)in20

years?• Whatwouldyouliketodoresearchon?This last question is worth a little morediscussion.Itwillbeofbenefittohaveanideaofasubjectareaandbewellreadinthatarea,howeverfromourexperienceyouareunlikelytobepenalisedfornothavingafullyresolvedideaforaresearchproject.Bear in mind that many schemes are largelyclinicalinitiallyandsotheinterviewmayinclude

questionstoprobesuitabilityforaclinicalpostaswell.Evenifyourresearchdoesnotworkoutasyouwouldwish,thedeaneryinvolvedneedstobereassuredtheyaretakingonsomeonewhocancopewiththeclinicalrequirements.Theimportanceofenthusiasmandcommitmentto research, as well as the post you havechosentoapplyfor,wasemphasizedbyalltheacademicswemet.

conclusionsWe hope this article provides some practicalhelp to colleagues who are considering thiscareerpathbuthavelittleornoexperienceofresearch.Wewerepleasantlysurprisedbyhowenthusiastic andencouragingacademicswerein reply to our enquiries and questions. Inotherwords,it’sgoodtotalk…

notes1 http://www.nihrtcc.nhs.uk/intetacatrain/index_ html/copy_of_Medically_and_Dentally- qualified_Academic_Staff_Report.pdf

2 RCoA Bulletin 2009;58:18-19

3 Forexample,TheAnaesthesiaResearch SocietyWinterMeetingattheRCOA, December2009

4 http://www.peninsuladeanery.nhs.uk/index. php?option=com_content&view=article&id=7 14&Itemid=624

5 PersonalcommunicationwithDr.Su Underwood(HeadofBristolSchoolof Anaesthesia)

6 http://www.nes.scot.nhs.uk/medicine/ postgraduate_training/academic/

7 For example the Devon Northcott Medical Foundation.

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Where do i find out more?

• NationalInstituteforHealthResearch–ACFsareshownherehttp://www.nihrtcc.nhs.uk

• WellcomeTrusthttp://www.wellcome.ac.uk/Funding/Biomedical-science/Grants/PhD-programmes-and-studentships/index.htm

• BMJCareers,BMAacademictrainee’sconference

• Deanerywebsites

Peninsula: http://www.peninsuladeanery.nhs.uk/index.php?option=com_content&view=article&id=714&Itemid=624

London: http://www.londondeanery.ac.uk/

Edinburgh ECAT scheme: http://www.ecat.mvm.ed.ac.uk/scheme.html

• NIAAhttp://www.niaa.org.uk

• RCOAAcademicAnaesthesiaDays-http://www.rcoa.ac.uk/index.asp?PageID=40

• ScottishClinicalResearchExcellenceDevelopmentScheme(SCREDS)http://www.scotmt.scot.nhs.uk/docs/SCREDSFINALRevisedGuidetoScheme16thJanuary09.pdf

• Viayourdepartment–askaround,peopleknowpeople!

• JaneMontgomery(ConsultantAnaesthetist,TorbayandPeninsulaResearchOfficer)

• ProfessorSneyd(ProfessorofAnaesthesiaandVice-DeanPeninsulaDeanery)

Morebroadlypeopleinacademiaareusuallyquiteaccessibleandhelpfuloveremail.Wefoundcontactingpeoplealreadyworkinginaresearchdepartmentinvaluable.

53

Box 1

Applying to the London Deanery UCL/ImperialAcademicClinicalFellowships

AdvertinmedicalpressNovember

Detailed information on Imperial / UCLwebsites

Briefjobdescription,applicationform,personspecificationandshortlistingcriteriaonline

ShortlistedinDecemberforinterviewbeforeChristmas.

Pre-InterviewPreparation(1weeknotice)

Askedtoprepare2x10minutepresentations:

•Ateachingpresentationto1styearmedicalstudentsonaspecifiedtopic

• A research proposal to an academicsupervisor

Interview:

Billed as 2 x 30 mins though due to theweatherchangedatshortnoticeto1x45mins

Panelof3senioracademics

Presented academic presentation viapowerpoint, brief questioning on technicalaspectsandlogisticsofrecruiting,consent

Separatediscussionson

• Research plans and career, intellectualpropertyrights,appreciationofethics

• Discussion of a clinical scenario involvingmanagementofaclinicalteamandappreciationoftheroleofamiddleranktraineeandtheroleoftheconsultantbothduringandafteradifficultcase

•CV

Box 2

Applying to Edinburgh Clinical AcademicTrackWellcomeTrustClinicalPhD

Advert inmedicalpress lateSeptember (forallWTposts)

Detailed information on University ofEdinburgh(UoE)website

Applicationformonline,CVinformationandsupportingstatement,deadlineendOctober.

Shortlisted inNovember for interview earlyDecember

Interview:25minutes

Panel of senior academics from UoE, plusthePostgraduateDeanandoneexternal.Noanaesthetists.

Begunby3minutepresentation(noaids)onexperience and personal qualities suited tocareer.

Progressed to wider ranging discussioncovering items from CV, possible researchinterestswithsomemore focussed technicalquestions.

Minimaldiscussionofclinicalwork.

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In 2008, following the introduction of thenovel and ever changing system of selectionand allocation of junior doctors to trainingprogrammes, the Royal Devon & ExeterHospitalanaestheticdepartmentwasfacedwiththedauntingprospectof12noviceanaesthetictraineeswithnopriorknowledgeorexperienceof anaesthesia or intensive care medicine,arriving for work on the first Wednesday inAugust.August isadifficult timeofyearatwhich toabsorb this number of trainees as there areconsiderable changes in staff throughout thehospitalanditisthemostpopulartimeforthepermanent members of staff to take holiday.Ourdepartmentusuallyhas23 trainees, fromFY1toST4.Thetrainees,followingtheinitial3 month introduction to anaesthesia, areexpected to be on the on-call rota, assumingcompetencieshavebeenachieved.InAugust 2008,wehad to accommodate the12newtraineesintothedepartment.Wehadtoprovideconsistent,effectivetrainingsuchthatinNovember 2008 theywould be competentto practise anaesthesia under supervision andcontributetotheon-callrota.Wedecidedthatthiswasanidealopportunityto devise a comprehensive 3-month teachingand training programme, integrating regular,planned tutorials with simulation and in-theatre teaching and experience. We werealsofortunatetohaveaccesstothee-learningmodule which was being organised via theRoyalCollegeofAnaesthetists.We devised a curriculum which covered thebasic pharmacology, physiology and physicsfor junior anaesthetists in addition to basicand advanced airway skills, assessment of a

patient for anaesthesia, practical anaesthesia,common medical co-morbidities and criticalincidents. The teaching programme startedwith an introduction to theatre, pre-operativeassessment and the anaesthetic equipment.Thisenabledthetraineestobeconfidentwhenfirst encountering an anaesthetic room and asurgicallist.The tutorials,whichall the traineesattended,occurred twice a week. They were split into3 groups of 4 for the simulation sessionsandhad3halfdaysover the3months. Thesubjects in these sessions reflected the topicscovered in the tutorials to aid consolidationand test knowledge and practical skills. Therestofthedepartmentweregivenalistofthetopics tobecoveredandwe tried tocoincidein-theatreteachingwiththetopicoftheweekbeing covered in the tutorials and simulationsessions.Thecurriculumalsogavethetraineesa framework to work around as well as thee-learningmoduleswhichweremonitoredbyDrHammond.Each trainee was expected to attend a basiccritical care skills course organised locallywhich covers such topics as advanced lifesupport, recognition of a sick patient andinterpretationofarterialbloodgases.Each traineewas linked to 2 consultants; theaimbeing to try to give some consistency tothe theatre experience in the 1st three-monthperiodtohelpwithlearningandconsolidationof knowledge. Achieving this proved verydifficultinpracticebuteveryeffortwasmade.Thetraineeswerenotonlyintheatreduringthedaybutalsoshadowedtheon-callanaesthetictraineeinthetwilightperioduntil8pm.Thisenabled the trainees toexperienceemergency

here come the Trainees…All 12 of Them!

Dr Kathryn Davies, consultant in Anaesthesia and Pain MedicineRoyal Devon and Exeter Hospital

Anaesthesia Points West Vol. 43 No. 1Article

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andoutofhoursanaesthesiaandsurgery.The feedback we had from the trainees wasveryfavourablewithsomehelpfulsuggestionson how to improve the course. We haveincorporated these into thesubsequentcoursewithgreatsuccess.

Wehavebeen impressedwith the confidenceand ability of the trainees once they havecompleted the 3-month training programmeand therefore plan to continue this trainingprogrammewitheveryintakeofnewtrainees.

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Anaesthetic training has always had a goodreputation. This was one of the reasons Iwanted to become an anaesthetist. WheneverI pick up a BMJ I am reminded that trainingtimeisbeingreduced,largelyasaresultoftheEuropeanWorkingTimeDirective,andoftenthenumbersoftraineesonarotationisincreasing.Havinggone through thefirst threemonthsofanaesthetic training at the Royal Devon andExeter I canhappily say that their anaesthetictraining programme has been successfullyadaptedtocopewiththesechanges.During induction in the department wewereall given a timetable of the tutorials thatwouldbeheldonceortwiceperweekforthefirst three months. These tutorials coveredpharmacology, physiology and physicsand practical anaesthetics such as airwayemergencies, massive haemorrhage and painmanagement.Theynotonlyprovideduswiththefoundationsforourpracticebutwerealsoa great way to meet other members of thedepartment.Wetraineescouldexchangestoriesofthepreviousweek’sexperiences.Manyofthetutorialsconsistedofpresentationsbyeachof the traineeswith a consultant supervising,allowing us to both research the topics andpractiseourpresentationskills.Thebeginningofour trainingcoincidedwiththe launch of e-LearningAnaesthesia. Thisweb-basededucationalresourcewasdevelopedby the Royal College of Anaesthetists inpartnershipwithe-LearningforHealthcare.DrEdHammond, one of theRD&E anaestheticconsultants, was Joint Clinical Project Leadfor thisnationwide training initiative. At the

startofourtrainingheshowedushowtousethe learning tool and we were encouragedto complete the first block of tutorials bytheendofourfirst threemonths. Severalofthe e-Learning tutorials were relevant to theweekly face-to-face tutorials and were usedtolearnaboutatopicbeforeatutorial.Manyof theRD&Econsultantswereawareof,andinvolved in creating, the e-learning tutorialsand used them as a teaching tool whilst intheatre.Another part of our first three months oftraining was a three half-day SimMan®course. The simulation scenarios were heldin very realistic settings involving a mocktheatre.ThisincludednotonlytheSimMan®andanaestheticmachine,butanODP,surgeon,scrub nurse and plenty of fake blood. Thescenarios began with the administrationof a basic anaesthetic and moved on to themanagement of airway emergencies such asfailedintubation.Thefinalscenariosinvolvedmanagementof anaesthetic emergencies suchas anaphylaxis, massive haemorrhage andmalignanthyperthermia.Eachofthescenarioswas videoed and this was played back anddiscussedinmorerelaxedsettings,quiteoftenleading to more general questions regardinganaesthetics.Thiscoursegaveusexperiencesandconfidencewemaynothavegainedinthefirstfewmonthsofin-theatretraining.BytheendofthefirstthreemonthsoftrainingIwashappytohavesololistsandtostartgeneralon-call duties. A great proportion of myconfidencewasduetothedepthanddiversityoftrainingIhadreceived.

A Trainee’s Perspective of the first Three Months of Anaesthetic Training at the royal Devon and exeter hospital

Dr c gibson, cT1 AnaesthesiaRoyal Devon and Exeter Hospital

Anaesthesia Points West Vol. 43 No. 1Personal View

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Itwasfouro’clockinthemorningandIhadjustsitedaparticularlydifficultepiduralforlabourwhen theyoungmother-to-beasked“howdoanaesthetistslearntodowhatyoudo?”Iwasshakenfromtheautopilotofmynightshiftbythis seemingly very simple, yet surprisinglydifficult question. After a moment’s pauseI told her thatwe have access tomodels forcertainproceduresbutthat,intheend,wehaveto practise on patients, relying on skills wehave acquired both from the aforementionedmodelsandfromsimilarbutslightlydifferentprocedures. It may have been the entonox,extreme fatigue or my reassuring tone but,remarkably,sheseemedverycalmhavingbeentoldthatwepractiseonpatientstoacquireourskills.Itmademeponderonhowmuchfaithourpatientshaveinus,notknowingquitehowjuniorwemaybewhenwewalkintotheroomas the ‘anaesthetistwhowill take away theirpain’.IamaCT2 trainee inanaestheticsandat thetimeofwritingamsixweeksintomyobstetricanaesthesiatraining.Ithasbeenquitesimplythe steepest learning curve of my career. Itwould be an understatement to say I wasapprehensive about starting in obstetrics,havingdoneonlyoneyearofanaestheticsandcriticalcareatasmalldistrictgeneralhospitalwith approximately400casesundermybelt.My obstetric anaesthetic experience up tothatpointconsistedofadistantmemoryofacaesarean section under spinal anaesthesia,which I observed as a fourth year medicalstudentatfiveinthemorning.NeedlesstosayIwasstartingfromtheverybeginning.

Iworkinthebusiesttertiaryreferralobstetricunit in the region, with approximately 6500birthsduring2009,sotherewasnoshortageofcasestotrainmeupon.Ihadatotalof11daysinwhichtolearntheropesbeforegoingitalone.OndayoneIwasgivenahugelistoftopicstodiscusswithaconsultantataquietmomentplustheformalpaperwork:thecorecompetencieswhichhadtobesignedoffpriortostartingoncalltwoandahalfweekslater.Overthenext11trainingdaysIwasluckyinsomewaysinthatIsawalmosteveryobstetricemergencyinthebookandcountlesselectivecases.Spinals,whichwereonceabittricky,seemedeasyevenwhen themidline was only a figment ofmyimagination.OntheemergencyfrontIwasnotsurewhetherIwastotallyterrifiedbyknowingquitehowbadthingscouldget,orgladthatIhadseenthematleastoncewithaconsultantintheroom.TheseniorregistrarsassuredmethatthelatterwasdefinitelybetterthandoingyourfirstGAsectionordealingwithamassiveobstetrichaemorrhage,aloneinthemiddleofthenight. Iwasnotsosure,myanxietywasrisingandIwasyettodoasingleepidural.Despite simulator training and having myconsultant scrubbed up to guide me on realpatients, it felt like a case of the traditional‘see one, do one’when it came to epidurals.Luckily, I really like practical procedures, IsupposeI’minthewrongspecialtyifIdidn’t,andIwasfortunatetodoninepriortomyfirstoncall. Actually, they turnedout tobequiteeasyandthefearofstickingsuchahugeneedleinto a moving target gradually subsided, atleastuntil Ididmyfirstduralpuncturewhen

crash Sections and epidurals – A Trainee’s Perspective of Starting obstetric Anaesthesia

Dr Anoushka Winton, cT2 AnaesthesiaNorth Bristol NHS Trust

Anaesthesia Points West Vol. 43 No. 1Personal View

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itreturnedquiterapidly.ButasIwastoldbyaseniorcolleague‘peoplewhodon’tdoduralpuncturesdon’tdoepidurals!’ThemomentfinallycamewhenIhadmypieceofpaperwhichsaidIwascompetenttodothejob,andIwasleftonmyowninthedeliverysuite to provide the obstetric anaestheticservice.Iwascompletelypetrified.However,I held my head high and concentrated onmaintainingacalmexteriordespitemyragingtachycardia. It was always going to happenthen,thatIwouldbeputtothetestduringthosefirst two hours on call with a surprise failedepidural top-up. This necessitated a spinalwhichthenprecipitatedadifficultanaesthetic,not helped by a post partum haemorrhage ofover 1.5L all with the patient’s nearest anddearest sitting right next to me. The addedfactor of the patient’s family being quite soclosetotheactioniscertainlydifferenttoanyanaestheticIhavegivenpreviouslyandmakesitevenmoreimportanttoexudecalm.Sixweeksdown the line, several night shiftsand a lot of emergencies later, I am slowlyconqueringmyfearofthedeliverysuite.Inolongerdreamaboutdoingepiduralsandthinkmy alarm clock is the bleep for a categoryonesection. InowknowIcando the thingsIworriedaboutandthathelpisreallynotfarawaywhenyouneedit.IknewthisallalongbecauseoftheconsistentsupportfromallmyseniorsbutitwassomethingIhadtoexperiencetobelieve.Thefearfactorofstartingobstetricanaesthesiais not something new. Even the mostexperienced of anaesthetists will recall theearly days when they too felt apprehensive.The anxiety amongst today’s trainees maynot be helped by our diminishing traininghours and the need to push us to acquire thenecessary skills to fulfil service requirementson already very tight rotas. There is somedisputeastowhetheractualcasenumbersare

falling following the implementation of theEWTDbutnoonecandenythatlesstimespenttrainingwillinevitablyresultinlessexposureto anaesthetic emergencies and possiblyadd to a lack of confidence amongst noviceanaesthetistsinthosesituations.TheRoyalCollegeofAnaesthetistsmandatesthattraineesshouldbeassessedforcompetenceprior to working with distant supervision.However, it does not mandate how long oursupernumerarytraininginobstetricanaesthesiashouldbenoratwhatstageinourtrainingthisshouldbecommenced.Thisperhapsexplainsthe differences across the countrywith sometrainees beginning obstetric on calls in theirST3yearandothersinCT2,afteronlyafewdaysof training. TheRoyalCollegerecentlysentasurveytoallnewobstetricanaesthetistsaskingifwefeltconfidentingoingoncallandifwewereworried aboutdifferent scenarios.Iawaittheresultswithinterest.Thereseemstobeariteofpassagethatwemustgothroughand the only stipulation as to when we areready is that we are assessed as competent.Thequestion remains,doescompetence inferconfidence?So, returning to my patient who, at fouro’clock in the morning, put her trust in metobecompetentatmy joband relieveherofher pain. Little did she know that the calmand apparently confident doctor who stoodbeforeherwasreallyalittlebitnervousdoingthe epidural especially whilst riding out acontraction just after loss of resistance at 8(andabit)centimetres.Everythingwentwellandwithabitofwitchcraft/strongtop-upsandlateralpositioningIfinallygotherepiduraltoworkwell.I think my training, although short, wasexcellentinpreparingmeforthedifficultiesIface on the delivery suite. Itwas consultantlead,intensiveandfocusedwhichhelpedmetolearnthekeynecessaryskillsandconsolidate

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themoverashortperiodoftime.Ilearntthat,asinallareasofmedicine,thekeytosuccessisgoodcommunication.Itcankeepalabouringwomanstillwhenitcountsthemostbytalkingher through her contractions and reassure awoman having a caesarean section that thesensationsshecanfeelarenormalanditwillnothurt.

Despite my initial fears I am enjoying myobstetric experience and I can honestly say Iam confident of my ability as well as beingcompetent.Icertainlyhopethatalltraineesaregiventhetime,trainingandsupporttheyneedtofeelconfidentwhenstartingthischallengingspecialty.

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It’s6.30amonday9and,yetagain,it’sarelieftogetupandabandonbed.Itiseasiertoturnnow,butlyingonmyside,withoutacomplexsystemofcushionsunderkneesandso forth,results in a deep ache in the joint, and thussleeplessness.ThankGodfortheBBCWorldServiceandearplugs! Ihaveneversleptonmybackforanylengthoftime,anddoingsothislastweekorsohasprobablybeenthemostdifficultthingIhavehadtoadjustto.IarriveonSheppardWardat7.15onMondaymorning, to a cheery greeting from the nightstaffnurse-“…andyouare?”.Iamfirstonthe list. A perk?! Duly checked in, bloodpressured, temperatured, and bled for “groupandsave”bytheratherintimidatedF2,Iwaitfor my anaesthetist, surgeon, consent andso forth. Everyone is friendly, professional,thorough. Whenwill I start to get seriouslynervous? Two patients, one beside and oneopposite me, greet my arrival cheerily. Theman opposite had his operation cancelled 10daysbeforebecauseofamilkycupofcoffeeatsixo’clock.Mythoughts–whatapieceofluck that I had remembered to abstain. TheearlymorningcupofteaissuchanintegralpartofourhomeroutinethatIalmostdidit!Livethatonedown?Theyareincrediblycheeryandsupportive,realcamaraderieexistsinC-bay.Thesurgeonandanaesthetistcomeandgo. Iam the patient, you are the doctors. You dowhatyoudo.I’lljustliethereandtakeit.Wesettleforaspinalandlightsedation.Nonervesyet. Cheery staff from theatre arrive at 8.45towhiskmeoff. Fancymeetingyou. Goodluckmate!Stillnorealnerves.Whenwilltheystart?Theanaestheticroomisreallysmall.Isuppose

Ihadnoticedbefore,but lying there it seemsso cramped. Everyone is friendly, but veryprofessional.Thenitdawns–it’stheneedlesIamscaredof!AsmallbleboflocalandIreallydon’tfeelthe16gaugecannulapiercetheskin.A small dose of midazolam before we start.Hmmm,interesting.Noamnesia.Sittingup,hunched, no cares. A bit of an ache, he hitsitfirsttime. Thewarmthinmylegsandfeetstartssoquickly.Amazingbutweird.Pluggedintothepropofolpump,“we’rejustgoingtogointotheatrenow”hesays.ThenI’mrecovery.Iopenmyeyes,andthereisafriendlyface.Iknowyou… I think? I feel quite lucid andincontrol,butmybloodylegsdon’tbelongtome.Suchastrangefeeling.Nosenseoftimepassing,justflickthelightsoff;flickthembackon.By11o’clockIambackinbed.They’vemovedme to a side room. I am awake, butjustlietherenotreallycaringaboutanything.Justwatchingeverything.Nursescomeandgo.Bloodpressure,oximeter,eartemperature.Theroutinebegins.IpluginmyI-podandlistentoHaydn’sTheresienmesse,afavourite.I’mnotsleepybutjustdon’tcareaboutanything.Nopain.At somepointmynurse comes in andoffersmefood.Iamsohungry!Acheesesandwich,yoghurt and a chocolate muffin goes downinnotime.Irest,doze,wake-alltoHaydn.ThenwatchingTVseemslikeagoodidea,soI try that. Over thefollowinghourIbecomeawareoffeelingabitdizzysoabandontheTV.JustatthispointDavid–occupationaltherapist–arrivestogothroughmypre-completedOTform.WegetasfarastoiletseataidsbutbeforeI can answer his questions,with virtually nowarning…upitallcomes.Cheesesandwich,

Total hip replacement – a Personal experience

Dr ian gauntlett, consultant AnaesthetistTaunton & Somerset NHS Foundation Trust

Anaesthesia Points West Vol. 43 No. 1Personal View

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yoghurtandachocolatemuffinmakeacurioushomogenisedmix!Thevomitbowlsaregood,buttoosmall!PoorDavid.Hefetchesmethreeextraandthenit’sthelastIseeofhimforthreedays!It’sacuriousthing.WealwaystalkaboutPONV–post-operativenauseaandvomiting–as an integral event. I suffered no nausea, IjustbecameawarethatIwouldvomitmomentsbeforeithappened.Immediatelyafter,Icouldhaveeatenanothercheesesandwich(maybe?).Anotherlesson.The final piece of my first hand anaestheticlearning experience is the spinal. It lasts forages–atleast4hoursbeforethenumbnesshascompletely receded. As expected my thighsarethefirstbitsIbecomeawareof.QuitesoonIcanmovemylegs,butmyfeetaregluedtothebed.NotatwitterofmovementcanIelicit.Notparticularlydisconcerting,becauseIknowtheywillreturn. WhatIsupposeIknow,butdid not expect, is the last bit of sensation toreturn.Thescrotum!Amostpeculiarsensationfeelingabitofanitch,butmyattempttoscratchleavesmehalfwaydowntomyknees,missingcompletely!Nospatialawarenesswhatsoever.The diamorphine in the spinal is good.Full movement and sensation returns, butunaccompaniedbyanypain. Ikeepwaiting,thinkingitisgoingtobeagonising,butnothing.Eventually a bit of painwithmovement, butminimal.Itisn’tuntilbed-timethatthingsgeta bit tough. My usual sleeping technique istossingandturning, left toright, right to left.Irarelysleeponmyback.Tryingtosleepallnightonmybackprovestobethehardestthingtoendureoverthesucceedingnights.This iswherePatientlinecomes into itsown.Tohaveinstantlyavailable24hourradioandTVisa lifesaver. Atasmallcost Iamabletosharemynight-timeagonieswiththewholeof the BBCWorld Service. They are greatcompany.What other indignities in the first 24 hours?

The inevitable consequence of a spinal isthe awareness of “need to pee”, without thewherewithal.Meandmybottleenjoyedaverycloserelationshipduringthefirstevening,butthebottleremained“unfulfilled”.Myeveningnursecameonandweagreedtositmeontheedgeof thebed, she tactfully facing away tothe door. Still no luck. The final solution -I found myself standing beside the bed, onehandonher shoulder, theother clutching thebottle,desperately“relaxing”whileIdribbledaway.Wewereoff!Atall times Iwashugely impressedwith thecare andkindnessof all theward staff. Oneafter the other the nurses pass by, senior orjunior,allfindingthatlittlebitoftimetochatandmakemefeelhuman.Nottoomuchfuss,not ignored,I feelatall times theyget it justright.Thechangesofdressinggogently.Thesupportgettinginandoutofbedjustenough.OddsnippetsofconversationIrememberaboutwheretheyarefrom,whattheyhavedone.Daytwodawns(atlast).Thephysiocometh.A chance to get moving. Only a brief visitbut all themeans to get started. Hourly bedexercises, plus three times a day standingexercises.UptotheZimmerandhowtowalk,initiallywithhelp.Thefirstfewexercisesareagonising.Ican’tab/adductmyleg.Itreallyhurts.Persevere.BytheendofthedayIcando it – just. The standing ones aren’tmuchbetter. Mywifehad“lectured”meabout theimportanceofexercise.Iamnotoriouslylazyaboutthesethingsandhaveatendencyto“letnature take its course”. She’s right – again.Within2-3days Iamactuallyable to liftmyleg,unaided,fromfloorontobed.Progressisencouragement.Everybodyencourages.Thenurses,thephysios,Gillthehousekeeper.AsIshuffleupanddownthewardtryingtobuildupmomentum.GillisaGodsendasshepicksupournewspapersforus.Alwayscheerful,asareher staff, as theydelivermymealspromptly.

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Athome Ieat lunch (maybe)ataboutone totwoo’clock,anddinneratabouteight.LunchonSheppardis1200,and“supper”isat1700.BythetimetheyarriveIamstarving.JustwhenI’mfeelingrelaxed,alongcomesthephlebotomist.Bloodcountcheck,justtomakesure.Iabsolutelyhatehavingneedlesstuckinme!Isupposeitdoesn’treallyhurtthatmuch–it’sjustthethought.Wimp.I get chattingwith aman inB-bay, probablylate sixties. He had his hip on Mondayafternoon.Ideclaremyinterest.Wechat.ItseemsdistinctlypossiblethatinanotherageIanaesthetisedhimforhisprostate. Heseemsblownoverbythat.ByThursdaylunchtimeheannouncesproudlythatheisoffhome.There’snostoppingsome.ByThursdayIknowIamon themend,withonlyoccasional “obs” checks, and thenurseshave rightly moved on to more deservingcauses. I headoff down the corridors to getsome exercise, bumping into any number ofacquaintances.Upanddown,littletokeepmeinterestedandIcan’tgohomeuntiltomorrowbecause there’s no-one at home. Final visitfrommy friendly F2 – another blood check.Help.Isthisreallynecessary?Hehitsitfirsttime.

Friday lunchtime, a rather ludicrous trip in awheelchair down to the Duchess Buildingadmission bay, armed with my sticks,“Helpinghand”, and raised toilet seat! Ihope no-one spots me. It’s a rather bumpy,uncomfortable car journey home, and I amfeeling tense and vulnerable. I negotiate themyriadstepsaroundthehouse,dodgethedogs,andslumpintoachair.Madeit.What comments can I make about myexperience? I gained invaluable experienceaboutwhatapatientgoesthrough.Asdoctorswewanderonandoffthewards,withorwithoutourentourage,blissfullyconvincedthatwearethecentreofitall.Forthepatient,everythinggoesonholdwhenthedoctorsarrive.Wesayanddowhatisexpectedofus,thengetbackto“normal”whenthetrainpasses.Patientsgiveeachothersupport,hope,andencouragement.Somuchgoesoninawardthatwedoctorshaveno idea about. Sheppardward runs superblyefficiently.Clearlyeveryoneknowstheirjobsand they all, from the greatest to the lowest,knowtheirrolesandexecutethemeffectively.Myfinalconclusionfromitall?Acceptyourfate, trust the professionals, do what you’retold!

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I have found the single short article 1 thatshowshowprofoundlymedicineandmedicalpublishingchangedinmyprofessionallifetime.ThearticleisalettertotheEditoroftheBMJ(butthentheBritishMedicalJournal)and,yes,Editoriscapitalised.Theletterisaboutsurgeryfor peptic ulcer. Of the allowed 500words,andomittingthestarting“Sir”,finishing“Iam,etc”, and the references, theauthoruses424.Buthisfirsttwoparagraphsarenothingmorethananextendedthankyoutotheauthorofthearticlepromptingtheletter.“WeareallindebtedtoMrHaroldBurgeforhisarticle”, the author politely starts, “recordinghis experience with vagotomy and drainageprocedures…” The next 50 words repeatsomeofBurge’sconclusions, afterwhich thesecondparagraphspeaksof“pointsinmyown

experiencewhichmaybeworthrecording,asthey differ somewhat from the experience ofMrBurge”.Orrwritesofhis“smallseriesof50vagotomyandpyloroplastyoperations”,andof“myownseries of 1,900 operations for peptic ulcer”:1900operationsforpepticulcer!Thereisnoinformationaboutthepatientsortheirselection.Statementsaboutthemaresimplymade.But some thingsneverchange. On the samepageasthepdfversionoftheletterisaletterabout distinction awards. “Iwould predict”,writestheauthor,“thattherewouldbeaclearmajorityagainstthepresentposition.”

1 OrrI.Surgeryforpepticulcer.BMJ1964;2:382; doi:10.1136/bmj.2.5405.382-b

The Past is a foreign country

Dr neville goodman, retired consultant AnaesthetistBristol

Anaesthesia Points West Vol. 43 No. 1Personal View

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Poem

Leaving (Antigua 2010)

AndsuddenlyatourdoorinsunshinethistallEnglishmaninfadedjeans,tornattheedges,theseainhiseyes

Andapetitewifewhoworriesforhimandtriestoholditalltogether

NearHaiti,they’dsailedoveragreatcraterintheseabed,asiftothecentreoftheearth;theseaaboveitstrange,uneasy........

Onthatisland,withahundredthousanddead,theydarednotdockforfearofrefugees,terrorists.

Theidyll’sover,theCaribbeandream,thevillashecreatedoutofshells,coral,piecesofsky.Theyachtthey’dislandhoppedonIt’sallgottogo.

Somethinglikerusteatsatthemslowly....

robin forward

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Having established myself (by means ofrelentless self publicity) as something of anauthorityonwine,peopletendtohandmethelistinrestaurants.IacceptthetaskbutIknowittobesomethingofamixedblessing.Chooseincorrectlyandyourreputationisshot.Choosesafebutexpensiveandyou’reaknow-nothingwithmoremoneythansense.Picksomethingdelicious and inexpensive, however, and youcanbaskintheglowofajobwelldone.In the famously sociable Gloucesterdepartment,IwearthehatofSocialSecretary;itisathanklessjobbutthoseSPA’sdon’tjustearn themselves you know! As part of thisextended role I undertook the arduous taskofselectingthewinefortheChristmasParty.Accompaniedby Ian,a fellowoenophileandbon viveur, I threw myself whole-heartedlyinto the task. Wehadabudgetofaround£7aheadforwinesocateringforageneroustwothirds of a bottle per person (thirsty lot ourdepartment after a long year) that meant wecouldextendourselvesa littleand indulge insomequalitypurchases.Aninitialplanningmeetingata localvintnerrapidlycausedustocastasideourpreconceivedideas of Rioja for red and Chablis for whiteas several outstanding candidates presentedthemselves. Many consultations later, itwaswith some astonishment that I ended uphandingover thecreditcard foraPinotNoirand aViognier –both fromChile. Thoseofyoukindenoughtoreadmypreviousmusingswill know my fondness for the creamycharms of the divine V and my distaste fortheoverpricedditchwaterusuallyservedupasPinot.Viognierhaslongbeenmysecretotherlove. Theonlywine thatcouldconvinceme

thatRieslingisnotthequeenofwhitegrapesandperfectforalloccasions.ButfromChile?Veryunlikelytobepossessedofthepeachandapricotperfumeandsensuoustexturethatthevery best can prise from this reluctant star.Andyetitwaswonderful.Andcheap!MoresurprisingstillwasaPinotNoir,withinbudget, packing an intensity of fruit flavourthat fewcanmanage. Proper,dense,velvetywinewithlengthandfinesse.Ifonlymoreofitwaslikethis!CrowdswerepleasedbybothatthedinnerandIsetaboutsearchingforsimilarbargainsformyownenjoyment.Chile benefits from its unique geography. Itis a 3000 mile long corridor of a countrysandwichedbetweenthecoldoceantotheWestandthecoldmountainstotheEast.Thecapital,Santiago lies on a similar latitude to Beirut,whichistosaylowforwinegrowingandtheclimate,awayfromthecoast,isMediterranean.Therainfallvariesbetweenextremes. Tothenorth of the country lies theAtacamaDesertwhereithardlyeverrainsandintheSouth,ithardlystops.Thesunshinesalldayinmanyparts allowing for optimum ripeness, but thecoolinginfluencesstopitcookingthegrapes.So,youcanbasicallypicktheconditionsyouwantandplantvines.Toowarm,gouphillornearerthesea,toocold…..yougetthepicture.Addedtothisarediseasefreevinesand,atlast,externalinvestment.Traditionally Bordeaux varietals have beenbeingplanted.CabernetSauvignonandMerlotwith someMalbec. SemillonandSauvignonfor whites predominate but as we saw atChristmas, they are growing a wider varietyevery year with Rhone, Spanish and Italianstylesemergingallthetime.Forthemostpart,

The Wine column: cool Stuff from chile

Dr Tom Perris, consultant AnaesthetistGloucestershire Royal Hospital

Anaesthesia Points West Vol. 43 No. 1

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standardeasydrinkersarebeingturnedoutbutqualityisrising.Inarecentblindtasting,topChilean Merlots outperformed the legendaryChateaux Petrus. Whether this reflects theoutstandingwine ofChile or the over blownhype inFranceIcannotsay,nothavingbeeninvited to the tasting,butIcanvouchfor thefact thatmore andmore often, I am lookingto SouthAmerica for my drinking pleasure.ArgentinaandUruguay,nottomentionMexico(yesMexico!) are forgingaheadwithqualityrisingfasterthanprices.Presumably,likeeverywhereelse,they’llcatchonandthebargainswillgethardertofindbutfornow,fillyourboots!Howwrongcanyoubeforfiveorsixquid?

Perris’s PicksErrazurizWildFermentPinotNoir2008MajesticWinesAbout£11unlessyougetitonadeal(whichwedid–butit’sstillworthit)

Concha y Toro Winemaker’s Lot No33CasablancaViognier,2008MajesticWinesorTheWineSocietyAbout£8 (but againdiscounted atChristmastoaround£6)

Enjoy.

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crosswordDr Brian Perriss

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cartoonsKathy Jenner & Jason Trevitt

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Prizes and Bursaries

Details of all prizes, rules, and entry deadlines can be found at www.saswr.org.uk

The SASWr intersurgical Trainee Prize

Thisprizeof£1000isawardedannuallyattheNovemberScientificMeetingofthesociety.Entries/abstractsofupto2000wordsmaximumintheformofanessayorshortpaperonanytopicrelatedtoanaesthesiaandintensivecareshouldbesubmittedelectronicallyto theHonorarySecretaryoftheSociety(honsec@saswr.org.uk)by30thSeptembereachyear.Thismaybeoriginalresearch,areviewarticle,resultsofaparticularlyusefulaudit,ortheunveilingofanewanaesthetictechniqueorpieceofequipment–allsortsofentrieshavewoninthepast.WeareverygratefultoIntersurgicalfortheirsponsorshipoftheprize.Thebestthreeentries,aschosenbyapanelofjudges,willbepresentedattheSASWRmeetinginNovember,andtheprizeawardedatthatmeeting.Anyentrantswhodonotmaketheshortlistwillbeinvitedtodisplayaposteroftheirworkatthesamemeeting.

The ross Davis Adventure Bursary

Thisannualawardof£1000 ispresented inmemoryofDrRossDavisbyhis familyandfriendsto traineesofST3orabove from theWessex,PeninsulaorBristoldeaneries tosupport ‘excitingendeavoursinanaesthesia’.Furtherinformationincludingapplicationformsandrulescanbefoundatwww.rosswindsurf.co.ukandapplicationsshouldbedirectedtotheHonorarySecretaryofSASWR(honsec@saswr.org.uk)by1stMayeachyear.ThesuccessfulapplicantwillbeinvitedtoaccepttheirawardatthefollowingNovembermeetingofthesociety,althoughtheawardmaybereleasedbeforethen!

The feneley Travelling fellowship

Thisprize(usually£500)isawardedannuallytotraineesorconsultantstosupporta‘missionabroad’.

ApplicationsarewelcomedthroughouttheyearbytheHonorarySecretaryofSASWR.(honsec@

saswr.org.uk)

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notice to contributors

Allarticlesshouldbesentbyemailtotheeditor(seebelowforaddress).Scientificarticlesshouldbepreparedinaccordancewithuniformrequirementsformanuscriptssubmittedtobiomedicaljournals(British Medical Journal 1994; 308: 39-42) i.e.asusedbyAnaesthesia.Theymustbeaccompaniedbyaletterrequestingpublicationandsignedbyallauthors.Pleaseensurethatreferencesarecompleteandcorrectlypunctuatedintherequiredstyle.Theapprovedabbreviationswillbeusedforjournaltitles.Photographsshouldbesentasseparateattachments.

Thedeadlineforsubmissionsisusually10weeksbeforethemeetingofthesociety.

SubmissionofarticlestoAnaesthesiaPointsWestimpliestransferofcopyrighttotheSocietyofAnaesthetistsoftheSouthWesternRegion.Submissionswillbeacknowledgedonreceiptandnoticeofacceptance/rejection/needforcorrectionswillbesentaspromptlyaspossible.

editorDrFionaDonaldDepartmentofAnaesthesiaSouthmeadHospitalNorthBristolNHSTrustSouthmeadRoadBristolBS105NB01179595114fiona.donald@nbt.nhs.ukdonald_fiona@hotmail.com

Assistant editorDrVanessaPurdayDepartmentofAnaesthesiaRoyalDevonandExeterHospital(Wonford)BarrackRoadExeterDevonEX25DW01392402475Vanessa.purday@rdeft.nhs.uk

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