Strong Collaboration Drives Research

November 2019 Embracing clinical innovation in anaesthesia

Preparing for Curriculum 2020: a pilot project for novices

Tackling childhood obesity at preoperative level

Strong collaboration drives research

HSRC Annual Report

www.rcoa.ac.uk @RCoANews Bulletin | Issue 118 | November 2019 RCoA Events FEBRUARY Further information about all of our VOLUNTEER AS A CLINICAL CONTENT LEAD events can be found on our website. FPM Study days: Acute/in-hospital pain management – hot topics and www.rcoa.ac.uk/events updates [email protected] 3–4 February 2020 RCoA, London @RCoANews Airway Workshop 4 February 2020 RCoA, London Clinical Directors Meeting NOVEMBER 18 November 2019 DECEMBER Anaesthetists as Educators: RCoA,London Teaching and training in the Anaesthesia Research 2019 Updates in Anaesthesia, Critical workplace % 2–3 December 2019 % Care and Pain Management Leadership and Management: 10–11 February 2020 The Principle Hotel, York 4–6 November 2019 Working well in teams and RCoA, London making an impact The Studio, Birmingham Winter Symposium 20 November 2019 Patient Safety in Perioperative % 10–11 December 2019 UK Training in Emergency RCoA, London % Practice RCoA, London Airway Management (TEAM) 13 February 2020 7–8 November 2019 Anaesthetists as Educators: RCoA, London % Royal Infirmary of Edinburgh Anaesthetists’ Non-Technical JANUARY 2020 Skills (ANTS) Updates in Anaesthesia, Critical Would you like to get involved in planning an upcoming event? RCEM/RCoA Major Trauma 22 November 2019 Tracheostomy Masterclass % Care and Pain Management Study Day RCoA, London % 10 January 2020 25–27 February 2020 Do you have ideas for topical, relevant and diverse topics and speakers for a 13 November 2019 RCoA, London RCoA, London programme? etc venues Prospero House FPM LPMES Day 2019 28 November 2019 Primary FRCA Revision Course We are currently looking for volunteers to get involved as Clinical Content Leads Anaesthetists as Educators: RCoA, London 14–17 January 2020 RCoA,MARCH Londo for educational events throughout 2020. As a Clinical Content Lead you will % Teaching and Training in the RCoA, London work with the College to develop event content and themes to meet the needs of Introduction to leadership and Workplace FPM 12th Annual Meeting our members. This will involve suggesting topical, relevant and diverse speakers management: The essentials 14–15 November 2019 29 November 2019 GASagain (Giving Anaesthesia and chairs for the programme as well as supporting the event during the build-up, 3–4 March 2020 RCoA, London RCoA, London Safely Again) attending on the day and de-briefing to ensure event evolution. 15 January 2020 Mecure Sheffield, St Paul’s Hotel FULLY BOOKED Please email the events team at [email protected] for more information. Bradford Royal Infirmary Ethics and Law % Final FRCA Revision Course 11 March 2020 18–20 May 2020 20–24 January 2020 RCoA, London GASagain (Giving anaesthesia RCoA, London APRIL safely again) at Old Trafford, the Ultrasound Workshop 29 April 2020 Home of Manchester % 13 March 2020 After the final FRCA: Making the Anaesthetists as Educators: RCoA, London United RCoA, London most of training years 5 to 7 % Advanced educational supervision 3 April 2020 28 January 2020 Leadership and Management: The Studio, Birmingham MAY The Studio, Leeds % Personal Effectiveness SAVE 10% Co-badged with: 19 March 2020 Limited early bird places Cardiac Symposium Anaesthesia 2020 RCoA, London available – quote 23–24 April 2020 18–20 May 2020 EARLY10 Developing World Anaesthesia RCoA, London Old Trafford, Manchester when booking BOOK YOUR PLACE NOW 23 March 2020 RCoA, London

Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors Discounts available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Foundation Year Doctors % and Medical Students. See our website for details. % and Medical Students. See our website for details. | 1 Bulletin | Issue 118 | November 2019 Bulletin | Issue 118 | November 2019

The President’s View 4 News in brief 8 Contents Faculty of Pain Medicine (FPM) 14 From the editor Faculty of Intensive Care Medicine (FICM) 15 SAS and Specialty Doctors 16 Dr David Bogod Revalidation for anaesthetists 18 Saving the planet: can we Welcome to the November Bulletin. change our practice? 20

The Technology Strategy Back in the mists of the time, I was asked a question during a viva in my Final FRCA (as it then was) which went, Programme 22 as I recall: ‘Why was Dr Guedel riding a woman’s bicycle along Brighton sea front in 1943?’ Questions like these A reflection on reflection 24 used to mean either that you had already passed or that your performance to date had been so abysmal that all Fellowship ad eundem 26 hope was gone. In any event, I never found out any more about Dr Guedel’s obviously chequered life and career, Perioperative Journal Watch 28 but his airway lives on and, if Dr Harrop-Griffiths is right in his latest Soapbox article, it does so largely in the hands of trainees who like to slot it in as soon as the patient’s eyes close. Is there a relationship between the age of the Sprint National Anaesthesia Projects: out with the old… 30 anaesthetist and the number of Guedel airways he or she uses annually? Does anyone fancy doing the study? Guest Editorial Onwards and upwards My early trainee years were also marked by completely failed attempts to invent new and better kit. My The second PQIP annual report revolutionary coaxial, switchable Lack-Bain breathing circuit (‘ideal for both the spontaneously breathing and the finds great improvements – but Embracing clinical innovation ventilated patient’) was trumped by Dr Humphrey and his ‘ADE’ system (younger readers will have to look it up). still some challenges 32 And my brilliant insight that the addition of a third wavelength of light to the newly developed pulse oximeter Inspiration, ideas and insights – in anaesthesia would allow a beat-to-beat measure of haemoglobin to be displayed was totally ignored for about 10 years until making the NELA data talk 34 The Clinical Entrepreneur Training Scheme helping anaesthetists turn their it was introduced de novo by a Japanese manufacturer. It is therefore gratifying to read Dr Young’s guest editorial ideas into reality 36 NAP7: perioperative cardiac arrest about the successes of the Clinical Entrepreneur Training Scheme. If only this had been around in the 1980s, you Page 12 For (s)he’s a jolly good fellow… could now all be using the Bogod breathing system, and I could have a little place in the South of France. past, present, future…? 38 Anne Meaklim, a trainee from Northern Ireland, has gifted us a complex and philosophical piece about how The Children’s Acute Surgical Anaesthesia Associates Preparing for Curriculum Abdomen Programme 39 we might better manage ‘fragility’ in our professional development. She questions our reliance on ‘resilience’ – essentially the ability to take the hard knocks of life as a clinician without flinching, and instead proposes the and the Perioperative Care 2020: a pilot project for The quantitative/qualitative concept of ‘anti-fragility’. The ‘anti-fragile’ individual not only absorbs the slings and arrows of outrageous fortune Team novices conundrum 40 but also uses them to become more flexible and thus better able to adapt and bounce back from setbacks. Statutory regulation – fully realising the Our review process is teaching us Rethinking resilience 41 potential of anaesthesia associates how to shape the implementation of Anaesthetic Soapbox: In praise Philosophy being a topic rarely explored in the pages of the Bulletin, the College’s resident brainiac, Professor Page 4 Curriculum 2020 of the Guedel airway (not) 44 Jaideep Pandit, has kindly appended a commentary to Anne’s article which seeks to make it more comprehensible Page 48 Interhospital transfer training 46 to those of us who struggle with the metaphysical. I find it easier, when pushed to my limits, to resort to cliché, on Health Services Research Introducing foundation doctors the grounds that nothing can be so complex that it can’t be condensed into a motivational aphorism on the wall Centre (HSRC) Tackling childhood obesity to perioperative medicine 50 of a student’s bedroom. Thus, I am tearing down my metaphorical ‘Bloody but unbowed’ WE Henley poster, and at preoperative level replacing it, much to my own surprise, with Nietsche: ‘What does not kill me, makes me stronger’. HSRC share some of the work that Anaesthetic research group at has been going on and what is in the Three in ten children are obese, the Brighton Marathon 54 Be strong, readers, and prosper over the festive season! pipeline in its Annual Report however one project is showing us An insider’s view: being a remote that reducing the problem might all Page 29 educational supervisor 56 be in the assessment NIAA Research Grants 58 Page 52 As we were... 60 New to the College 62 Notices and adverts 64

Professor Ravi Mahajan President

In August, it was my pleasure to meet Irfan Mehmood, President of the Association of Anaesthesia Associates, to discuss the welcome news that the Government has asked the General Medical Council (GMC) to regulate anaesthesia associates (previously known as physicians’ assistant (anaesthesia) (PA (A)) across the UK.

Anaesthesia associates are invaluable members New models of care are evolving against a of the anaesthesia team in many UK hospitals. backdrop of these challenges. Ensuring multi- The College has long been campaigning for disciplinary teams have the right skills mix is central appropriate regulation of this group of the to an effective, sustainable, healthcare system – a healthcare workforce, and we are very pleased system that ensures patients receive the most that the Department of Health and Social Care appropriate care, at the most appropriate time has now heeded our calls. Regulation is essential and from the most appropriate person. for the future development of anaesthesia Hence, it has become necessary for us to see associates as an integral part of anaesthesia and whether, alongside the medical/clinical role perioperative teams across the UK. of an anaesthetist in deciding and overseeing appropriate anaesthetic management of a Perioperative care faces a number of challenges surgical patient, there is scope for certain in the NHS, from a steep rise in the elderly specific tasks and roles to be undertaken by an population and multimorbidity to downward appropriately trained, regulated and supervised financial pressures. The growing evidence that non-physician workforce. Anaesthesia a well co-ordinated, multiprofessional and associates, in some hospitals in the UK, already multidisciplinary approach to perioperative care fill this space nicely. can provide some solutions to these challenges demands that, as a specialty, we think innovatively. In this edition of President’s View, I celebrate the key role that anaesthesia associates are Over the past 10 years, demands on the playing, as part of perioperative care teams, anaesthetic workforce have increased in providing safe, accessible and high-quality immensely. In particular, anaesthetists are patient care. Statutory regulation will provide a The President’s View increasingly being required to spend more stronger quality assurance mechanism, allowing time in preoperative assessments and departments to use the specialist skills and preparation, dealing with intraoperative knowledge of anaesthesia associates even tasks and management, providing services more effectively in future. ANAESTHESIA ASSOCIATES AND outside operating theatres and participating in postoperative care. It is projected that Deliverers of perioperative care THE PERIOPERATIVE CARE TEAM a further 25-40 per cent expansion of The RCoA and Association of Anaesthetists has anaesthetic and intensive care service previously produced a document on the Scope provision will be required by 2033.3 of Practice for anaesthesia associates. In view of

the expanding demands on perioperative Supporting a sustainable procedures eg sedation for minor for doctors and Allied Health Professionals. It will also care teams, and the proposed regulation workforce procedures provide a guarantee of the necessary resources to underpin Bulletin by the GMC, we will now need to work the revalidation processes and fitness to practice machinery, of the Royal College of Anaesthetists Having worked with anaesthesia ■■ support for some ‘task’ elements of the together in defining a curriculum for ensuring public confidence in anaesthesia associates. associates in Nottingham University service delivery, eg vascular access Churchill House, 35 Red Lion Square, London WC1R 4SG the training of anaesthesia associates, Hospital NHS Trust, I have seen how, ■■ greater opportunities for anaesthetic 020 7092 1500 their assessment of the training and In turn, statutory regulation is a required precursor to when supervised appropriately, they trainees’ education while maintaining www.rcoa.ac.uk/bulletin | [email protected] their supervision and practice within any national growth, and essential to engender trust and make a valuable contribution towards patient safety @RCoANews multidisciplinary perioperative teams. confidence amongst employers that anaesthesia associates a sustainable anaesthetic workforce ■■ reduction in the service component of are clinically competent to realise the benefits they can bring /RoyalCollegeofAnaesthetists – increasing capacity, flexibility and trainee anaesthetists’ workload. to perioperative care. A defined route of entry – Registered Charity No 1013887 theatre efficiency. the Anaesthesia Associate Statutory regulation – better The new regulatory framework, underpinned by the GMC, Registered Charity in Scotland No SC037737 VAT Registration No GB 927 2364 18 Postgraduate Diploma By supporting the delivery of healthcare, national governance and will allow greater oversight of the scope of practise of There is a single defined route of entry anaesthesia associates can provide anaesthesia associates from the regulator, employers and accountability President Emma Stiby to the profession, through the 27-month a much required ‘headroom’ for professional bodies, including the RCoA, the Association of As the number of registered anaesthesia Ravi Mahajan SAS Member Anaesthesia Associate Postgraduate anaesthetists and trainee anaesthetists Anaesthesia Associates and the Association of Anaesthetists associates increases and they are Diploma, a course comprising 12 modules from certain task elements of their – and give greater guidance. Vice-Presidents Katie Samuel introduced to new NHS hospitals every which introduce the clinical practice work, thereby facilitating much desired Fiona Donald and Anaesthetists in Training year, they will help in meeting the pressures Following statutory regulation, the potential of the Mike Grocott Committee of anaesthesia, the use of anaesthetic service management and teaching on health care delivery. anaesthesia associate role in augmenting anaesthesia equipment, monitoring principles and opportunities. Editorial Board Carol Pellowe service provision, may be fully realised. relevant applied basic sciences. The announcement of statutory regulation David Bogod, Editor Lay Committee Although the data are still forthcoming, is an important step towards ensuring that Jaideep Pandit Gavin Dallas Entrants are graduates with a biomedical it is anticipated that increased capacity The future anaesthesia associates, under appropriate Council Member Head of Communications or biological science degree or to deliver perioperative care by Statutory regulation is an important step in supporting supervision, continue to develop and registered healthcare professionals anaesthesia associates will transform anaesthesia associates to become further integrated Krish Ramachandran Mandie Kelly provide high quality, safe care as part of a such as nurses or operating department perioperative care in a number of ways within the perioperative care team, and the College Council Member Website & Publications Officer multiprofessional team. Statutory regulation practitioners with at least three years such as: welcomes the news that the GMC will be the regulator will provide a standardised framework of Joanna Budd Anamika Trivedi clinical experience and/or degree for anaesthesia associates. ■■ preliminary work up and triage in governance and assurance across the UK Lead Regional Advisor Website & Publications Officer level studies. A portfolio of evidence is pre-admission clinics for the clinical practice and professional Anaesthesia collected demonstrating competence, We look forward to a continued close relationship with ■ conduct of anaesthesia associates, assessed by the local supervising ■ freeing up in-theatre consultant colleagues at the Association of Anaesthesia Associates, Sudhansu Pattnaik preventing unwarranted variation in the consultant and training centre staff. Local time for resolution of complex and Association of Anaesthetists as we engage with Lead College Tutor quality of education and training. performance monitoring through audit, perioperative problems the GMC, the Department of Health and Social Care, Health Education England and wider partners to ensure a Articles for submission, together with any declaration of interest, incident reporting and Mortality and ■■ faster response by medical teams for Regulation will also ensure that there statutory register is implemented as soon as possible. It is should be sent to the Editor via email to [email protected] Morbidity Meetings is an integral part of attendance to ‘outreach’ patients is one unified code of conduct for all anticipated that this will take 18-24 months. All contributions will receive an acknowledgement and anaesthetic departmental practice. ■■ less waiting for certain out-of-theatre anaesthesia associates, paralleling those the Editor reserves the right to edit articles for reasons of References space or clarity. 1 Department of Health and Social Care, The regulation of physician associates (PAs) and anaesthesia associates (AAs): The views and opinions expressed in the Bulletin are solely Written statement, 18 July 2018 (bit.ly/32twrfP). those of the individual authors. Adverts imply no form of 2 RCoA Medical Workforce Census, 2015. (bit.ly/RCoA2015Census). endorsement and neither do they represent the view of Anaesthesia associates can undertake some roles 3 CfWI In-depth review of Anaesthetics and Intensive Care Medicine. the Royal College of Anaesthetists.

© 2019 Bulletin of the Royal College of Anaesthetists traditionally only performed by anaesthetists, helping All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other to provide a more flexible workforce and increasing means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of the Royal College of Anaesthetists. patient access to the right care by the right person. ISSN (print): 2040-8846 Irfan Mehmood, President of the Association of Anaesthesia Associates ISSN (online): 2040-8854

NEWS IN BRIEF News and information from around the College

RCoA appoints Jonathan Joint statement on the Survey reveals National recognition for Dudley Brüün as new Chief Executive statutory regulation of extent and impact Group anaesthetic department Anaesthesia Associates of fatigue on The College welcomed news of the General Medical hospital consultants Council being named as the regulator for Anaesthesia Associates. We look forward to working with the government, the GMC and wider stakeholders to ensure a statutory register is implemented as soon as possible.

The College, Association of Anaesthetists and the Association of Anaesthesia Associates will work together to A survey on the scale and impact of ensure Anaesthesia Associates become further integrated out-of-hours working on consultant within the perioperative care team. Where Anaesthesia anaesthetists and intensivists has been Associates are employed, they are highly valued and published in the journal Anaesthesia. The The College is pleased to confirm the appointment of Jonathan contribute greatly to patient care. Many hospitals could joint campaign with the Association of Brüün as its new Chief Executive who will join in January 2020. realise benefits for their services by employing Anaesthesia Anaesthetists and FICM to Fight Fatigue Associates to meet their particular patient and service Jonathan is currently the Chief Executive of the British amongst anaesthetists is something the needs. Anaesthesia Associates do not replace their medical Pharmacological Society (BPS) where he has been College has long been committed to colleagues but, can complement service provision which responsible for their substantial growth in performance and and the survey demonstrated that fatigue may traditionally only have been provided by anaesthetists. This month the College was very pleased to present the anaesthetists at Dudley impact. Under Jonathan’s leadership, BPS membership has is having a large impact with 91 per cent Group NHS Foundation Trust with the prestigious Anaesthesia Clinical Services risen by over 20 per cent, while diversification of the Society’s of consultant doctors who responded Read the full statement at: bit.ly/2kIDkZo Accreditation (ACSA). The accreditation is richly deserved and demonstrates business portfolio has seen annual revenues also grow. experiencing work-related fatigue and their commitment to providing the best possible care for their patients. 50 per cent of them reporting this had Jonathan joined the BPS in 2009 as Head and then as a moderate or severe impact on health, Dudley is the first trust in the West Midlands to become accredited, and only Director of Communications. He was appointed CEO wellbeing, work and home life. It is also the 33rd in the UK. in June 2012 and has been responsible for delivering having an impact on safety with 45 per the vision, mission and strategy of BPS and its subsidiary cent of respondents admitting to either Patient engagement is a key focus of what we do as a medical Royal College companies. BPS represents over 4,000 members studying having a car accident or near miss when and the review team was particularly impressed by the integration of services and working on drug discovery, development and delivery commuting whilst fatigued, with 1 in 10 from doctors to support staff which developed and enhanced the quality of in industrial, academic and clinical sectors. of these as a consultant. Senior doctors care they provided across the hospital. The anaesthetic team also demonstrated do not feel they are being listened to an imaginative use of IT systems improving processes and the patient journey. in the workplace over their wellbeing As well as meeting the standards, the department demonstrated many areas of and health concerns, we need to see PQIP releases second annual report excellent innovative practice that have now been highlighted for sharing through changes in organisations including better Perioperative Quality Improvement Programme’s (PQIP) has released it’s second annual report. PQIP has continued to work the ACSA network. rest facilities and a change to working towards reducing the risk of complications after major surgery through ensuring that patients get the best possible care patterns. Improving working conditions ACSA is the College’s peer-reviewed scheme that promotes quality throughout their perioperative pathway. benefits both the workforce and patients improvement and the highest standards of anaesthetic service. To receive The report showed major outcomes are improving, as well as some key process measures; however, other processes, in and by working cross speciality and accreditation, departments are expected to demonstrate high standards in particular those that might require multidisciplinary engagement or structural changes are proving somewhat more difficult to gaining support from politicians we areas such as patient experience, patient safety and clinical leadership. The gather pace. Approximately 124 hospitals are now involved in PQIP – sign up at: www.pqip.org.uk hope the Fight Fatigue campaign will College’s website has all the information required for you to understand how encourage changes across the NHS. ACSA could benefit your anaesthetic department (www.rcoa.ac.uk/acsa). You can view the annual report at: https://pqip.org.uk/pages/ar2019 See bit.ly/34Os6F9 for more information.

NEWS IN BRIEF News and information from around the College

Response to the Prevention Green Book now for Anaesthesia Research 2019 government agreeing to Paper ‘Advancing place anaesthesia on the our health: shortage occupation list prevention in the 2020s’ First speakers announced The government has published its Green Paper ‘Advancing our health: prevention The programme is well under way for the third edition of in the 2020s’ (bit.ly/2k0TWva). In recent the College’s flagship conference Anaesthesia 2020. The years the NHS has moved away from There is still time to book your place at ‘Anaesthesia Research 2019’, a brand new conference is taking place on 18–20 May 2020 in Manchester. prevention to instead focus its efforts on two-day event to be held at The Principal Hotel in York from 2–3 December 2019. We have teamed up with the College of Anaesthetists of immediate, acute demand – this Green This is aimed at being a new flagship event in UK academic anaesthesia. Meeting Ireland and the Hong Kong College of Anaesthesiologists to Paper is a chance to rebalance this and partners include the Anaesthetic Research Society/BJA Research Forum, the invite internationally renowned speakers to this event. return the NHS from an ‘illness’ to a ‘wellness’ service. Health Services Research Centre, the National Institute of Academic Anaesthesia, Professor Gerard Curley, Professor of Anaesthesia and the Perioperative Medicine Clinical Trials Network, the Research and Audit Critical Care at Royal College of Surgeons in Ireland The College looks forward to Federation of Trainees, and the RCoA. In 2013, Professor Curley was appointed Assistant Professor of supporting the government in its efforts to deliver greater emphasis on the There will also be a poster display for trainees undertaking research relevant to the The government agreeing to implement the Migration Anaesthesia and assumed the role of clinican/scientist at St. role of secondary care providers in work of these partners including basic science and translational research, clinical Advisory Committee’s proposal that all medical Michael’s Hospital/Keenan Research Centre for Biomedical population health and prevention. studies, clinical trials and trial proposals, and health services research. practitioners be added to the shortage occupation list was Science. Professor Curley returned to Ireland in 2016 as the head of Anaesthesia at RCSI in Beaumont Hospital. a welcome step forward. We welcome the government’s The single day rate is £87.50, or £175 for both days, with reduced rates for trainees, ambitious targets to end smoking AHPs and QuARCs. 10 CPF points are anticipated. To book your place, visit Overall, 75 per cent of departments across the UK have Professor Michael Irwin, Daniel CK Yu Professor and Head, and halve childhood obesity by bit.ly/RCoAResearch2019 at least one unfilled consultant anaesthetist post. This Department of Anaesthesiology, University of Hong Kong 2030. If government is to reach its represents a combined total of 411 unfilled consultant Professor Irwin has published over 260 articles in peer- aim of boosting life expectancy and posts or a 6.9 per cent gap across the UK; a 57 per cent reviewed scientific journals and is a regular invited journal decreasing health inequality, it needs increase since 2015. reviewer. He is an editor of numerous publications including to go further than individual policies, SAFE Anaesthesia and the Hong Kong Medical Journal. His research SALG-BIDMC Scholars ANAESTHESIA LIAISON GROUP We know that 30 per cent of our members received interests include intravenous anaesthesia, pharmacology, but work to embed prevention in The Safe Anaesthesia Liaison Group has announced their Primary Medical Qualification from outside the UK, enhanced recovery and organ preconditioning. system-wide measures. This will the second round of its programme of fellowships for therefore the College is very happy to see the removal of facilitate greater collaboration between anaesthetists interested in patient safety. recruitment barriers including the resident labour market A limited number of early bird tickets are available now, care settings. test and minimum income threshold. so book your place today to enjoy these two speakers In collaboration with the College and the Association of Anaesthetists, the Safe as well as many others. We look forward to contributing to the Anaesthesia Liaison Group (SALG) is offering a unique programme of formal The College has previously called for significant consultation and to seeing the truly training through Harvard Medical School that aims to develop international www.rcoa.ac.uk/anaesthesia investment into training so the UK can become self- cohesive, preventative and people- expertise in perioperative quality and safety. sufficient in doctors by 2025. However, growing a focused system outlined in NHS domestic workforce will require time to develop. In the Co-badged with: England’s Long Term Plan. Please note at least Steps 1 and 2 of the United States Medical Licensing Examination interim, it is therefore essential that the NHS be able to are essential. The closing date for applications will be Friday 10 January 2020, with recruit talent from abroad to fill rota gaps and maintain interviews at the end of January 2020. adequate staffing levels. Further details of the programme are available here: bit.ly/2Xyqbj1

Little Journey TeamScreen Dr Christopher Evans, PhD student, Dr Hannah Lonsdale, Consultant Anaesthetist, University College London Sheffield Children’s Hospital

Having witnessed the anxiety and distress experienced by Think back to some of the crash calls you attended as a junior children undergoing anaesthesia, I have spent the past few doctor. How would you describe them? Chaotic? Stressful? years creating a series of innovations designed to enrich Did you ever count adrenaline syringes to figure out the total children’s experience of hospital and improve physical and number of CPR cycles? We know that recall of life-support mental outcomes following surgery. In the UK, approximately guidelines and awareness of time-blur under pressure. 600,000 children each year undergo elective diagnostic Currently the best assistance most teams have are laminated and therapeutic procedures, with 50–75 per cent of them paper protocols, whiteboards for calculations, and freehand experiencing significant anxiety during their hospital visit. pen-and-paper documentation. National audit data is also Short-term implications, such as delayed recovery, increased often collected on paper proformas and then inputted manually pharmacological agent requirements, and unplanned to computer. ‘TeamScreen’ offers a comprehensive support admissions, as well as long-term regressive behavioural solution for resuscitation in the form of a large visual dashboard changes, mean that perioperative anxiety is a modifiable controlled by a tablet computer. The whole team can see variable that can directly alter quality of recovery. With the interactive treatment guidelines, prompts, timers, treatment huge variation in the preparation of children for surgery in tracking, and paediatric calculations when needed. After the the UK – often due to staff-costs and time commitments, event, TeamScreen provides automated documentation upload effective tailored psychological preparation can be to the Electronic Patient Record and feedback for the team to challenging to achieve. The solution, ‘Little Journey’, is an Dr Peter Young learn. Customisable protocols for any acute medical condition interactive and engaging smartphone application designed Consultant Anaesthetist, Queen Elizabeth Hospital, Kings Lynn can be added, such as for management of status epilepticus for use by children and their parents in the comfort and Mentor, Clinical Entrepreneur Programme and acute asthma. Digitally collected audit and research data safety of their own home. Co-designed with healthcare will be automatically submitted to national projects, and in professionals, children and parents, the app enables children time will reach the scale of ‘Big Data’. This will allow machine to undergo a virtual reality tour of the hospital, play games learning to give us new insights into the optimal treatment in a and watch child-narrated relaxation animations – all designed Guest Editorial traditionally challenging research area. to help them understand the process and experience of coming to hospital. For parents, tailored information is drip Thanks to a €50,000 Phase I grant from the European fed over the whole perioperative period, with checklists, Institute of Innovation and Technology, we have developed EMBRACING CLINICAL INNOVATION notifications and nudges to help them get ready. To date, the TeamScreen as a functional prototype. Using simulation, we app has been tailored for more than 30 hospitals, used in 24 have tested and improved the technology. Advanced Life countries and had nearly 100,000 views of its animations. Support providers reported that TeamScreen gave them IN ANAESTHESIA Creating a sound evidence base for new innovations like feelings of reassurance and a sense of safety and support, this can be challenging though, and so, as part of a PhD at describing it as ‘like SatNav for resus’. The Clinical Entrepreneur Training Scheme is now on a fourth intake. With RCoA University College London supervised by Professor Ramani We are now developing a larger funding bid with the support, the scheme helps clinicians who are developing and championing their Moonesinghe, I am performing a multicentre randomised Resuscitation Council (UK), the Advanced Life Support Group controlled trial to assess the effectiveness of the app at and the NIHR Children’s and Young People’s MedTech innovations alongside their day job. Anaesthetists are well represented on the reducing anxiety before surgery. This is supported by the Collaboration to take TeamScreen through medical device programme, perhaps reflecting the tradition of innovation and the wide scope NIHR and the ‘Research for patient benefit’ scheme. regulation and into clinical use. of our specialty.

Clinical innovation in the NHS is not technology adoption lifecycle describes entrepreneurs, thereby facilitating the easy, and requires individual sacrifice, the acceptance of any new innovation culture of innovation in our specialty. dedication, and the resilience to cope as taking on a normal distribution, Not all innovations will succeed, and all with repeated failures and delays. with early adopters at one end and will eventually be overtaken by newer Implementation and adoption by the laggards at the other. Each of us lies innovations, but adoption must begin to NHS at the end of the long and arduous somewhere within this behavioural provide an opportunity for innovation to innovation pathway is commonly quoted curve, and can help by shifting from thrive. In this article we celebrate two of as causing a further 17-year delay. The laggard towards early adopter for our our innovators.

Dr Douglas Natusch Dr Rhian Lewis Torbay Hospital, Ysbyty Gwynedd, Bangor Torquay, Devon Clinical Lead, e-PAIN Clinical Lead, e-PAIN

Faculty of Pain Medicine (FPM) e-PAIN… new format… new Dr Peter Macnaughton Chair, FICM Professional Standards Committee

content… looking good?

2019 sees the launch of two revised e-PAIN modules on the new ‘Adapt’ Faculty of Intensive Care Medicine (FICM) platform. We are confident that you will be impressed! It converts e-PAIN to an up-to-date format which is engaging and accessible. It is ideal for a mobile platform – vital in today’s world of learning, offering versatile options for Update from Professional reading and revising. The most frequently used module, Affairs and Safety Committee Acute Pain, was the first to be updated, with excellent work undertaken by This committee has replaced the Joint Standards Committee, which in Jane Quinlan’s team in Oxford. This recent years had met as a joint committee with the Intensive Care Society update will be of great value to many colleagues, and we hope it will pique Standards, Safety and Quality Committee. The remit of the new committee their interest enough to encourage them includes professional practice standards and guidance, revalidation, patient to work through other modules. safety, and quality improvement. The revised module was launched The main focus of the committee has guidelines. Individual chapters relating to a high-quality service within this at May’s British Pain Society Annual been the production of Guidelines for the provision of support for each of the challenging environment. Scientific Meeting with a vote of thanks the Provision of Intensive Care Services main organ systems have replaced the The role of a document such as GPICS to Jane Quinlan and her team. We (GPICS) Edition 2, published at the previous clinical sections. Any relevant, Dr Rhian Lewis presenting to Dr Jane Quinlan is to improve the standards of care that also played our e-PAIN promotional end of June (bit.ly/34f8tWo). GPICS is high-quality, evidence-based guidelines critically ill patients receive and to reduce video, aimed at online advertising via the definitive reference source for the produced by other professional bodies geographical variation. GPICS is written social media https://player.vimeo.com/ Revision of Treatments and Therapies Hopefully, you will have seen tweets from planning, commissioning and delivery are signposted within these chapters. to assist and support units in developing video/336325214 (Dr Roger Knaggs and his team in our communications group, who are doing of adult critical care services in the UK. A number of new chapters relating their services so that patient care is of Nottingham) is progressing well, as is a wonderful promotional role cascading The second edition has been produced to service delivery, including those The second module to be completed is the highest quality. All units will find that Introducing Pain Management (Dr Lyn information via social media (#epain_elfh). following wide consultation both with on capacity management, focused there will be some aspects of GPICS the Musculoskeletal Pain module, by Gail Margetts and her team in Torquay). It the key stakeholder organisations and ultrasound and serious infection Have you had a look? Are we succeeding that they do not currently meet, and we Snowden and her team in Keele. This vital is surprising how quickly information through an open public survey. outbreak, have been added. There in our aim of providing up-to-date hope that they will use these gaps as a module is the bread and butter of most becomes out of date; the opioid sessions, is also a new chapter addressing the information in attractive bite-sized The second edition focuses on service driver and focus of where to develop clinics, and will be formally launched in particular, will ensure that we reflect particular issues for remote and rural pieces? Whatever your views, we’d love delivery, quality, and safety, with less and enhance their local service for the at the Pain Management Programme most recent guidelines. Other modules units that provides guidance for ensuring to hear from you email [email protected]. a sustainable solution to maintaining conference in September. are scheduled for updates soon. emphasis on specific clinical practice benefit of patient care.

Dr Robert Fleming Specialty Doctor in Anaesthesia, Nottingham University Hospitals NHS Trust

SAS and Specialty Doctors DIVINE COMEDY: experiences of taking the Final FRCA exams as a specialty doctor

In my last article for the Bulletin, I described my career in the manner of a local courses run for the trainees and often provide excellent model answers. circles of hell, somewhere in the eighth children’s story. The literary references continue here, but, in keeping with the if you can access these it is very useful. While the syllabus is broad, the College circle lies a space for the ‘Imposters’, If you aren’t sure where to start, your question bank is finite and you may be imprisoned in a hell of their own creation subject matter, you may identify a few darker themes in this one. department’s College tutor should be lucky enough to see questions in your where they endlessly try to learn the able to point you in the right direction. exam that you have answered in your whole syllabus of the Final FRCA. There were a variety of reasons why I be crossed and ferrymen to be paid. For exams were more than eight years ago preparation. The more you prepare the I took the Final SOE exam in June, only decided to leave specialty training, but example, the exam regulations state that already, I was in effect given 18 months For all components, practising technique luckier you will become. not having to take further exams was the Primary FRCA is only valid for seven to complete the Final exams. Each is as important as learning individual weeks before my 10-year deadline. After more of a perk of my decision than a years, after which time the College can component is only held twice a year, so topics. The syllabus is so vast that during I tried to find ways of doing small a short wait in purgatory while the results reason for it. In fact, I had a feeling of ask you to retake it in order to progress my number of attempts was very limited. the exam you will inevitably encounter amounts of revision each day, even when were finalised, I discovered I had passed. unfinished business when it came to to the Final. Having planned to attempt This sharpened my focus somewhat. questions for which you have not working. Without endorsing any given I would like to take this opportunity to the FRCA. I was also aware that if I ever the Final exams again when my children prepared. Your ability to deal with this brand, I listened to educational podcasts thank all of those who supported me. In order to prepare, the first step was decided I wanted to apply for specialist were at school, when the time came I and still get marks is an essential part during my commute and used an app to This includes the trainees who let me to tell people that I was intending to registration via CESR I would need to discovered I was ineligible to do so. of passing each exam. Try to be broad do MCQs and SBAs when time allowed. gate-crash their teaching, the colleagues do the exam. While keeping it quiet complete this or an equivalent test of in your learning rather than delving Doing this I encountered several topics who quizzed me without making me Fortunately, these regulations are not may save on embarrassment if you knowledge. too deeply into any specific topic. and questions that came up in my actual feel too silly, and my friends and family, absolute. Colleges have flexibility to be are unsuccessful, help from your There are lots of sources of historical exams. It is important to find ways of who coped admirably with my absence To anyone thinking of taking any more lenient if they find it appropriate. colleagues is vital to your success. If questions, including all the recent revising that work for you. from social occasions. You’ve all been postgraduate exam as a specialty doctor, If you are initially denied entrance, you nothing else, being frequently asked written papers published on the College wonderful. Another hurdle to overcome in your I would urge you to read the exam’s may need to keep asking until you find how your preparation is going is a good website. Looking through these will preparation may be a drop in your eligibility criteria when planning for the correct head of the multi-headed motivator. I also found I worked better allow you to identify topics that recur confidence. I found that as the exams got your future. As with all good mythology dog on guard. After several emails over with a little healthy competition, and and to hone your technique. I found closer I felt less ready, and I suspect this is about mortals entering Hades, there are several months, my Primary FRCA validity engaging with the local trainees was that the BJA educational supplements accepted routes to take, various rivers to was extended to 10 years. As my Primary also very motivating. It is likely there are common. In the descent through the nine

The Royal College of Anaesthetists has developed a toolkit that offers patients the information they need to prepare for surgery, including the Chris Kennedy important steps they can take to improve health and speed up RCoA CPD and Revalidation recovery after an operation. Coordinator The Fitter Better Sooner toolkit consists of:

Revalidation for anaesthetists ■■ one main leaflet on preparing for surgery ■■ six specific leaflets on preparing for some of the most common

surgical procedures Enhanced functionality with CPD ■■ an animation which can be shown on tablets, smart phones, laptops and TVs. in the Lifelong Learning platform You can view the toolkit here: www.rcoa.ac.uk/fitterbettersooner We have also created printable posters, flyers and stickers to help you signpost patients to the One of the aims in the College Strategic Plan 2018–2021 is the completion of toolkit. The animation can be shown on TVs in waiting areas. You can find all these additional the Lifelong Learning platform to support members throughout their career resources and instructions on how to download the animation in MP4 format on our website and meet their needs for revalidation, and the final stage has now been here: bit.ly/RCoA-FBSresources delivered with the incorporation of CPD functionality. Please share this toolkit with colleagues in both primary and secondary care settings. In addition to delivering a completely number of applicable CPD credits report in the new system is fully joined-up system including access to and the attached skills customisable, and the user can filter the Logbook, and a system which is fully ■■ additional mapping and reporting by the start and end date which will responsive to mobile devices, some of – based on stakeholder feedback, all then populate the PDF. the new enhancements, when compared CPD activities and events (including CPD access in the Lifelong Learning with the former CPD Online Diary, applications for CPD approval) can platform (via the ‘Learning’ tab) will be include the following: be mapped and reported on against available for all users of the CPD Online It has been shown both the Good Medical Practice Diary, and anaesthetist-in-training users ■■ adding ‘realtime reflection’ during Domains and the Standards for of the Lifelong Learning platform will be that people who attendance at a CPD-approved Medical Educators event – while the CPD Online Diary notified when they become eligible to ■■ assigning more than one personal improve their lifestyle only allowed reflection to be added use CPD features. activity to a CPD-approved event once an event had concluded, the – in the new system, users can While the CPD Online Diary will remain in the run up to Lifelong Learning platform allows associate more than one CPD activity available until the end of August 2020, users to easily edit and incrementally against a CPD-approved event. This is we encourage all users to move over to surgery are much add/save to their reflections particularly useful where the user has the Lifelong Learning platform as soon ■■ amending information about been involved both as a delegate and as possible to benefit from the improved more likely to keep attendance at a CPD-approved a member of the faculty functionality. Further information, event – in the Lifelong Learning ■■ the CPD activity report – where the including YouTube video guides, is up these changes platform the user has full editorial CPD Online Diary required users to available on the College website at control over the attributes associated specify their Cycle 1 start date upon www.rcoa.ac.uk/lifelong-learning/news- after surgery. with a CPD-approved event – eg, the initial registration, the CPD activity and-updates.

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Bulletin | Issue 118 | November 2019 Bulletin | Issue 118 | November 2019

This summer has seen a surge in dire warnings about climate catastrophe Carol Pellowe and the end of life on earth as we know it. As we are commended for a Chair, RCoA Lay Committee significant reduction in the use of plastic bags when shopping, it seems a small step in the light of the fires raging in Siberia, and the events of this weekend when the inhabitants of Whaley Bridge are moving out due to a major flood alert. The latter story is very significant for me, as I grew up in SAVING THE PLANET: CAN WE a neighbouring village and know the area well. In fact, my father learned to sail on the Toddbrook reservoir.

We are all encouraged to do our bit especially the Sustainability Strategy has always been available to people CHANGE OUR PRACTICE? 1 for the planet by recycling, upcycling, 2019-2022. This strategy aims for a not able to attend, the move to and thinking carefully about our reduction in carbon footprint by raising holding a meeting entirely by Skype is resources. This got me thinking about and discussing the issue in education beginning to take effect. I appreciate our practice in hospitals in an age and training events and by measuring the savings in time, travel and hotel when single-use, disposable materials College business performance. As many expenses, but for me the change are paramount in safe care. This is trusts sign up for ACSA, this is an ideal is difficult. My mind wanders, the particularly so in operating theatres, opportunity to share our vision and discussion is stilted, especially if you but can we make changes without discuss their efforts. Although it features cannot see all contributors online, and endangering patients and staff? in the strategy, I have not experienced I am not convinced that the calibre As a co-author of the original Epic it in an ACSA visit, but I intend to of discussion is as good as it is when guidelines for preventing healthcare remember to do so in the future. face-to-face. associated infections in acute care One of the major changes for College settings (now in its third edition), I feel One of my reasons for retiring when business has been the decision to ambivalent about advocating the use I did was the proposal to mark all distribute Council papers by email of gloves, which in a 24-hour period assignments online (except PhD and only provide paper copies on must produce a huge amount of theses). I admire anyone who can waste. Although I could not support request. Given that nearly all members check references and appendices no use of gloves, I do wonder if we are use computers, I think this is the right against text on screen! I think this harming the planet at the same time as decision. The downside of this decision means I am a dinosaur! Fair enough, protecting the patient? can be that members may not engage as fully as they might in the discussion, I accept my position. I am very adept In addition to this, if we consider preferring to answer emails instead. at making, mending and making do. I intravenous lines, oxygen masks and I remain one of the few that prefers grow my own vegetables and recycle tubing, syringes, cannulas, three-way paper copies for anything important. everything I can. I just hate doing taps, and urinary catheters, plastic in However, even I, in preparation everything on screen. its many forms is a major aspect of for meetings, have read all the our practice. Have we gone too far or attachments in advance and can print Now I must wander up the garden to the is there an opportunity to re-evaluate the ones I need. compost heap with my shredded paper! and change? The second change to College Reference The College has taken climate business has been the increase in the 1 Sustainability Strategy 2019–2022. protection to heart with its policies, use of Skype in meetings. Although it RCoA 2019 (bit.ly/RCoASustainability).

Aaron Woods RCoA TSP Director The Technology Strategy Programme At the time of writing it is mid-summer, and while we are in the latter stages of the Technology Programme, the heat is on still with lots running in parallel and coming to fruition soon. Our people are very busy releasing the new CPD Diary, designing our new membership system and preparing to launch the new website, to name but a few. Work on our new website continues across the College, with ‘go-live’ scheduled towards the end of this year. We are collaborating with various external suppliers and teams across the College, with much appreciated support from College fellows and members.

So a lot still to come, but this is a good moment to look back at what the programme has so far delivered for the College and our membership. Below is a summary of the six workstreams and the various initiatives within them completed to date, and of what is yet to come. Delivered so far: Workstream Project What is it?

Lifelong Learning e-Portfolio The Trainee aspect of the Lifelong Learning platform Logbook The clinical logbook aspect of the Lifelong Learning platform And going live over late 2019/early 2020: Events and Exams booking system The EventsForce system for events and exams booking, which replaced Online Services Workstream Project What is it? Engagement and Webcasting System An upgrade to the hosting and user interface of our member-facing webcast system Website Our new College website for members and the wider public Public Facing Website Specification A research piece for how our new website(s) should work for different types of users, Engagement and and for its structure and design style Public Facing Member Portal New member portal for accessing learning systems and updating your information Infrastructure Exchange Migration The move of College email systems being hosted internally over to Office 365 in the ACSA Portal An ACSA registration and management tool for participating trusts Cloud Single Sign-On Automatic login to learning and events/exams booking systems from within the Member Unified Communications Implementing Skype for Business as our new combined phone system, tele/video Portal conferencing and instant messaging platform Exams Management A new system to develop questions, public exams, and, in time, the taking of exams Servers – Cascade Migration Migration of our Human Resources system from being hosted inside the College to Lifelong Learning electronically supplier hosting and access via the web CPD Diary The Continuing Professional Development Diary aspect of the Lifelong Learning platform Document Collaboration Implementation of the new SharePoint collaboration platform for sharing documents securely via the web to external contacts Internal Applications Finance System The new finance system for running the accounts, processing payments and managing Network Improvement A refresh of the underlying cables and junction boxes at the College, over which all expenses our IT systems and data run CRM System Our new membership management system for handling subscriptions, communications Technology Technology Assurance Group An externally chaired strategic group, formally reviewing and endorsing College and training details Governance technology plans IT Processes Embedding the industry standard ITIL process for running technology services – a So we are not footloose and free yet, but the programme team have done and continue to do a great job in delivering each Gold Guide for IT if you like initiative on time and within budget. That latter point in particular is an important one – we need to demonstrate to you, our Change Advisory Board An internal group formally controlling all changes to the College IT estate and so membership, that we are spending wisely and avoiding the danger zone of spiralling project costs which blight so many large, reducing errors and downtime complex technology initiatives. I am pleased and proud of the team in confirming that the £2.4 million Technology Strategy ITSM System A service management system to collect and prioritise all IT requests in one place, Programme remains on track for completion within budget as planned. and to communicate progress with those raising them For more information on CPD head to Chris Kennedy’s article on page 18. Architecture Architecture A College wide design for how all processes, applications, data and underlying infrastructure will work together as a whole

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Bulletin | Issue 118 | November 2019 Bulletin | Issue 118 | November 2019

What is the guidance? supervisors can then employ techniques The GMC guidance: ten key points on like the Gibbs cycle to help trainees The Reflective Practice Toolkit highlights being a reflective practitioner2 techniques that encourage the reflector further develop reflections, improving to think about the event and the the depth of thinking and the learning 1 Reflection is personal and there associated feelings, and to conclude with opportunity. is no one way to reflect. A variety an action plan or learning point during of tools are available to support structured thinking that help to the evaluation phase. The toolkit includes The reflective future focus on the quality of reflections. reflective templates and examples of Reflection can be a powerful tool reflections using the following methods – allowing individuals ‘to examine their 2 Having time to reflect on both previous beliefs about their practice’. positive and negative experiences 1 Schon et al (1983) We can all learn that things can be – and being supported to reflect a What were you thinking at the time? done differently, and, ‘by continuously – is important for individual b What influenced your thinking? evaluating previously held beliefs and wellbeing and development. Society for Education in Anaesthesia (UK) c Reflection on action. assumptions, learning occurs and practice 3 Group reflection often leads to d What is your thinking about the develops’.3 Reflections will remain ideas or actions that can improve event now? fundamental to continuing professional patient care. A REFLECTION ON 2 What? Why? How? development. Having a framework helps guide the reflection, but it is important 4 The healthcare team should have 3 Rolfe et al (2001) that reflections are carefully anonymised, opportunities to reflect and discuss a What? – description of event. and are not a description of events openly and honestly what has REFLECTION b So what? but focused on the learning gained. happened when things go wrong. c Now what? Importantly, all doctors should be aware 5 A reflective note does not need 4 Gibbs cycle (1988) that, while reflections will not be asked to capture full details of an for in GMC investigations, they may be a Description – what happened. experience. It should capture required in court. Dr Laura Dyal Dr Peeyush Kumar b Feelings – what you were thinking/ learning outcomes and future plans. ST6 Anaesthetics, Consultant Anaesthetist, feeling. References 6 Reflection should not substitute University Hospital University Hospital Coventry, c Evaluation – what was good and bad about the experience. 1 Reflective Practice Toolkit. Academy of or override other processes that Coventry Secretary, Society for Education Medical Royal Colleges/COPMeD, 2018; p.2 are necessary to record, escalate d Analysis. in Anaesthesia (UK) (bit.ly/34iIHAw). or discuss significant events and e Conclusion. 2 The Reflective Practitioner. General Medical serious incidents. f Action plan. Council, 2018; p.3 (bit.ly/34hCZin). 7 When keeping a note, The Schon or Rolfe templates are often 3 Reflective Practice Toolkit; 2018; ibid. As doctors, we are continually involved in professional development and use the information should be used by trainees to reflect and learn anonymised as far as possible. reflection as an essential part of this process. Reflection provides benefit to from their experiences. Educational 8 The GMC does not ask a doctor us, our patients, and our teams. However, are medical professionals getting to provide their reflective notes the most from their reflective practice, and are they aware of the guidance Figure 1 Reflective in order to investigate a concern Organisation and teams practice: an overview1 reﬂect on the quality about them. They can choose to of their systems offer them as evidence of insight available to do so? Lessons are learned and changes made into their practice. continued development and, ultimately, Practice Toolkit with examples and A need for guidance? 9 Reflective notes can currently be The 2010 Royal College of Anaesthetists to safer patient care. However, following templates, giving guidance on how Safer Safer required by a court. They should systems culture curriculum includes several domains for recent controversial cases, including best to write and record reflections. Better focus on the learning rather than patient reflection, requiring trainees to commit to the ‘Bawa Garba’ case, guidance was Subsequently, the General Medical care a full discussion of the case or Council collaborated with the Academy situation. Factual details should be ‘regular reflection on their own standards needed regarding doctors’ records of their Leadership and Individual healthcare education professionals reﬂect recorded elsewhere. of medical practice’. The Gold Guide 7th reflective practice and the potential use of of Medical Royal Colleges, the UK on the quality of Safer their work Conference of Post Graduate Medical professionals 10 Tutors, supervisors, appraisers Edition 2018 for postgraduate training also them in court proceedings. Lessons are learned and changes highlights the importance of self-reflection Deans, and the Medical Schools Council made and employers should support and its involvement in professional In August 2018, the Academy of Medical to produce the latest guidance, The time and space for individual and group reflection. development. Reflection is integral to Royal Colleges produced a Reflective Reflective Practitioner, in September 2018.

Professor Robert Sneyd Emeritus Professor, Faculty of Medicine and Dentistry, University of Plymouth

Dr Kirstin May Chair of RCoA Nominations Committee, Horton General Hospital, Banbury

person’, and be able to demonstrate ■■ the equivalent for pain or intensive should be that the assessor believes that they have furthered the interests care medicine (faculty tutor) (from the evidence provided) that ‘on the of the College. Inevitably, the latter is balance of probabilities’ the applicant FELLOWSHIP AD EUNDEM ■■ regularly lecturing at College CPD subjective. To assist potential applicants events or courses with good feedback will, over the next few years, meaningfully and their assessors, the College has engage with the College and its aims in a Have you looked in the College Bulletin or in the minutes of our Council ■■ other service to the College. meetings and wondered what a ‘fellowship ad eundem’ is? Professor Rob published guidance. While the guidance sustained and useful manner, or that they does not form part of the regulations These examples are not intended to be are already doing so. Sneyd (past chair of the College Nominations Committee) explains… it aims to assist individuals considering exclusive, and in some cases applicants So, does this sound like you? Perhaps submitting an application and in turn may be ‘on the cusp’ of some of these you have a colleague for whom it may those who will assess it. roles. Most fellows of the Royal College of (bit.ly/RCoAHonoursAwardsPrizes) individual and the College and reflects a be appropriate. In either case please Anaesthetists have achieved this status by and, after an administrative check, two-way commitment. The objective of the selection process External markers of above-average have a look at the website at bit.ly/ examination. Fellowship ad eundem is an their application is considered by the is to identify and support individuals contribution include participation RCoAHonoursAwardsPrizes, read the alternative track available to doctors who This fellowship is open to doctors Nominations Committee, who may who are furthering, or are beginning in regional, national or international guidance, fill in the application form and may have trained abroad or achieved practising in anaesthesia, critical care or recommend it to the College Council for to further, the interests of the College. societies, national NHS roles, etc. These get it submitted! alternative qualifications. Recipients pain medicine in the UK who do not hold approval. Successful applicants attend Typically, a new fellow ad eundem will can be considered by the Nominations are medical practitioners practising the RCoA Fellowship in Anaesthesia and We look forward to hearing from you... the College to receive the award and have the characteristics of someone who Committee as evidence of furthering the anaesthesia in the UK in a substantive who meet certain criteria defined in the to be introduced to members of our is both FRCA and a ‘good consultant’ – consultant post, who have been elected interests of the specialty as as a whole College Regulations. Briefly, they must plus a ‘bit more’. as fellows by College Council for Council. when considering an application, but be in practice in the United Kingdom furthering the interests of the College. Typically this might comprise: cannot wholly substitute for a degree of Fellowship ad eundem is not aimed at in a substantive or honorary consultant engagement with the College. ■■ being a College tutor Those seeking the fellowship apply in ‘stamp collectors’ aspiring primarily to post, possess an eligible specialist writing (the form and guidance can be extend their list of post-nominal letters. qualification in anaesthesia, critical care ■■ making other significant educational When evaluating an application for found on the College website Rather, it represents a link between the or pain management, be a ‘fit and proper contributions in their own department fellowship ad eundem, the threshold

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Bulletin | Issue 118 | November 2019 HSRC Annual Report | 2019 HEALTH SERVICES RESEARCH CENTRE Annual Report 2019

PERIOPERATIVE JOURNAL WATCH Professor Ramani Moonesinghe Director, Health Services Dr Katie Samuel, ST7 Anaesthetist, Bristol School of Anaesthesia, Dr Michael McEvoy and Dr Muataz Amare, Cochrane Anaesthesia Group Dissemination Fellows Research Centre Perioperative Journal Watch is written by TRIPOM (trainees with an interest in perioperative medicine – www.tripom.org), and is a brief distillation of recent important papers and articles on perioperative medicine from Professor Iain Moppett across the spectrum of medical publications. Deputy Director, Health Services Research Centre Perioperative alcohol Intraoperative analgesia The impact of preoperative Supplemental perioperative cessation intervention for with remifentanil vs. intravenous iron on quality of intravenous crystalloids for postoperative complications dexmedetomidine: a life after colorectal surgery postoperative nausea and Egholm JWM, et al. Cochrane systematic review and meta- Keeler et al. Anaesthesia 2019; vomiting Database of Systematic analysis with trial sequential 74:714–725 Jewer JK et al. Cochrane Reviews 2018, Issue 11 analysis Database of Systematic Grape S et al. Anaesthesia This multicentre, open-label, Reviews 2019, Issue 3. Art. This Cochrane review 2019; 74:793–800. randomised controlled trial No. CD012212. studied patients with a high was done as a follow-up alcohol intake undergoing Remifentanil is widely used for to the IVICA study, which This Cochrane review The Health Services Research Centre (HSRC) is the UK national centre of surgery, testing whether intraoperative analgesia, and showed that IV iron treated assessed whether increased excellence for health services research to define, evaluate and improve intensive alcohol interventions there is currently a debate preoperative anaemia more IV fluid administration can (IAIs) aimed at complete about the benefits and harms effectively than oral iron but reduce postoperative nausea quality in anaesthesia and associated specialties. Hosted and supported alcohol cessation reduced of intraoperative opioids in did not reduce transfusion and vomiting (PONV). by the College, the HSRC could not do our work without the support and postoperative complications, general and drugs such as rates. In the trial, 116 anaemic The review included 41 in-hospital mortality and dexmedetomidine in offering patients undergoing involvement of RCoA members. We are delighted to be able to share some randomised controlled trials length of hospital stay, an alternative. This meta- colorectal cancer surgery in which ASA 1 and 2 patients of the work that has been going on and also what is in the pipeline. and promoted continued analysis sought to compare were assigned randomly to were given a higher volume abstinence from alcohol. the effect of remifentanil receive either IV or oral iron, of fluid to prevent PONV. It has been a really exciting year. We scientist who help provide scientific London Surgical Outcomes Research and dexmedetomidine and followed up at three Three studies (140 patients) have chosen and begun work on the rigour to our work.It has also been a year Centre, all of whom support individual during general anaesthesia months to assess quality of There was moderate-certainty with moderate-quality 7th National Audit Project (NAP7); touched by sadness, with the sudden projects or our fellows’ academic on postoperative pain. From life using different assessment evidence that supplemental evidence showed that IAIs chosen the topic for the 3rd Sprint death of our friend, colleague and development. We also rely hugely on 21 randomised controlled tools. Eleven components of IV crystalloids reduced the reduced the occurrence of National Anaesthesia Project (SNAP), PQIP/HSRC fellow Dr David Gilhooly. the amazing support team at the RCoA, trials including 1,309 these assessments increased risk of nausea (risk ratio 0.62, postoperative complications, as well as publishing a bunch of papers We are honouring his memory and including Cristel our data analyst, Jose patients, those who received significantly in the intravenous 95% confidence interval 0.51 the risk ratio (95%CI) from SNAP2; launched the Children’s his contribution to the HSRC and to (our research manager), James (the dexmedetomidine had iron group, including to 0.75) and reduced the risk being 0.62 (0.40 to 0.96), Acute Surgical Abdomen Programme; science, by launching a prize that will Head of Research), Sharon (the Deputy less pain during the first 24 functioning and fatigue of vomiting (risk ratio 0.50, and promoted continued and continued to make improvements reward early career researchers doing CEO), and Laura, Trevor, Karen and postoperative hours (95% scores, compared to one in 95% confidence interval 0.40 abstinence, risk ratio (95%CI) systematic or scoping reviews. More of Dorian who provide administrative and to 0.63), with no increase in to patient care through the National confidence interval of -0.9 the oral group. this on page 38. 8.22 (1.67 to 40.44), Emergency Laparotomy Audit (NELA) project management support for our (-1.7 to -0.2), p = 0.01) and adverse events reported. suggesting some benefit. IV iron therefore seems not work. But that support would achieve less hypotension, shivering, and Perioperative Quality Improvement The work of the HSRC relies on There was no effect on length only to treat preoperative There is therefore evidence nothing without the engagement and and postoperative nausea and Programme (PQIP). Our work and our numerous external funders, including of hospital stay, and the data anaemia more effectively than that supplementary encouragement of members of the vomiting. Dexmedetomidine team have been featured in the BMJ, the Healthcare Quality Improvement on mortality were insufficient. oral iron but also to improve crystalloids decrease College and our many colleagues from was thus superior to Lancet, BJA, Anaesthesia and many other Partnership, the Health Foundation, such patients’ quality-of-life PONV in ASA 1 and 2 other professions. Thank you. If you want Such an intervention can remifentanil in improving pain journals. Over the next few pages we’ll the Association of Anaesthetists, the scores. patients undergoing surgical to find out more, just get in touch. thus be recommended showcase some of this activity as well Association of Paediatric Anaesthetists, outcomes. procedures that require only a perioperatively. as the achievements of our fellows, and the National Institute for Health [email protected] short length of stay. introduce our statistician and social Research, and the University College www.niaa-hsrc.org.uk The College is committed to developing a collaborative programme for the delivery of perioperative 28 | care across the UK: www.rcoa.ac.uk/cpoc | 29 HSRC Annual Report | 2019 HSRC Annual Report | 2019

SPRINT NATIONAL ANAESTHESIA PROJECTS: OUT WITH THE OLD… Professor Ramani Moonesinghe, Director, Health Services Research Centre Nine days, around 290 hospitals, more than 50,000 participants, five research papers, big news coverage and a suite of new resources for patients and clinicians... that’s what’s happened so far – so what’s left for SNAPs 1 and 2?

Improving patient experience at University College London Hospital to a starting point for the development of and outcomes after surgery reduce postoperative thirst and featured guidelines for how enhanced care units and anaesthesia in the BMJ (‘Sixty seconds on... ice lollies’, should be set up, staffed, financed, and 19 August 2019). The patient satisfaction governed. The guidelines are being led SNAP1, which evaluated patient- and outcome measure used in SNAP1, by the Faculty of Intensive Care Medicine reported outcome from anaesthesia the Bauer questionnaire, has since with multidisciplinary/intercollegiate input, care, continues to impact on patient been adopted into the Perioperative and will be published around the turn of care. The Quality Improvement Programme and the calendar year. Two more manuscripts RCoA’s recommended in international consensus should hopefully be published soon – a Fitter Better our huge thanks to them and to our of strong painkillers (including opioids) pressure environment (coordinating more guidelines on which patient-centred paper describing the accuracy of various Sooner Toolkit thousands of collaborators for making after surgery. The panel had a fascinating than 250 hospitals can be stressful!), outcomes should be used in clinical trials risk prediction methods (including clinical has been these studies possible. day hearing the different proposals, and, perhaps most importantly, their (British Journal of Anaesthesia, in press). judgement) for predicting short-term developed which reassuringly all had representation ability to work with, supervise and mentor postoperative mortality in the international to provide In with the new… SNAP3 will from trainees and colleagues from other the trainee lead who will be appointed Understanding the cohort, and a manuscript using UK data patients specialties and disciplines as well as subsequently. The candidate will be able only, describing what clinicians perceive be… (drum roll) with high- epidemiology of high-risk anaesthetists. In the end, we decided to claim 1 PA salary backfill, and will be the benefits of postoperative critical Following approval by the RCoA of quality, easily surgery that both frailty and delirium presented supported by a trainee (who will work at care to be, and how they decide which provision of greater financial support for accessible SNAP2: EpiCCS – which looked at issues huge opportunities for pragmatic, large least 75 per cent WTE on the project), patients should be admitted there. In future SNAPs, we invited our community information around critical care provision after surgery scale SNAP-style research which could and the RCoA/HSRC team who will particular, we hope that the risk prediction to submit their ideas for what SNAP3 before surgery and anaesthesia, with – took place in the UK, Australia and potentially be evaluated together in a provide administrative, academic, and paper will be a game-changer: we know should be based on. After more than the aim of better preparing patients New Zealand. The first manuscript, based single well designed project. project management support. We hope from SNAP2 and also PQIP that we are 50 nominations were submitted, we on UK data only, was published in the BJA and therefore reducing anxiety and shortlisted three topics, each of which to appoint the Chief Investigator around not great at assessing and documenting So, the commissioning brief for SNAP3 improving outcomes. SNAP1 data last year and provided rates, reasons and Easter 2020, and will work with them to individualised risk of poor outcomes from was proposed by three individuals or risk factors for last-minute cancellation is now out. We are inviting submissions provided important, generalisable groups who had submitted their ideas. appoint the trainee lead soon after. surgery, and so we hope that the SNAP2 from colleagues who wish to be the information about short-term outcomes of surgery. The second paper, using data findings provide clinicians with some The decision-making panel included from all three countries, described how senior lead (ie, Chief Investigator) for For more information see: and how unpleasant effects of surgery representatives of the RCoA Council, much needed reassurance about the best a SNAP3 topic based on frailty and www.niaa-hsrc.org.uk/SNAP3-Home and anaesthesia can be predicted and critical care is provided after surgery, methods of risk prediction we can use. the HSRC Board, the Research and including the first empirical description delirium. The successful candidate mitigated. Quality improvement initiatives Audit Federation of Trainees, the two of the ‘enhanced care units’ which have will be selected on the basis of their based on SNAP1 data continue to be Both previous SNAP studies have also previous SNAP trainee leads and a lay evolved in response to the intermittent credibility to lead SNAP3, including developed, and have recently attracted supported the doctoral degrees of the person. The shortlisted topics were crises we have with critical care bed clarity of ideas for the research questions attention in the medical press – eg, the national trainee lead investigators, Ellie frailty, delirium, and the long-term use and methods, ability to work in a high- ‘Pompops’ ice lollies initiative developed capacity. This paper has been used as Walker and Danny Wong. As always,

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ONWARDS AND UPWARDS: The second PQIP annual report finds great improvements – but still some challenges The national Perioperative Quality Improvement Programme (PQIP) has been recruiting patients in NHS hospitals since December 2016. Its aim is to measure, report and improve processes of care and outcomes for patients having major planned surgery. More than 20,000 patients have been recruited and around 125 hospitals are participating. We have received endorsement from NHS England/NHS Improvement by being added to their Quality Accounts list of recommended audit/improvement programmes, and engagement with PQIP is also being recommended by the Getting it Right First Time (GIRFT) programme in perioperative care.

In our second annual report we were is likely to be of greatest value if the most common types of major delighted to be able to report some undertaken as early as possible in postoperative morbidity, which are clear improvements, including shorter the preoperative workup, so that the consistently infection and wound related. length of stay, lower postoperative patient and the multidisciplinary team morbidity, and improved rates of can prepare adequately for surgery PQIP 2020 and beyond drinking, eating and mobilising within and perioperative care. High-quality In the light of the Y2 findings, we have 24 hours of surgery. However, we perioperative pain management requires refined our top five improvement have also found some areas in which not just a good anaesthetist, but also priorities (see infographic). We have it has been difficult to bring about adequate patient preparation and produced a number of infographics improvement, despite these being expectation management. Anaemia and aimed at supporting teams in delivering amongst our national improvement diabetes tests are only useful if there is their quality improvement goals. Over priorities – individualised risk assessment, sufficient time to treat the conditions the next year, we hope to build on the preoperative anaemia management, before surgery (in the case of anaemia successes so far, and start to tackle some HbA1c measurement, and perioperative and many cases of poorly controlled of the really difficult issues. We want to pain management. diabetes), and to plan the pathway foster greater collaboration between of care during and after surgery that hospitals through sharing of information One theme which links these areas is will reduce associated risks such as about successes and challenges in the need for high-quality and timely transfusion, dysglycaemia, infection, improving perioperative processes and preoperative assessment. Individualised and wound complications. Significantly, outcomes. If you’re not already involved, risk assessment in the elective setting this also ties in with our findings about get in touch at [email protected]

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To date, analysing NELA data has What data are available? yielded many fascinating findings, The starting point of any project including how to view pre-optimisation is data. At local level, individual in the emergency setting, and whether hospital datasets can be accessed surgical specialisation affects emergency through the designated NELA surgery outcomes, as well as enabling leads. National data from England the development of a new risk prediction and Wales are accessible through model. Moreover, a number of NELA, and comes in two main randomised clinical trials have used types: aggregate hospital-level NELA as a platform for data collection. data, and anonymised patient- level data. Those of you familiar with entering data into the webtool will have noticed seven NELA routinely publishes a great distinct pages corresponding to different deal of aggregate-level data, stages of a patient’s journey. These trials start dates. Applications are reviewed on which are publicly available and does add bespoke fields to collect information a monthly basis by the NELA team, and not require any special permission for specific to the trial. all applications are subsequently sent use. Prior to designing any project it is to the Healthcare Quality Improvement well worth looking to see if the data is Notable examples of large-scale Partnership (HQIP). Further information already available (bit.ly/34slKes). If your clinical trials are the FLO-ELA (Fluid about this process and data governance research requires data that has not been Optimisation in Emergency Laparotomy) requirements can also be found on the published, the NELA team is able to and EPOCH (Enhanced Perioperative website. Additionally, there may be a generate the required aggregate data. Care for High Risk Patients) trials. cost involved in producing the requested FLO-ELA (www.floela.org) is an ongoing data as detailed in the Data Sharing Cost It is also possible to obtain anonymised project investigating whether cardiac- Recovery document on the website. patient-level records. Record-level data output-guided fluid therapy is associated includes patient demographics, process with a survival benefit. The EPOCH trial To generate reports, NELA uses Office variables looking at whether a patient had (www.epochtrial.org) examined the for National Statistics mortality data. a preoperative CT-scan, physiological National Emergency Laparotomy Audit (NELA) implementation of quality-improvement This information is unfortunately not parameters, surgical indications and programmes for patients having available from NELA. However, we have findings, and discharge dates, as well emergency laparotomy. found that recorded inpatient mortality as inpatient mortality. To get a good corresponds well with ONS-derived Inspiration, ideas and insights: A number of projects come from current understanding of the data fields that are 30-day mortality. trainees. A great example is the ALPINE available and the potential limitations of study (www.uk-plan.net/ALPINE), which each, the NELA Clinical Audit Export The NELA team are always keen to hear making the NELA data talk originated from a trainee-led research Key (https://data.nela.org.uk/), found about quality-improvement or research network and has the advantage of under the ‘Support’ tab, is invaluable. projects using the NELA data, and may Dr LJ Spurling, Dr Emma Stevens, Dr Michael Berry drawing on the collaborative expertise This lists all data fields and can be read in be able to help showcase your work. NELA Fellows and experience of the network. Getting conjunction with a local-data download We support a large number of projects; involved with such a group or with or patient-data entry page to fully the strongest applications have a clear The National Emergency Laparotomy Audit (NELA) has been running for local teams is a perfect introduction understand each variable. question that can be answered using to research and quality-improvement NELA data. Data requests should be well nearly six years. In this time, local clinicians have collected observational projects. If you would like to take things The first step to obtaining any type of defined and request only the data that is data on more than 100,000 patients. These data are widely used for quality- further, fellowships, potentially leading data is to complete an appropriate required. to MD/PhD degrees, are advertised request form, to be found on the improvement projects, both locally and nationally. through the HSRC (www.niaa-hsrc. NELA website (www.nela.org.uk/ org.uk) with positions within the NELA NELA_Research). Do submit your What can be achieved? project team among others. applications well in advance of project The United Kingdom is home to more gathers standardised information on hospitals. Projects using the NELA than 50 clinical registries, ranging from patients’ diagnoses, care processes, data have come from anaesthetists, hip fractures to stroke services registries. and outcomes, enabling systematic surgeons, haematologists, and elderly- The NELA team can be contacted via email at [email protected] Like all of these programmes, NELA comparison and analysis across care physicians.

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NAP7: PERIOPERATIVE CARDIAC ARREST Dr Jasmeet Soar, NAP7 Clinical Lead Dr Tim Cook Director, RCoA National Audit Programmes

The 7th National Audit Project of the RCoA (NAP7) will examine perioperative definitions, inclusion and exclusion ■■ the NAP7 panel will include an engagement. We hope that all UK criteria, and how and which data will be increased number of trainees anaesthetists will get behind NAP7 and cardiac arrest. Drivers for the choice of the NAP7 topic include the common collected. We will ensure permissions compared with previous NAPs, as make it a success, as they have before. fear of patients that they ‘might not wake up after their anaesthetic’, and, and necessary approvals are in place well as patient, public, operating The NAP7 team is working on creating although perioperative cardiac arrests are rare, our current lack of knowledge for collecting data in England, Northern department practitioner and nursing guides for Local Coordinators and on Ireland, Scotland and Wales. representatives. As with previous building up a library of FAQs. Expect about how often they occur. NAPs most of the stakeholders will be these to arrive in the next few months. NAP7 is in its early days, and, like all NAPs, practising anaesthetists representing The current ‘best-guess’ estimate is that (www.nationalauditprojects.org.uk) and that in subgroups of patients (eg, there are novel elements to this project: specialist societies As of 1 August there were 226 the incidence is 4 in 10,000 general work collaboratively with anaesthetic children, obstetrics) and specialties Local Coordinators signed up at ■■ a first for NAPs is that there are three ■■ we intend to involve independent anaesthetics, and that about 1,200 colleagues across the UK, and involve (eg, cardiac and vascular anaesthesia) 315 NHS hospitals (listed at www. HSRC-NAP7 Fellows (Drs Richard hospitals in NAP7 to a greater extent perioperative cardiac arrests occur stakeholder groups, which will include nationalauditprojects.org.uk/NAP7- ■■ a registry to enable identification and Armstrong, Andrew Kane and Emira than in previous NAPs. While 100 every year in the UK. Furthermore, patients. Previous NAPs have been Sites#pt ). If your hospital does not have review of individual cases to identify Kursumovic). All three will be working per cent of NHS hospitals engaged the National Cardiac Arrest Audit of service evaluations, and this will remain a Local Coordinator, please do get in common themes and important on the core NAP7 project, as well as with NAP6, only 13 per cent of invited in-hospital cardiac arrest only includes the case for the main NAP7 project. touch. issues for learning. All cases will be developing their own projects independent hospitals took any part. those cardiac arrests where there Confidentiality, anonymity, and a fair anonymised, and reviewed by a ■ We look forward to working with and structured review of individual cases ■ Dr Cecilia Vindrola, a social is a 2222 call and attendance by a panel using a structured process. The representatives of the independent for the purposes of learning will remain anthropologist, has joined the team resuscitation team, meaning that the vast precise data that will be collected healthcare sector to achieve this. the key tenets. NAP7 will use a similar to add a qualitative dimension to the majority of perioperative cardiac arrests has yet to be determined, but we will structure consisting of: project. The aim of her work will be As with every NAP, the project requires are unlikely to be included. build on experience and feedback to help us understand the impact the mass co-operation and involvement from previous NAPs, and will, where The previous NAPs have had both a ■■ a baseline survey of structures and of perioperative cardiac arrest on of anaesthetists throughout the UK. appropriate, use accepted definitions national and international impact that processes, and views of anaesthetists individual clinicians, surviving patients, The success of previous NAPs is a used in existing cardiac arrest audits. have led to changes in practice and, we about perioperative cardiac arrest teams, and organisations direct consequence of that generous believe, improvements in patient care, ■■ an activity survey to measure The current plan is to launch NAP7 and and this remains a primary aim of NAP7. denominator values to help provide collect data for one year starting in May Specifically, we will follow the same an estimate of the overall incidence 2020. In order to achieve this we will Contact us on [email protected] for all inquiries or ideas about NAP7 ethos as the previous NAPs of perioperative cardiac arrest, and be working with stakeholders to agree

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For (s)he’s a jolly good fellow… past, present, future…? Professor Ramani Moonesinghe, Director, Health Services Research Centre

The HSRC couldn’t deliver its objectives without the hard work of our fellows. All our main workstreams have fellows working on the project teams, helping with the day-to-day running of NELA, PQIP, Sprint National Anaesthesia Projects, etc, and also contributing to the strategic direction of the HSRC itself.

We have now appointed an astonishing far exceeds just academic credentialing including Bath, Exeter, London, 30 fellows since 2011, with nine starting – all fellows require excellent time Middlesborough, and Nottingham. this year alone. Of the previous 21 management and project management This means that trainees don’t lose their fellows, 14 have completed or are skills as well as a strong sense of both clinical skills while developing other skills working towards doctoral research team-working and leadership. alongside them. Fellows are now more degrees, and all have contributed to commonly choosing to focus on quality All our fellows do some clinical work major programmes such as NELA and improvement skills rather than research, THE CHILDREN’S ACUTE SURGICAL alongside their academic activity, PQIP (with co-authorship of annual but lots of different opportunities are and this provides their salary. Some available and we are always keen reports) or the new RCoA Quality do this in private hospitals in London to support the ideas coming from Improvement Recipe Book. The skills ABDOMEN PROGRAMME and an increasing number do it in appointed fellows. Dr Amaki Sogbodjor, CASAP Fellow gained by the fellows range from the NHS, working in a part-time post seriously scary stats programming (usually covering the on-call rota and If you are interested in an HSRC through to seriously in-depth qualitative an additional day in theatre) but still fellowship, look out for our adverts which The HSRC is navigating its way through uncharted territory as it undertakes its methods. The personal development receiving a fully banded salary. Our appear annually in September/October, first paediatric perioperative initiative. The Children’s Acute Surgical Abdomen which is possible in an HSRC fellowship NHS posts are based all over England, or contact us on [email protected] Programme (CASAP) is an observational cohort study which has evolved in response to mounting evidence of significant variation in outcome within this patient group.

Such variation implies that some children We aim to recruit every child (1–16 years underpinned by adopting such a ‘citizen- David Gilhooly Award for Systematic Reviews are experiencing potentially avoidable old) meeting the inclusion criteria in science’ approach. Like these projects, Dr David Gilhooly was an HSRC (PQIP) fellow who died unexpectedly in 2019. adverse events. In addition, the number participating hospitals across the UK. therefore, CASAP will recognise every He was born in Ireland and trained as an undergraduate at St James’ College Dublin, of children undergoing completely The dataset, including information on collaborator in subsequent publications. subsequently training as an anaesthetist. He came to London initially to do a clinical unnecessary procedures seems to be demographics, perioperative physiology, This also provides another great fellowship and was then appointed as an HSRC fellow, undertaking research based on on the increase. CASAP aims to help and postoperative morbidity, will be opportunity for trainees to get involved PQIP towards an MD(Res) degree at University College London. He was appointed as understand some of these issues. We linked with NHS Digital databases in research that builds on previous work a consultant anaesthetist at University College Hospital in 2018 but continued to work are delighted that CASAP is supported to ascertain longer-term outcomes, delivered by the HSRC, the Paediatric academically as well, and he remained a valued member of the research teams at UCL by the Association of Paediatric tracking these children for 10 years. Anaesthesia Trainee Research Network, and the HSRC until his untimely death. Anaesthetists of Great Britain and Ireland The validity of this study is largely regional trainee networks and the (who with the RCoA and the University dependent on the perioperative Research and Audit Federation for David developed expertise in systematic and scoping literature reviews, and in his honour, College London Surgical Outcomes clinicians (surgeons and anaesthetists) Trainees (RAFT). We hope that all of you we are launching a prize to be awarded annually for systematic or scoping reviews which Research Centre are funding the project) and research nurses collecting high- involved in paediatric perioperative care have trainees as first, senior or corresponding authors. Full details of the prize, entry criteria and the British Association of Paediatric quality data at the coalface. There is no will be inspired to get involved and join and deadlines can be found at: www.niaa-hsrc.org.uk/David-Gilhooly-Award Surgeons. Recruitment will have started doubt that the success of most HSRC us as we try to improve the care our by the time this article is published. projects, including PQIP and SNAPs, is children are receiving.

The quantitative/qualitative conundrum As well as the clinical leads, research fellows and the support staff at the RCoA, the HSRC team has recently recruited some career scientists to support its work. Peter Martin (statistician) and Cecilia Vindrola (medical anthropologist) are critical to helping the HSRC develop and deliver robust research which can be trusted and therefore used to influence practice. Both quantitative (statistics) and qualitative (social sciences) research can seem like a bit of a black box to us clinicians. So, here’s a little from them about what they do…

PETER CECILIA MARTIN VINDROLA Lecturer in Applied Senior Research Statistics, Department Fellow, HSRC Social of Applied Health Scientist Research, HSRC I’m working with Statistician the HSRC to help My main role is to incorporate perspectives provide rigorous, and methodologies unbiased data analysis and data presentation for NELA from the social sciences in the design and implementation and PQIP. I also help the HSRC fellows in their own data of HSRC research. My role is to help understand the ‘why’? analysis – there is more to statistics than the FRCA exam! of our findings, as opposed to just the ‘how much’. Dr Anne Meaklim ST4, Antrim Area Hospital, Northern Ireland Examples of my work that you may have seen include the An important part of my work is the training and supervision funnel plots of mortality rates and other outcomes used to of anaesthetists who want to use qualitative approaches in compare different hospitals fairly in this year’s NELA report, their research, particularly as most clinical doctors are much and analysis of national data to estimate rates of readmission more comfortable with quantitative methods – ie p-values! to hospital after surgery. My involvement focuses on making sure colleagues develop a better understanding of the role of social theory in the I am also leading on the development of statistical shaping of research, acquire new skills in qualitative data techniques such as control charts that will allow individual RETHINKING RESILIENCE collection and analysis, and contribute to the integration of hospitals to understand any changes in their outcomes in research findings into policy and practice. near real-time rather than having to wait for annual reports. There is much ado about resilience in anaesthesia; it is a word which feels I am currently working in six hospitals across the UK more unsatisfactory the more I hear it. Despite having read many perspectives As a non-clinical statistician, I am very keen to see how evaluating whether (‘if’, ‘how’, ‘why’ and ‘why not’) PQIP is data are used to make a difference to practice and patient on the matter, I am yet to understand how to improve my resilience or that achieving its goals of supporting clinicians to use data for outcomes, rather than just sitting in a report. improvement at local level. I will soon also be contributing of my colleagues. So, how do we increase resilience? Could selection be to the development of qualitative research for NAP7. improved? Or is its source post-hiring socialisation? In which case, training might be advocated. Or is resilience not the word we are looking for at all?

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Bulletin | Issue 118 | November 2019 Bulletin | Issue 118 | November 2019

Current selection for and training in harmful coping mechanism. The doctor you label it ‘fragile’, then you want it medical school could be described as role can provide a safe retreat, a place to be left alone in peace, quiet, order, Procrustean. Procrustes was an innkeeper which denies expression of true identity and predictability. Further, everything in Greek mythology who, in order to and a source of inhibition of personal The that does not like volatility does not Comment make travellers fit in his perfect bed, cut relationships at home. like stressors, harm, chaos, events, Editors of the Bulletin felt this article may need elaboration and I am happy to the limbs of those who were too tall and disorder, ‘unforeseen’ consequences, antifragility of write a short footnote explaining why I liked it. The author begins by drawing stretched those who were too short. But I am suggesting a paradigm shift which uncertainty, and, critically, time. And our attention to the recent emphasis on ‘resilience’. The concern within the NHS he had the bed fitting the visitor with could be adopted in our approach antifragility flows from this definition of (employers) and many professional organisations seems to be that too many staff total perfection, should they ever visit. to considering mental and emotional our staff is the fragility. It likes volatility et al. However, are taking too many days sick leave, or are taking career breaks, or, in the early development. In defining resilience, it also needs time. In this definition, stages of training, ‘F3’ or ‘gap’ years’. Or they are simply resigning and leaving From the first day in University, medical perhaps one needs to identify its experiencing certain acute stressors with glue which (or retiring early). Or, they are continuing in work but are fatigued, unhappy or students are told they are unique, far antithesis. sufficient recovery time is important in disengaged – or at worst, experience mental health difficulties. Much of this is different from the average citizen and growth – for example, when one goes certainly beyond psychological harm.1 Let’s consider a thought experiment. holds the attributed to stress. And the proposed solution to manage stress is ‘resilience’. Imagine you are in the post office about to the gym and then rests before the The subjects taught are on how to keep to send a precious family heirloom to a next session. However, development will The author observes that traditionally this sort of resilience was learned at your patient alive. We are to give the cousin in Siberia, perhaps a collection not as easily occur when stressors are medical school. Whether it is the first encounter with a cadaver or witnessing a help, not receive it. Very little, if anything, NHS together of china teacups. As the package can chronic, with no relief or downtime for death, or hearing a tragic life story, the medical student is encouraged not to let is taught about self-preservation. 3 be damaged during transportation, reflection and healing. any adverse ideations affect them, but to develop a thick skin and to continue The medical student acquires a false you would stamp ‘fragile’, or ‘handle the day’s work. Moving effortlessly from one tragedy to another crisis is all part of In summary, I am unsatisfied with the personalisation – the prescribed with care’ on it. Now, what is the exact the profession. Stopping to dwell on one’s feelings or reactions only consumes current label of resilience. l believe that identity of the NHS culture, which can opposite of such a situation, the exact valuable time and effort and could itself harm one’s own character. Even better, the process of discovery depends on overwhelm the individual identity and opposite of ‘fragile’? Almost all people disorder, and stressors; they love to laugh and joke about the day’s events over pints of beer with colleagues in encouraging antifragile tinkering and risk personality. Alongside this socialisation, a answer that the opposite of ‘fragile’ is adventure, risk, and uncertainty. Yet, in the bar afterwards, in an exaggerated show of bravado. Moreover, long hours bearing, rather than merely coping with sense of superhuman emotional strength ‘robust’, ‘resilient’, ‘solid’, or something spite of the ubiquity of the phenomenon, of duty and sleepless nights are all unavoidable part of doctors’ working lives, the demand of work. The antifragility is expected. It is at this early stage that similar. These are items that will not there is no word for the exact opposite and medical students who appreciate and accept this ‘reality’ are those selected 3 of our staff is the glue which holds the students acquire ‘rugged individualistic’ break so you would not need to write of fragile. Taleb calls it ‘antifragility’. for entry. Indeed, it is accepted wisdom that the best doctors are those with the NHS together. We are here thanks to characteristics. The term ‘rugged anything on them – have you ever seen Antifragility is beyond resilience or thickest skins – in the author’s sense, the ‘please mishandle’ allusion. the appetite for risks and antifragility of a individualism’ was used by President a package with ‘resilient’ in thick green robustness. The resilient resists shocks certain class of people whom we need However, the author notes that through this tradition we have been taking a Herbert Hoover at the time of The Great letters stamped on it? Logically, the exact and stays the same; the antifragile gets to encourage, protect, and respect. The wide range of different characters from school and hammering them into a Depression, as a term that indicates the opposite of a ‘fragile’ parcel would be better. This property is behind everything alternative is to continue to select, train fixed stereotype (the allusion to Procrustes) in the hope they will withstand the virtuous ideal, where an individual is a package on which one has written that has changed with time: evolution, and treat doctors as Procrustes did his pressures. The statistics around fatigue, burnout, early retirement, mental health, totally self-reliant and independent from ‘please mishandle’. ideas, revolutions, political systems, visitors. etc, show that this approach has failed. In part this may be generational, with outside assistance.2 It is a potentially technological innovation, cultural and In fact, many people benefit from shocks economic success, corporate survival, millennials and post-millenials having a different view of life and different needs – References and trauma; they thrive and grow when good recipes and bacterial resistance but policies must be sensitive to changing norms. 1 Armitage R. Police suicide: risk factors and exposed to volatility, randomness, – even our own existence as a species. intervention measures. Routledge 2017. The real solution, the author argues, is to recognise the pressures that doctors are Antifragility determines the boundary 2 Rothbard M N. America’s Great Depression under and to develop supportive ways to help them manage, understand and between what is living, complex and (5th edn. 2000). Ludwig von Mises Institute, reflect on those pressures. Ideally also to use technologies and innovations to organic, say, the human body, and Auburn, Alabama. reduce the pressures, and this includes novel and sensitive employment contracts what is inert, for example, a physical 3 Taleb N. Antifragile: things that gain from to encourage recruitment and retention. The author (after Taleb) calls this object such as the stapler on your disorder. Random House, New York 2012. ‘antifragility’ and creating a culture of antifragility is the responsibility of all – the desk. The antifragile loves randomness employee, the employer and society. and uncertainty, which also means— crucially— a love of a certain class of Professor Jaideep Pandit errors. Antifragility has the singular RCoA Bulletin Editorial Board Member and RCoA Council Member property of allowing us to deal with the unknown, and often to do well.

To understand the definition of antifragile, think of your fragile family collection of china teacups again. If

Dr Will Harrop-Griffiths RCoA Council Member and Consultant Anaesthetist, Imperial College Healthcare NHS Trust, London ANAESTHETIC SOAPBOX #3 In praise of the Guedel airway (not) This Soapbox brings us back to the airway, and in particular what I see as an outbreak of the overuse of the venerable Guedel airway by many anaesthetists.

Arthur Ernest Guedel was a remarkable through the stages and planes of NMBDs. Why then do I so frequently clinician. He described the physical anaesthesia. It also explains why many see this sequence: signs associated with the classical stages patients were sufficiently anaesthetised 1 pre-oxygenation and planes of anaesthesia, developed for their airway to become obstructed, 2 induction with propofol with or an inflatable cuff for tracheal tubes, but not so deeply anaesthetised that the without NMBD described the Guedel airway (in 1933), associated muscular relaxation made because of the first step. You need to caused dental damage on very many So here is my recommendation for those and had a dog called ‘Airway’ (really) it easy to ventilate their lungs – this 3 one quick but failed attempt at bag- wait this short period for the patient to occasions, although admittedly usually of you who find themselves using a whom he repeatedly anaesthetised, commonly occurred (and still occurs) in mask-valve ventilation descend through and beyond Guedel’s on emergence from anaesthesia if you Guedel airway more than once a week intubated and placed in a tub of water to Stage 2 or Plane 1 of Stage 3 of Guedel’s 4 insertion of a Guedel airway second plane of anaesthesia or for the have left one of these devices in place for fit patients with objectively normal prove the efficacy of his cuffed tracheal classification. This was also an era before NMBD to work sufficiently to allow you (and if you have, shame on you). I will airway morphology: 5 successful bag-mask-valve tube (really again). The clues to the the introduction of the non-depolarising to ventilate the patient’s lungs with ease. readily admit that I occasionally come ■ ventilation. ■ pre-oxygenate frequent need for an oral airway in the neuromuscular blocking drugs There are two good reasons (other than across a patient whose airway is tricky ■■ induce anaesthesia with whatever If you were to excise the third and fourth simple lack of necessity) not to insert enough (I don’t use the word ‘difficult’, era in which he practised are all there: (NMBDs) that make lung ventilation drugs you choose to use the stages and planes of anaesthesia with bag-mask-valve easy at any stage steps in this all too often practised a Guedel airway in patients who are as this summons up painful images of ■■ at the very moment that you have your were describable because intravenous of anaesthesia. The Guedel airway is sequence and substitute them with a passing through Guedel’s second plane. overly complex algorithms) to require first urge to ventilate the patient’s lungs induction was not in common use, and therefore of some use in patients who pause of, say, 20 to 30 seconds, you The first is that this is the ideal plane the insertion of a Guedel airway even using bag/mask/valve, desist, click anaesthesia was induced slowly by the are only lightly anaesthetised, but is would find that it is easy to ventilate of anaesthesia in which to promote though they are deeply anaesthetised, your heels together three times, and inhalation of soluble anaesthetic agents of precious little use in the substantial the lungs of the substantial majority such problems as coughing, vomiting or paralysed, or both. However, I reckon think to yourself ‘There’s no fool like an such as diethyl ether. This allowed the majority of patients who are deeply of patients without an oral airway, and and laryngospasm by putting a large that I use no more than two Guedel old fool like Dr Harrop-Griffiths’ observation of the patient’s progression anaesthetised or who have been given it is safe to allow yourself this pause piece of cold plastic deep into the airways a year for this purpose, although oropharynx of a lightly anaesthetised I use more in the emergency department ■■ now have your first go at ventilating and not yet paralysed patient who for patients who have neatly parked the patient’s lungs and – magically – does not need it. The second is this: themselves in Stage 2 of Dr Guedel’s you will succeed more often than not Guedel airways are not nice things – excellent classification because of without the assistance of the piece of they can cause oropharyngeal trauma, head trauma or – more frequently in plastic upon which you formerly relied. Guedel airways are not nice things… are associated with sore throat even in my part of west London – recreational the absence of overt trauma, and have pharmacological folly.

Dr Benjamin Milne Dr Nur Lubis Core Anaesthetic Trainee, Consultant Anaesthetist, Whipps Cross Hospital, London Whipps Cross Hospital, London

INTERHOSPITAL TRANSFER TRAINING Interhospital transfers are a notable feature of the management of critical care patients, and present an additional burden to the workload of trainees. Intensive Care National Audit and Research Centre data suggest that in excess of 4,500 critical care transfers occur per annum, and previous studies have suggested a figure closer to 11,000.1,2

These transfers have potential mortality interhospital transfer during their training, course.9 This training is a mandatory © Whipps Cross Hospital and patient-outcome implications with with data suggesting that at least 2–3 part of the novice programme for CT1 up to two-thirds involving difficulty or transfers for each year of training could anaesthetists, and follows completion of complications, yet some of the most junior be expected. Fewer than half of trainees the e-Learning for Healthcare Transfer trainees play a prominent role in their surveyed (48%) had received formal modules prior to starting on-call duties. 3,4,5 5 L Paton et al. Still preparing to fail by failing delivery. Increasing centralisation of transfer training before their first transfer. ‘simple’ transfer, care needs to be our trainees with this comprehensive The one-day, face-to-face element coordinated between at least three course puts us ahead of the curve.10 to prepare? A survey of trainees experience services means interhospital transfers will Unsurprisingly, no respondents stated of and training in inter-hospital transfers. JICS involves lectures on topics ranging from Our CT1s are introduced early on to remain a feature of critical care practice. that they were ‘well prepared’ prior to teams – that referring, that transferring, 2014;15(1):43–47. patient stabilisation to the physics of the practicalities and complexities of undertaking their first interhospital transfer, and that receiving the patient. The 6 Educating, training and setting standards in The College has included mandatory transfer, hands-on tutorials on transfer patient transfer, upon which real world anaesthesia, critical care and pain medicine, while 62% felt that they were ‘adequately teaching is delivered by senior trainees, ‘Transfer’ modules in the training equipment, and orientation to the experience can be based and further RCoA, London (bit.ly/RCoA-TP). prepared’ and 38% felt ‘under prepared’. anaesthetic and critical care consultants, curriculum at all levels, but completion 7 Ulyatt BC, et al. Audit of transfer training in ambulance environment. Attention and paramedical staff. training can expand. Of those trainees that had received Scotland. Anaesth 2009;64(7):798–799. of workplace-based assessments is also paid to the appropriate use of training, 85% felt more prepared because 8 Cook CJ et al. Are trainees equipped to transfer (WPBAs) can prove difficult, as most transfer documentation and tools such The course reports high levels of trainee References of it, yet only one-third had been trained critically ill patients. JICS 2008;9:145–147. trainees undertake transfers solo and satisfaction and better preparedness for 1 Guidelines for the transport of the critically ill as the ‘Safe-Transfer App’ (STrApp). 9 Inter-hospital Transfer. AAGBI, 2009. 6,7,8 at a mandatory course. The educational often outside normal working hours. being on call. It helps form a structured adult (3rd Edition). Intensive Care Society 2011. The day concludes with structured 10 Transfer of critically ill adults. HSIB, 2019. In their respective guidelines, both methods utilised on these courses varied, 2 Mackenzie PA et al. Transfer of adults between simulation training, including transferring introduction to transfer medicine, where with a predominance of lecture-based intensive care units in the United Kingdom: the Association of Anaesthetists and course learning precedes intrahospital a simulated patient through the corridors postal survey. BMJ 1997;314:1455–1456. the Intensive Care Society stress the learning or ‘sim-suite’-based simulation of the hospital and on a short journey transfers, before the competence and 3 Flabouris A et al. Outcomes of patients importance of transfers being undertaken (both of these experienced by 73% of in the back of an ambulance. This confidence is developed to allow for admitted to tertiary intensive care units by doctors with the requisite skills respondents), over in-situ simulation after inter-hospital transfer: comparison introduces candidates to the realities interhospital transfers. Furthermore, and training, but reported that trainee (40%), tutorials (40%) and e-learning (7%). with patients admitted from emergency of the transfer environment and the it provides an opportunity for the experience can be highly variable.1,5,9 departments. Crit Care Resusc In line with AAGBI guidance, our practicalities of using the necessary completion of the appropriate WPBAs. 2008;10(2):97–105. We surveyed trainees at all stages within department has developed a multimodal equipment, as well as helping to develop Given the findings of a recent Healthcare 4 Lovell MA et al. Intrahospital transport of critically ill patients: complications transfer course – the ‘Transfer and non-technical skills and reminding Safety Investigation Branch report into our school, and found that over 83% and difficulties. Anaesth Intensiv Care of respondents had completed an Retrieval of the Acute Patient’ (TRAP) candidates that, even on a relatively critical care transfer, we believe providing 2001;29:400–405.

Dr Joe Lipton Dr Claire Mallinson For this pilot, we have left the required ST6, South East Consultant Anaesthetist, Guy’s & St Thomas’ NHS number and nature of SLEs intentionally Figure 3 Formalising School of Anaesthesia Foundation Trust and RCoA Council Member open-ended. Instead, the programme entrustment Russell Ampofo mandates consistent participation, RCoA Director of Education, Training and Examinations with trainees completing regular SLEs throughout the novice period to document their learning progression.

Responding to trainees’ feelings that our EPA curriculum lacked achievable intermediate milestones, we created a ‘fishbone’ diagram (Figure 2) to highlight PREPARING FOR CURRICULUM 2020: the range of skills that a novice must acquire for entrustment in EPA 2. SLEs should focus first on individual elements a pilot project for novices in isolation, but must later capture the and specific markers of a trainee’s of information to assess the readiness integration of skills in the varied contexts capabilities, yet in the current system they for progression (Figure 3). Transparency As the College prepares to implement curriculum changes mandated by of clinical practice. Below we outline how are relegated to ‘corridor conversations’ and flexibility in this process will enable the GMC,1 our team in south-east London are supporting the Anaesthetic SLEs form part of the decision-making and closed-door meetings. targeted interventions for trainees not process for managing trainee progression. progressing at the expected rate. Curriculum Review Group through continued work on the novice period. Trust will feature prominently in our trial, Entrustment: capturing expert from the formal entrustment process Shaping the future curriculum for each EPA, to the smaller articles of In 2018, we reported on our ‘outcome- facilitating learning. Reviewing 10 years use we can encourage more constructive judgement With this pilot we are seeking to based’ curriculum for novices using of literature, Massie and others report trainee engagement. trust that otherwise go unnoticed. We Trust is interwoven within the trainee– match our curriculum to the fantastic Entrustable Professional Activities (EPAs).2 that assessments are viewed by most encourage our trainers to highlight supervisor relationship. It is implicated learning environment enjoyed by UK Supervised Learning Events (SLE) are trust within the SLE structure. A ‘mini- An EPA is a unit of practice which a trainee as a ‘hoop-jumping exercise’, with little Anaesthetists. We hope the lessons learnt low-stakes observations of practice that in every decision to allow learner 5 is trusted to perform once they have positive impact on learning.4 entrustment’ , for example, might be are intended to capture learning as it participation in patient care, and is will help shape the implementation of demonstrated the required competence.3 ‘emergency preparation’ for an elective the product of complex and nuanced Curriculum 2020 and keep us at the The word ‘assessment’ may be in part takes place in the workplace. Figure 1 case. An explicit declaration of trust We defined the novice period as: forefront of postgraduate medical training to blame as it implies a judgement of shows an example SLE template from judgement. gives purpose and value to the trainee, EPA 1: ‘Performing an anaesthetic pre- internationally. performance with a pass/fail outcome. In our workbook, illustrating a record of with the episode recorded as an SLE. assessment’ (including high-risk patients). Knowledge and skills are important our first pilot, ‘formative assessments’ were feedback and a plan for development. determinants, but trust also touches Acknowledgements EPA 2: ‘Anaesthetic care of an ASA 1 or intended to support feedback, reflection ‘Supervision levels’ capture consultants’ We also encourage ‘novice faculties’ on more difficult but vital areas, like Thank you to Drs Rose and Barry (SESA 2 patient having uncomplicated urgent/ and learning. However, as reported in the holistic judgements of trainees’ – small groups of consultants who will professionalism, which are crucial to TPDs), and Dr Muldoon and Dr Ong for emergency surgery.’ literature, our trainees did the minimum capabilities, which serve as a useful work more closely with novices. Such safe practice. Supervisor judgements of groups make entrustment decisions their invaluable contributions to this project. Trainees valued the transparent learning required to progress, avoiding assessments quick reference to track progression. The trustworthiness may be our most sensitive until they felt ready to ‘pass’. Perhaps by graph illustrates how SLEs could provide together, drawing on multiple sources objectives, while consultants felt that References EPAs offered a more robust and holistic first addressing the terminology that we a written record of a period of learning. Figure 2 Fishbone schematic for EPA 2 1 Excellence by design: standards for judgement of trainees’ capabilities. Some postgraduate curricula. GMC 2017. trainees, however, felt that our curriculum Team Working Task Management 2 Lipton J et al. An outcome-based curriculum lacked achievable intermediate milestones. for the novice period. RCoA Bulletin Preassessement Vascular Transfer & Post-op Figure 1 Risk Stratiﬁcation Analgesia 2018;111:54-55. Anaesthetic planning access positioning analgesia For this pilot we have made significant Capturing 3 Ten Cate, O. Entrustability of professional Drug Recovery Induction Homeostasis changes to the workplace learning and progression preparation handover activities and competency-based training. assessment strategy which might usefully with Supervised Med Educ 2005;39:1176–1177. inform the College’s wider curriculum Learning Events 4 Massie J et al. Workplace-based assessment: a review of user perceptions and strategies to Emergency review process. Monitoring Maintenance Emergence address the identified shortcomings. Adv in planning Health Sci Ed 2016;21:455–473.

Equipment Post-op care 5 Peters H et al. Twelve tips for the Time up for ‘assessments’? Team brieﬁng Airway Ventilation preparation planning Current models of workplace-based implementation of EPAs for assessment and entrustment decisions. Med Teach assessment have proved unsuccessful at Situation Awareness Decision Making 2017;39(8):802–807.

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Bulletin | Issue 118 | November 2019 Bulletin | Issue 118 | November 2019

How we did it Figure 1 Pre- and post-course questionnaire results Following the FDs’ and the RCoA’s Dr Isra Hassan Dr Emily Buckwell curriculum and the RCoA’s POM Tell us about a real-life example in which you have personally encountered ST7 in Anaesthesia, University ST7 in Anaesthesia, University guidance, we designed teaching one of these scenarios within your clinical practice: sessions covering core themes. Learning Hospital of Wales, Cardiff Hospital of Wales, Cardiff ■■ ‘Post-anastomotic leak following colorectal tumour resection’ outcomes were mapped to the FDs’ ■■ ‘Pre-op clinic for colorectal surgery’ curriculum and basic RCoA POM ■■ ‘During surgical placement, post-op reviews’ competencies. Separate sessions for Year ■■ ‘More pain after surgery’ Dr John Dunne, Consultant Anaesthetist and Foundation Programme Director, 1 and Year 2 FDs allowed for progression University Hospital of Wales, Cardiff of learning and teaching relevant to What went well? the stage of training. Staying with the ■■ ‘Good communication’ principles of perioperative medicine we ■■ ‘Initial assessment and diagnosis of complication and initial management’ had a multidisplinary teaching faculty. ■■ ‘I was confident in clerking but was not particularly confident in the pathway’ Introducing foundation doctors ■■ ‘ABCDE approach’ Following a fictional patient’s perioperative journey, we delivered material through What made it difficult? interactive lectures and simulation. ■■ ‘Not understanding anaesthetic charts’ to perioperative medicine Preoperative sessions for Year 1 FDs ■■ ‘No formal teaching’ included admission clerking, risk ■■ ‘The significance of the operation performed’ With the current emphasis on perioperative medicine (POM) the surgical assessment, ASA and NICE investigation pre-assessment ‘missed patient’ should be a thing of the past. guidelines, medication reviews, and On the pre-course questionnaire we asked you to give a real-life example of starvation times. Progressing the session for one of the scenarios. Is there anything that you would now do differently? ■ As anaesthetists in training we are very FDs play an integral role in providing term conditions and patient education Year 2 FDs, we covered more complex and ■ ‘Check into Hb; know when to flag-up high-risk patients when clerking’ topical areas, including PQIP, preoperative ■■ ‘I now know that pre-op clerking is a lot more involved. The role/importance aware of the benefits of and processes care throughout patients’ perioperative in POM. However, there is currently little anaemia, and diabetes. Intraoperative of risk scanning and explaining risk to patients. Also OSA and it’s wider of POM, but this message doesn’t always journey. Exposing them to POM early teaching or knowledge of the overlap teaching looked at the anaesthetic chart, significance’ in their career not only increases their and influence from other specialties.1 filter through to all those involved in the concepts of goal-directed therapy, ■■ ‘Access resources given in our handouts’ confidence in managing complex patients’ surgical journeys. With this cardiac-output monitoring, epidural care, patients, it also provides essential skills Our objectives were to emphasise General comments: in mind, and in the light of personal and spinal care. Simulation scenarios they can take forward into their chosen the importance of FDs’ role in the ■■ ‘Really good teaching. I feel this topic is not done well in medical school’ experiences with the ‘missed patient’, covered common postoperative subspecialities. In response to the Shape perioperative care of surgical patients, and ■■ ‘Course was taught well, with useful information that will be very helpful on complications and their management, and we felt that a teaching programme of Training mapping exercise ‘Training for to give them an understanding of POM wards. Include next year please!’ key concepts in effective communication. for foundation doctors (FDs) could and provide a toolkit they can use in daily ■■ ‘Gained more confidence for my surgical role’ Doctors’, the RCoA emphasised that FDs Topics included pain, the WHO ■■ ‘Good combination of simulation and lectures’ significantly improve patient care. must demonstrate knowledge of long- practice and with the ‘missed patient’. analgesic ladder, pneumonia, sepsis, postoperative cognitive dysfunction and Figure 1 Combined F1 & F2 feedback on Perioperative Care Teaching Session the importance of ‘DReAMing’ (drinking, eating, mobilising). A take-home handout Pre teaching Post teaching More than 133 FDs in the Cardiff and POM should be incorporated into the 120 included scoring systems, helpful websites, Vale University Health Board have now FDs’ curriculum. FDs’ training should contact numbers, and hospital guidelines 100 received this teaching as part of their include not only recognition of the acutely relevant to POM. foundation training programme unwell patient and the complexities of 80 Pre- and post-course questionnaires long-term conditions, but also the benefits 60 assessed attendees’ confidence in Looking forward and processes of pre-optimising patients requiring surgery. Exposing FDs to POM 40 providing perioperative care. We asked With the support of the foundation raises awareness and lays a foundation Number of attendees of Number for examples of POM that they had programme director, POM is now 20 to build on throughout training and into encountered within their clinical practice, embedded in the FDs’ teaching future careers. 0 and asked them to identify those which programme for Cardiff and Vale Not at all Not so Neutral Confident Very Not at all Not so Neutral Confident Very they had struggled with. Following the confident confident confident confident confident confident University Health Board. With such Reference Preoperative patient care 2 42 70 24 0 0 3 13 113 4 course they reflected on these events and positive results, we aim to roll it out 1 Training Doctors for Patients, RCoA response 16 61 49 12 0 0 3 39 85 6 identified what they would do differently Knowledge of intraoperative pathway across Wales with advanced anaesthetic to the Shape of Training Mapping Exercise. Preoperative patient care 2 37 63 35 0 0 0 13 116 4 next time. Their increased confidence in trainees in POM, delivering it at their RCoA, 2015 (bit.ly/34cQuQn). managing patients was clear. base hospitals.

that the levels of child obesity are worse Figure 2 Implementing the POOCH guidance at the Preoperative Assessment Clinic than those for England, as 11.7% of children in reception are classed as obese. 60 52 Not referred Obese children are more 50 Referred

likely to become obese adults, 40 so can we make a difference? 28 At RMCH the preoperative and 30 endocrinology teams, guided by the NICE 20 15 guidelines, have developed the POOCH referral guide to assist in referring obese 10 children preoperatively when they present 0 at the preoperative assessment clinic, so 0 2017 before POOCH 2018 aer POOCH that they can have their condition assessed and managed by a suitable service.

Dr Muataz Amare Dr Jacques Diacono Since the Department of Health growth ST6 Specialist Trainee, Consultant Paediatric chart classifies children with a BMI above hospital building at RMCH – where Acknowledgements Advanced Paediatric Anaesthetic Anaesthetist, Royal Manchester the 91st centile as ‘overweight’ and an overnight stay can be provided if 1 Dr Mars Skae, Paediatric Trainee, Royal Manchester Children’s Hospital children above the 98th centile as ‘very needed. Since at the present we do not Endocrinologist: helped in Children’s Hospital overweight (clinically obese)’,4 we started postpone surgery in cases of raised BMI. producing the guideline. our referral process with children above 2 Louise Chamberlain, Specialist One of the limitations of the referral the 91st centile.4 Nurse Practitioner: data collection. process was the occasional parent 3 Dr Sana Riany: Logo designer. Figure 1 Summarised version of referral refusal for the referral; we aim to address 4 Dr Rebecca Sutton, Consultant guidance by child’s body-mass index this through better parental education at Anaesthetist. Tackling childhood obesity 1 (BMI) a community level. 5 Dr Moataz Abdelrahman, Clinical 1 Well children with a BMI >91st The ‘Manchester Joint Strategic Needs Director, RMCH anaesthetic at preoperative level centile: refer to a community-based Assessment 2015/2016 document, has department. weight-management service. aimed to encourage and support all References 2 Children with a BMI > 99.6th potential partners statutory, voluntary The Preoperative Obese Children (POOCH) Project, is an inspiring project 1 Obesity: identification, assessment and centile, or >95th centile with and commercial sectors, as well management; National Institute for Health originally started at our hospital, the Royal Manchester Children’s hospital comorbidities: refer to a general as local communities, to become and Care Excellence 2014 Clinical Guideline (RMCH), with the aim of tackling childhood obesity in Greater Manchester. paediatrician at their local hospital. involved through contributing their [CG189] (bit.ly/34ddZc2). 3 Children with a BMI > 99.6th skills, knowledge and influence to bring 2 Manchester Joint Strategic Needs Assessment 2015/16, Children and Young Childhood obesity and excess weight of their weight, to the strong association 1993 and 2011, and about 3 in 10 about changes needed to achieve a centile with two comorbidities: refer People (Starting Well And Developing Well), family-based approach. This has been are significant health issues for individual between obesity and a wide range of children aged between two and fifteen to paediatric endocrinology service. (bit.ly/2UsDDoP). through a wide range of interventions children, their families, and public health, chronic illnesses such as diabetes and years were overweight or obese.1 3 Manchester City Council Report for it can have some serious implications heart disease. Other challenges could Using the POOCH guide in the period aimed at tackling obesity and improving Information, Children and Young People for the physical and mental health of a be faced when some drug dosages between January and June 2018, 34.8% health through education, food Scrutiny Committee, 4th December, 2018 The Manchester picture public report pack, (bit.ly/2UsDHVB). child, which can then follow them into need to be adjusted to the ideal body of the children with a BMI above provision, physical activity, transport, and In 2013/14 The National Child 2 4 New UK- WHO 0-4 years growth charts adulthood. weight of the child instead of a total body the 91st centile have been referred behavioural change. Measurement Programme showed 2009, (bit.ly/2Uoi4Ws). weight, adding to that of planning the compared to none in 2017, we aim to As anaesthetists we are aware of the that the percentage of obese children We wanted to share our referral guide intraoperative course, positioning and improve that over the coming years. challenges imposed by childhood in Manchester during those years was and experience, as there has not been ventilation for a high-BMI child. One of the major benefits of our work obesity. From a preoperative perspective, higher than the national average. It was a formally published guideline for the was that we could now identify children these range from the poor emotional and According to the National Institute for also found that the prevalence of obesity preoperative referral of children with high in category 2 of (Figure 1), and so offer BMI to the appropriate services and for the physical health experienced by the child, Health and Care Excellence (NICE), UK is higher in the deprived areas.2 in 2018 those a daycase surgery in our main tackling of obesity at a preoperative level. such as bullying and poor sleep as a result obesity rates nearly doubled between a Manchester city council report showed

of metalloproteinase-2) are increased ■■ Blood sampling: 2 researchers at all Climate following the marathon.2 times for blood sampling. Lastly, the study was carried out on an ■■ Urine sample processing: 1–2 exposed section of beachfront in April. Runners were invited to participate in researchers. With wind-chill, the team were working three visits – at temperatures as low as 5°C, requiring Further task delegation included two Visit A – Baseline sample. appropriate clothing. Location: research tent located in the ‘spotters’ for Visit B who identified study marathon race village. participants in the stream of runners Learning points! coming through the finishing area and This was collected 24–48hrs pre-race. directed them to the research tent. To Space develop a good 3 ml of venous blood were taken for improve recognition, runners were given a relationship with event serum creatinine and a urine sample for wristband when they were enrolled in the organiser, and request biomarkers IGF7 and TIMP-2. study. Overall proceedings were overseen a suitably sized work space early. (We have Visit B – Immediately post marathon. by two researchers. Attendance at Visit asked the event team Location: finish-line tent in the enclosed A was naturally staggered, and Visit C for a larger finish-line finishing area. only saw 23 runners, making processing the study participants straighforward. The space for next year). Runners were intercepted as they walked race-day visit (Visit B), in contrast was, Team recruit help early – through the enclosed finish-line area, far more challenging, with the majority research at these with repeats of the same blood and urine of runners finishing within 90 minutes of events requires lots samples collected within 30 minutes of each other, and therefore arriving at the of helpers, especially completion. research tent in quick succession. The as the sample size Alex Hunter system rapidly saturated, and to deal increases. Visit C – 24 hours following the race. CT1 Anaesthetics Worthing Hospital with this, benches were employed to Location: locally hired room. Venous Sample/kit a time-consuming create an ordered queue. Team members blood and urine samples were taken. transport process, with the responsible for paperwork guided each hospital and lab being We recruited 91 marathon runners, using individual runner around the circuit and seven miles away, and a combination of the race organisers and out of the tent ensuring that all stations with the road closures local running clubs to disseminate study were completed. Runners were kept and pedestrian information. Eleven runners were not Anaesthetic research group comfortable with sugary snacks, hot restrictions in place intercepted, as they passed the research beverages and congratulations by the on race-day. tent and were thus lost to follow-up. research team. At full capacity, 40–50 Twenty-three runners returned for Visit C. Weather wrap up warm! at the Brighton Marathon runners were processed in under an hour. Todd Leckie, CT2 Anaesthetics; James Wright, CT1 Anaesthetics; Luke Hodgson, Consultant ICM/ Discussion Work space We hope this has given you an insight into our research group, and given insight into Respiratory; Richard Venn, Consultant ICM/ Anaesthetics; Worthing Hospital, Study team/task delegation Visit B tent was in a shared tent with the the challenges of carrying out research at Dan Fitzpatrick, Honorary Research Fellow, School of Sport and Service Management, The main image in this article highlights medical team. This resulted in a cramped a mass participant event. Results are being the large team required to run the study, working environment and limited University of Brighton written up currently and we aim to submit with shifts covered from Friday morning the number of runners that could be a paper to a suitable journal shortly. The Brighton Marathon Research Group is formed of anaesthetists, to Monday afternoon (around 28 hrs processed at any one time. There were total). Peak demand for helpers was the no significant limitations on space at Our ethics were approved via the intensivists, sports and exercise medics and scientists, who have been day before and on race-day, requiring Visits A and C. University of Brighton. conducting research at the Brighton Marathon since 2017. This account gives 10 and 11 people respectively. Each tent used a carousel system that ferried Transporting equipment References you an insight into our research, and discusses the logistical challenges of runners through data collection tasks. We transported all equipment from 1 Hodgson LE et al. Acute kidney injury carrying out a study at a marathon event. Helpers were deployed as follows – a central stock (local hospital) to the associated with endurance events—is it a research tent in the morning at the start cause for concern? A systematic review. BMJ ■■ Paperwork: 2–4 researchers were of each day. Collected samples were Open Sport Exerc Med 2017;3:e000093. In 2019, the Brighton Marathon aimed to establish whether the rise new renal biomarkers implicated in doi:10.1136/bmjsem-2015- 000093. tasked with completing enrolment stored in a cool bag, and at the end of Research team conducted the ‘Renal in creatinine that is associated with detection and prognostication of acute 2 Kashani K et al. Discovery and validation of paperwork and post-race and follow- each day transported to the hospital lab. Function in Marathon Runners’ study. endurance running is reflective of kidney injury (insulin-like growth factor- cell cycle arrest biomarkers in human acute up questionnaires. As a brief background, the study intrinsic renal injury,1 and whether two binding protein 7 and tissue inhibitor kidney injury. Crit Care. 2013;17(1):R25.

Dr Michelle White Consultant Anaesthetist, Great Ormond Street Hospital, London Medical Capacity Building Consultant

R CoA: Tell us a bit about yourself. you are going to die, that is perceived and quality of surgical and anaesthesia Did you know much about being a as a curse and you will die. The patient care, and not to impose western values remote educational supervisor before was naturally horrified at the thought and western-designed solutions, or to you started? of a doctor uttering a curse to kill him. tick a box on a training module. A remote MW: Since 2017 I have been a in such a culture, therefore, what the educational supervisor should be able to consultant at Great Ormond Street patient expected was for the doctor to help a trainee develop this perspective; Hospital. However, I started my say something along the lines of ‘the otherwise we will end up by creating, consultant career in Bristol in 2007 in outcome is in the hands of the gods’. As at best, a generation of ‘do gooders’, paediatric anaesthesia and intensive I learnt more about the different cultures at worst, a new 21st century form of care. In 2012, I resigned and worked I was working in I had sympathy with colonialism. for Mercy Ships* for five years, where this view: after all, who of us as doctors RCoA: Can you share your most I was involved in setting up a number really knows what is going to happen! interesting experience so far from your of RCoA fellowships for trainees, Nearly every patient I met had a story time as a remote educational supervisor? including arranging remote educational to tell about curses, witch doctors and supervision. traditional healers, and many of these had MW: In addition to the one about no rational or logical explanation. breaking bad news, another memorable RCoA: How long have you been a occasion was helping a trainee understand AN INSIDER’S VIEW remote educational supervisor? Why did If we don’t take a step back and try to why not keeping the laryngoscope with you put yourself forward for this role? understand cultural differences we can end you in theatre all the time your patient is MW: I’ve been involved for about six up becoming arrogant. Instead of taking anaesthetised might actually be a sensible years through Mercy Ships. On returning our western traditional values and thinking plan, not a dangerous one. There was only Being a remote educational to England, it was a natural progression ‘we’re right, they’re wrong’, something I one laryngoscope shared between four to stay involved as a remote education found it helpful to remember was ‘it’s not theatres, so it was kept at a central location supervisor with Mercy Ships, and also necessarily wrong, it’s just different’. where everyone knew where it was. supervisor more recently with King’s College RCoA: What are the important qualities London, where I am involved in research RCoA: If you could give one piece of with the Centre for Global Health. a remote educational supervisor advice to someone thinking about More than 1,700 of our fellows and members selflessly and enthusiastically should have? becoming a remote educational contribute their time, energy and skills to the work of the College, through RCoA: Can you share any experiences, MW: I think it is important for the remote supervisor, what would it be? roles ranging from examiners and committee members, to ACSA leads professional and personal learning or educational supervisor not only to have a MW: Please step forward and try it – you skillsets that you have gained through passion for developing the next generation can always step down if you don’t like it! and Advisory Appointments Committee assessors. Our 2018 membership your work with the College? of healthcare leaders (ie, our trainees), but * Mercy Ships is a faith-based international MW: People who work overseas for also to have had a personal experience of survey results showed that many more of our fellows and members would development organisation that deploys hospital the first time are often struck by the working in a low-resource or crisis setting. ships to some of the poorest countries in the also like to get involved in the work the College undertakes. This, the differences in approach to patient care. That way they can better help the trainees world, delivering vital free healthcare to people second ‘Insider’s View’ interview in the series, highlights these roles further For example, I can remember one process situations that they may encounter. in desperate need. www.mercyships.org.uk doctor struggling with the way bad news and provides you with a true taste of what they involve. was broken. The doctor wanted to tell However, I think the most important the patient using the model that we in quality for an RES is having an open This ‘Insider’s View’ interview is with of a named doctor’s educational doctors to learn by reflecting on cases the UK are taught is best practice, ie. mind to different ways of working Dr Michelle White, one of the College’s progress during a training placement and taking responsibility for patient care ensure the patient understands that they and being open to different cultural remote educational supervisors in a low- or middle-income country. while adhering to clinical governance have an incurable disease and they are values and expectations. We should be To find more about being (RES). An RES is a trainer who is The RESs will help training doctors and patient safety standards. going to die. However in some animistic aiming to serve the local population, a Remote Educational appropriately trained to be responsible with their professional and personal cultures the doctor is like a god whose and to collaborate in the design of for the supervision and management development. They support training Supervisor, please contact: role is to heal, and if the doctor says solutions that will improve the equity © Mercy Ships © Mercy [email protected]

NIAA Research Grants Results of 2019 Round 1 LETTERS TO THE EDITOR On Wednesday 26 June the NIAA Grants Committee met to consider the first round of applications for 2019 on behalf of If you would like to submit a letter to the editor please email [email protected] the Association of Anaesthetists, Anaesthesia, and Barema, the British Journal of Anaesthesia (BJA) and the Royal College of Anaesthetists (RCoA), the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI), the Difficult Airway Society Dr David Bogod (DAS), the Obstetric Anaesthetists’ Association (OAA), Regional Anaesthesia UK (RA-UK), and the Vascular Anaesthesia Society of Dear Editor, Great Britain & Ireland (VASGBI). The committee considered 45 applications over nine categories for a requested sum of £1,871,840, and made 15 awards over six Is credentialing the future for pain medicine? categories to a value of £432,973. Success rate: 33% RCoA Bulletin;116:67 The successful applicants are listed in the following table and the project abstracts can be viewed online at Lorraine de Gray makes a logical case for credentialing in pain medicine. A note of caution is needed, however, if we are www.niaa.org.uk/2019---Round-1 not to follow the path of doctors in the USA. When I was a clinical fellow at the Mayo Clinic some years ago, I was appalled Minutes from all NIAA grant committee meetings are available at www.niaa.org.uk/NIAA-Grant-Committee-Minutes that the renal physicians were not allowed to give an opinion on the retinal changes in a patient with severe kidney disease. Only the eye doctors had the credentials to look in the eyes! In a broadly based interdisciplinary area like pain medicine, Association of Anaesthetists/Anaesthesia Research Grants any credentialing needs to be flexible enough to allow for a degree of common sense.

Dr John Andrzejowski Plastic levels in intravenous crystalloid solutions stored in fluid-warming cabinets £1,920 Professor David Hatch Dr Adam Boulton Moral distress amongst intensive care unit professions in the UK (MODEST) £4,867 Retired Anaesthetist Dr Rachel Collis mSeP: Improving outcomes in maternal sepsis using physiological and biological markers £30,661 Dr Brian W Johnston PREdiction of new-onset atrial FIBRillation In criticaLly iLl septic pATiEnts (PRE-FIBRILLATE) £11,751 Dr Karen Kerr To assess the feasibility of using the 6-minute walk test during a patients first visit to £12,820 surgical outpatient clinic to identify those individuals with a significantly reduced level of cardiorespiratory fitness Dr William Rook Can continuous non-invasive monitoring improve stability of intraoperative blood pressure £6,330 (iSTABILISE) – a feasibility controlled trial Association of Anaesthetists/Barema Joint Research Grants The College Shop Dr John Bramwell Investigating the ability of cardiopulmonary exercise markers to predict successful £28,685 extubation in intensive care (CPEXtubate) Led by our commitment to environmental responsibility, we are pleased to annouce that our College Shop has added Dr Federico Formenti Continuous arterial oxygen monitoring to personalise ventilatory strategies £33,412 items such as an eco-friendly RCoA branded travel cup and APAGBI Small Research Grant water bottle.

Dr Robert Dickinson The effect of xenon-treatment on the developing brain following paediatric neurotrauma £39,925 As well as being useful and attractive items, these are a BJA/RCoA Project Grants great way to show your involvement with, and commitment Dr John Blaikley Ventilating circadian rhythms: a novel cause of circadian disruption? £69,929 to the College and the specialty. Dr Gareth Kitchen Visit our website at bit.ly/College-Shop for more information. Dr Ben Creagh-Brown Muscle wasting in major abdominal surgery (MAMAS) 2 £24,970 Professor Rupert Pearse Post-operative carer led monitoring (P-CALM) £49,820 DAS Small Grant Dr Cyprian Mendonca Temporomandibular joint dysfunction following the use of a supraglottic airway device £4,090 OAA Large Project Grants Dr Gareth Ackland EPIFEVER-2: personalised genomic medicine to guide labour analgesia £59,782 Dr Reshma Patel National obstetric anaesthesia health audit research and patient-centred outcomes project £54,011 1 (NOAH’s ARC 1): neuraxial anaesthesia for obstetric surgery bit.ly/College-Shop [email protected]

Dr Peter Featherstone RCoA Heritage Committee Member and Consultant in Intensive Care Medicine and Anaesthetics, Dr Peter Featherstone AS WE WERE...Cambridge University Hospitals NHS Foundation Trust RCoA Heritage Committee Member and Consultant in Intensive Care Medicine and Anaesthetics, Christmas at Humphry’s Cambridge University Hospitals NHS Foundation Trust

In his quest to discover the properties of nitrous oxide, Humphry Davy (1778–1829) was no stranger to self-experimentation. On 23 December Having recovered by Boxing Day, Davy quarters of an hour…the pleasurable the discoveries I had made during the resolved to inhale nitrous oxide ‘in such feelings continued to increase….I experiment. I endeavoured to recall the 1799, Davy (who was ‘little accustomed to wine or spirits, and had never quantities, as to produce excitement had now a great disposition to laugh, ideas, they were feeble and indistinct; been completely intoxicated’1) decided to examine the effects of nitrous equal in duration and superior in luminous points seemed frequently one collection of terms, however, intensity to that occasioned by high to pass before my eyes, my hearing presented itself: and with the most oxide following the excessive consumption of alcohol: intoxication from opium or alcohol’. was certainly more acute and I felt intense belief and prophetic manner, a pleasant lightness and power of I exclaimed...“Nothing exists but ‘At four PM…I drank a bottle of the pulse feeble and quick. In this state and depression not very different in ‘On December 26th, I was enclosed exertion in my muscles. In a short time thoughts! – the universe is composed wine in large draughts in less than I breathed for near a minute and half degree from those existing before the in an air-tight breathing box…in the the symptoms became stationary....I of impressions, ideas, pleasures and eight minutes. Whilst I was drinking, five quarts of gas [nitrous oxide]...but as experiment succeeded.’1 presence of Dr Kinglake. After I had now came out of the box, having been pains!” ’ I perceived a sense of fullness in the it produced no sensations whatsoever, taken a situation in which I could, in precisely an hour and a quarter. The head, and throbbing of the arteries, and apparently rather increased my by means of a curved thermometer Reference moment after, I began to respire 20 not unanalogous to that produced in debility, I am almost convinced that inserted under the arm, and a stop- quarts of unmingled nitrous oxide… 1 Davy H. Researches, chemical and the first stage of nitrous excitement. it was from some accident, either watch, ascertain the alterations in my philosophical, chiefly concerning nitrous my visible impressions were dazzling After I had finished the bottle, this common air, or very impure nitrous pulse and animal heat, 20 quarts of oxide, or dephlogisticated nitrous air, and and apparently magnified, I heard its respiration. J Johnson, St. Paul’s Church– fullness increased, the objects around oxide….The head-ache and debility nitrous oxide were thrown into the box. distinctly every sound in the room and yard, London 1800. me became dazzling, the power of still however continuing with violence, For three minutes I experienced no distinct articulation was lost, and I I examined some nitrous oxide which alterations in my sensations, though was perfectly aware of my situation. By was unable to walk steadily. At this had been prepared in the morning, immediately after the introduction of degrees as the pleasurable sensations moment the sensations were rather and finding it very pure, respired seven nitrous oxide the smell and taste of increased, I lost all connection with pleasurable…the sense of fullness in quarts of it for two minutes and half. I it were very evident. In four minutes external things; trains of vivid visible the head soon however increased as was unconscious of head-ache after the I began to feel a slight glow in the images rapidly passed through my to become painful and in less than an third inspiration; the usual pleasurable cheeks, and generally diffused warmth mind and were connected with words hour I sunk into a state of insensibility. feeling was produced, voluntary power over the chest. In ten minutes…20 in such a manner as to produce In this situation I must have remained was destroyed, and vivid ideas rapidly quarts more of nitrous oxide were perceptions perfectly novel. I existed for two hours or two hours and half. passed through my mind… Immediately thrown into the box, and well-mingled in a world of newly connected and I was awakened by head-ache and after the exhilaration had disappeared, with the mass of air by agitation…. In newly modified ideas. I theorised; I painful nausea. The nausea continued I felt a slight-return of the head-ache; 30 minutes, 20 quarts more of gas were imagined that I made discoveries. Sir Humphry Davy. Oil Painting. even after the contents of the stomach it was connected with transient nausea. Credit: Wellcome Collection. introduced. My sensations were now When I was awakened from this had been ejected. The pain in the After two minutes, when a small quantity Reproduced under Creative Commons pleasant; I had a… sense of exhilaration semi-delirious trance…my emotions head every minute increased; I was of acidified wine had been thrown Attribution (CC BY 4.0). similar to that produced by a small dose were enthusiastic and sublime….As I neither feverish or thirsty; my bodily from the stomach, both the nausea and of wine, and a disposition to muscular recovered my former state of mind, and mental debility were excessive, and head-ache disappeared; but languor motion and to merriment. In three I felt an inclination to communicate For more information about the Heritage Committee please email [email protected]

Dr Elin Jones (Birmingham Wales North West Emily Buckwell Children’s Hospital) in Susan Yeung Ngok Kao Mohammed Akuji Isra Hassan succession to Dr Janet John Barrett NEW TO THE West of Scotland Warwickshire Stansfield Michael Charlesworth Jhalini Jawaheer Nancy Cox Anver Donnelly Niall O’Reilly Alastair Fairfield Yorkshire and the Amy Glenn COLLEGE Humber Yin Loo Wessex July 2019 South Yorkshire Fiona Martin Heidi Artis The following appointments/ Barts & The London Dr Nina Plant (Acting Tutor at Ananya McCarthy Li Gan Shylesh Aravindan Dual ICM re-appointments were approved Sheffield Children’s Hospital) Graham Nelson James Plumb Sarah Greenaway (re-appointments marked with Zoe Parry West of Scotland Ross Hutchison Clifford Shelton Certificate of Elizabeth Beattie an asterisk). Simon Trundle Steven Tran Completion of Robert Bonar Thomas Walton College Tutors Northern Training Birmingham Yvonne Bramma Felicity Corcoran Philip Hamilton Wales Dr Fiona Smith (James Cook To note recommendations Northern University Hospital) Benjamin Smith Jonathan Fortune John O’Donoghue Dr Shrisha Shenoy (Ysbyty made to the GMC for Elaine Winkley Emily Robertson Glan Clywd) in succession to approval, that CCTs/ East Midlands South West Alvin Soosay Dr James Dougherty CESR (CP)s be awarded David Green Northern Ireland Peninsula to those set out below, William Watson East of England Najmiah Ahmad *Dr Harsha Reddy (Wrexham Dr Mark Human (Torbay who have satisfactorily Sarah Chetcuti Dual ICM Simon Marcus West Yorkshire Maelor Hospital) Hospital) in succession to Dr completed the full period of Michael Carrick Joel Chin Alexandra Murphy Andrew McEwen higher specialist training in James Reid Tasmeen Ghafoor England Fiona Faulds Anaesthesia, or Anaesthesia Carl Ilyas Dr James Cockcroft (Royal Vikram Malhotra Dual ICM oxford London with Intensive Care Medicine Paramesh Kumara Devon & Exeter Hospital) in David Wotherspoon Jamie Strachan Dual ICM or Pre-Hospital Emergency Jonathan Moore North Central London Joint ICM succession to Dr Katharine Medicine where highlighted. East of Scotland Laura Vincent Dr Michael Gilhooly (Royal Meikle Katie Stewart Peninsula National Throat, Nose and June 2019 Ear Hospital) in succession to Severn Imperial Victoria Field Barts & The London David Hutchins Dr Mark Lambert Dr Mala Greamspet (Great Simon Braude Reshma Patel Dual ICM Western Hospital) in Richard Doyle Jonathan Rivers St George’s Suresh Sanapala succession to Dr Jill Dale Kent, Surrey & Sussex Severn Dr Ian Lambert (Croydon East & North Yorkshire Katyayani Ruth Greer University Hospital) in West Yorkshire Christopher Smales Dual ICM Dawn Harpham Sian Moxham succession to Dr Rahim Dr Thomas Scarrott (Bradford East Midlands Yin Ng Ahmed Royal Infirmary) in succession Mersey Ileana Antonopoulou Joint ICM Peter Steed to Dr Samantha Kritzinger Sanjay Desai Dr Zacharia Jose (Croydon Barbara Stahl Sarah Warwicker Amy Hill Dual ICM University Hospital) in Dr Gemma Woodward Kent, Surrey & Sussex Martin Kelly South East succession to Dr Vanessa (Calderdale & Huddersfield Vidhi Patle Carol Kenyon Ali Watts Cowie Foundation Trust) in Claire Lister South East Scotland succession to Dr Stephen Hill North West Joint ICM North West Jennifer Eccles North Central London Thomas Craven Dr Rachel Hopper (Salford Richard Gordon-Williams Alasdair Ruthven West Midlands Peninsula Royal NHS Foundation Trust) Tal Heymann Birmingham David Levy Stoke in succession to Dr Abdul Raj Shah Dr Michael Clarke Karthikeyan Nagarajan Lalkhen South East Sarah Wintle Dual ICM (Worcestershire Royal Selvaraju David Hutchinson Dual ICM Hospital) in succession to North of Scotland Dr Kate Bailey (Salford Royal Wales Dr Gavin Nicol David Nesvadba NHS Foundation Trust) in St George’s Michael Adamson succession to Dr Stuart Dolling Rita Saha Catherine Britton-Jones

APPOINTMENT OF FELLOWS APPOINTMENT OF MEMBERS, TO CONSULTANT AND SIMILAR ASSOCIATE MEMBERS AND POSTS ASSOCIATE FELLOWS The College congratulates the Associate Fellow Dr David Tyl following fellows on their consultant appointments: Associate Members Dr Alexander D Wilson Dr Michael Adamson, Cardiff and BJA Peer Review Applications for Dr Cristina Uguccioni Vale University Health Board Dr Chidiebele S Ikenga Dr Ileana Antonopoulou, Queens Fellowship Editor, British Journal Dr Mary Gunasekaran Medical Centre, Nottingham Dr Rubeena A Magloo Dr David Buckley, Royal Victoria A key ambition of the BJA is to foster our research community by addressing Dr Mahesh Eddula Infirmary in Newcastle the needs of individuals in the early stages of their independent clinical and/ of Anaesthesia Dr Nemanja Mijajlovi or academic careers. Demystifying the peer review process through the early Dr Elitsa M Mileva Dr Helen Cronshaw, Northampton The British Journal of Anaesthesia (BJA) invites applications for two development of peer reviewing and editorial skills is essential for clinical Dr Sanjeev K B Marulaiah General Hospital new editors to begin in 2020. The appointment will be for a five-year and non-clinical academic researchers, although seldom addressed during Dr Jack E K E Khalil term in the first instance, renewable for a further five years subject to Dr Henry Jefferson, Oxford higher degree and/or postdoctoral training. We have therefore launched the Dr Enoch O Onya University Hospitals NHS performance. BJA Editorial Fellowship, which is designed to train and mentor early career Dr Husham H A M Mohammed Foundation Trust researchers from all disciplines. Applicants may either be clinicians interested in The BJA, first published in 1923, is a global anaesthesia journal publishing Dr Deepika Arora Dr Bianca Kuehler, Chelsea contributing or junior faculty undertaking postgraduate degrees or already with original clinical, translational and fundamental research and reviews in Dr Lubna Shaheen and Westminster Hospital NHS academic appointments. areas of anaesthesia, perioperative medicine, critical care and pain, with Dr Meghana M Hipparagi Foundation Trust a focus on clinically relevant research and education. Special expertise in Dr Maureen Estrada Up to two successful Fellows will receive behind-the-scenes insight into Dr Gopal M Tripathi Dr Eoghan McGrenaghan, North one or more areas is desirable; we anticipate appointing one editor who Manchester General Hospital the review process at the BJA for 12 months, in accordance with both our Dr George Pitchers has expertise in pain management to complement the expertise of the continuing professional development and conflict-of-interest policies. Fellows Dr Rohit A Kooloth Dr James Reid, Belfast Health and current editorial board. Social Care Trust will be matched for 12 months with a BJA Editor, initially undertaking monthly Dr Ahmed M A A Abdelaal mentoring on one (or more) submitted manuscripts. Travel expenses will cover Eligible applicants should be engaged in a substantive academic or Dr Mohamed H F H Abdallah attending one editorial meeting during the 12-month period where fellows can clinical position, with significant clinical and/or research experience in Dr Yashodhan V Joshi meet with each other, as well as the Editor-in-Chief, editors and publishing staff. one or more fields of anaesthesia and pain management. Applicants Dr Abhinav Gupta CONSULTATIONS The BJA anticipates that the Fellowship will strengthen their roles as reviewers, should have experience in the preparation, submission and review of Dr Anamika Kansal authors and grant applicants. high-quality articles for publication. Dr Eeswary Sundaramurthy The following is a list of consultations Dr Sharoz Rayhanal which the College has responded Eligibility Responsibilities of BJA editors include: handling and deciding on Dr Surbhi Abrol to in the last two months. Those ■■ A postgraduate degree (MD(res), PhD) is desirable. approximately 100 manuscripts per year; commissioning articles and Dr Joseph Halaka published on the College website editorials; commitment to innovation and development of the journal; ■■ Formal evidence for pursuing either clinical or university-based research. Affiliate Mr Brian Corrin via our Responses to Consultations Examples include registration for higher degree or being a principal attending and contributing to at least one of two editorial board area (bit.ly/RCoA-consultations) are investigator for a clinical study. meetings held each year (one in London and one elsewhere); assisting marked with an asterisk. the editor-in-chief by providing editorial expertise and reviewing articles ■■ Recent authorship (within the last three years) will receive priority. DEATHS submitted for publication; and ensuring that all editorial tasks and With regret, we record the death of those deadlines are met promptly. Originator Consultation Submission process listed below. ■■ Please submit a cover letter detailing the reasons for your interest Health The Future If you are interested in joining an outstanding and collaborative team Dr Iain C M Gray, Fife and eligibility, plus a two-page CV with email contact details to: Education Doctor – Call of international editors committed to advancing academic anaesthesia, Dr Ponniah Janaganathan, Nedlands, [email protected] England for Evidence please send a one-page covering letter detailing your interest in and Western Australia ■■ For informal enquiries, please contact: [email protected] or potential contributions to the journal, as well as a brief CV that includes Dr Alexander G Kidd, Surrey Cabinet Office/ Green Paper: [email protected] publications, employment history and relevant experience to the editor- Department Advancing Dr Helen L Spencer, Carlisle in-chief, Professor Hugh Hemmings, at [email protected] of Health and our health: Please submit obituaries of no more than Social Care prevention in Application deadline is 22 December 2019, for a start by 31 December 2019. 500 words to: [email protected]. the 2020s in January 2020. British Journal of Anaesthesia is a Charitable Company Limited by Guarantee. Charity no. 1121817 (England & Wales), SC 039825 (Scotland), Company no. 06410445. All obituaries will be published on the College website (www.rcoa.ac.uk/obituaries).

| 67 WINTER SYMPOSIUM 2019 Patient safety, health and wellbeing 10–11 December 2019 RCoA, London

Keynote speakers:

■■ Dr Clare Gerada, GP and Medical Director, Practitioner Health Programme (PHP)

■■ Professor Donal Buggy, Consultant Anaesthesiology and Perioperative Medicine, The Mater Hospital, Dublin

■■ Dr Matthew Tuck, Associate Professor of Medicine, George Washington University

■■ Professor Simon Gregory, Director and Dean of Education and Quality, Health Education England (HEE)

www.rcoa.ac.uk/winter-symposium-2019

Updates in Anaesthesia AIRWAY COURSES Critical Care and Pain Tracheostomy Masterclass Management 10 January 2020 | RCoA, London 4–6 November 2019 | The Studio, Birmingham Airway Workshop 25–27 February 2020 | RCoA, London 4 February 2020 | RCoA, London

CPD credits 15 %

Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, % Foundation Year Doctors and Medical Students. See our website for details.

ANAESTHETISTS EXAM REVISION AS EDUCATORS LEADERSHIP AND

CPD COURSES approved % MANAGEMENT COURSES 2019–2020 Our series of Anaesthetists as Educators events support clinical educators in delivering high quality training and education in the workplace. Participation in the courses provides supporting evidence towards the GMC approval Have you ever thought of going into non-clinical management in the NHS but are uncertain of where to start? process for trainers. There was never a time when an anaesthetist needs leadership and management skills more than today. Teaching and Training in the Workplace Join us for one of our workshops designed to give you confidence and support, drawing on the most up to date | RCoA, London 14–15 November 2019 experiences of the leadership and management professionals as well as NHS leaders. 10–11 February 2020 | RCoA, London

Advanced Educational Supervision An Introduction: the essentials 28 January 2020 | Leeds 3–4 March 2020 | Sheffield Anaesthetists’ non-technical skills 5–6 May 2020 | London 22 November 2019 | RCoA, London Gain a deeper understanding of how the NHS works as 27 April 2020 | RCoA, London well as your own strengths and weaknesses to increase your impact and effectiveness as a leader on this two day course.

Cardiac Symposium 23–24 April 2020 | RCoA, London Working well in teams 20 November 2019 | London Participants on this course will enhance their Primary FRCA Revision Course understanding of how to lead effective teams through the introduction of basic tools and frameworks that can | RCoA, London 14 – 17 January 2020 be applied in your workplace. A highly rated 4-day intensive course of lectures and MCQs covering key and difficult subject areas. An opportunity to compare your knowledge against other candidates.

Personal effectiveness Final FRCA Revision Course 19 March 2020 | London 20 – 24 January 2020 | RCoA, London Consisting of interactive group exercises, plenary This revision course is designed for those who are sessions and discussions, these workshops will help preparing to sit the Final FRCA Examination. you develop your skills in how to handle a range of situations as a leader, including dealing with challenging You will gain detailed knowledge on topics covered in the relationships and conflict. exam syllabus, and will leave with a better understanding on what examiners are looking for when marking answers to exam questions. BOOK EARLY TO AVOID DISAPPOINTMENT

Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, % Foundation Year Doctors and Medical Students. See our website for details. % Foundation Year Doctors and Medical Students. See our website for details.

70 | Book your place at www.rcoa.ac.uk/events Book your place at www.rcoa.ac.uk/events | 71

18–20 May 2020 Old Trafford, the Home of Manchester United www.rcoa.ac.uk/anaesthesia

Co-badged with: SAVE 10% Limited early bird places available – quote EARLY10 when booking

Book your place at: www.rcoa.ac.uk/anaesthesia