SURGICAL NEWS the royaL Australasian College of Surgeons Vol 15 No 8 / SEPTEMBER 2014

Behind the mask Dr Wisam Ihsheish’s humanitarian aid work p30

Global Health Successful Scholar William Kaptigau leads Corey Scholes’ research for neurosurgery in PNG advancing orthopaedics The College of Surgeons of Australia 20 24 and New Zealand contents 17 18 Working on Director of Alcohol Surgery, Mr Related Brian Kirkby Harm

that regular a second pages doesn’t 4 PD Workshops 10 relationships & Advocacy 12 Surgical Snips skin… irritate 14 Dr BB G-loved 15 Curmudgeon’s Corner 16 Case Note Review the first 50 Book Club

The GAMMEX® Non-Latex product line delivers the most complete range of non-latex surgical 38 gloves. GAMMEX® Non-Latex gloves include options that not only protect you and your patients from latex allergies, but also type IV chemical allergic Correspondence to Surgical News should be [06] The fair fee issue reactions. sent to: [email protected] Letters to the Editor should be sent to: SURGICAL NEWS College President speaks out THE ROYAL AUSTRALASIAN COLLEGE OF SURGEONS GAMMEX® NON-LATEX SURGICAL GLOVES - [email protected] VOL 15 NO 8 / SEPTEMBER 2014 [20] Surgical advances in PNG FOR BEST-IN-CLASS HAND PROTECTION. T: +61 3 9249 1200 F: +61 9249 1219 W: www.surgeons.org Extraordinary effort by former ISSN 1443-9603 (Print) / ISSN 1443-9565 (Online) Rowan Nicks Scholar To find out more or request a Surgical News Editor: David Hillis sample, please call 1800 337 041 or © 2014 Royal Australasian College of Surgeons [28] Surgical research event visit www.medical.ansell.com.au All copyright is reserved / The editor reserves the rights Rich program over two days in November to change material submitted / The College privacy policy and disclaimer apply – www.surgeons.org / [34] Handwriting challenges The College and the publisher are not responsible for errors or consequences from reliance on information in Poor handwriting still a concern GAMMEX® Non-Latex range minimises the risks of type IV this publication. Statements represent the views of the Behind the mask Dr Wisam Ihsheish’s humanitarian aid work p30 allergies and skin irritations, but some chemicals contained in author and not necessarily the College. Information is [38] Buttons and bows ® not intended to be advice or relied on in any particular GLOBAL HEALTH SUCCESSFUL SCHOLAR GAMMEX Non-Latex gloves may cause allergic reactions or William Kaptigau leads Corey Scholes’ research for neurosurgery in PNG advancing orthopaedics The College of Stories of times past circumstance. / Advertisements and products adver- Surgeons of Australia irritations in some users. 20 24 and New Zealand tised are not endorsed by the College The advertiser Ansell, ® and ™ are trademarks owned by Ansell Limited or one of its takes all responsibility for representations and claims / on the cover: Dr Wisam [44] Sir Benjamin Rank Published for the Royal Australasian College of Surgeons affiliates. © 2014 Ansell Limited. All rights reserved. Ihsheish’s humanitarian aid work by RL Media Pty Ltd. ACN 081 735 891, ABN 44081 Scholarship pays tribute to renowned 735 891of 129 Bouverie St, Carlton. Vic 3053. Copyright: Camille Gillardeau/MSF. plastic surgeon WWW.MEDICAL.ANSELL.COM.AU 2 14 professional development workshops & activities

Safer Australian Surgical Teamwork competencies and increase awareness of Training Non-Technical Skills for Surgeons (NOTSS) Standards in the workplace, including the ability to 2 October - Bega, NSW interpret standards and use them to assess own and 24 October - Launceston, TAS September-November The Royal Australasian College of Surgeons (RACS) with the other’s performance. The NOTSS workshop focuses on the non- technical skills Australasian College of Anaethetists (ANZCA), the Australian which underpin safer operative surgery. It explores a College of Nursing (ACN) and Australian College of Operating behaviour rating system developed by the Royal College Clinical Decision Making (CDM) Room Nurses (ACORN), is offering a combined workshop for of Surgeons of Edinburgh which can help you develop ACT QLD surgeons, anaesthetists and scrub practitioners working in 24 October, Melbourne; 29 October, Brisbane the knowledge and skills to improve your performance in rural and regional Australia. The workshop focuses on non- Clinical Decision Making (CDM) is a three hour workshop the operating theatre in relation to situational awareness, 10 October, Canberra 9 November, Gold Coast technical skills which can enhance performance and teamwork designed to enhance a participant’s understanding of communication, decision making and leadership/teamwork. Keeping Trainees on Track Supervisors and Trainers for in the operating theatre thus improving patient safety. their decision making process and that of their Trainees Each of these categories is broken down into elements or (KTOT) SET (SAT SET) and colleagues. The workshop provides a roadmap, or behavioural markers that indicate can be used to assess your Keeping Trainees on Track (KTOT) algorithm, of how the surgeon forms a decision. This own colleagues. This activity is proudly supported by AVANT. NSW SA 18 October, Newcastle; 22 October, Wellington algorithm illustrates the attributes of expert clinical This 3 hour workshop focuses on how to manage trainees by decision making and was developed as a means to Academy of Surgical Educators Forum 2 October, Bega 13 November setting clear goals, giving effective feedback and discussing address poor clinical decision making processes, 13 November - Adelaide, SA Safer Australian Surgical Academy of Surgical particularly as a guide for the supervisor dealing with a expected levels of performance. You can also find out more The evening will be convened by Associate Professor Stephen Teamwork Educators Forum struggling Trainee or as a self-improvement exercise. about encouraging self-directed learning at the start of term Tobin, Dean of Education and Professor Julian Smith, Chair, 18 October, Newcastle meeting. Academy of Surgical Educators and will feature preeminent Keeping Trainees on Track TAS Preparation for Practice thought leaders discussing progressive topics in medical (KTOT) education. Attendees will enjoy a three course meal and 24 October, Launceston Supervisors and Trainers for SET 25 to 26 October, Brisbane 18 October, Newcastle drinks whilst workshopping questions at their tables and Non-Technical Skills for 18 October, Newcastle; 21 October, Wellington; 20 This two day workshop is a great opportunity to learn Supervisors and Trainers for engaging in a Q and A session with the panel of experts. Surgeons (NOTSS) November, Melbourne. about all the essentials for setting up private practice. SET (SAT SET) The Supervisors and Trainers for Surgical Education and The focus is on practicality and experiences provided by 23-25 October, Sydney fellow surgeons and consultant speakers. Participants VIC Training (SAT SET) course assists supervisors and trainers Surgical Teachers Course to effectively fulfil the responsibilities of their very important will also have the chance to speak to Fellows who have 15 November, Sydney 29 September, Melbourne roles. You can learn to use workplace assessment tools experience in starting up private practice and get tips Building Towards Retirement Academy Educator Studio such as the Mini Clinical Examination (Mini CEX) and Directly and advice. This activity is proudly supported by proudly Session Observed Procedural Skills (DOPS) that have been introduced supported by the Bongiorno National Network, mlcoa, 24 October, Melbourne as part of SET. You can also explore strategies to help you Rooms With Style and MDA National. NZ to support trainees at the mid-term meeting. It is an excellent NHET Sim 23 September, Auckland opportunity to gain insight into legal issues. 24 October, Melbourne Building Towards Retirement Non-Technical Skills for This workshop is also available as an eLearning activity by Clinical Decision Making (CDM) logging into the RACS website. 15 November, Sydney Surgeons (NOTSS) 24 October, Melbourne Work is an important part of life so when you stop full Contact the Professional 21 October, Wellington Training Standards: Training Standards: Interpretation and time surgery or are approaching retirement, you need Development Department Supervisors and Trainers for Interpretation and Application to take time to plan for the next stage. It’s crucial that SET (SAT SET) 15 November, Melbourne Application (TSIA) as much thinking and planning are undertaken for life on +61 3 9249 1106, 22 October, Wellington Communication Skills for 24 October, Melbourne; 29 October, Brisbane after surgery as was given to building your career in the Keeping Trainees on Track Cancer Clinicians Training Standards: Interpretation and Application (TSIA) is first place. Surgeons who attend can expect to receive by email [email protected] (KTOT) a new course offering. This three-hour workshop expands information about retirement and motivation to plan for or visit www.surgeons.org 20 November Melbourne Supervisors and Trainers for on the concepts outlined in the Becoming a competent retirement, share the experience of retired Fellows to - select Health Professionals and proficient surgeon booklet developed by the College in stimulate interest in alternative careers and lifestyles QLD SET (SAT SET) 2012. The course aims to provide a baseline standard for and gain financial and legal management information then click on Courses & Events 21 November, Melbourne 25 to 26 October, Brisbane College educators in Competency Based Education, ensure and resources. This activity is proudly supported by Non-Technical Skills for www.surgeons.org/ Preparation for Practice that College educators know the required standards for proudly supported by the Bongiorno National Network Surgeons (NOTSS) for-health-professionals/ 28 October, Gold Coast Competent and Proficient performance across the nine RACS and mlcoa. register-courses-events Non-Technical Skills for /professional-development Surgeons (NOTSS) WA 29 October, Brisbane 25 September, Perth Clinical Decision Making Foundation Skills for Surgical Global sponsorship of the Royal Australasian College of Surgeons’ (CDM) Educators Professional Development Program has been proudly provided by Avant 29 October, Brisbane 15 November, Perth Mutual Group, Bongiorno National Network and Applied Medical. Training Standards: Building Towards Retirement Interpretation and Application (via weblink) president’s perspective

I am so proud that our College is “showing leadership in this area the Ongoing ” Discussion around Fees

Being silent will only further Michael Grigg erode our community standing President

ollowing June Council, I initiated a discussion predominantly occurring in the younger surgeons.” about the mounting concerns with excessive, “The latest one I heard about was an $8000 ‘booking Fextortionate fees. This has received positive media fee’… who knows what the eventual cost for surgery attention. Why have I done this? Well, I believe a major would be!” purpose of the College is to protect the professional “Fraud is obviously a legal term, so I will simply status of surgeons. That professional status is very much indicate that in spinal surgery, it seems relatively common dependent upon the simple equation of autonomy now to bill for services not rendered.” (the freedom to act in the best interests of patients) in “The trashing of the reputation of RACS, the Australian return for self-regulation. The vast majority of surgeons Orthopaedic Association and other professional act responsibly in terms of fees, but those who don’t, organisations is to be lamented and condemned.” encourage the perception of failure of self-regulation “Pressure also needs to be exerted on government and by the profession that in turn threatens the ongoing insurers who have created a situation of fee anarchy by professional status of all. their undermining of fair value.” The Council and I felt that it was important to provide “I would have rather more concerns about the very some leadership on this issue. The challenge was to move blatant fraudulent manipulation of the MBS item the College into an open discussion so that the views of numbers which is occurring all around us, than a fee the Fellows of the College could be clearly heard. agreed between patient and surgeon prior to surgery.” Thus far the response has been overwhelming. In my “I believe surgeons should be accountable for their fees nine years on Council, I have not seen another issue and I also believe that a system needs to be put in place where the Fellows making comments have been so vocally so GPs and patients are able to see the fees a particular positive and supportive of our stance. Certainly, we have surgeon will charge for a number of the main operative received emails of concern that the College has ventured procedures.” supporting the College’s stance. My interactions is applicable... Those orthopaedic surgeons abusing ‘into this minefield’. There are surgeons who are very “Patients also need to know that surgical fees have no with the AOA have been through the President the Medical Benefits Schedule are not contributing concerned that we might have any discussion at all with direct correlation to the surgeon’s skills.” of the AOA, Peter Choong. I know him to be to the honour and noble tradition of the medical the ACCC. The AMA has raised specific objections, which And perhaps it is best summed up by one response: highly motivated and passionately ethical – profession; quite the reverse. The AOA endorses the College will certainly need to evaluate carefully and “I am so proud that our College is showing leadership what else could one request of a colleague? In any action or actions by the Department of Human learn from. in this area”. the midst of all this discussion around fees, the Services to improve correct use of the MBS.” However, in the various Regional meetings that are And so, we shall continue. College needs to praise the stand by the AOA The College highlights this strong stand by the currently underway, the voices have been echoing what about the inappropriate use of item numbers. AOA on this important issue. It is sage advice for has been sent in correspondence. Comments have College praises the stand of the The AOA First Vice-President, Mr John Tuffley, all surgeons. included: in the latest AOA Newsletter wrote extensively “It is the College responsibility to become involved in Australian Orthopaedic Association about this issue. He highlighted that: So why are we in this discussion? these issues.” (AOA) about inappropriate use of “It would be timely for orthopaedic surgeons The AMA has been and is concerned about the “Excessive fees should be brought out into the open.” item numbers. to review the introductory and explanatory statements and submissions the College has been “Surgeons charging fees which can only be described as There have been suggestions of differences of opinion sections of the MBS Schedule, which lay out in making about fees, particularly to the current Senate rapaciously greedy is abhorrent and certainly brings the between the AOA and the College. I have not experienced detail how the schedule should be used. The Committee enquiry. Part of my response was: whole profession into disrepute.” these as President. Instead my experience has been intention and ‘spirit’ of the schedule is that for “As you say, the College of Surgeons does not “As far as I can determine, this is a culture shift that many Orthopaedic surgeons have contacted me almost every procedure, only one item number traditionally get involved in discussion around fees. u

6 Surgical News september 2014 Surgical News september 2014 7 president’s LETTERS TO perspective THE EDITOR

SURGICAL SKETCHES AND SILHOUETTES

This is an area where the AMA and many of the But the issue of fees is complex. As the College surgical specialty societies / associations are far more pointed out in its submission to the Senate EMPIRICISM The part active and appropriately so. However, there have been Committee enquiry, the failure of Medibank and Empiricism Letters to the Editor plays in scientific and surgical increasing concerns expressed by Fellows of the College private insurance agencies to keep pace with inflation development to the President and other Councillors about the is a recipe designed to increase ‘out of pocket’ costs. Companion volume to the Keystone text. negative impact of extortionate fees. This has moved And again, there is the issue of individuals claiming from anecdotal comments to survey based responses to be surgeons when we would not recognise them where the surgical profession and the standing of as such i.e., they are not Fellows of the College, but surgeons in the community is now under threat. The can still use the non-protected descriptor of surgeons. College will always step into a discussion where the These ‘surgeons’ often charge exorbitant fees utilising with the senses, then with the on those cold winter evenings, in the Simple to More on Penicillin mind’; I thought it was worth smoke-filled den, talking to the local legal recounting my experiences, on entities. Not far away was Grays Inn, off standing of the surgical profession is being eroded or our reputation and prestige to justify their charges, the development of the Keystone Lincoln’s Inn Fields, the legal precinct of save water n my dissertation on Empiricism in Flap. This word can refer to London where QCs are born and bred either the architectural concept and where Francis Bacon’s statue still negatively impacted.” but in doing so, unjustifiably harm us. They may be of an arch or the central theme resides. t was in early April 2014 when flicking or ideation of a philosophical process. His French contemporary Descartes note with interest ‘Surgical News’ (July, 2014), I touched through the obituaries in ‘The Age’ Even John F Kennedy used that word talked about Bacon’s non-metaphysical It will be eroded if the professional organisation of members of the AMA but they are not members of I Ithat I saw the anniversary notice of in his final speech when he described (abstract reasoned thinking) approach Francis Bacon’s death in 1626 describing the United States as the “keystone in the to science. Voltaire introduced him as Professor Catchpole’s upon the penicillin story. the English lawyer, who became Lord development of world peace” at that last the Father of scientific method to French I Chancellor of England, as a philosopher breakfast meeting in Dallas on that fateful audiences. Thus Bacon was the inventor surgeons, the College, does not make clear statements the College! and scientist, a man for all seasons and day in November 1963. My original of the process of discovering unwritten letter in the recent edition Since that time I came across some facts the father of Empiricism. Tragically terminology of an “arc” flap was improved laws from evidence of their application, he died of pneumonia in the English by Alan Breidahl’s suggestion of the combining empiricism and induction in about the appropriateness (or not) of manifestly The Vice President (David Watters) and I will be countryside while experimenting with word “keystone”. a way that was to imprint his signature the use of ice for the preservation of meat, While residing at the College of on the English scientific establishment. of ‘Surgical News’ (August that I was unaware of at the time. And I working on an eviscerated chicken. Surgeons in London, my Sunday evenings Bacon was the then guiding spirit of the As observational empiricism is a were sometimes spent in the local pub Royal Society. excessive fees. It will be eroded by lack of transparency meeting many Fellows at Regional meetings over basic tenet in any scientific process, and (dare I say decadently) the Seven Stars, The Angiotome concept, the 2 014 ). cannot recall it in the books by McFarlane even Aristotle said in paraphrase ‘first where I experienced warm English ale, neurovascular basis of the keystone, on fees for the public. It will be eroded by not the next two months. We need your opinions and 32 SURGICAL NEWS JULY 2014 The amount of water used and Williams about Florey and the focusing on the primacy of the patient in our clinical your advice. Separately the issue is being discussed during the surgical scrub Penicillin story. relationships. with the Presidents of all other Medical Colleges. was the subject of a small The SBS news commentary mentioned grey mould, obviously from some days in None of this is ‘news’. However, the groundswell I have been meeting with the ACCC to ensure that project we conducted in the fact that it was the Pfizer company in the sun beforehand. She must have been from the public, other professional groups and discussions about fees are not regarded as collusion 2009. I would direct Prof New York that delayed production because attuned to keep an eye out for various various government and regulatory authorities is and thus anti-competitive. The AMA is calling a Catchpole to our article in they wished to install patents on this impor- moulds in pieces of garbage. something that no professional membership based Round table to have broader discussion. RACS fully the ‘Australian Journal of tant discovery. This was unknown to me. She took that to the lab where organisation can ignore. The threat of accountability expects there to be divergent and sometimes firmly Rural Health’. It was the British biochemist Ernst production was being organised in the old replacing autonomy of professionals is very real as held views. Petterwood J, Shridhar Chain who isolated penicillin in the 1930s milk factory, using old milk cans, and it evidenced by the current ‘assault’ on the autonomy of We need to define the key principles that we will V. Water conservation in and insisted that patents in the UK should proved to be a bonus beyond belief. Plastic Surgeons by the private endorse. RACS will never establish a fee schedule. That surgery: A comparison apply, but Florey overruled him and said The next point in this story is that insurance industry. is for other groups like the AMA. However RACS does of two surgical scrub no, this is for the good of humanity and we penicillin mould proliferates under the need to be able to provide clear principles in the way techniques demonstrating will leave it untouched commercially. influence of maple syrup as a sort of that these issues should be approached. Our principles So where to the amount of water saved Incidentally this patent factor meant fertiliser to accelerate growth. currently include: next? using a ‘taps on/taps off’ that the National Health in the UK had to But to aerate the fluid medium in • Surgeons, like all professionals, are entitled to We know from technique. ‘Australian Journal pay royalties across the Atlantic. Need I which this whole concoction sat in the establish and charge fees for their clinical work. Government data of Rural Health’ 2009; 17: say also, it was the Pfizer company which milk cans, the production team found • Fee levels should be based on skills, experience, time that the vast 214–217. has reaped the benefits from the use of that bubbling in oxygen (the lining of the and resources used for the clinical services. majority of fees We found that a standard Viagra which was used initially in the bubble increased the surface area to allow • Surgeons should have established fee structures (more than 80 per surgical scrub used a mean treatment of Parkinsonism. One of the the reaction and accelerate the production that are justifiable (discounting of fees may be cent) of patients of 15.5L per scrub. Utilising a incidental effects of this prescribed drug in of penicillin) – which came out in appropriate in certain circumstances). in hospital do not ‘taps-on, taps-off’ technique the elderly male needs no elaboration. abundance. • Fees should not be regarded by involve an ‘out of led to a mean saving of 11L The second thing of interest is that they Whereas Florey at Oxford had a tea- their professional peer group as excessive or pocket’ expense, per scrub (p<0.001). needed a more robust penicillin mould spoonful for his first treatment of the rose disproportionate to the service provided. so most surgeons I agree that we need to than that sewn into the lining of Florey’s thorn prick in the face of the gardener with • Surgeons must not inhibit nor discourage a patient’s will not be personally emphasise the need for garments when he flew across to America periorbital cellulitis (who died), in New request for a second opinion with respect to either affected by the outcome of conservation of materials in via Lisbon. One should appreciate this York they were producing it in such vol- the course of treatment recommended or the fee this debate. surgery and the simple ‘taps- was done in case he was captured by the umes it was beyond their comprehension. to be charged. They must co-operate fully with the on, taps-off’ technique is one Germans during wartime. I finished off that story in the practitioner providing the second opinion. way in which we can do this. Fortuitously, the third thing of interest: Empiricism article about how it saved the Dr Joshua Petterwood a person by the name of Hunt happened lives of a quarter of a million injured US What else should be included? SET5 Orthopaedic to call into one of the fruit market squares soldiers and many others after the D-day Please let me know. This is a really important issue Registrar in New York city at midday and when all invasion. for our profession. We cannot be silent. St Vincent’s Hospital was finished came upon a cut cantaloupe Felix Behan Melbourne that was totally covered with this blue Victorian Fellow

8 Surgical News september 2014 Surgical News september 2014 9 Relationships and Advocacy

responsibilities as Fellowship Elected Councillors to act in the FELLOWSHIP ELECTED Election to best interests of the College as a whole. COUNCILLORS All Councillors are expected to attend and contribute to Current Fellowship Elected Councillors are: Why Vote? the meetings of their Regional Committee and to convey College Council accurately the decisions of Council and the reasons behind Retiring Members: them. Sean Guy Hamilton (Plastic & Reconstructive) WA Councillors are expected to be independent, demonstrate Simon Alan Williams (Orthopaedic) VIC leadership, promote and support the values of the College, Members who are eligible for re-election: work cooperatively and to willingly and energetically take on Phillip James Carson (General) NT government agencies charged with monitoring performance in any task asked of them by Council or the President! As one Lawrence Pietro Malisano (Orthopaedic) QLD the health system. A motivated and wise Council is a prerequisite takes on more senior positions on Council, the more time to being effective in these and many other areas of College and commitment is involved. Because Councillors only stand for re-election activity. No Councillors receive remuneration, though expenses every three years, the members not due for re- Candidates provide photographs and information about are reimbursed and training is provided, including funding election on this occasion are: David Watters themselves. The Fellows supporting their candidacy make for the Australian Institute of Company Directors graduate John Charles Batten (Orthopaedic) TAS Vice President brief statements about why they think they would make good course, which all Councillors are encouraged to do. The Spencer Wynyard Beasley (Paediatric) NZ Councillors. These statements are intended to assist you in knowledge and skills acquired are applicable to all aspects of he College is a not-for-profit organisation that is owned voting, whether or not you know the candidates. a surgeon’s life. Ian Craig Bennett (General) QLD by its members, now 7000 Fellows. It is governed As the College embarks on ever more rigorous advocacy on The majority of Councillors regard the time they serve on Graeme John Campbell (General) VIC by a Council of 25 Fellows who are elected by its behalf of our members, it needs the best talent making decisions T the Council as rewarding, a privilege and a significant life Catherine Mary Ferguson (Otolaryngology) NZ membership. The Council consists of 16 Fellowship Elected at the Council table. We need your vote. experience, despite the pro bono time and effort involved. Councillors, elected by all Fellows and nine Specialty Elected Please take the time to read about the candidates and submit Sally Jane Langley (Plastic & Reconstructive) NZ Being a Councillor might not appeal to all, but we still hope Barry Stephen O’Loughlin (General) QLD Councillors who are voted for only by those with a Fellowship in your vote. Electronic voting makes the process even quicker and that you will exercise your right to vote and give your mandate Richard Edward Perry (General) NZ the relevant Specialty. easier. The introduction of electronic voting in 2013 was a great to those elected. Fellows are entitled and encouraged to vote regardless of success and increased the number of returns. If you would like more information, please contact me Julian Anderson Smith (Cardiothoracic) VIC whether they are active or retired. There are more than 5800 [email protected] Philip Gregory Truskett (General) NSW active Fellows and just over 1000 who are retired. Responsibilities of being a Councillor Marianne Vonau (Neurosurgery) QLD On Friday September 19 you will receive an email with a link Becoming a Councillor is not a role Fellows take lightly. It means to the ballot to elect Fellows to vacancies on the College Council. becoming a company director with significant duties prescribed Vacancies and Current Councillors David Allan Watters (General) VIC The current elections whose results will be announced by the Why should you bother voting? in law. end of October will see the successful candidates commence Firstly, the authority of Council is enhanced by a strong Councillors hold a position of trust and have a fiduciary duty SPECIALTY ELECTED their terms as Councillors after the Annual General Meeting mandate from the Fellowship. to act in the best interests of you, the members. COUNCILLORS in May 2015. Each Councillor is entitled to stand for three Secondly, the authority of the College as a professional body is Duties include: There are nine Specialty Elected Councillors. Two current three year terms – nine years in total. Those who wish to enhanced by evidence of strong engagement by its membership. • to act in good faith in the interests of the College as a whole Specialty Elected Councillors are retiring and four are remain on Council after each three year term must be re- Thirdly, Councillors who are elected by a good proportion • to exercise care and diligence elected. eligible for re-election. of the Fellowship, feel a commensurate obligation to keep faith • not to improperly use their position or information For 2015, there are four vacancies in the category of with their electors by doing the best job they can on Council • to declare conflicts of interest and to not influence Council’s Retiring Members: Fellowship Elected Councillor with two current Councillors and to be held accountable. decision on those matters Michael John Grigg (Vascular Surgery) VIC standing for re-election. Not all Fellows may wish or be in a position to stand for • to prevent insolvent trading Alan Charles Saunder (General Surgery) VIC • to ensure appropriate records are kept. election, but by voting, every Fellow demonstrates their Members who are eligible for re-election: engagement with the organisation which after appropriate Councillors commit to not only attend Council and committee meetings, but to read agenda papers carefully, Julie Ann Mundy (Cardiothoracic Surgery) QLD training and assessment, bestowed their means of livelihood – There are six vacancies among the contribute to deliberations and to be accountable for decisions. Anthony Lloyd Sparnon (Paediatric Surgery) SA the Diploma of Fellowship. Specialty Elected Councillors. Council’s role is to set, monitor and review the College’s David Robert Theile (Plastic & Reconstructive Surgery) QLD The College aspires to champion surgical standards These are – and to this end actively promotes Continuing Professional strategic direction and budget, determine and review policies Neil Anthony Vallance (Otolaryngology Head & Neck and monitor their implementation by management, and to Cardiothoracic Surgery (264 Fellows) Development (CPD), lifelong learning, mortality and morbidity General Surgery (2,420 Fellows) Surgery) VIC audit and a Code of Conduct. On our patients’ and our Fellows’ ensure legal and reporting requirements are met. Specialty Elected Councillors are an important conduit for Otolaryngology Head & Neck Surgery (621 Fellows) The Specialty Elected Councillors who are not behalf we advocate on lifestyle issues such as the harm that Paediatric Surgery (168 Fellows) information between Council and the Specialty Societies, enabling due for re-election on this occasion are: can arise from excessive alcohol intake, the effects of smoking Plastic & Reconstructive Surgery (537 Fellows) the College to be the unified voice for surgery. They are expected Andrew James Brooks (Urology) NSW or obesity on health and operative outcomes and the risks in Vascular Surgery (226 Fellows) medical tourism. to have a close relationship with the Executive of their Societies. Bruce Ian Hall (Neurosurgery) QLD We ensure that surgeons have a voice and an influence on As a Councillor they have full voting rights and the same Roger Stewart Paterson (Orthopaedic Surgery) SA

10 Surgical News september 2014 Surgical News september 2014 11 surgical surgical snips snips

Standing tall Learning from Severely debilitated by the audit a spine defect, East Deaths resulting from Timorese teenager surgery have been reduced Margarita can now stand and are continually falling tall. After two years and each year. special weight treatment, The sixth annual report from she has finally had the the Victorian Audit of Surgical surgery she needed Quit advice from surgeons Mortality (VASM) shows that with the help of surgeon Controversy has been sparked with surgery is far from the risk it Michael Johnson. Working statements from Scotland that some doctors once was. hard to ensure that refuse to see patients who smoke. However, VASM Clinical Margarita understood the “Evidence shows that they would not do Director Barry Beiles also risks of the surgery, Mr well in treatment,” Vascular surgeon Zahid pointed out the importance Johnson was happy to Reza said. of feedback as part of the perform the operation Support for the right of surgeons to suggest Insurers playing doctor audit. “She could continue to patients attempt to quit before treatment is Many people are unaware that their health insurance may not cover reconstructive “[Feedback] is essential live as she is, but I got offered came locally. surgery after cancer, burns or accidents due to health insurers deeming the operations to the audit’s overarching the clear impression “If you’ve got to ration treatment, there as ‘cosmetic’. purpose, which is the from her that this was are better outcomes for those who are off A survey conducted by the Australian society of Plastic Surgeons found that eight out ongoing education something she wanted,” cigarettes,” Australian and New Zealand of ten people would not know that their policies excluded plastic surgery such as breast of surgeons and the Mr Johnson said. Society of Vascular Surgeons president reconstruction following a mastectomy. “Insurers are playing with people’s health with improvement of surgical care Daily Telegraph, Dr John Quinn said. their own bottom line in mind,” ASPS president Dr Tony Kane said. for all patients,” he said. August 9 news.com.au August 14 Sunday Telegraph, August 10 AusMed, August 19

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Royal Australasian College of Surgeons ANZSVS 2014 7-8 November 2014 Sheraton On The Park Perth 161 Elizabeth Street, Sydney, NSW

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12 Surgical News september 2014 R Surgical News september 2014 13 Surgeon Curmudgeon’s Health Corner

per cent of surgeons and up to oncogene activation, irradiation, 30 per cent of specialists reported having DNA damage, oxidative stress and suffered mental illness, few feel it is safe viral infection. Telomeres play to admit as much to their colleagues for an important part in all dividing How fast are fear of being perceived as dangerous or tissues, including the hippocampus, underperforming. the immune system and bone. you aging? Of course, this just makes their plight Oxidative stress among all its all the worse. It reduces their likelihood other ill effects is associated with shortening of telomeres. Depressive Conserving your telomeres of seeking help, appropriate treatment and/or support. Beyond Blue reported illness can also be associated with Does every a third of 51-60-year-old doctors had age-matched shortening – not suffered burn-out symptoms of emotional overnight, but over many years. problem have exhaustion and/or cynicism, though only Inflammation and thus cytokines to come down by professor grumpy 12 per cent believed it had affected their do sing the blues with their score of to ageing? professional efficacy. Similar findings have inflammatory and oxidative effects been reported from a US-based Medscape wailing through the body like a survey. requiem. Studies of telomere length Old timers Managing health have usually been performed on T L O’Meares already has some excess leukocytes, but oxidative stress abdominal adiposity. Lipids were slightly and deficient telomerase (an here is one thing that really annoys me and that is raised, blood pressure similarly. I checked enzyme that restores and repairs ageing. I know that the few readers I have under the iron and haemoglobin, thyroid function, telomeres) have also been shown to age of 50 will stop reading now as they are not aged contribute to telomere shortening T serum calcium (for hyperparathyroidism), nor will they age in their view. But the others might read on. Vitamin D, magnesium and B12. in oligodendrocytes of the brain. It is not ageing that gets at me, not the increase of numbers There were no dramatic changes Telomeres are shortened in war from one decade to the next (as happened to me recently), but though the magnesium was on the lower veterans with post traumatic stress the increasing minor symptoms that are damned annoying. A limit of the lab normal (total red cell disorder, victims of family violence single ache or symptom is fine – tolerable, even enjoyable for magnesium later proved low). There was and social disruption. There is an a dinner table conversation – but three or four are more than no argument from TL about treating association with Type 2 diabetes, one should really have to put up with. the depression, starting magnesium depression, poor sleep quality, high What is even worse is the attitude of some medical supplements and raising Vitamin D levels visceral adiposity and metabolic professionals. A painful big toe joint when one walks, a bowel to at least 70nmol/L – nor with taking syndrome. that does not absorb Mrs Curmudgeon’s culinary delights time off. Albert Schweitzer once said: properly, a heartbeat that is irregular are dismissed as “just o you ever wonder why some T L O’Meares was sleeping poorly and O’Meares asked initially whether it “The tragedy of life is what dies arthritis”, an “aging gut” and “age related dodgy ticker”. Well, patients and colleagues age had had a torrid time emotionally. Vivid would be fine just to reduce the workload inside a man (woman) while he let me say that they are all diseases that are clearly defined – so much faster than others? Is recollections of a traumatic life event by a day a week. I counselled otherwise – (she) lives.” Although the length why trivialise them by saying they are “just age related”? D of telomeres is programmed in aging preset at birth and unchangeable? some years earlier were flashing back so a four-week break was agreed starting Recently I had a minor procedure and the nurses decided Although an individual’s DNA is during the night and at other times. This the following Monday. Then on return utero, stress during childhood and that I should be on the aged pain relief protocol because I was programmed early, life events affect its manifestation of post traumatic stress I recommended a further consultation later life accelerates the erosion nearly 70. It is true I was nearly 70, but I was not quite there so decay. ‘Age’ is not just greyness of hair disorder (PTSD) had been unmasked by followed by a day off each week till the of telomeres. Life’s events are why should I be labelled as aged? I protested but was pacified (which can, of course, be concealed with a heavy workload, family worries (young end of the year. responsible for 50 per cent of the with: “At your age we can’t be too careful.” I was tempted to say colour), but recognised by skin texture adult children) and a growing sense of Poor T L O’Meares had a full house of speed of aging. that I could outwalk all of them, but walking is a little hard (cosmetically unaided), alertness, strength, failure coupled with grumbling cynicism, factors that shorten telomeres. Telomeres There is therefore great value with a catheter in place. energy and a whole lot more going citing the unreliability of family and are like protective caps on the end of your in addressing your (oxidative) We curmudgeons are proud of our prowess, be it physical on inside with neurotransmitters and frustration with everyone involved in the chromosomes (DNA), akin to the ends of stressors and minimising or or mental. We don’t need to have seats offered to us on buses; hormones. health system. It was not hard to diagnose a bootlace that prevents the lace fraying controlling them. First you have we don’t need special driving tests and we don’t always need Last week Dr T L O’Meares consulted depression and burn-out. and becoming unthreadable. We want to recognise they exist. The earlier to wear glasses to read menus. The latter problem is the fonts me. I hadn’t seen O’Meares for some years, I find most surgeons are reluctant them to be as long as possible as once you do this, the longer will be your that are used in menus – too small and the wrong colours – try but I was shocked at the changes I saw. T to admit to being depressed, but T L they are sufficiently shortened, the cell telomeres. Most of my readers are reading 12 point size in a French Script MS that is red on a L O’Meares had aged, aged significantly O’Meares had at least come seeking enters stable cell cycle arrest unlikely to live to 100, but your yellow background. – at least in appearance. What had treatment. Australia’s survey of mental or senescence. longevity is partly bestowed in So ageing can be a pain, an unnecessary accompaniment to happened and how had it happened over health in doctors (Beyond Blue) suggested Cellular senescence is caused by those bootlaces. Look after them! maturing and gaining wisdom, but as Orson Welles said, “Old a relatively short period? that although around 20 various insults such as telomere erosion, Dr BB G-loved age is the only disease you don’t want to be cured of”.

14 Surgical News september 2014 Surgical News september 2014 15 Audits of Relationships and Surgical Mortality Advocacy

Case Note Review Guy Maddern Chair, ANZASM Benign jaw tumour surgery in elderly patient

his elderly patient was seen at an The patient was then admitted to patient requiring reintubation, perhaps Oral and Maxillofacial clinic. The intensive care in an unplanned manner. suffering aspiration of blood and Tassessment was by an Oral and Soon after the patient required formal then going through a period of urgent Maxillofacial Registrar who diagnosed a tracheostomy and a revision tracheostomy tracheostomies and tracheostomy revision. left anterior mandible lesion. It was noted some days later. The patient continued to Another area of consideration was the level that the patient had gastro-oesophageal have issues with postoperative bleeding, of thromboembolic prophylaxis; there reflux, for which the patient was taking including a leak around the tracheostomy were only scant records regarding this. Somac, and had been a heavy smoker for tube; hence the need for revision. This case highlights the problems some 50 years. There was no history of The patient’s general condition with single department decision-making alcohol intake and past history included a continued to worsen and there was a in major surgical resection for non-life tracheostomy for a cyst. sudden further deterioration some 13 threatening diseases in major hospitals The examination notes of the days postoperatively, which led to death. where multidisciplinary teams exist for Working on outpatient attendance describe an The overall findings were those of this purpose. This patient may well have expansile left anterior lesion with normal a significant pulmonary embolism. been managed differently if the input of inferior dental nerve sensation and left However, there was a background of other specialties had been sought and Alcohol related harm sublingual fullness. The recommendation deteriorating general health in the certainly the assessment of all potential David Watters Vice President was ‘review by the consultant in a week lead-up, mainly due to respiratory comorbidities prior to major non-urgent College progresses on key advocacy issue for possible biopsy or en bloc resection failure, acute pulmonary oedema and surgery would have been better. with workup including chest x-ray, basic pneumonia. There are findings of acute Some of these investigations may have bloods’. respiratory distress syndrome. There was been undertaken externally, but there s this topic is a key item of harm and a reduction in the severity of The review took place approximately also a background of severe coronary is little in the way of records to support advocacy for the College, I would injuries. one week later, confirming that there atherosclerosis. this. Likewise, the assessment by an Alike to keep you informed as to • Attended the launch of the Alcohol’s was a left mandibular cyst and an open experienced Head and Neck anaesthetist the College’s involvement in the issue of Burden of Disease in Australia study biopsy was to be undertaken under Clinical lessons preoperatively may have raised the need reducing alcohol related harm. Over the funded by FARE and VicHealth in local anaesthetic. The review was to be The major areas of consideration in this for a tracheostomy intraoperatively, last 90 days, the College has:- collaboration with Turning Point. two weeks post-open biopsy and the case are at the preoperative level and also rather than encountering the airway • Had representation at the National patient was to have a CT scan and an relate to the immediate intraoperative issues postoperatively that necessitated Alliance for Action on Alcohol summit The study looked at hospitalisations Orthopantomogram (OPG) performed. management. The scanty nature of the reintubation and ultimate tracheostomy in Canberra relating to the marketing and deaths due to alcohol and its The next outpatient entry was 14 outpatient notes suggests that there was with a subsequent revision. of alcoholic products to children. contribution to cancers, cardiovascular days later and had only the letters ‘R/V’ little in the way of multidisciplinary All these factors contributed to a diseases, digestive diseases, infections and recorded. The clinical notes are then workup in the decision-making process. prolonged stay in intensive care which The conclusions of that summit were parasitic diseases and neuropsychiatric somewhat deficient in that they do not Certainly the multidisciplinary Head and ultimately would have been the cause that relying on the alcohol industry to diseases. The data shows that in include the objective report of the surgical Neck clinic at this major hospital was not for the patient developing a deep vein self-regulate and cease marketing through 2010 there were just over 157,000 procedure. Several descriptions suggesting involved in the decision-making. thrombosis and then a pulmonary sports events including televised games hospitalisations related to alcohol (does that the surgical procedure of partial The full assessment of comorbidities embolus. The lack of documentation of before 8.30pm was ineffective. not count harm to third party) and over mandibulectomy and iliac crest bone has not been well documented and, deep vein thrombosis prophylaxis is also • Responded to a submission requested 5,500 deaths. graft proceeded uneventfully have been with a background of the removal of a an area of concern, given the fact that by the NSW Legislative Enquiry as • Agreed to support the “Call for Action” documented. benign tumour in an elderly patient, is none of this was well documented. to the impact of legislative changes in New Zealand. The NZ Medical However, the Coroner’s report does certainly another area of consideration. made affecting the Sydney CBD Association recently endorsed a Call indicate that the induction of anaesthesia There also seems to have been no definite Entertainment Precinct. for Action on Alcohol to the incoming was difficult and that nasal intubation preoperative anaesthetic assessment: Join the conversation: http:// government of 2014. – even via fibre-optic visualisation – was the anaesthetic at the time of surgery www.surgeons.org/my-page/ It is encouraging to hear information not possible and that an oral tube was was quite complicated and difficult, and racs-knowledge/blogs/all-blogs/ from surgeons working in the area that The Call is for legislation to enact used. Extubation was accompanied by the perceived need for intraoperative anzasm-case-note-reviews/2014/ indicates a reduction in the number four priorities related to marketing and respiratory distress almost immediately tracheostomy was obviously not anzasmcnrsep2014/ of presentations to the emergency pricing, the two main drivers of alcohol and required reintubation. anticipated. This effectively led to the ▲ department as a result of alcohol related demand.

16 Surgical News september 2014 Surgical News september 2014 17 IN THE NEWS

e-news

Pay online at the College he College now has an online secure payment capability, which allows certain College financial transactions to be completed via Tthe website. These transactions currently include donations to the Foundation for Surgery as well as the purchase of College merchandise via the online store. This secure payment allows all purchasers to immediately receive email confirmation of payment and an emailed tax invoice/receipt Hybrid theatre for Tassie as well as shipping confirmation for any merchandise purchased. It is intended that the capability will be expanded in the future to include other payments to the College. New theatre in Launceston will make a difference in improving outcomes for patients Please visit the online store at Royal Australasian College of Surgeons Webstore where there are several items of College merchandise, including wearable items for Fellows only, and other College specific goods. Donating to the Foundation for Surgery via the online store allows he Launceston General Hospital “This co-ordination was vital because “While we might lose some space, the designation as to which particular area of the Foundation will receive the (LGH) is the first regional hospital we wanted to be able to use the hybrid benefits of having the imaging equipment benefit of your donation. Tin Australia to house a purpose- theatre to perform trauma surgery, where we need it are unquestionable, both Your donation will make a real difference, so please visit the website built hybrid operating theatre featuring a vascular and urology procedures, such as in terms of patient safety and surgical today to make your safe, secure donation to support: $1.5 million 3D X-ray imaging machine. stone surgery and for orthopaedic cases, efficiency. • Indigenous health Part of a multi-million dollar particularly spine surgery. “For instance, in the past if a surgeon “Most of this equipment in the hybrid • International medical programs redevelopment and refurbishment of the “We were also assisted by the design suspected that a patient may have theatre is a first for a regional hospital,” • Yes, ScholarshipsI would li andke Grantsto donate hospital, the new hybrid theatre opened team from Phillips and Maquet.” internal bleeding or compromised blood he said. • to Educational our Found programsation for Surgery in July. The new facility – designed via The 3D X-ray and imaging machine is set flow they would have to pack up the Mr Kirkby said LGH staff were proud • All donations Where are taxsupport deductible is needed most input from senior surgeons across a range on rails that can rotate around the patient patient and move them, with all the of the new hybrid theatre, one of only 20 Name: of specialties and the hospital’s chief and requires a room almost seven metres equipment attached, to a separate unit for in use across the country, with all others Address: Telephone: angiographer – is also the first theatre wide to allow it to be used effectively. angiograms and then take them back to found in metropolitan hospitals. Email: Speciality: of its kind providing staff with real-time It is the single most expensive piece of theatre if necessary. He said that while it had been mooted Enclosed is my cheque or bank draft (payable to Foundation for Surgery) for $ . measurements of X-ray exposure. equipment to be installed as part of the “Now, we can take those scans at the for future installation, extra funding had The Director of Surgery at the LGH, Mr redevelopment of the hospital’s intensive time they are needed without disturbing been sourced to allow for its development Please debit my credit card account for $ . Brian Kirkby said the new theatre would care unit, central sterilisation department the patient, right there in theatre. ahead of time. Mastercard Visa AMEX NZ Bankcard reduce operating times, patient recovery and operating theatres. “It also allows surgeons to conduct “It is pleasing to be part of a first for a Credit Card No: Expiry: / rates and decrease morbidity and post- Mr Kirkby said it would allow surgeons procedures that require X-ray imaging, regional hospital in Australia and there is operative complications. and specialists to work within a space that which will be of great benefit to the certain kudos in having access to facilities Your passion. Card Holder’s Name - block letters Card Holder’s Signature Date Your skill. I would like my donation to help support: He said it had been designed and combined components of a traditional orthopaedic surgeons.” that are not available in some major General Foundation Programs International Development Programs equipped for a range of procedures. operating theatre and a traditional X-ray Mr Kirkby said another benefit of the metropolitan hospitals.” Your legacy. Scholarship and Fellowship Programs Indigenous Health Programs “The hybrid theatre took four months to and imaging facility. state-of-the-art X-ray equipment was that The new hybrid theatre is in use all day Educational Programs I have a potential contribution to the Cultural Gifts Program plan and involved input from me as a vascu- “Most surgeons will understand that it reduced exposure to radiation by up 80 every day and for emergency procedures Your I do not give permission for acknowledgement of my gift in any College publication lar surgeon, urology surgeon Steve Brough, having a hybrid theatre necessarily percent. at night. It is one of five new theatres at Foundation. Please send your donation to: AUSTRALIA & OTHER COUNTRIES NEW ZEALAND orthopaedic surgeon David Edis and the requires compromise, which is why we Monitoring equipment also allowed for the LGH; another four are in the process Foundation for Surgery Foundation for Surgery 250 - 290 Spring Street PO Box 7451 East Melbourne , VIC 3002 Newtown, 6242 Wellington hospital’s chief angiographer and radiogra- spent so much time and attention on the the real time measurement of exposure for of being redesigned and refitted. Australia New Zealand pher Robbie Miller,” Mr Kirkby said. design details,” he said. all theatre staff. With Karen Murphy

18 Surgical News september 2014 Surgical News september 2014 19 Global Surgery

Joao Pedro (Timor Leste Surgeon), Lino Tom (Trainee), Professor Ren Hong Bing, Sammy Thomas, Professor Jeffrey Rosenfeld and William Kaptigau.

PNG neurosurgeon achieves outstanding results

Dr William Kaptigau’s extraordinary effort to improve patient “A decade later in 2007, the mortality from severe head outcomes for the people of Papua New Guinea injury in Port Moresby had reduced to 26 per cent which is a great credit to the work undertaken by Dr Kaptigau not only through his own skills as a neurosurgeon, but ormer Rowan Nicks Scholar Dr William Kaptigau Professor Watters trained Dr Kaptigau as a general surgeon also because of the training he has provided others in pre- has become the first surgeon in the country to during his time as Professor of Surgery at UPNG, and lent hospital trauma care and post-operative care. graduate as Doctor of Medicine for his research support to his application for a Rowan Nicks Scholarship “Neurosurgery under his leadership is one of the few based on his audit over the first decade of the when Chair of the RACS International Committee. specialties in PNG to produce annual written reports introductionF of a neurosurgical service at Port Moresby Now the Vice President of the College, the Divisional and make submissions for vital equipment all as part of General Hospital, Papua New Guinea. Director of Surgery at Geelong Hospital and Professor Dr Kaptigau’s dedication to advancing the specialty and Dr Kaptigau, PNG’s first national neurosurgeon, of Surgery at Deakin University, Professor Watters has improving patient care in PNG. established the country’s first neurosurgery service in 2004 maintained his support and mentorship to Dr Kaptigau “His dedication and commitment to his work and his and from the outset began compiling rigorous reports of since his departure from PNG in 2000. patients has shown PNG what a specialist neurosurgery activity and outcome across the full range of procedures “Very few surgeons in PNG go onto a higher degree and service can achieve and what it can become, even in an conducted. the fact that Dr Kaptigau completed his research and thesis environment of limited resources given that Dr Kaptigau Until he established the service, with the assistance of when he was dealing with his own health issues shows didn’t even have access to a CT scanner until 2008. neurosurgeon Professor Jeffrey Rosenfeld and the former tremendous strength and resolve,” Professor Watters said. “He has saved many lives, particularly the lives of Professor of Surgery at the University of Papua New Guinea “He is the first surgeon to get his Doctor of Medicine, which children suffering from hydrocephalus, has given 10 years (UPNG) Professor David Watters, most neurosurgery cases is a remarkable achievement in itself. The fact that he took on of excellent service to the people of PNG and his audit were treated by general surgeons across the country. that work while running the neurosurgery unit, training and data describes extremely impressive results across a range Marianne Vonau, the College Treasurer is another ongoing doing general surgery makes it even more outstanding. of procedures.” supporter of William and neurosurgery in PNG, having led “The audit of his unit, which predominately treats Dr Kaptigau completed medical school in 1987 and was a neurosurgery team with neurosurgeon, Teresa Withers, to head trauma, spinal disease, hydrocephalus and space- later posted to Kimbe where he spent three of five years assist William over the past six to seven years. occupying lesions, demonstrates continuous improvement working as a medical superintendent. Dr Kaptigau’s audit showed a dramatic decrease both during the decade of his leadership, particularly in head Accepted for surgical training in 1995, he completed his in the mortality rate from severe head injuries and injury outcomes. Willie had already published a number MMed in 1999 with a thesis on the changing patterns of complication rates in patients treated in the Port Moresby of a papers in a focus edition of the ‘PNG Medical Journal’ abdominal surgery in Port Moresby over 40 years. unit over the decade of its establishment, indicating the dedicated to neurology and neurosurgery [2007; Vol 50 Having chosen to pursue training in neurosurgery, Dr value of the specialist surgical service. March-June pp 1-101]. Kaptigau came to Australia in 2002 under the Rowan Conducting all the research alone while heading the unit, “For example, in 1996, an article comparing head injury Nicks Scholarship and the International Scholarship and training another neurosurgeon and also providing general outcomes in Goroka and Port Moresby demonstrated a carried out his attachment at Townsville Tertiary Hospital surgery, Dr Kaptigau’s graduation in April as Doctor Of mortality rate for severe head injury (GCS < 9) of 60 per under Mr Eric Guazzo and Mr Reno Rossato before Medicine from UPNG represents a remarkable achievement, cent in Port Moresby and 55 per cent in Goroka,” Professor moving to Melbourne to work under the supervision of according to Professor Watters. Watters said. Professor Rosenfeld. u

20 Surgical News september 2014 Surgical News september 2014 21 Global Surgery

By the end of 2004, he had successfully completed his Higher Postgraduate Diploma in Neurosurgery at UPNG, ANOTHER becoming not only the first qualified neurosurgeon trained in PNG, but also the first in the South Pacific. ® Mr Guazzo, who continues to work and teach at Townsville Tertiary Hospital, said he first met Dr Kaptigau during a College-managed Pacific Island visit to PNG in the late 1990s. He said he was so impressed with his ZY OX skills and dedication to his patients, he en- couraged Dr Kaptigau to apply for a Rowan VICTORY Nicks Scholarship and organised visiting L-R: Mr Sammy Thomas (PNG’s second trained neurosurgeon, now working in Madang Base 1-4 rights to allow him to train and operate Hospital), A/Prof Ikau Kevau (Head of Surgical Department, University of Papua New Guinea, and EVIDENCE-BASED RESULTS under supervision at Townsville Hospital. orthopaedic surgeon, Port Moresby General Hospital), Prof Jeff Rosenfeld OBE FRACS, Professor During the year of his visit, Dr Xie Yan Feng (Visiting Chinese Neurosurgeon, now is based at Chong Qing Medical University Kaptigau conducted outpatient Affiliated Hospital-China), Mr William Kaptigau MD, PNG’s first neurosurgeon. consultations, operated under supervision and participated in ward work both at Townsville Hospital and the Mater Private Dr Kaptigau was so highly regarded, teach and operate for more than 30 years hospital alongside Mr Guazzo. Mr Guazzo said, that he was invited and supervised Dr Kaptigau during his While there, he participated in the to attend the 2006 Annual Scientific attachment to the Alfred in 2003. treatment of 117 cases including spinal Meeting of the Neurosurgical Society of Since then, he has helped develop a surgeries, tumour, skull fracture and VP Australasia. neurosurgery curriculum for the UPNG, shunt surgeries. acted as an examiner and worked closely Mr Guazzo said Dr Kaptigau brought He was the right person with Dr Kaptigau to set up the audit his wife Eimi, a senior nurse, and his In recent years, Dr Kaptigau has also which he used as the basis of the thesis. children with him to Australia for the selected patients with benign pathology “William set out to see whether duration of his visit. for pro-bono neurosurgery by Mr Guazzo neurosurgery patients treated in one PBS Information: This product is not listed on the PBS. “When I met William I was very and others at the Mater Hospital. dedicated unit led to improved results impressed by his devotion to the people Mr Guazzo congratulated him on and to do this he collected and analysed of his country while it was clear he had achieving his Doctor of Medicine and the outcomes of 3626 patients over 10 BEFORE PRESCRIBING ZYVOX® (LINEZOLID) REVIEW FULL APPROVED PRODUCT remarkable capabilities,” Mr Guazzo said. said Dr Kaptigau was a wonderful years,” Professor Rosenfeld said. “At the time he came to Townsville he example of the worth of the Rowan Nicks “His findings showed a dramatic INFORMATION AVAILABLE AT WWW.PFIZER.COM.AU. was a very capable General Surgeon, but and International Scholarships. improvement in head injury cases, better ZYVOX® (linezolid 2mg/mL, 600mg, 20mg/mL) injection, tablets, granules for oral suspension. INDICATIONS: Infections due to resistant organisms, including was determined to develop his skills in “I’ve long been a great supporter of management of more complex patients MRSA and VRE. No clinical activity against Gram-negative pathogens. CONTRAINDICATIONS: Hypersensitivity; Monoamine oxidase inhibitors; Potential interactions neurosurgery so we selected cases for him to the RACS’ commitment to promoting and a reduction in complication rates. producing elevations of blood pressure; Potential serotonergic interactions. PRECAUTIONS: Monitor blood in certain populations. Antibiotic associated pseudomembranous work on that would advance that ambition. colitis. Reports of serotonin syndrome when co-administered with serotonergic agents. Symptoms of visual impairment; monitor visual function. Convulsions (rare). Safety expertise in our geographical “Both the results and the research and effectiveness following 28 days not established. Gram-negative pathogens. Caution in patients with severe renal and hepatic insufficiency. Pregnancy. Category B3. “We included the management of neighbourhood,” he said. represent an enormous achievement and Lactation. Discontinue. INTERACTIONS: Tyramine; serotonergic agents; vasopressive/dopaminergic agents; rifampicin.* See full PI for details. ADVERSE EFFECTS: trauma of both the head and the spine, “Dr Kaptigau is a perfect example the culmination of years of extraordinary Headache, candidiasis; taste perversion; GI disturbances. Peripheral and optic neuropathy. Lactic acidosis, angioedema, rash, myelosuppression, bullous skin disorders and infections of the central nervous system, of how we can help many people by effort to improve the health system and serotonin syndrome (very rare). Abnormal haematology and liver function tests. See full PI for details. DOSAGE AND ADMINISTRATION: IV (30-120 min infusion) or oral tumour surgery and a variety of spinal b.i.d (with or without food). Adults and adolescents: CAP/ nosocomial pneumonia: 600 mg IV 12 hourly or orally b.i.d for 10 to 14 days; SSTI: 400 mg to 600 mg orally b.i.d selecting the right person and giving patient outcomes for the people of his or 600 mg IV 12 hourly for 10 to 14 days; Enterococcal infections: 600 mg IV 12 hourly or orally b.i.d for 14 to 28 consecutive days. Children: Nosocomial pneumonia and procedures. them the skills and support they need to country. SSTI: 10 mg/kg IV 8 hourly or orally t.d.s for 10 to 14 days. Enterococcal infections: 10 mg/kg IV 8 hourly or orally t.d.s for 14 to 28 days. Neonates: Refer to PI. See full PI “It seemed a huge task to set up a neu- do the work that needs to be done.” “David Watters and I wrote a book a for detailed dosing schedule. The current product information is available at www.pfizer.com.au. rosurgery service in PNG with all the eco- Professor Jeffrey Rosenfeld, Head of few years ago called ‘Neurosurgery in *PLEASE NOTE CHANGE(S) IN PRODUCT INFORMATION. nomic and social challenges involved, but the Department of Surgery at Monash the Tropics’ because we believed such a if anyone could do it, it was Dr Kaptigau University and Director of the Department resource was needed for General Surgeons Pfizer Australia Pty Limited. ABN 50 008 422 348. 38-42 Wharf Road, West Ryde NSW 2114. not only because of his surgical skills, but of Neurosurgery at the Alfred Hospital, treating such cases in developing ®Registered trademark. Medical Information 1800 675 229. www.pfizer.com.au P9133 08/2014 PFIZ3683 because he is a champion for his country helped Dr Kaptigau establish the countries. and a strong advocate for his people.” neurosurgery service in 2004. “Then William took up the challenge References: 1. Weigelt J, et al. Am J Surg. 2004; 188:760-6. 2. Wunderink RG, et al. Clin Infect Dis. 2012; 54:621-9. 3. Birmingham MC, et al. Clin Infect Dis. 2003; Mr Guazzo said he remained in contact Having completed a six-month rotation of becoming a neurosurgeon and without 36:159-68. 4. Wilcox M, Nathwani D, Dryden M. J Antimicrob Chemother. 2004; 53(2):335-344. with Dr Kaptigau following his return to in PNG when a Trainee at the Royal him there would be no neurosurgery PNG and often consulted on complex Melbourne Hospital, Professor Rosenfeld service in PNG.” cases via email and telephone. has been travelling back to PNG to With Karen Murphy

22 Surgical News september 2014 Surgical News september 2014 23 Successful Scholar It’s good to know that the College thinks we are on the right track and also that this work is of interest “ to the wider clinical community ”

esearch supported by the may be at risk of rapid onset and In particular, he said that patients College is now underway development of degeneration as a result with a combined bicruciate and Helping others at the Sydney Orthopaedic of MLKI,” Dr Scholes said. medial injury stepped shorter and Research Institute (SORI) “We are therefore working to wider and also spent more time in Raimed at providing clinicians with a advance efforts to provide clinicians double support, alterations which were stand tall better understanding of knee function with an objective method to identify associated with reduced confidence and and structural integrity following patients at risk of poor outcomes or altered joint loading. Support from the College is crucial to surgery to repair multiple ligament knee accelerated knee degradation so that “In addition, we also found continuing work of young research group injury (MLKI). treatment plans can be individualised significant differences in knee motion The Director of Research at the as required.” during gait,” he said. Institute, Dr Corey Scholes, was Working with patients recruited from “We now believe that these inter- last year awarded the Brendan the Institute’s database, Dr Scholes is in limb differences in knee angle during Dooley and Gordon Trinca Trauma the process of conducting a ‘gait’ study weight acceptance and the resulting Research Scholarship – one of the few using facilities and equipment at the abnormal knee kinematics will likely scholarships offered by the College Biomechanics Laboratory, University of have implications for the long term which is open to medical researchers Sydney, comparing the knee kinematics health of the joint, including the working outside the field of surgery. of post-operative MLKI patients with possible development of osteoarthritis.” Dr Scholes said that while a great deal matched controls while also using Dr Scholes also said new software Awards and was known about the results of anterior custom-designed software to map had been designed at the Institute to Scholarships cruciate ligament (ACL) reconstructive cartilage from MRI data. measure the quality of the cartilage achieved by Dr Corey surgery, considerably less was known He said the ‘motion capture’ study across the entire knee joint with Scholes about whether surgical reconstruction now underway, was only the second researchers now analysing both the could restore knee function to resemble to be conducted on MLKI patients, patient and control’s cartilage for 2013 that of uninjured knees and prevent according to a review of published comparisons. Friends of the Mater Hospital cartilage degeneration following MLKI. English scientific papers, and that He said he expected to complete the Foundation: (2 projects) He said the majority of such injuries the team had discovered functional mapping within the new few months, were caused by trauma such as motor differences in knee kinematics never with his findings to be presented at 2013 vehicle accidents, sporting injuries or before reported. the next meeting of the Australian Brendan Dooley – Gordon Trinca falls. “Knowledge about the long-term Orthopaedic Association meeting in Trauma Scholarship: Royal “Traumatic injuries to the knee effects of MLKI is quite poor for a October. Australasian College of Surgeons. involving multiple ligaments are less number of reasons,” he said. “Our future work will be the 2005 - 2008 frequent than isolated injuries, but “This is due to the difficulty in continuing exploration of the are often more serious and in some Queensland University of obtaining pre-operative data because relationship between cartilage quality, Technology Vice-Chancellor’s cases devastating to joint function with of the traumatic nature of the injury injury patterns and functional tasks,” Blueprint Postgraduate Award. associated local vascular and neural and also because most patients who he said. disruption,” Dr Scholes said. suffer a MLKI are usually young, active The Sydney Orthopaedic Research 2004 “These types of injuries are and part of a mobile demographic that Institute is a stand-alone not-for-profit Queensland University of complicated to repair and involve makes long-term follow up analysis organisation established by Dr David Technology Faculty of Health lengthy and costly rehabilitation and can difficult and because there are fewer Parker and Dr Myles Coolican in 2003 Honours Research Scholarship. involve long-term negative consequences patients overall to study. with a mission to empower patients for the patient with regards to loss of “This means that while surgeons and and clinicians with improved methods joint function and decreased quality of scientists have long had a suspicion of diagnosis and treatment to restore life. that these patients face an increased knee function. Society, the Surgical Research Society “A recent survey revealed that despite risk of developing osteoarthritis we Dr Scholes has contributed to the and the Mater Orthopaedic Research the lower frequency of multiple ligament don’t know the percentage increase and multi-disciplinary team at SORI with Meeting. injuries, the mean financial cost per we don’t know which patients are most a background in biomechanics. With He said that while initial findings occurrence is highest for the knee when at risk.” surgical and engineering contributions, were encouraging, the small patient compared to all orthopaedic joint Dr Scholes said the small gait study the team has presented papers on cohort and enormous variability dislocations. now underway – which examines MLKI to the International Society of in individual movement, patient “We also know there is an increased knee angles during walking in three Arthroscopy and Knee Orthopaedic confidence and quality of treatment incidence of knee osteoarthritis in dimensions – had already revealed that Surgery as well as to the Australian following the initial trauma meant these patients compared to the general MLKI patients demonstrated signifi- New Zealand Orthopaedic Research there was still much to be understood. population; however, there remains cant deficits in overground locomotion Society, the Australian Orthopaedic “There are a number of factors little data to help identify patients that compared to healthy controls. Association, the Australian Knee that come into play when you are u

24 Surgical News september 2014 Surgical News september 2014 25 Successful Scholar in memoriam Our condolences to the family, friends and colleagues of the following Fellows whose death has been notified over the past month: EXTENDED David Rogers, New Zealand Fellow OPPORTUNITIES Denis Campbell, Queensland Fellow Ian MacIsaac, Victorian Fellow Research Alfred Lewis, NSW Fellow John Maloney, & Scholarships NSW Fellow Due to availability of funding the College is Richard Fletcher, Victorian Fellow pleased to be able to readvertise the following: Arthur R. Waterhouse, Victorian Fellow SORI Directors: Dr David Parker, Dr Myles Coolican and Dr Brett Fritsch Raymond Carroll, NSW Fellow Thomas A. Parsons, looking at longer-term functional physiotherapy or pain management Queensland Fellow outcomes following treatment for therapy.” Thomas Stack, MLKIs such as the injury itself, With up to eight researchers WA Fellow the nature of the surgery, the working alongside him, depending character of the patient and the on funding available, Dr Scholes said Hugh Johnston ANZ ACS Travelling Fellowship John Collibee, rehabilitation,” he said. he was delighted to have won the WA Fellow “Then when you add to these support of the College for the work factors the enormous variability in being conducted at the Institute. how people move and individual “As a relatively young organisation, he Hugh Johnston ANZ Chapter American College of We would like to notify readers anatomy, the variables can seem receiving this scholarship felt like a TSurgeons Travelling Fellowship has been established that it is not the practice of infinite. big pat on the back for us in terms of to support an Australian or New Zealand Fellow of Surgical News to publish obituaries. “There is still some uncertainty the research we are conducting and the College to attend the annual American College of When provided they are published even in regard to the long-term how we are going about it,” he said. Surgeons (ACS) Clinical Congress in October 2015, which along with the names of deceased results and optimal approaches to “It’s good to know that the College is to be held in Washington DC, USA. It forms part of a bi- Fellows under In Memoriam on the ACL surgery and we’re far behind in thinks we are on the right track and lateral exchange with the ACS and is open to Fellows who College website www.surgeons.org our understanding of MLKI so the also that this work is of interest to the have gained their College Fellowship in the past 10 years go to the Fellows page and definitive links between outcome, wider clinical community.” (2004 or later). Applicants are expected to have a major Brendan Dooley & Gordon Trinca click on In Memoriam. treatment and long-term function Dr Scholes said he would like interest and accomplishment in basic or clinical sciences Trauma Research Scholarship will probably only be solved through to acknowledge funding from the related to surgery and would preferably hold an academic Informing the College multi-centre research. Sydney Orthopaedic Research appointment in Australia or New Zealand. The applicant pen to Fellows, SET Trainees and Medical If you wish to notify the College of “Still we are working toward giving Institute as well as the input and must spend a minimum of three weeks in the United States OScientists who are conducting a research topic the death of a Fellow, please contact clinicians a better understanding of effort of colleagues and collaborators of America. While there, they must: relating to the prevention and treatment of trauma the Manager in your Regional Office. the response to treatment through that have assisted with the project • Attend and participate in the American College of Sur- injuries in Australia and New Zealand. They are understanding both what is driving and grant-seeking particularly Amy geons Annual Clinical Congress in 2015 For any other queries, please contact the ACT: [email protected] abnormal post-operative knee Brierley, Joe Lynch, Dr Joe Costa, • Participate in the formal convocation ceremony of that Scholarship Program Coordinator, NSW: [email protected] function and movement, and also Laurant Kang, Jack Batchen, Milad congress • Visit at least two medical centres in North America be- Royal Australasian College of Surgeons, NZ: [email protected] trying to determine the risk factors Ebrahimi, Dr Brett Fritsch, Dr Myles fore or after the Annual Clinical Congress to lecture and 199 Ward Street, North Adelaide SA 5006. QLD: [email protected] specific to MLKI associated with Coolican, Dr David Parker and Prof to share clinical and scientific expertise with the local Tel: +61 8 8219 0999, SA: [email protected] knee degeneration. Qing Li (University of Sydney). “If we understand those, surgeons He also thanked Professor surgeons. Email: [email protected]. TAS: [email protected] could be in a better position to Richard Smith and Mr Ray Patton VIC: [email protected] adjust or refine surgical techniques (Biomechanics Laboratory, University For further information, email: [email protected] Applications close midnight CST midnight Monday WA: Angela.D’[email protected] or identify patients with a poor of Sydney) for their assistance with 13 October 2014 NT: [email protected] prognosis after surgery so they access to the laboratory and its Applicants must not have commenced their travels prior to are more swiftly provided with equipment. the closing date for applications. This scholarship offers a stipend of longer term treatment plans such as With Karen Murphy This Fellowship is valued at AU$8,000. AU$10,000 with a 12 month tenure.

26 Surgical News september 2014 Royal Australasian College of Surgeons Academic Surgery Royal AnnualAustralasian Academic College Meetings of Surgeons NovemberAnnual 13 Academic and 14 Adelaide Meetings 2014 November 13 and 14 Adelaide 2014

Academic Surgery Mid-careerAcademic SurgeryCourse Mid-career Course Thursday 13 November - morning Feast of ThursdayBasil Hetzel 13 Institute November Woodville - morning SA Section of ProfessorBasil Hetzel Andrew Institute Hill Woodville - Convener SA AcademicSection Surgery of Professor Andrew Hill - Convener academic Visiting Speaker Heads Academicof Departments Surgery meeting Associate Professor Taylor Riall, University of Texas Visiting Speaker Heads (withof Departments interested others) meeting Associate“Emerging Professor Trends Taylor in Surgical Riall, University Research” of Texas (with interested others) events “Emerging Trends in Surgical Research” Professor John Windsor ‘Success in Academic Surgery’ Thursday 13 November - afternoon Academic surgery involves and has ProfessorProfessor John Guy MaddernWindsor ‘Success‘Academics in Academic and the College Surgery’ ThursdayBasil Hetzel 13 InstituteNovember Woodville - afternoon SA ProfessorProfessor Marc Guy Gladman Maddern ‘The ‘Academics Triple/Quadruple and the College Threat’ Basil Hetzel Institute Woodville SA something to offer every Fellow and ‘Research, the College & the Section of Academic Surgery’ Trainee – and there’s lots happening ProfessorProfessor Andrew Marc HillGladman ‘Higher ‘The Degree Triple/Quadruple vs No Higher Threat’Degree’ ‘Research,Mr Richard the Hanney College - Chair & the Section Section of of Academic Academic Surgery Surgery’ ProfessorProfessor LeighAndrew Delbridge Hill ‘Higher ‘Making Degree an Internationalvs No Higher Impact’ Degree’ Mr Richard Hanney - Chair Section of Academic Surgery ProfessorMr Richard Leigh Hanney Delbridge ‘The Section‘Making of an Academic International Surgery’ Impact’ Workshop Topics Mr Richard Hanney ‘The Section of Academic Surgery’ Workshop Topics All heads of Surgical Departments have at Concord last year presented six papers Research Requirements During Surgical Training Richard Hanney been invited, and all interested Fellows and poster presentations, including the ResearchResearch Requirements Funding During from the Surgical RACS Training and Trainees are welcome. John Windsor Young Investigator Award winner,who Research Funding from the RACS his year, the November academic and Jonty Karpelowsky will chair will attend the Academic Surgical Academic Career Pathways meetings of the Academic Section ‘Research requirements during training’; Congress in Las Vegas next February. Academic Career Pathways Tand the Surgical Research Society Alan Saunder and Stan Sidhu will chair In recent years, the SRS meetings of Australasia take place in Adelaide ‘Research funding and the College’, while have been highlighted by an increasing on Thursday, November 13 and Friday, Guy Maddern and Julian Smith will chair involvement from junior doctors and Surgical November 14. The Academy of Surgical ‘Academic Career Pathways’. medical students, further broadening Educators is hosting a dinner forum on This last session may have some very the academic church. Details regarding ResearchSurgical Society of the Thursday evening, further enriching interesting light to shed on a challenging abstract submission are available from ResearchAustralasia Society of an intellect-packed two day cornucopia. area, with a full day meeting of key [email protected] with Annual AustralasiaScientific Meeting For the Thursday morning, Andrew international stakeholders to address this the closing date for submissions this year Hill has once more put together an issue being scheduled the day before. being September 22. Annual Scientific Meeting Friday 14 November impact-rich program for those committed Julian Smith and Stephen Tobin Professor Riall will again speak, this Academy of to a fulltime academic career. The course will host the Academy dinner forum time on ‘Pancreatic Cancer: Translation Basil HetzelFriday Institute 14 November Woodville SA is planned to assist with career direction in Glenelg on Thursday evening, of Outcomes Research into Practice’. SurgicalAcademy Educators’ of Forum Basil Hetzel Institute Woodville SA by guidance from those with proven addressing the theme of ‘Professionalism Associate Professor George Chang, from Surgical Educators’Dinner Forum Professor Leigh Delbridge success and track records. Academic in training and practice: opportunities the MD Anderson Cancer Centre, will Dinner Professor Leigh Delbridge promotion, raising one’s international and obligations’. Last year’s forum was present his paper (of which the abstract prominence, the value of higher degrees engaging and interactive, with dynamic was the highest scored of nearly 2000): Thursday 13 November, 7-10 pm Jepson Lecturer and involvement with the College will all discussion during a terrific meal. ‘Risk-adjusted Pathologic Margin ThursdayStamford 13Grand November, Hotel, Glenelg 7-10 pm ProfessorJepson Julian Lecturer Smith be addressed. Associate Professor Taylor Leigh Delbridge will convene the Positivity Rate as a Quality Indicator in ‘ProfessionalismStamford Grand in Training Hotel, and Glenelg Practice: Professor Julian Smith Riall, a proven outcomes researcher from 51st annual Surgical Research Society Rectal Cancer Surgery’. International Visitors the University of Texas in Galveston and meeting on Friday, with national and ‘Professionalism Opportunities in andTraining Obligations’ and Practice: Associate ProfessorInternational George Chang,Visitors MD Anderson visiting from the Society of University international travel grants and awards on Opportunities and Obligations’ Associate ProfessorCancer George Center Chang, MD Anderson Surgeons, will speak on ‘Emerging Trends offer to the most successful presenters. Associate ProfessorCancer Taylor Center Riall, University in Surgical Research’. This prestigious meeting showcases Thanks to generous support from Presenters of Texas James Lee has arranged three research work from some of Australasia’s Foundation Academic Sponsors Covidien, Associate ProfessorPresenters Alison Jones Associate Professor Taylor Riall, University these two full days of quality science and workshops to be conducted concurrently finest young surgeon scientists, and the of Texas interaction will cost you a grand total Associate Professor AlisonDavid HillisJones on the Thursday afternoon. The goal of attending senior academic surgeons have of $160 for ASE members, $180 total AssociateConvenors Professor David Hillis Enquiries to [email protected] these is to provide guidance for ongoing been increasingly delighted by the ability cost for non-members. Join us, bring Associate ProfessorConvenors Stephen Tobin orEnquiries by calling: to [email protected] 82190900 direction of your Section and academic and enthusiasm on show. your families and enjoy the beautiful wine surgery as currently practised. Marc Gladman’s Department of Surgery regions of Adelaide on the weekend. AssociateProfessor Professor Julian Stephen Smith Tobin or by calling: 08 82190900 Professor Julian Smith 28 Surgical News september 2014 Surgical News september 2014 29 My overwhelming thoughts throughout my work were of how terrible war and its weapons are, and how fortunate we are to live in a stable society here in Australia.

Fellows abroad

Serving the needy

Left: Wisam Ihsheish works on internal fixation on a 40-year-old man. after a trauma accident in Kundunz Trauma Centre. February 2013. Copyright: Camille Gillardeau/MSF. Above: Afghani patients waiting at medical centre. Copyright: Mikhail Galustov.

brought about the impetus to give back More recently you were in innocent civilians with no connection to in appreciation for what I once received. Afghanistan. Could you describe any group. From a professional viewpoint, this the project you were working on? As well as trauma, we saw a good type of work exposes one to rare and The situation in Afghanistan is tragic number of neglected orthopaedic challenging scenarios, such as classic for the general population; the context conditions. Some had been neglected surgical presentations, high level trauma, of course is that the country has been at because of the vast distance patients It was a sense of giving back to populations in need, while also taking on the and managing health care in settings with war for several decades now. The most had to walk to get to a clinic, or the language and cultural variations, all with obvious effect is that the local population war situation, or the local preference challenge of surgical care in resource poor settings, that drove Canberra- limited resources. has had its progress severely retarded, to seek treatment from ‘traditional’ based surgeon, Dr Wisam Ihsheish, to work for the medical humanitarian aid with health care provision being hit healers before seeking out the western organisation Médecins Sans Frontières (Doctors Without Borders) You spent six weeks working in particularly hard. Although there are doctors. It was fascinating to encounter Port Harcourt, Nigeria, in 2012. some medical services available in the and manage many classic orthopaedic What did your role involve? bigger cities, the vast size of the country conditions one often only reads about I worked in a trauma hospital in Southern and the extreme poverty puts these during our training. Since joining Médecins Sans Frontières in 2012, Dr Ihsheish has Why did you decide to work with an Nigeria as one of two orthopaedic services out of reach of most. been on two assignments. The first was to Southern Nigeria where international medical aid organisation? surgeons. The role entailed managing The hospital was established in a What did your role involve? he worked as an orthopaedic surgeon at the organisation’s trauma Surgery is a very rewarding and varied career, and trauma cases from start to finish. This historic building that had been built The hospital is set up and managed by a program in a private hospital in Port Harcourt. Political tensions in the adding a regular stint with aid organisations adds to including initial assessments/triage, by the Soviets decades ago. Médecins Belgian arm of Médecins Sans Frontières; oil-rich Niger Delta region had led to an increasing need for emergency the interesting nature of the work. Working in areas, assignment of theatre time and resources, Sans Frontières, as with other groups, it is in the northern city of Kunduz. Our surgery, with the team carrying out 9,000 emergency consultations and hit hard by man-made or natural disasters, with surgery, care on the wards and a post- utilises services of a great number of intake was limited mainly to trauma treating 500 victims of sexual violence in the year of 2012. needy populations allows us to contribute our skills operative clinic. professionals, including architects, cases, approximately two thirds of these and resources to these populations that are often In 2013, Dr Ihsheish went on his second field assignment, this time to Kun- Although we had a general surgeon labourers and logisticians, to bring these were orthopaedic trauma. I worked unfortunate merely by virtue of their place of birth or duz in northern Afghanistan. Here Dr Ihsheish worked in the trauma cen- working with our team, there were no projects to life. It was a pleasure to be alongside two general surgeons and an ethnic background. tre developed by Médecins Sans Frontières, which provides free, specialised other specialist surgical or medical involved in the ongoing process of getting anaesthetist, from Italy, Mexico, and My personal interest in contributing to this type of surgical care to victims of general trauma and people with conflict-related services available. The hospital had been this project up and running. Russia respectively. work has stemmed from personal and professional injuries, such as injuries sustained from bomb blasts, shrapnel, and gun- established at a time when civil unrest Our cases were mostly acute trauma, The hospital had been set up only in reasons. Having grown up for the first years of my shot wounds. Before the hospital opened, most people with life-threatening existed, and although this has now and although our policy was not to delve recent years, and our role was in primary life in a region where I experienced first-hand the injuries had to travel to the capital, Kabul, or to Pakistan for treatment. changed, the population had no ready into how people acquired their injuries, and ongoing management of trauma benefits these organisations give to needy populations Over 2013, surgeons carried out 4,500 surgical procedures. access to government trauma facilities. it was quite evident that most were and neglected orthopaedic conditions, as u

30 Surgical News september 2014 Surgical News september 2014 31 Fellows Regional abroad News

well as input into managing the limited resources of the hospital. We had a keen number of locally trained Afghan doctors, It is all about nurses, and physiotherapists. A very important role in the hospital included setting up a program to pass on surgical the falls…! skills and theoretical knowledge to allow them to take over once we had left. ‘A wound, a hurt, a defeat’ define the John North QASM Clinical Director What does it take to go into the field Greek origins of the word trauma. in an area such as this? The skills, knowledge and motivation needed to help and endure in areas of ften a patient’s trauma leads to death, and this is When reviewing trauma data and falls, specifically, the suffering – whether they are man-made or confirmed in a large proportion of surgical mortality following was revealed: natural disasters – I believe are possessed Oaudit data. • the majority (81 per cent) of falls occur at home or in a care by most doctors. The biggest hurdle is the Since 2011, the Queensland Audit of Surgical Mortality facility apprehension about personal safety in (QASM) has been collecting trauma data and investigating its • a minority (7 per cent) of falls occur in hospital such regions. relationship to surgically-related death. In doing so, QASM asks It is fair to say that there is risk L-R: Dr Wisam Ihsheish (second from left) with fellow aid workers from Afghanistan, the following questions: Was trauma involved in this surgical If we consider then that 88 per cent of fall-related trauma involved; however, it must be said that the Belgium, and Brazil. Taken during the morning ward round at Médecins Sans Frontières death? Was the trauma the result of a fall? Was the trauma the occurred in homes, care facilities, and hospitals, then we, populations are hugely appreciative of the Trauma Hospital, Kunduz, Afghanistan. result of a road traffic accident? Was the trauma the result of as surgeons, need to be more proactive in promoting falls- care we provide them and the fact that it violence? prevention programs (particularly in the older age groups). imposes no further financial burden on Since 2011, QASM has audited 2,275 cases and 30 per The surgical care is costly for patients who suffer trauma them. We built a great rapport with the learnt back in medical school or junior in my travels, especially given our cent (n=683) are trauma cases. Therefore, trauma occurs in as a consequence of a fall at home or in a care facility or in a local professionals and populations, and training years. relatively small population. This work significant numbers in surgical patients who die. hospital. Preventing the falls may be the best option for both the I felt safe and well regarded throughout Our resources were limited in man- is not financially rewarding, and entails Of the 683 trauma cases: patient and the care provider. our time there. The challenge in working power, equipment, medicines and space spending time away from comfortable • 80 per cent are related to falls With this QASM data in mind, surgeons can consider all long hours with often very tragic cases available to care for these patients. There settings at home, but is very rewarding • 15 per cent are related to road traffic accidents opportunities to reduce the fall-related surgical load. was well rewarded by the positive results was also the lack of availability of other professionally and certainly highly • 5 per cent are related to violence We must reduce the burden on health care and surgical care that were borne out. specialists to help deal with complex needed and appreciated in less fortunate by reducing fall-related injuries (particularly in the older age groups). medical and surgical presentations. Falls-80%areas. of I allwould trauma encourage my colleagues to Falls-80%When investigating the of 683 alltrauma trauma cases, the following was revealed: Did any patients make a particular The other major difference is you look into it if their circumstances permit. • median age was 82 years (*IQR 65-88). impact on you? always have to take into account the • 491 patients had surgical procedures The cases come thick and fast, so to cultural, religious, or language differences Where next? • 56 per cent were related to orthopaedic injuries and needed speak, and most are very tragic innocent that inevitably exist in all these settings. I have a young family and a new practice surgical intervention stories. One has no time to dwell on any in Canberra and Goulburn, both very Of all the trauma cases that led to death, 70 per cent had an Falls= one case. My overwhelming thoughts Did it make you a better surgeon exciting. I hope to continue to contribute operation. throughout my work were of how terrible working in conflict ridden and to third world health in my capacity as a Of all the non-trauma cases that led to death, 80 per cent had 80% of all war and its weapons are, and how resource poor settings? surgeon also on a regular basis. an operation. fortunate we are to live in a stable society Undoubtedly so. The surgical, trauma here in Australia. interpersonal and management skills are When reviewing trauma data and age groups, the following was Every year, Médecins Sans Frontières’ constantly called uponNUMBER OF FALLS and tailored. The NUMBER OF FALLS revealed: NUMBER OF FALLS surgeons perform more than 75,000 major How does being a surgeon in a war physical and emotional endurance you • For patients under 66 years (n=152), who had an operation, surgical procedures. Surgeons working torn country differ from working in develop is also a big advantage. neurosurgery was required in 50 per cent of cases. with Médecins Sans Frontières support Australia? All of these are a big asset when working independent surgical and medical care • For patients between 65 and 80 years (n=122), who had an The work in the field is varied in that it in any demanding situation back home. to people affected by conflicts, natural operation, orthopaedic surgery was required in 50 per cent allows you to view ‘text book’ orthopaedic Home Care FacilitydisastersHospital or healthcareUnknown exclusion.Other Your Home Careof cases Facility and neurosurgeryHospital Unknown in 30 per centOther of cases. Home Care Facility Hospital Unknown Other conditions and manage them, while also Do you have any advice for other • For patients over 80 years (n=331), who had an operation, the FALLskills TYPE and experience can support this FALL TYPE FALL TYPE being confronted with a high number surgeons considering work with important work. Learn more about the numbers substantially increase and 75 per cent required an of severe and high energy war trauma, an international medical aid rewarding experience of working as a orthopaedic procedure. *IQR (interquartile range) shows the middle 50 per cent all with very limited resources. You often organisation? surgeon with Médecins Sans Frontières at Therefore, as a trauma patient’s age increases, the need for of data – it does not include extremes. have to call on the basic general medical I was proud to see a number of www.msf.org.au/join-our-team orthopaedic surgical intervention increases and the need for “Other” includes falls at workplace, in streets, on stairs, and surgical principles that you have Australians working for aid organisations neurosurgical intervention decreases. on farms, in shopping centres, in parks etc.

32 Surgical News september 2014 Surgical News september 2014 33 Audits of Mortality

Poor handwriting in medical pressures and a substantial amount References records is a serious concern. In of paperwork. However, our feedback 1/2.Schneider K A, Murray C W, Shadduck R addition to being time-consuming to together with other research suggests D, Meyers D G (2006) Legibility of doctors’ decipher, misinterpretation of notes that the issue requires greater attention handwriting is as good (or bad) as everyone and instructions can lead to delays to avoid the potential pitfalls of poor else’s. British Medical Journal Quality and Doctor’s Safety, 15(6), 445. or errors in patient management. At documentation. Regarding audit forms, 3. Berwick D M & Winickoff D E (1996) The the level of the audit it may lead to a the simplest solution is the use of the truth about doctors’ handwriting: a prospective handwriting: less comprehensive or unfavourable Fellows Interface allowing surgeons study. British Medical Journal, 313, 1657-1658. assessment of the case. As most notes to complete and submit surgical case 4. Sokol D & Hettige S (2006) Poor handwriting Age-old typecasting or cause for concern? are handwritten, the only solution at forms and first-line assessments online. remains a significant problem in medicine. present is increased mindfulness when The Fellows Interface requires only an Journal of the Royal Society of Medicine, 99(12), writing in the case notes. Looking internet connection and a username 645-646. forward, technology may provide a and password (supplied by the SAAPM 5. Lefter L P, Walker S R, Dewhurst F & Turner R solution. A study published in the office). The system is convenient, W L (2008) An audit of operative notes: facts International Journal of Surgery decreases turnaround time and reduces and ways to improve. ANZ Journal of Surgery, 78(9), 800-802. describing the implementation paperwork. Alternatively, typing reports 6. Lyons R, Payne C, McCabe M & Fielder C of electronic operation notes or dictating them to a secretary removes (1998) Legibility of doctors’ handwriting: demonstrated a marked improvement the issue of legibility. Where typing is quantitative comparative study. British Medical 6 in the quality of the documentation. not possible, taking care to write clearly Journal, 317, 863. and legibly using only widely known Words: 847 7. Ghani Y, Thakrar R, Kosuge D & Bates P (2014) Conclusion abbreviations is important. Writing ‘Smart’ electronic operation notes in surgery: Strap: Audits of Mortality Factors contributing to doctors’ poor in print rather than cursive and using An innovative way to improve patient care. Headline: Doctors’ handwriting: handwriting include significant time block letters can increase readability. International Journal of Surgery, 12(1), 30-32. Author: Mr Glenn McCulloch Clinical Director, SAAPM Precede: Age-old typecasting or cause for concern? Mr Glenn McCulloch Clinical Director, SAAPM Side quote: “While SAAPM is very grateful for the time and effort of surgeons in completing and returning the forms, a significant amount of time is spent deciphering the handwriting in these cases” e’ve all heard the old adage identified and then assessed by a first-line Case notes about doctors having terrible assessor. The first-line assessor will either Once data from a Surgical Case Form is handwriting, but is it true? A We’veclose all the heard casethe oldor adageadvise about that doct theors havingcase terrible handwriting,enteredbut into is it thetrue? database, A a typed form W quick online search has revealed a wealth of publications on the issue. Some argue that quick online search has revealed a wealth undergo further analysis, i.e. a ‘second- can then 1,2be printed, eliminating the doctors’ handwriting is no better or worse than that of any other profession, while others of publications on the issue. Some argue suggestline assessment’that not only does (case this stereotypenote review). have basis in fact, butissue that it ofis alegibility serious quality for first-line assessors. that doctors’ handwriting is no better or and safetySurgical issue case which formscan lead and to delays first-line or errors in treatment, and leave doctors potentially vulnerable to litigation.3,4,5 However, cases that are progressed to worse than that of any other profession,1,2 assessments can either be handwritten, The SAAPM experience second-line assessment require a review while others suggest that not only does or completed online using the Fellows of the entire medical record. Feedback Surgical case forms this stereotype have basis in fact, but that Interface. In 2013, 54 per cent of surgeons suggests that assessors also experience The South Australian Audit of Perioperative Mortality (SAAPM) is one of the state-based it is a serious quality and safety issue auditselected within to the complete Australian and theNew forms Zealand by Audithand. of Surgical frustrationMortality (ANZASM) with. their colleagues’ which can lead to delays or errors in While SAAPM is very grateful for the The audit process begins when the SAAPM office is notified of handwriting.the death of a patient A recent who SAAPM survey treatment, and leave doctors potentially wastime under and the effortcare of aof surgeon surgeons in a participating in completing hospital. returned the following comments from 3,4,5 vulnerable to litigation. Whenand the returning consultant thesurgeon forms, provides a significant a completed surgical caseour form assessors:regarding the death toamount the SAAPM of office, time it is de spent-identified deciphering and then assessed by a first-line assessor. The first- line assessor will either close the case or advise that the case undergo• “Legibility further analysis, of doctors i.e. a notes in The SAAPM experience ‘secondthe handwriting-line assessmen t’in (case these note cases. review). Of hospital case notes still very poor and Surgical case forms Surgicalcourse, case not forms all and cases first -presentline assessments a challenge can either be handwritten,signatures or completed not accompanied by printed onlinein cryptography; using the Fellows Interface.some surgeonsIn 2013, 54 writeper cent of surgeons elected to complete the The South Australian Audit of forms by hand. While SAAPM is very grateful for the time and effortnames.” of surgeons in Perioperative Mortality (SAAPM) is completingwith beautiful and returning script the forms that, aissignificant a pleasure amount of time• is spent“Audit deciphering of doctors the handwriting and handwritingto read. iInn these our cases. experience, Of course however,, not all cases this pres ent a challenge in cryptography; one of the state-based audits within the some surgeons write with beautiful script that is a pleasure to read.comments In our experience in ,audit would be wise Australian and New Zealand Audit of however,is unfortunately this is unfortunately a minority. a minority. Some Some lessless favourable examplesand photocopies are provided of examples where Surgical Mortality (ANZASM). below.favourable examples are provided below. handwriting poor.” The audit process begins when the • “Reading other reports as an assessor, SAAPM office is notified of the death of I am often disappointed that a junior a patient who was under the care of a person writes the report rather than surgeon in a participating hospital. the treating surgeon. Particularly if When the consultant surgeon provides done in ‘longhand’, the reports can be a completed surgical case form regarding FigureFigure 1: Handwriting 1: Handwriting excerpts from excerpts SAAPM Surgical from Case Forms un-readable or even misleading. Much the death to the SAAPM office, it is de- CaseSAAPM notes Surgical Case Forms room for improvement here!” Once data from a Surgical Case Form is entered into the database, a typed form can then be printed, eliminating the issue of legibility for first-line assessors. However, cases that are 34 Surgical News september 2014 progressed to second-line assessment require a review of the entire medical record. Surgical News september 2014 35 Feedback suggests that assessors also experience frustration with their colleagues’ handwriting. A recent SAAPM survey returned the following comments from our assessors:

• “Legibility of doctors notes in hospital case notes still very poor and signatures not accompanied by printed names.”

• “Audit of doctors handwriting and comments in audit would be wise and photocopies of examples where handwriting poor.”

• “Reading other reports as an assessor, I am often disappointed that a junior person writes the report rather than the treating surgeon. Particularly if done in ‘longhand’, the reports can be un-readable or even misleading. Much room for improvement here!” Poor handwriting in medical records is a serious concern. In addition to being time- consuming to decipher, misinterpretation of notes and instructions can lead to delays or errors in patient management. At the level of the audit it may lead to a less comprehensive or unfavourable assessment of the case. As most notes are handwritten, the only solution at present is increased mindfulness when writing in the case notes. Looking forward, technology may provide a solution. A study published in the International Journal of Surgery describing the implementation of electronic operation notes demonstrated a marked improvement in the quality of the documentation.6 Conclusion Factors contributing to doctors’ poor handwriting include significant time pressures and a substantial amount of paperwork. However, our feedback together with other research suggests that the issue requires greater attention to avoid the potential pitfalls of poor documentation. Regarding audit forms, the simplest solution is the use of the Fellows Interface allowing surgeons to complete and submit surgical case forms and first-line assessments online. The Fellows Interface requires only an internet connection and a username and password (supplied by the SAAPM office). The system is convenient, decreases turnaround time and reduces paperwork. Alternatively, typing reports or dictating them to a secretary removes the issue of legibility. Where typing is not possible, taking care to write clearly and legibly using only widely known abbreviations is important. Writing in print rather than cursive and using block letters can increase readability. 1. Schneider K A, Murray C W, Shadduck R D, Meyers D G (2006) Legibility of doctors' handwriting is as good (or 2. bad) as everyone else's. British Medical Journal Quality and Safety, 15(6), 445. 3. Berwick D M & Winickoff D E (1996) The truth about doctors' handwriting: a prospective study. British Medical Journal, 313, 1657-1658. Global Surgery ARE YOU PROTECTING YOUR MOST VALUABLE ASSET? Apart from intangibles like good health, what would you regard as your most valuable asset... your family home... your superannuation?

Twenty years of service WHAT ABOUT PROTECTING YOUR BIGGEST ASSET... YOUR ABILITY TO EARN INCOME! for Hangzhou hospital Let’s look at it in monetary terms. Know your benefit period. Know the difference between ‘Agreed You wouldn’t neglect to insure your Make sure you know how long you’re going Value’ and ‘Indemnity’ contracts. The Sir Run Run Shaw Hospital, in the picturesque East China city of home or other assets so why ignore to get paid for - the most comprehensive With an indemnity policy, you are Hangzhou, celebrated its twentieth anniversary in April, this year. your biggest asset? For example, policies go to age 65 or 70, which is a insured for what you say you earn. The College was represented by members from Project China if you earned $250,000 per year, better outcome for most health But, if you make a claim you will have to keeping pace with inflation of 3% pa professionals. Also if you’re insured verify your income. If your income is the value of your income stream over a through your super fund check your lower than when you applied for cover, 30 year working life would be almost benefit period as Super Funds often only your claim will be paid on the reduced he Sir Run Run Shaw Hospital is a remarkable 2000 surgery refresher programs together with other activities. $12 million – an amount worth insuring. cover you for two years. amount whereas with an Agreed Value bed hospital in the east side of Hangzhou, a city of Australian colleagues of various specialties have also policy, you prove your income up front seven million people. It is affiliated to the Medical participated in conferences there and others have spent time Income Protection pays a monthly benefit of Choose your waiting period carefully. T up to 75% of your annual income if you’re Some policies have a 30 day waiting and insure to receive a set amount. School of the Zhejiang University (Zhejiang is the Province in the hospital sharing their experience with the Chinese unable to work due to illness or injury. period, but if you can survive for three south of Shanghai). It is remarkable because a substantial surgeons. Has your policy moved with the times? months without income you could save up portion of its capital cost was donated by a philanthropist These exchange programs have been made possible by the But before you purchase a policy, it’s Policy and definition upgrades are very to 30% on your premiums. Cash you can from Hong Kong, Sir Run Run Shaw, hence its name. From frequent visits of Gordon Low and his wife Rosie to Hang- important that you understand what the important for people with older policies use elsewhere. as definitions along with medical its opening in 1994, it was nurtured by the Loma Linda zhou, and have stimulated other colleagues to emulate their ef- contract is actually all about and what advances have improved. Ensure you University of California, a well-known institution of the forts. Alex Konstantatos, an anaesthetist at the Alfred Hospital, your entitlements are. Is there a Specified Injury Benefit? haven’t been left behind! Seven Day Adventist Church. Melbourne, has made yearly visits to Hangzhou for the past INCOME PROTECTION - NOT ALL This type of benefit is payable from the In recent years the hospital was led by the immediate eight years to conduct Pain Management and Peri-operative POLICIES ARE CREATED EQUAL. date of injury, meaning the waiting period As your personal circumstances and is waived. These injuries may include market conditions change, it is prudent past-president Dr He Chao. He is a charismatic and dynamic Courses. John Reeves, the Director of Intensive Care at the Do you have needlestick cover? Some figure who has galvanised the staff into an enthusiastic and Cabrini Hospital, Melbourne, has conducted programs to fractures of the wrist, ankle or jaw. This is to review your financial situation. income protection policies pay a lump an important benefit for surgeons. diligent work force. Furthermore, most of the doctors, the enhance the efficiency of their Intensive Care Department. sum if you contract a blood borne A FULL REVIEW COSTS NOTHING. nurses and the administration possess a very good standard At the anniversary celebrations, a statue of the late Sir disease such as HIV or Hepatitis at work Don’t get short-changed by Please contact Peter Blassis of English, probably because of the American influence. Run Run Shaw was unveiled in the presence of Lady Mona but always read the fine print because ‘claims offsets’. at Langley Securities on 03 9823 1456, Energetic and devoted, they are proud of their institution and Shaw. All the guests were invited to tour the Xiasha Hospital, some will only pay out for HIV. A lot of policies like to reduce what run the hospital to a high degree of efficiency. From 2006, the a 1200 bed sister hospital opened a year ago and managed they pay you by any amounts you 0421 001 323 (mobile) Is there a return-to-work clause? might receive from other sources - or email [email protected] Sir Run Run Shaw Hospital has earned three awards of the by the same administration. As well, some of the guests Some policies include return-to-work avoid nasty surprises and check for for your obligation-free personal risk Joint Commission International (JCI) certificate for quality were presented with exquisite glass vases for ‘Distinguished clauses which let you work for up to claims offsets carefully! management review. healthcare (the JCI is an American system of grading the Service’ to the hospital. We wish to thank President Cai 10 hours a week while still being paid performance in healthcare of hospitals). Xiujun and the hospital for their kindness and generosity your benefit. Visit langleysecurities.com Since 2004, Project China has brought a number of and, above all, for their trust and friendship. colleagues from the Sir Run Run Shaw Hospital to Australia With Alex Konstantatos, John Reeves and Gordon and to attend trauma courses, hospital administration and plastic Rosie Low Langley Securities: Experts in personalised advice for Medical Professionals.

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36 Surgical News september 2014 MUNCHAUSEN SYNDROME K Y M C Factitious disorders Surgical Sketches and Silhouettes Plate: Musings about Munchausen Syndrome, are there three types?

Incidentally not many would know his aide-de-camp and I had organised young Trainee – sotto voce – is reported to thelater thoracic that evening surgeon discharged in charge herself. at the This clin-his accommodationAs we know atmusing the College is gazing for meditativelyhave responded by saying, “And when you Westminsterical history stimulated then was Sirme Clementto recount Price the storythat and weekly refl ectivelystay with in Lady a literary Rank. Thecontext. Thisget led your knighthood, Sir, I will give you the Thomas, who had performed the pneu- ceremony occurred at Buckingham Palace same courtesy.” Don knows his name. of some of my other Munchausen experiences me to ponder the Munchausen syndrome. OpusOPXIII XXXIV monectomy on George VI on 23 Septem- that afternoon and that evening Benny, in over the last three and a half decades, and three Whether by proxy or direct involvement ber, 1951. The whole theatre contingent a contemplative phase, reminiscing about Felix Behan cases in particular spring to mind – I wonder in the public or the private sectors, Silkthis thread had moved en masse to Buckingham his surgical career, told me his conversation VictorianFelix FellowBehan if this is the statistical average (one every ten psychiatric disorder is classifi ed as a facti-Now back to my 3.0 silk and my loose Victorian Fellow Palace for the procedure. Even the theatre with the Queen: which I repeat. years and I would welcome other comments). tious sequence of clinical episodes - fancied,button on my Saville Row jacket. table was given an honorary brass plaque. He recalled the Queen’s comments I managed to get the special needle n a recent theatre list I had an inter- The second case makes an interesting feigned or self-infl icted-. It is interesting how Incidentally the King had an attitude of that afternoon, “So Sir Benjamin, I see from the theatre sister who could only esting clinical experience even at narrative, in the 1980’s. In those days the medi- this eponym arose: Richard Asher in 1951 was knighting his surgeons during their post- you are a doctor?” His response quite be described as exclusivity personified, my age. In the Anaesthetic room a operativecal administrator visits. allowed us to transfer insur-self-assuredlythe fi rst to was, describe “No Ma’am, such self-harm,I am a recall- Date: 27-SEP-2009 O and did the repairs. Initially my attempt patient was awaiting surgery. My registrar was ance patients to the private domain. Over a two ing Baron Munchausen in an article in the I heard this knightly experience from Sir surgeon.” He even asked me about my was successful, but needless to say it fell not there with me to present the details on his month period a general surgeon and I operated Lancet. He mentioned how the Baron had a James Patterson Ross when entertaining future plans in surgery in London and off again. After another try, I went and line of management. He had mentioned before- on this young man a number of times. He had list of fantastic stories, beyond belief, refl ect- me at dinner (incidentally he loved subsequently invited me back to work in sought the help of a specialist, taking it sustained abdominal injuries in a motor vehi- ing daring exploits, quite unbelievable. In his hand that this lady had presented for removal Aussies). He did a sympathectomy with Melbourne. My hesitation initially was to a tailor in Pimlico who diagnosed that of something off her leg. Jamescle accident, Learmonth a perfectly on the Kingcredible in 1949. story He until Icrystallised obituary into in the a positive British Medicalresponse Journal, when it thewas cutting edge needle was the culprit. When I addressed the patient in this recountedlater questioned during thethe post-op multitudi visit,nous the maturehe saidmentioned to me quite how openly,Asher respectfully“If you don’t dedicated This is how we learn. It is a good surgical context, my question was “now what am I Kingabdominal asked himwall to scars kneel – anotheron the cushion warning sign. comethis back syndrome now son, to forgetthe Baron Melbourne!” principle that if you fail twice, get another removing today?” She said “I have a scar on the and with a ceremonial sword (presumably Don Marshall told me about opinion – and I learnt this trick early in leg at a skin graft site and I was told you could a Wilkinson), knighted him on the spot, as Price Thomas when he edited these my surgical career which has stood me in possibly fi x it”. Previous attempts at serial scar must“As have one happened of tomy Sir Clementmentors Price andrecollections. later Hecolleagues recounted the story said of good stead since. revision had been unsuccessful. People knew Thomas.years ago “Plastic surgeonsJohn (Sister,are givesometimes me what I want not,described Surgically I keep modifying what I I have successfully closed similar defects in as psychiatrists with knives”what I– asked but for) not Hayward. always.” He was a am taught and in the creative phase of melanoma patients with the usual keystone Royal talk cardiothoracic surgeon from RMH who my career – doing mattress sutures on technique. Here’s another story of knightage: when worked with Sir Clement Price Thomas almost every theatre list for over 50 years. Like any experienced surgeon, I exposed BennyThree Rank days came before to London discharge to receive he asked ain London.The OnBaron his returnserved to inMelbourne the Russian mili-I learned to lock a mattress by inserting the whole lower limb to examine it and found, hisyoung knighthood nurse for in $15 October so that 1973, his I wasclothes couldone taryof his forces registrars against in trainingthe Ottoman was late Empire theand needle through the loose loop of the to my horror, she had a donor site dressing on be dry-cleaned. I asked the young lady somefor oneacquired of the atheatre reputation sessions for andwitty John and exagger-mattress which locked the tissue into her upper thigh. On further questioning, it months later whether she had ever received herreprimandingly ated tales and said became to this the young subject Trainee, of numerous perfect eversion – simplicity personified. Page: 40 transpired, this had been there for six months. money. She was never paid. “Whentexts I publishedwas working in 1862with bythe Gustav great Sir Doré, fromI use this trick to repair my own socks I then glanced at her notes on the anaesthetic Some years later, I was doing MondayClement balloon Thomas fl ights, Price to taming in London, wolves I would to shooting (being basically parsimonious). I do note Buttons & Surgical Bbench.ow There were fi ves volumes, each about fi ve morning rounds when I encountered thenever fl ocks have of dreamed ducks and of beingbeing late.”mauled The by bears that(en. Professor Grumpy’s wife rejected his inches thick – “a warning sign”. At this stage the same individual, recently admitted again wikipedia.org). requests for haberdashery help, like my A protean perspective alarm bells were ringing and I asked her “why with abdominal trauma. Needless to say he However the idea occurred to me thatFrench wife told me to caisse toi. have you been in hospital so often?” suspect- signed himself out within the hour when I this recollection had a similar ring to anotherZips and Velcro (Velours velvet, and ing some major clinical catastrophe like neph- confronted him. particular person who also wrote aboutcrochet hook en Francaise) are mentioned rotic syndrome. She gave a history of repeat A further story relates to a nursing aide fi ctional and fanciful adventures. He wasin far the Grumpy article. The Velcro n this, another letter from Spring French cuffs (the Francos call them folded irresistible to her.overdose She was needing en grande ICU admission. It transpired who burnt her fi nger on a steriliser. The regis- more readable and he became the second mostprinciple was established by George de Street, I note the feature of Cur- cuffs) nor cufflinks, which mirror our tenue, yet a little shedeshabillé was seen if innot our risqué unit six months earlier and trar in the Emergency Department referred translated author of all time, (second onlyMestral to from the Swiss Alps, having found mudgeon’s Corner in Surgical News dress style. – she opened theit front was doorfound of that the Rollashe has been putting oven her to me for grafting (which failed), which Agatha Christie). Having written Journeymicro to hooks on the native seeds after is always stimulating. Originally I This brings me to a little pearly vignette and positioned herselfcleaner next on the to him,skin graft donor site. was repeated and failed a second time before the Centre of the Earth in 1864, then 20,000walking his dog. Human hairs have the Ihad to use the OECD to find this meaning about Don Hossack, a man of artistic obviously with professional intent. Don’s same micro hooks, which are important I took her into theatre and manually debri- doing a cross fi nger fl ap. The resultant stiff Leagues Under the Sea in 1869, and Around the (churlish or miserly), but it is really a col- background who loved to drive a yellow immediate response – while still stationed in the pathogenesis of pilonidal sinus. ded the wound under general anaesthesia and fi nger years later resulted in a ray amputation World in 80 days in 1873 – none other than the lection of cantankerous idiosyncrasies – of Silver Dawn (Benny Rank drove the same at the red light – was that he just showed Now the curmudgeon’s story gets dressed it with the usual donor site techniques, of the middle fi nger, by another specialist, as great Jules Gabriel Verne (1828-1905) a bad tempered old man. model in black). her his Police Association cufflinks and even better. The reference to the reinforced with soft topical non-removable I discovered when she came back to me for a He lived along the Loire Valley. At the This is a 16th century word. Don was a surgeon at Prince Henry’s madePub: CMC TOTS one remark, “You understand I zip intrigued me. The word has dressings, and signed it “not to be removed medico legal report seeking compensation for school of St Donation College, one of his Incidentally the composer Wolf Ferrari in the 1980s who sometimes wore a am the Victorian State Police Surgeon.” its origin from the onomatopoeic without my permission”. I heard that she had this work related injury. tutors in drawing and mathematics was possi- wrote a comic opera in the 1900s called bowtie (now almost an edict from Without hesitation she retreated back into element of the sound echoing the ‘Four Curmudgeons’, but he was more Infection Control Departments). He was the shadows of theSURGICAL night. NEWS P40 / Vol:10 No:8 September 2009 the sense for the ascending and famous for his piece ‘The Jewels of the also the Victorian State Police Surgeon. In London, one of the buttons of my descending phase, fastening Madonna’. One evening going to an emergency at reefer jacket became detached and here or unfastening. The idea was In his diatribe in the June 2014 issue, Prince Henry’s and while driving along is the genesis of another story. I needed a patented by a Californian engineer I find Professor Grumpy is bugged by the St Kilda stretch, he was surprisingly 3.0 silk on a Keith needle which was only called Whitcombe Judson. When buttons, on tailored shirts, spare parts intercepted at the red light intersection by available from the thoracic department I phoned Rodney Judson, Director hidden under contour shapes and missing a street courtesan. stores and the sister-in-charge had the key of Surgery at RMH about this from the cuffs. He did not mention The appeal of the car must have been to the stock cupboard. nominal association, he was u

38 Surgical News september 2014 Surgical News september 2014 39 Surgical Sketches Medico- The 10th COWLISHAW and Silhouettes Legal Symposium Speakers include: Mr Wyn Beasley (Kenneth Russell Memorial Lecture) Prof. Donald Simpson unaware of the link and a little taken Mr Graham Stewart back. But his response was quite Doctors affected Prof. Alan Thurston amusing when he said, “Felix, if Prof. David Watters you suddenly find the Judsons have bought a flat in Paris, you will know by blood borne we have collected some untapped Saturday 4 October 9.30am royalties, but I am not holding my Hughes Room, breath.” viruses Buttons and Hand Surgery warrant Michael Gorton Royal Australasian College of Surgeons College Solicitor a place in this story – Benny Rank New guidelines for special case doctor management 250-290 Spring Street – the Australian facile princeps was EAST MELBOURNE Vic. 3002 the first president of the Australian Fee: $140 inc. GST Hand Surgery Society involving Covers morning tea, luncheon, afternoon tea, cocktail reception plastic and orthopaedic surgeons. he Medical Board of Australia, through AHPRA, is John Hanrahan, later PRACS, initiated currently consulting on new guidelines to regulate the Contact [email protected] +61 3 9276 7447 my membership to the Society in the Tmanagement of doctors who are infected with blood- 1980s. Benny showed us the technique borne viruses. at the VPSU, of reattaching the long For members of the public, this will be a sensitive and PLEASE RETURN THIS SECTION WITH PAYMENT TO: flexor over a subungual button for a controversial area, where a great deal of understanding and ROYAL AUSTRALASIAN COLLEGE OF SURGEONS zone 1 division of the FDP. I also did education may be necessary. Grainne Murphy, Collections something similar in my long flexor It raises significant issues of patient safety, balanced by issues College of Surgeons Gardens, tendon repairs in zones 2 and 3, no of discrimination. 250-290 Spring Street, East Melbourne, VIC 3002 man’s land – using the Kessler and The guidelines are timely, given the recent case settled in Alternatively fax completed form to +61 3 9249 1219 paratenon appositional repairs, thread Victoria involving an anaesthetist who infected female patients the loose ends of the 3.0 nylon up the with Hepatitis C. The doctor was convicted of a criminal offence DELEGATE INFORMAtiON (Please print in BLOCK LETTERS) lumen of a 20 gauge lumbar puncture and a large class action arising, was settled in favour of the needle and tie it over a subungual Title / Given Name: patients. As a matter of principle, there is nothing wrong with button at the pulp cord down the doctors with some impairment or condition continuing to Surname: tendon. Thus one can test patency of practice, so long as patient safety is protected. The same principle Mailing Address: movement with confidence. applies in relation to doctors infected with blood-borne viruses, I presented this technique (level who are clearly able to practice and treat patients without risk of Postcode: 4/5 evidence) at the Australian Hand infection, so long as appropriate safety measures are taken. • If an infected doctor is fully compliant with CDNA Ph: E-mail Surgery Society meeting in Cairns in The draft guidelines recognise the many views of stakeholders guidelines, there is no requirement to notify the Medical the late ‘90s. and the public in relation to these issues. The draft guidelines Board of Australia, and a treating physician of the infected Dietary Requirements: Incidentally that was the last time include the following general principles:- doctor is under no obligation to report. PAYMENT OPTIONS I went marlin fishing with the late Bill • Doctors have a responsibility to prevent transmission to Employers and contractors dealing with infected doctors 1. Please make all cheques/bank drafts payable to the Royal Wilson. Over four (with four XXXX) patients. must do so in a non-discriminatory way, under general anti- hours we enjoyed the buoyancy of • Doctors should comply with the general safety guidelines Australasian College of Surgeons (payable $AUD) discrimination legislation. Accordingly, treating an infected each other’s company, the buoyancy issued by the Communicable Diseases Network of Australia 2. The following Credit Cards are acceptable doctor differently could give rise to a claim under anti- of the boat in those placid reef (CDNA), as the current benchmark for science and clinical discrimination law, unless patient safety or other health Amex MasterCard Visa card conditions and Bill’s repetitive stories practice in this area. risks arise. of the world figure associates (Rex • Doctors have a responsibility to know their blood-borne Card No: The guidelines do not deal with circumstances in which an Harrison and Jean Renoir, to name a virus status, and particularly be tested following any sharps infected doctor may be required to advise or warn patients, Expiry Date ……....… /………... few). And yes, the magnificent marlin injury or potential exposure. but if doctors are practising safely, in accordance with CDNA Month Year eluded these city slickers. • Doctors can continue to practice, when infected with a blood- guidelines, and there is no risk to the patient, then obviously Card Holder’s Name In conclusion I congratulate borne virus, so long as they practice safely and comply with there may be no legal obligation to inform a patient of the Professor Grumpy for his efforts, but CDNA guidelines. However, their blood-borne virus status doctor’s health status. Card Holder’s Signature like retiring academics a cliché is may require a limitation of scope of practice, where issues of often quoted – how they regret losing patient safety are involved. Amount (inc. GST) $ their faculties. So keep publishing • A doctor who is infected should be under regular care of an Information regarding the draft guidelines, and the consultation sir, and the weeds won’t grow under appropriate specialist doctor, relevant to their blood-borne process, which all members of the public can comment on are Date……… /……… /………… the gate – an Irish metaphor my virus status (If the doctor does not comply with the treating available on the AHPRA website.

u grandmother taught me. doctor’s advice, mandatory reporting may be initiated).

40 Surgical News september 2014 Surgical News september 2014 41 College Awards

Awarded at the 2014 Singapore Annual Scientific Congratulations Congress on your achievements

PROFESSOR DAMIEN BOLTON FRACS Excellence in Surgical Research Award amien Bolton completed Dtraining in Urology through the Royal Australasian College of Surgeons in 1993, after having additionally undertaken a period of RACS-scholarship funded research leading to the degree of Doctor of Medicine through the University of Melbourne. Thereafter he commenced a clinical fellowship at the The John Mitchell Crouch Fellowship is the premier research award of the Royal University of California San form the basis of in excess of 100 peer-reviewed Australasian College of Surgeons. It is separate from Foundation Grants and Francisco, and extending his publications. Surgical Trainees from this program independently funded. The Fellowship commemorates an outstanding younger Fellow tenure there for a further period as have been presented with more than 20 separate of the College who died in 1977 on the threshold of a highly promising career. John an Assistant Professor of Surgery. awards and prizes on the basis of their research. Mitchell Crouch was a young surgeon who showed astute clinical, organisational Shortly after returning to Based on research undertaken in this program and research abilities and this award is made to an individual who, in the opinion of Melbourne he was appointed Professor Bolton was awarded the John Mitchell Council, is making an outstanding contribution to the advancement of surgery. Director of Urology at the Austin Crouch fellowship of the RACS, being the first Hospital where he initiated a urologist to receive this award, as well as the British PROFESSOR ANDREW outcomes from major abdominal urologic research Fellowship Association of Urologic Surgeons Silver Medal HILL FRACS surgery and medical education and he program with twin arms of clinical for surgical research. He has served on multiple has published over 150 peer-reviewed 2014 John Mitchell and basic laboratory research. international collaborative projects for clinical papers in these areas. Andrew leads the These have focused primarily research in urology, as well as the editorial boards of Crouch Fellow New Zealand and Australia Enhanced on clinical outcomes in urologic three urologic journals. rofessor Andrew Hill completed an Recovery after Surgery (NZERAS) group, oncology treatment, and on small In developing the Austin Hospital’s urology PMD in Surgery from the University an interdisciplinary research group protein function in urologic research Fellowship, Professor Bolton has been an of Auckland in 1996 and a Doctorate in aiming to improve patient outcomes malignancies. investigator on grants receiving over seven million Education in 2011. Following a research after major surgery. This group runs a To date, this research Fellowship dollars in competitive funding. Several of the fellowship at Harvard University in 1993 once yearly international symposium on program has been a stepping stone Trainees to have completed research through this and 1994, Andrew completed surgical enhancing recovery. for more than 25 Trainees who urology department have also gone on to undertake training in 1997 and worked in Kenya as The John Mitchell Crouch Research have gone on to gain selection to academic-based post-Fellowship training in North a medical missionary. Andrew returned Scholarship will be used to further advanced training in urology and America and the United Kingdom, with collaborative to the South Auckland Clinical School research into improving outcomes from general surgery after a period of surgical research projects consequently being at Middlemore Hospital in 2002 where colorectal surgery. full-time research. established between Australia and major centres he now practices as a Colorectal Surgeon The research output from abroad. Presently there are six surgical Trainees and is the Head of the South Auckland Established in 2000, the RACS Excellence this Fellowship program has participating in this surgical research program at Clinical School. He has received extensive in Surgical Research Award is an honour subsequently gone on to attain different levels of progress towards postgraduate research funding from the University and created to recognise the contribution of more than 50 postgraduate degrees including PhD, Doctor of Medical Science from External Sources and has used this a pre-eminent surgeon scientist who has scholarships for the Trainees and Master of Surgery. to develop a significant research portfolio. made significant contributions to surgical concerned, to produce multiple Citation kindly provided by Mr David Winkle His research interests are improving research. postgraduate degrees, and to FRACS

42 Surgical News september 2014 Surgical News september 2014 43 Interplast

Surgery of Repair scholarship enables the spirit of his surgery there and training various contribution to continue by enabling surgeons, for which he was awarded as Applied further training of overseas surgeons. Companion of the Order of St The bestowing of this scholarship Michael and St George in 1955 to Hand is a significant honour to recipients as • Was knighted for his services to Injuries my grandfather’s legacy of professional plastic surgery by the Queen in 1972 In his name achievements lives on to this very day. By • Was on the council of the Royal B K Rank & A R Wakefield Sam Gray way of a summary of some of those key Australasian College of Surgeons from t is a special thing, the bond between A scholarship in honour of Sir Benjamin Rank achievements, Sir Benjamin Rank: 1955, and served as its President from grandparent and grandchild. So • Served in the Second World War 19 6 6-19 6 8. has been established Iit was with my grandfather, Sir performing plastic surgery operations • Became in 1965 the first and only Benjamin Rank. in the Australian general hospital in overseas President of the British My most treasured memory of him 1941 Association of Plastic Surgeons is, whenever we used to visit his home • Is regarded as one of the pioneers of (BAPS) in Mt Eliza, his huge smile and beams plastic and reconstructive surgery in • Was appointed in 1958 as Sims Applied to Hand Injuries’ (1953) by B of delight radiating from his face as he Australia Commonwealth Professor of Surgery K Rank and A R Wakefield, which was opened the front door to welcome us. • Was pivotal in the establishment of and visited Canada in this role. translated into multiple languages. But on pondering my grandfather’s the charity Interplast in Australia, • From 1946-1966 was in charge of the It is a great honour to be able to life, the characteristic most revered was approximately 30 years ago Plastic and Facio-maxillary unit at help his legacy thrive, to recognise my his ever-present desire to give back to the • Through the Colombo Plan made Royal Melbourne Hospital grandfather and, most importantly, to community. Through the example he gave a significant contribution to India • Authored a number of books, contribute to our neighbours in the us through his actions, he passed this and Pakistan in establishing plastic including ‘Surgery of Repair as region who are less fortunate than us. on to his children and to me (amongst others) as one of his grandchildren. It has therefore been a great pleasure to have been able to initiate, with the wonderful people at Interplast, a scholarship in his honour, the Sir Benjamin Rank Scholarship. This is essentially an extension of the many Mayo School of Continuous Professional Development wonderful activities of Interplast. The scholarship will enable a surgeon or surgeons to visit Australia for short- Mayo Clinic Interactive Surgery Symposium term observational training, in order to ultimately develop and enhance their skills further. The first of these scholarships will be provided during 2014. Grand Hyatt Kauai Resort and Spa Interplast operates throughout the Koloa, Kauai, Hawaii Asia-Pacific region particularly in the poorer countries. It sends specialist February 8-13, 2015 surgical teams to perform free operations on those who would otherwise not SYMPOSIUM HIGHLIGHTS: be able to afford them. It also trains • Featuring Self-Assessment Credit Toward Part 2 of the surgeons from these countries, so as to ABS MOC Program improve their skill set – thus providing lasting changes to the quality of medical • Case Presentations and Panel Discussions services they offer. • Video Presentations of Surgical Techniques The training of others was an activity • Unique Format Utilizing Interactive Response Keypad System in which my grandfather was very active for a long period during his professional working life, including under what Note: Due to previous room sell-outs, book your sleeping room was known as the Colombo Plan. His accommodations early. Plan to attend now! Aloha! knighthood recognised his contribution to the field of plastic surgery in Australia Register Now! www.mayo.edu/cme and worldwide. It is fitting that this

44 Surgical News september 2014 Surgical News september 2014 45 Article of Interest Tips for successful Advance Care Planning conversations6 • The individual needs to be ready for the conversation and mentally capable of participating – conversation cannot be forced; at the same time clinicians, in most instances, need to take the lead in initiating such Use of ACDs conversations. In recent years there has been a greater • Capacity to engage in conversation must be focus on the role of advance care maximised by treating any transient condition Advance Care planning and ACDs. This policy has been affecting communication and optimising sensory driven by a number of factors including function (e.g. by ensuring the patient’s hearing aid is Australia’s ageing population, medical and being worn). Planning and technological advances which prolong • Conversations need to take place on more than one life, increased emphasis on autonomy and occasion (over days, weeks and even months) and patient-centred care, and the provision of should not generally be completed on a single visit. Advance Care quality care at the end of life. • Conversations take time and effort and cannot be However, to date, ACDs have not proved completed as a simple checklist exercise. to be a popular planning tool. This is • Conversations should take place in comfortable, Directives unhurried surroundings; time is a key factor. despite the fact that individuals are encouraged to discuss with their families • Conversations should be devoid of medical jargon, Dr Sara Bird how they would like their health care to be language should be positive, and trust must be built Manager, Medico-legal using empathic listening skills. and Advisory Services managed if they are no longer able to make MDA National their own decisions, and for doctors to • A step-by-step approach to identifying and resolving incorporate Advance Care Planning as part issues should be used, coupled with “time out” of routine health care, including raising the periods where doctors withdraw from the encounter topic with all older patients.2 to allow the patient and family to discuss among themselves the care options being presented. Some of the concerns that have been • Individuals should be given realistic information on raised in relation to the use of ACDs are: prognosis and treatment options with emphasis on • Validity and reliability – the how their illness is expected to impact on their daily person making the ACD may lack function. the information required to make an • Conversations should avoid focusing initially informed choice, especially where the on medical interventions (e.g. cardiopulmonary ACD is made prior to the onset of an resuscitation, intubation) but rather determine illness for which a treatment decision values, goals and preferences (e.g. prolonging life and must be made, and the way in which the preserving mentation versus minimising suffering ACD is written may be influenced by the and avoiding undignified states or an unacceptable manner in which questions are posed. functional status). • Durability – an individual’s treatment • Look out for cues suggesting individuals are choices can change over time such that becoming uncomfortable talking about certain issues an ACD made at a particular time may or may wish to end the conversation. • Encourage patients to identify a surrogate decision- This article is provided by MDA National. It was first published in MDA National’s not accurately reflect the person’s wishes at a later date, and may not reflect maker and to discuss their wishes with that ‘Defence Update’ Autumn 2014. MDA National recommends that you contact your advances in medical practice. individual; if desired, offer to facilitate a conversation indemnity provider if you have specific questions about your indemnity cover • Efficacy – the person’s true wishes may between the patient and their surrogate or other not be accurately ascertained from an family members; identify whether patients have ACD with sufficient clarity to guide specific desires for how information is shared among clinical management. family members. What is Advance Care Planning? generally a written document intended to apply to future • Accessibility – it may not be possible to • Summarise and check the patient’s and, if present, This is a process of planning for future health and personal periods of impaired decision-making capacity, which locate an ACD when needed. their surrogate’s understanding of what has been care whereby the person’s values, beliefs and preferences provides a legal means for a competent adult to record • Portability – each state and territory discussed at the end of sessions. are made known so they can guide decision-making at a preferences for future health and personal care and/or to has a different legislative framework for • Encourage patients and surrogates to have 5 future time when that person cannot make or communicate appoint and instruct a substitute decision-maker (SDM). ACDs. conversations documented, but reassure them that his or her decisions.2 Advance Care Planning is based on ACDs are not clinical care or treatment plans; but clinical these documents are not necessarily final or binding. principles of self-determination, dignity and avoidance of care and treatment plans can and should be informed by As a result of these factors, medical prac- • Plan for a review as clinical circumstances change. 2 suffering.3 ACDs. titioners may be concerned about following an ACD, especially where they do not be- Copyright © 2009 Royal College of Physicians. Adapted with permission. Reproduced from: Royal College of Physicians, What is an Advance Care Directive? When is an ACD valid? lieve it represents “good” medical decision- In general terms, an ACD is valid when it meets the National Council for Palliative Care, British Society of Advance Care Planning will often lead to the completion making, or that the ACD may not represent Rehabilitation Medicine, British Geriatrics Society, Alzheimer’s following criteria: of an Advance Care Directive (ACD). An ACD is a means the true wishes of the patient. Practitioners Society, Royal College of Nursing, Royal College of Psychiatrists, by which a competent adult can determine the medical • It is made by a competent adult. may also be concerned about potential li- Help the Aged, Royal College of General Practitioners. Advance treatment that he or she wants to accept or refuse in the • It is made free of undue influence. ability, especially where there is conflict with Care Planning. Concise Guidance to Good Practice series, No 12. future if decision-making competence is lost.4 An ACD is • It applies to the situation at hand. the wishes of the patient’s family. u London: RCP, 2009.

46 Surgical News september 2014 Surgical News september 2014 47 Article of Interest The Royal Australasian College of Surgeons Member Advantage Benefit Program

Code of ethical practice if an ACD is made by a capable adult, that affect their operation (see Table 1). for ACDs2 is clear and unambiguous, and extends 1. ACDs are founded on respect for a to the situation at hand, it must be A more detailed summary of the 7 person’s autonomy and are focused on respected. legislation in each state and territory can the person. In addition to the common law, be accessed at: 2. Competent adults are autonomous legislation governing ACDs has been • A National Framework for Advance individuals and are entitled to make enacted in every state and territory, except Care Directives, Appendix 1: their own decisions about personal NSW and Tasmania where the common ahmac.gov.au/cms_documents/ and health matters. law would apply with regard to ACDs. AdvanceCareDirectives2011.pdf. 3. Autonomy can be exercised in However, the legislation is complex • Advance Care Planning Australia’s different ways according to the and there is considerable variation in website: advancecareplanning. the scope of the legislation. Between org.au/advance-care-planning/for- International person’s culture, background, history or spiritual and religious beliefs. jurisdictions, the legislative name of ACDs professionals/the-law-of-advance-care- 4. Adults are presumed competent. varies and there are differing restrictions planning money transfers 5. Directions in ACDs may reflect a References can be found at http://www.defenceupdate.mdanational.com.au/advance-care-planning/ broad concept of health. at better rates than the banks! 6. Directions in ACDs can relate to any future time. Table 1 7. The person decides what constitutes State/ Name Restrictions quality of life. Territory Do you need to pay an international invoice, purchase 8. The substitute decision-maker (SDM) ACT Health Direction has the same authority as the person a property or send money to family members overseas? when competent. Our partnership with OzForex allows you to transfer 9. The SDM must honour residual NT Direction Effective only when person suffers from a terminal illness. decision-making capacity. money worldwide at significantly lower rates than banks. 10. The primary decision-making standard for SDMs is substituted QLD Advance Health For directions to withhold/withdraw life- Directive sustaining measures: judgment. Benefits of using OzForex include: 1. direction cannot operate unless there is no 11. A SDM should only base his or her chance of the patient regaining capacity and decision on “best interests” when any of the following: £ Free transfers for RACS Fellows and Trainees there is no evidence of the person’s • terminal illness/incurable condition $ preferences on which to base and expected to die in one year No receiving bank fees in most countries substituted judgment. • permanent coma/post-coma ¤ Phone access 24-hours a day, 5 days a week 12. An ACD can be relied upon if it unresponsiveness appears valid. • illness/injury so severe that no ¢ Online access 24/7 13. A refusal of health-related reasonable prospect of recovery ¥ Competitive foreign exchange rates intervention in a valid ACD must be without life-sustaining measures followed, if intended by the person to 2. for directions regarding artificial nutrition/ across 47 currencies hydration (ANH), commencing or continuing ANH apply to the situation. would be inconsistent with good medical practice. 14. A person, or their legally recognised Register online today to save on transfers, or SDM, can consent to the treatment SA Advance Care Effective from 1 July 2014. offered, refuse the treatment offered, Directive speak to OzForex’s accredited dealers for more but cannot demand treatment. Effective only when person is in terminal 15. A valid ACD that expresses preferences Anticipatory phase of a terminal illness, or in a persistent information about the service. or refusals relevant and specific to the Direction vegetative state. situation at hand must be followed. (Still legally effective after 1 July 2014.) VIC Refusal of Does not cover procedures that would be Call 1300 300 424 (Australia) or 0800 161 868 (NZ) Legal framework for Treatment considered palliative. ACDs Certificate Applies only to a current condition. www.memberadvantage.com.au/racs/ozforex The common law recognises, as part of the right to self-determination, that an WA Advance Health A treatment decision will not operate if individual can complete an ACD that will Directive circumstances exist that the person would bind a health practitioner who is treating not have reasonably anticipated at the time of that person, even if the directive refuses making the directive and would have caused a life-sustaining treatment. A 2009 NSW reasonable person to change their mind about the treatment decision. Supreme Court judgment confirmed that

48 Surgical News september 2014 Surgical News september 2014 49 Royal AustralasianYes, I would like toCollege donate of Surgeons to our Foundation for Surgery

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