' Winter Has Come'

January 2020 Greener Anaesthesia and Sustainability Project

How standards are changing the future of care

The Quality Improvement Compendium – coming soon!

‘ Winter has come’ Assessing the impact of pensions tax on workforce and service delivery in a large department Page 12

www.rcoa.ac.uk @RCoANews Co-badged with:

Confirmed topics

■■ Perioperative medicine. ■■ Anaesthesia and the brain.

■■ Tracheostomy QI toolkit. ■■ Global anaesthesia.

■■ Anaesthesia new frontiers.

Full programme available online.

18–20 May 2020 Old Trafford, the Home of SAVE 10% Manchester United Limited early bird places available until 31 January 2020 – Book your place at: quote EARLY10 www.rcoa.ac.uk/events/ when booking anaesthesia-2020 Bulletin | Issue 119 | January 2020 Bulletin | Issue 119 | January 2020

The President’s View 4

News in brief 8 Contents Guest Editorial 12 From the editor Faculty of Pain Medicine (FPM) 14

Faculty of Intensive Care Medicine (FICM) 15 Dr David Bogod SAS and Specialty Doctors 16

Revalidation for anaesthetists 18 Welcome to the January Bulletin.

Patient perspective 20 Editing the Bulletin is an honour and a pleasure, but sometimes the long lead-in time between submission Reducing drug errors in total and publication can be frustrating, and never more so than in relation to our lead article, by Dr du Plessis 22 intravenous anaesthesia and Professor Pandit, on the impact of the pensions crisis arising from the legislation on the tapered annual Perioperative cardiopulmonary allowance. As I write this comment at the tail-end of November, I really have no idea what the pensions exercise testing in the South West 26 picture will be when you, gentle reader, eagerly open this issue. Will trusts have taken up the added tax ‘Yes, your honour…’ 30 burden? Will variable contributions from PAYE have mitigated the risk? Will a Conservative Government have kept their promise to compensate doctors on retirement for huge tax bills incurred when taking on extra Greener Anaesthesia Guest editorial and Sustainability Project 32 sessions? Will we have a Conservative Government? Will we have a Government? As the writers point out, Jaideep Pandit accurately predicted all this way back in 2016, and I only wish I had access to his crystal ball. ‘Winter has come’ A call to arms 34 How standards are changing We could all do with a little more love, frankly, and so I must commend Oliver Boney’s article. An ST7 from Assessing the impact of pensions tax on workforce the future of care 36 London, Oliver urges us to undertake ‘small acts of kindness’ to our colleagues and our patients and points out that simply being nice is one of the best ways to improve morale and reduce stress and burnout. It is a and service delivery in a large department In praise of obstetric anaesthetists 40 message that is worth emphasising. I often end a talk on litigation with the anecdotal observation that, all else Page 12 being equal, nice doctors are less likely to run into medicolegal problems than nasty doctors. More recently, Perioperative Journal Watch 43 and less cynically perhaps, I have discovered that one of the great secrets to a happy work environment is Integrate... and simple – Malteser tiffin. Found on the BBC Good Food website (bit.ly/2Otb2ys), it takes 20 minutes to make, The President’s View ‘Bath tea trolley’ get the best of both worlds! 44 even for a total cooking duffer like me. Refrigerate overnight, cut up into small squares and deposit in coffee The College launches its Medical training (Part 1) The Quality Improvement room with a little note. The effect, especially on a busy maternity unit, is not unlike one of those shark feeding 46 Workforce Census 2020 and A novel method of providing Compendium – coming soon! frenzies you see on wildlife programmes, and suddenly everyone loves you. A word of warning: DO NOT, welcomes your input multidisciplinary team training in Adjusting to life in the UK: a under any circumstances, look at the site which comes up when you google ‘Maltester tiffin calories’. Page 4 first-person experience 48 the workplace ‘Keeping midwives happy’ is not one of the non-technical skills that Professor William Harrop-Griffiths Page 28 Supervision of safe clinical care 50 The milk of human considers in his latest Soapbox article on obstetric anaesthetists, but it probably should be. Members of New website. New look. Better the OAA should watch their blood pressures while taking a pinch of salt (mutually exclusive?) when reading kindness Exam preparation: service 52 his firmly tongue-in-cheek article. I’m hoping that he’ll have a crack at the difficult airway brigade next, so The importance of supporting myths and tips An insider’s view: being a watch this space. each other in the workplace Helping trainees plan a CPD Assessor 54 Finally, in this issue, we say goodbye to two long-standing members of the Lay Committee, Elspeth Evans and Page 24 successful journey as they As we were... 56 Stuart Burgess. They have been advising the College for six years, and their wisdom, good sense and humour prepare for the exam New to the College 58 will be greatly missed. The Lay Committee work hard for the membership and our patients, often behind the Page 38 scenes, and members are encouraged to find out more about their role by visiting their page on the website Notices 60 (www.rcoa.ac.uk/lay-committee). Letters to the editor 63 Happy 2020 to all our readers! Advertisements 64

College Events 68

Professor Ravi Mahajan President [email protected]

Looking to the future, the College will keep workforce as a key priority. We will continue to be a strong voice in supporting our fellows and members in their positions to not only help deliver the best healthcare system possible, but to look at how we can make the NHS a better place to work.

In recent years workforce has been placed The College continues to ensure its voice is at the front and centre of the NHS agenda heard through the presentation of accurate and at the College. A shortage of staff, an facts and figures to help recommend genuine ageing population and changes to pension and realistic actions on workforce and taxation, have all contributed to the challenging recruitment to national health bodies and high- times we work in and we have also had to level organisations. To do this an evidence adapt to workforce issues within the political base approach is important, and this month the landscape. However during these difficult College is pleased to have launched its Medical times, we have seen positive news such as the Workforce Census 2020. Our robust data announcement of the GMC as the named and information enables us to actively engage regulator for Anaesthesia Associates (AAs). with Health Education England and national Properly regulated, AAs under appropriate health bodies in England and the devolved supervision, will become important members of nations on workforce discussions, and respond perioperative care teams across the NHS. We to a wide range of consultations. To date this also welcomed the news of the Government’s has included the College’s response to the approval of the Migration Advisory Committees NHS Interim People Plan (bit.ly/2QT3VRa), in recommendation for all medical practitioners to which the College welcomed the themes and be added to the National Shortage Occupation ambitions set out in the plan. It is encouraging list. In addition, the College has previously to see a focus on cultural changes within called for significant investment into training the NHS, and a commitment to engage with so that the UK can become ‘self-sufficient’ in doctors and other front-line healthcare workers training doctors by 2025. However, growing in order to become a more compassionate and a domestic workforce requires time to develop fair employer. At the time of writing, the Final and therefore in the interim, it is essential NHS People Plan is expected to be published that the NHS is able to recruit talent from this month and we look forward to responding. abroad to fill rota gaps and maintain adequate The President’s View staffing levels for the safety of both the By continuing the conversation and the need workforce and patients. for an evidence base approach, we have consulted on the development of a College YOUR WORKFORCE DATA MATTERS workforce strategy by asking our fellows and members what they think should be the priorities of the strategy aligned to the key themes identified in the NHS Interim People

Where are the gaps in staffing Bulletin The Census 2020 is no different, if of the Royal College of Anaesthetists of anaesthetic services? Churchill House, 35 Red Lion Square, London WC1R 4SG Data collected in 2018 from clinical directors anything it is more important than ever to 020 7092 1500 across 86% of anaesthetic departments in the www.rcoa.ac.uk/bulletin | [email protected] UK found that; collect complete data and we need your @RCoANews help with this /RoyalCollegeofAnaesthetists 1 Overall, 75% of anaesthetic Registered Charity No 1013887 departments across the UK Registered Charity in Scotland No SC037737 75% have at least one unfilled VAT Registration No GB 927 2364 18 consultant post. President Hugo Hunton Plan. We thank you for your responses, In terms of recruitment, 48% of trusts The Census 2015 achieved a 100% Ravi Mahajan Lead College Tutor which helped shape an additional have advertised a consultant post but response rate, which is a significant document to NHS Improvement around had been unable to fill it. The most testament to the willingness and Vice-Presidents Emma Stiby 2 Around half (48%) of the People Plan, which presents the views common reasons why departments professionalism of the anaesthetic Fiona Donald and SAS Member departments have advertised from the frontline (bit.ly/RCoAsurvey) could not fill posts were reported as community, and recognition of the Mike Grocott Katie Samuel a consultant post that they and we look forward to presenting the a lack of applicants (34%) or a lack of importance attached to this aspect of Editorial Board Anaesthetists in Training have been unable to fill. workforce strategy this year. qualified applicants (35%). college activity. The Census 2020 is no David Bogod, Editor Committee different, if anything it is more important Helgi Johannsson, Editor Elect Carol Pellowe The College has been collating data The overall picture from these than ever to collect complete data and Lay Committee over the years which has seen the data suggests that the anaesthetic we need your help with this. Please Jaideep Pandit delivery of the Medical Workforce workforce is under-producing new encourage your department to complete Council Member Gavin Dallas Census Report 2015 and the anaesthetists to meet the increasing the census and raise awareness of this 3 T he most common reasons Krish Ramachandran Head of Communications Workforce Data Packs 2016 and 2018 demand, which is leading to an important task. The census closes in for anaesthetic departments Council Member Mandie Kelly (www.rcoa.ac.uk/workforce). To this day increasing workforce shortfall. early February and we urge every single reporting that they could Duncan Parkhouse Website & Publications Officer the information is comprehensive and is anaesthetic department to contribute. used alongside the data packs to help A common theme from responses to not fill consultant posts Lead Regional Advisor Anamika Trivedi inform policy makers and national bodies the consultation on the development The College plays an important role in were a lack of applicants Anaesthesia Website & Publications Officer about the pressures facing anaesthesia of a College workforce strategy was shaping healthcare policy and practice (34%) and a lack of qualified Articles for submission, together with any declaration of interest, as well as our position on the state of the appetite for credible data and by campaigning for change and working applicants (35%). should be sent to the Editor via email to [email protected] anaesthesia UK wide. intelligence through our surveys. The collaboratively with key partners and College recognises that without robust national governments. The data from All contributions will receive an acknowledgement and A survey completed by the National data we have no credible voice to argue the Census 2020 will also help us the Editor reserves the right to edit articles for reasons of Clinical Director network in 2018, our workforce position. This month the to identify key issues, such as how a space or clarity. reported complete data from 86% College’s Medical Workforce Census shortfall in the anaesthetic workforce The views and opinions expressed in the Bulletin are solely of trusts in the UK. They were asked 2020 was sent to our National Clinical can impact on surgery waiting lists, 4 There is a consultant those of the individual authors. Adverts imply no form of about consultant and SAS doctor gaps Directors Network and College tutors for example cancellations of lists and anaesthetist gap of 7% endorsement and neither do they represent the view of and difficulties recruiting. The survey to complete. We are making a call for NHS waiting times. Reliable and up to in England. the Royal College of Anaesthetists. showed that there was a total of 411 action for all to get involved and engage date data will help raise our concerns unfilled consultant posts across our in supporting your clinical directors further, and ensure that what the College © 2020 Bulletin of the Royal College of Anaesthetists sample, which represented a consultant and College tutors in providing the says is evidence-led, authoritative and, All Rights Reserved. No part of this publication may be gap of 6.9%. This is an increase from data requested. This data is essential in importantly, independent. reproduced, stored in a retrieval system, or transmitted in the College 2015 census where the monitoring the evolving gap in order any form or by any other means, electronic, mechanical, T here is an SAS anaesthetist gap was reported as 4.4% and in the to make official bodies aware of the 5 photocopying, recording, or otherwise, without prior 2017 Clinical Director survey where anaesthetic workforce crisis, and to gap of 19.8% in England. permission, in writing, of the Royal College of Anaesthetists. the gap had increased to 5.2%. The ensure our workforce position is based situation is similar for SAS doctor posts. on robust information. ISSN (print): 2040-8846 In 2018 there were 276 unfilled SAS 6 T he percentage of consultant ISSN (online): 2040-8854 posts, representing a gap of 18.9%. anaesthetists employed as locums is 4.5% in England.

NEWS IN BRIEF N ews and information from around the College

BOOK NOW! GOING GREENER How to opt out of your printed BJA and Introducing new Anaesthetic updates Every year the College runs four Updates in Anaesthesia, Critical Care and Pain BJA Education journals Management events and six CPD Study Days. The main noticeable difference for these events is the length, but essentially they are both run to provide an opportunity A Manifesto for to connect with specialty experts and peers, and bring back ideas that will improve Whilst the content of our academic journals, British Journal of Anaesthesia (BJA) and BJA Education is second to none, the your own practice. a 21st century College has had a growing number of requests from fellows and members who would like to opt out of receiving the printed copies. Whether it’s for ease of reading, personal preference, or for environmental reasons, opting out of print Due to their similar structure and function, we have decided to re-brand these National Health copies is easy to set up. Simply email [email protected] with your name and College reference number and your popular events and combine them into a series called Anaesthetic updates. This Service request. You will still retain full access to the journals online, and Bulletin will continue to be posted to you. series launches this month and varies in length from a one to three-day programme. Book your place now at one of our Anaesthetic updates: In our 2019 General Election manifesto, The College is committed to embedding sustainability in everything we do. Through the work of our President’s the College called on the next Environmental Advisor, Dr Tom Pierce, the College aligns itself with relevant national and international 31 January 2020 25–27 February 2020 17–18 March 2020 Government to address the critical issues initiatives related to anaesthesia and the wider NHS, aimed at mitigating further global Nottingham London London preventing the delivery of a 21st century temperature rise and climate change. This includes being a founder member national health service. Focusing on staff of the UK Health Alliance on Climate Change, working jointly with the www.rcoa.ac.uk/events wellbeing and integrated care is what’s Association of Anaesthetists, and there is also a College Council lead for needed to create a sustainable NHS, not sustainability, Dr Lucy Williams. Two articles exploring the environment and a total restructure. anaesthesia can be found on pages 32 and 34 of this issue.

Annual College award nominations With the General Election now over, More information on environment and sustainability, including our and a new Government in place, we will Sustainability Strategy 2019–2022, can be found on the College website at: The College is now inviting nominations for the College annual awards. Fellows continue to: www.rcoa.ac.uk/environment-sustainability or members are invited to suggest nominations for consideration on behalf of Council by the Nominations Committee. ■■ take a whole-person approach

■■ care for the people who care for us The process for nomination allows for any fellow or member to put forward nominations to be considered by the College Nominations Committee. This ■■ ensure a future doctor and nursing Committee is chaired by Dr Kirstin May and includes the President, Professor Ravi ‘pipeline’ Mahajan, and Vice Presidents, Dr Fiona Donald and Professor Mike Grocott. ■■ safeguard a sustainable NHS Three new websites... ■■ remove the culture of blame to Past recipients are listed on the College website and can be used as maintain patient safety a good starting point when considering for what award a nomination with much more to come should be submitted. More information can be found on the website at: ■■ deliver 21st century care www.rcoa.ac.uk/honours-awards-prizes. Nominations should be proposed using ■■ integrate health and care rcoa.ac.uk | fpm.ac.uk | cpoc.org.uk the form available at the bottom of the webpage. ■■ take a population health approach Completed forms should be submitted to: [email protected] by ■■ support multi-disciplinary working. More details on page 52 Tuesday 31 March 2020. Read our full manifesto here: bit.ly/RCoAManifesto19

NEWS IN BRIEF N ews and information from around the College Find out more about the ACSA scheme here: www.rcoa.ac.uk/ acsa

SNAP3 Commissioning

Visit Brief released the POMCTN POMCTN The Health Services Research Centre (HSRC) has released Views from the frontline of website to apply: the commissioning brief for a Chief Investigator for the third bit.ly/ recruiting future Sprint National Anaesthesia Project (SNAP3), based on frailty anaesthesia – supporting 2KMHDwP Chief Investigators and delirium. the development of the Our thanks to all who proposed topics for SNAP3. The selection The UK Perioperative Medicine Clinical Trials Network panel, which included representatives of the RCoA Council, the People Plan (POMCTN) is running a fresh round of recruitment to its HSRC Board, RAFT, the two previous SNAP trainee leads and a The College welcomed the themes and ambitions set Chief Investigator Scheme. layperson, felt that frailty and delirium presented opportunities for out in the Interim NHS People Plan in spring 2019 and large scale SNAP-style research within a single project. we look forward to the detailed proposals to ensure The Scheme is intended to provide training and mentorship N orfolk and Norwich the NHS is the most supportive and progressive for a small number of talented individuals who wish to lead The successful candidate will be selected based on their credibility University Hospital healthcare provider to work for. their own perioperative clinical trials. to lead SNAP3, clarity of their ideas for the research questions and methods, ability to work in a high-pressure environment and anaesthetists rewarded for Views from the frontline of anaesthesia presents Applicants can be from any clinical background relevant their ability to work with and supervise the trainee lead. our members’ views on what they feel should be to perioperative medicine, with a proven track record of high quality patient care the priorities for the College as we work towards recruitment to trials, ideally with experience of a complete The post is supported by 1PA salary backfill. Deadline for developing a 2020 anaesthesia workforce strategy. Anaesthetists at Norfolk and Norwich University Hospital research cycle as a grant co-applicant. applications is 5.00pm on Friday 7 February 2020. Between August and September 2019, the RCoA (NNUH) have been recognised for providing the highest quality surveyed the views of a number of stakeholders, care to their patients. The prestigious Anaesthesia Clinical Deadline for applications is Monday 27 January 2020. Visit the HSRC website for more details: bit.ly/SNAP3Brief including frontline anaesthetists, Clinical Directors, Services Accreditation (ACSA) from the College was presented Training Programme Directors and Heads of Schools. at a ceremony on 15 November. This paper captures their perspectives. We are ACSA is the College’s peer-reviewed scheme that promotes pleased to now offer this further document in support Patient Safety in Perioperative Practice quality improvement and the highest standards of anaesthetic of the People Plan. There is still time to join this one-day meeting to discuss patient safety, including the barriers to service. To receive accreditation, departments are expected to The College’s workforce strategy will closely align delivering safe perioperative care, and strategies on how to overcome them. It will be held at demonstrate high standards in areas such as patient experience, with the People Plan’s five themes; making the NHS the College on 13 February 2020. patient safety and clinical leadership. the best place to work, improving the leadership Our aims are to build upon knowledge and practice to make systems, processes and culture, tackling workforce shortages, delivering 21st During the accreditation process NNUH have demonstrated a organisations safer. Through an understanding of the science of patient safety, different century care and a future workforce. We look forward strong commitment to delivering high quality anaesthetic care, a perspectives and approaches, coupled with collaboration, education and quality to collaborating with NHS Improvement, Health clear focus on patient safety and a desire to continue to develop improvement programmes we hope to inspire delegates to make safety the golden Education England and wider partners in delivering the services they provide. The anaesthetic department has We will make a thread of patient care. the plan’s aims. £5 donation to shown excellence in a number of areas but in particular with their Book your place today and earn 5 CPD points: bit.ly/PatSafFeb20 Lifebox for every approach to innovation in the delivery of patient centred care. Read the full report here: bit.ly/RCoAsurvey delegate attending this event. | 11 80% 70% 60% 50% 40% 30% 20% 10% Bulletin | Issue 119 | January 2020 Bulletin0% | Issue 119 | January 2020 media journal advisor Financial Association Anaesthesia British Medial Newspapers/ Conversations with colleagues same at an estimated level of about 31 Figure 1 Source of knowledge of Figure 2 Mitigating strategies being FTEs.3 One of the consequences of this Dr Hanlie du Plessis Professor Jaideep J Pandit* pension tax (the last two columns relate employed to reduce pension tax bills is that extra paid sessions for managing to the 2016 article1 and the British (PA = programmed activity in job plan; Consultant Anaesthetist, Consultant Anaesthetist, the ever-rising demand in activity are Medical Association); n=99 private = private practice); n =99 Oxford University Hospitals Oxford University Hospitals the norm for trusts generally, and it is 80% 80% NHS Foundation Trust NHS Foundation Trust predominantly these that are being 70% 70% cancelled (Figure 2). Coupled with 60% 60% consultants reducing their workload 50% 50% Guest Editorial (Figure 2), this represents a projected 40% 40% shortfall of 20 to 30% – precisely as 30% 30% 20% 20% predicted by the 2016 paper.1 10% 10% ‘WINTER HAS COME’ Local negotiating committees and trusts 0% 0% PAS Early Other are considering a range of options to media journal private advisor Financial Reduced Reduced Reduced Assessing the impact of pensions tax on workforce extra lists try to reverse the trend of cancelled lists, retirement Association Anaesthesia British Medial Newspapers/ and some of these are shown in Table 1. Conversations with colleagues and service delivery in a large department However, option A is only meaningful (for service) if coupled to additional Table 1 Some measures discussed locally which might reduce impact of the In April 2016, the government introduced the ‘tapered annual allowance’, (paid) work, option B may not be legal, pensions tax (none are finalised) a final part of a sequence of changes to taxes on public sector pension and other options are unprecedented ¶At the time of going to press, the government appears to have gone forward on this proposal or untested. The pension tax changes (see: www.bbc.co.uk/news/health-50467400) 80% schemes. In August of the same year, an article in the journal Anaesthesia inevitably mean that each proposed 70%A: pay employer contributions over to employee if individual leaves NHS 1 solution will affect individuals differently, predicted certain consequences of these pension changes. 60% 1 Pension Scheme. and there will be no universal panacea. 50% The article predicted firstly that senior to pension tax. Although 97% of shows that the majority were reducing Reducing contributions to save pension 40%B: pay monies for paid extra lists into individual’s or group limited companies. tax, as suggested by the government’s 30% doctors would face tax bills of tens of respondents were aware of the tax, the extra NHS lists, reducing regular C: enhance study leave or other allowances and broaden scope of these payments. 20% thousands of pounds, and secondly single largest source of knowledge was sessions in their job plan, or taking early recent consultation, will mean a lower 10% that mitigating this risk would result in overall pension, so the only real solution D: enhance non-pensionable local clinical excellence awards. that of conversation with colleagues retirement (this last one being a particular 0% a reduction of approximately 20–30% concern given the age demography). is, of course, to reverse the pensions tax ¶ (Figure 1) rather than resources like the E: employer paysPAS pension tax on behalf of employee. Early Other in the NHS workforce, as these doctors 2016 paper.1 Of 99 respondents, 33 Other mitigations included reducing changes. This seems unlikely. For many private Reduced Reduced Reduced F: governmentextra lists allows flexibility in pension contributions. readers, it is probably worth dusting off retirement reduced their NHS sessions. (33%) stated that they had received managerial and teaching commitments the old 2016 paper1 and reading it quickly. a tax demand, of whom 28 were and not applying for clinical excellence G: offer additional annual leave in lieu of doing extra sessions. Three years later, media articles have prepared to indicate its size. The median awards. A minority were also reducing highlighted the rise in waiting lists as *Corresponding author: (interquartile range [range]) size of bill their private-practice income (which may [email protected] R eferences doctors have – as predicted – dropped have been a strategy coupled with other 1 Pandit JJ. Pensions, tax and the anaesthetist: significant implications for workforce planning. Anaesth NHS sessions. Personal stories tell of was £10,000 (5,000–20,000 [1,500– measures, since this question allowed 2016;71:883–891. doctors facing thousands of pounds of 55,000]), making a total of £360,000, multiple answers). 2 Pandit JJ, Tavare AN, Millard P. Why are there local shortfalls in anaesthesia consultant staffing? A extra tax simply for undertaking an extra all of which had been paid. Three case study of operational workforce planning. J Health Organ Manag 2010;24:4–21. list to try and help their trust meet waiting respondents declared an anticipated 3 Pandit JJ. Practical Operating Theatre Management. CUP, 2019. Conclusions targets. Trusts are reporting cancellations lifetime allowance charge of £20,000, of lists and difficulty in staffing A&E shifts. £70,000 and £150,000, making a total We believe these results to be of £240,000). In addition to the 33 who representative, coming as they do from We surveyed our department (more had already received a tax demand, 30 one of the largest UK departments. The than 120 consultants) to identify how respondents declared that they were predictions of the 2016 paper seem 1 any impact of the pensions tax changes expecting a charge but were awaiting to have come to pass. In 2010, when might be affecting behaviour. details. Thus, 63 out of 99 (63%) senior the department’s size was 66 full-time doctors in one department found equivalents (FTEs), an analysis showed Results themselves in the ‘pension tax trap’. there was then a shortfall of about 27 There were 99 respondents. The FTEs on the number needed to achieve largest single age group was of those Most worrying for clinical services was a fully consultant-delivered service.2 aged 51–60, the group most likely to that 75 out of 99 (75%) respondents With the department’s size now more have been affected by any changes had reduced their workload. Figure 2 than 120 FTEs, this shortfall remains the

Dr John Hughes Dr Alison Pittard Dean, Faculty of Pain Medicine Dean, Faculty of Intensive Care Medicine [email protected] [email protected]

Faculty of Pain Medicine (FPM)

Pain medicine Faculty of Intensive Care Medicine (FICM) going forward Invest to save This is my first article as Dean, and I am honoured By the time you read this I will have been Dean of to be taking over from Dr Barry Miller, who has the Faculty of Intensive Care Medicine for almost carefully steered the Faculty through an interesting three months, and I suspect my feet haven’t three years with significant success. touched the ground.

We thank him for his dedication This exercise has clarified that, although Over the last two years I have chaired releasing critical care capacity and and are delighted that he is going our fellows and members with a focus an Enhanced Care Working Party improving flow. Those delivering to lead our new Medicines Advisory on inpatient and acute pain have not (Recommendation 4 of our ‘Critical enhanced care must be trained to do Group, responsible for the ‘Opioids been forgotten, they have not been Futures’ initiative), and the guidance so, and thus education will be the key. Aware’ resource. at the forefront of some of these coming out of this is about to be Training in intensive care medicine developments. This has not gone published. This collaborative document will equip them with the necessary The Faculty has grown over the last unnoticed, and we are ensuring that impacts on many specialties, competence to ensure that the right 12 years since its inception, looking at these areas are integrated into our improving the patient experience treatment is delivered by the right pain training and professional standards workstreams and that active board and the safety and quality of care people, in the right place and at for pain medicine specialists from an representation continues. For example, they receive. Enhanced care bridges the right time. Although enhanced anaesthetic background. This expanded the Faculty is actively engaged with the gap between the ward (Level care will not normally be delivered to the development of curricula, the anaesthetic curriculum review, the 0/1) and critical care (Level 2/3), and by critical care staff, they will be assessment, the exam, and our multi- Centre for Perioperative Care project, we describe a set of key principles, integral to development and support organisationally endorsed core standards preoperative Getting It Right First Time based around the patient pathway, to for the service, providing guidance document (currently being updated). (GIRFT), and the FPM/College opioid ensure an overarching governance and training in this education-rich The Faculty now interacts with many prescribing working group. It is clear that structure is in place. environment. Our guidance provides there are opportunities here that can examples of good practice and external organisations (General The case mix of patients receiving Medical Council, NHS England, have a significant benefit for patient care. successful implementation where there Level 2 care has changed over is absence of evidence. We hope National Institute for Health and The broad strategic areas for the the last 20 years, and many now that this will be supportive for those Care Excellence, the Royal College Faculty going forward include: require a higher level of monitoring services already established, and will of General Practitioners, and others), and interventions rather than organ ■■ getting the best services for our also provide a structure to facilitate recognising the broadening remit of support. This additional demand needs patients (across all clinical settings) new initiatives. pain and its impact outside anaesthesia. an increase in capacity. However it ■ There is also a role for the Faculty to ■ ensuring the best use of therapeutic is important to invest wisely, keeping play in the changing environment for interventions the patient as the focus. Redesigning commissioning, de-commissioning, and ■■ building an attractive and the service may better serve the the use of medications. With this growth sustainable specialty needs of a larger number of patients, in activity, the Faculty is reviewing its ■■ educating the healthcare system strategic aims. about pain.

SAS and Specialty Doctors ‘Coming together is a beginning, keeping together is progress, working With a little help from together is a success’ our friends… Henry Ford

Dr Kirstin May Dr Lucy Williams RCoA SAS Member of Council, Banbury RCoA SAS Member of Council, Swindon [email protected] [email protected]

The Academy of Medical Royal Colleges healthcare politics and has no direct SAS others to innovate in SAS recruitment The SAS tutor Regular newsletters update everyone Clinical Tutors SAS Tutors Development and retention,1 SAS development,2 and (AoMRC) is the coordinating body for theme, but of course it does nevertheless Since I seem to be a person unable to on local and national issues. Although Day. SAS tutors from all over the UK the 24 Medical Royal Colleges and impact upon the professional life of SAS SAS support.3 we often feel left out, there is a lot of (except Northern Ireland) were present to say ‘no’, last year I took up the post of Faculties in the UK and Ireland. It sets doctors. It is therefore very important work at Health Education England, the share successes and some frustrations. It has been helpful to exchange good SAS tutor within my hospital. We have standards for the way doctors are trained, that an SAS perspective is offered to General Medical Council and within practice, ideas and data with other 56 SAS doctors across most specialties, Hopefully, your hospital has an SAS tutor. educated and monitored. It also gives discussions, and a reminder of the vast individual colleges focusing on our SAS leads. Running similar surveys some full-time and others very part-time They can signpost funding from bursaries a cross-specialty perspective to policy contribution made by SAS doctors can group as workforce pressures really bite. of members has achieved spookily as part of a portfolio career. or postgraduate medical education makers and regulators. be required. Sitting in a room with 24 SAS doctors are recognised as key staff similar results. funds, depending on what you want to presidents is certainly an interesting – and My primary role is to be a point of to develop for senior clinical and non- SAS doctors are represented at the do. They can help you fill in application intimidating – experience, and one I had We do well at the College, with contact for any career development clinical roles. AoMRC through its SAS Committee, forms – sometimes two heads are never expected to have! two full SAS Council Members and queries and to administer the SAS comprising the SAS leads of each This is where my role at the College definitely better than one. They are representation at all committees and development fund which comes from specialty. This group meets face- meshes really well with the SAS tutor there to help you consider options for Achievements since 2016 every level of College work. It is now up Health Education England. This is used to-face twice per year; other work role. As chair of the College’s SAS career progression, whether that is CESR, We have revitalised the SAS voice at to Dr Lucy Williams to represent SAS is carried out electronically. Since to fund generic courses of interest to all Committee, I attend the SAS Committee application for associate specialist grade the AoMRC and I am delighted to have anaesthetists and to the new Academy joining RCoA Council in 2015 I have and to top up study-leave budgets for of the Academy of Medical Royal (if available in your trust), or gaining handed over an expanded and active SAS chair Dr Waleed Arshad from the represented the SAS anaesthetists at the individual applications. Colleges. At our recent meeting we postgraduate qualifications. They should committee to the SAS lead of the Royal RCP to represent SAS doctors across the AoMRC, and acted as the AoMRC SAS discussed proposed General Medical be able to act as mentor or coach, or College of Physicians (RCP). We have Academy. Good luck! Last year, my predecessor ran an off-site Committee chair from summer 2016 Council changes to the Certificate of find someone else who can. given a regular SAS voice to Academy day, and had excellent feedback. People until summer 2019. R eferences Eligibility for Specialist Registration business in many areas. A successful really enjoyed getting out of the hospital If you don’t have an SAS tutor, 1 SAS development and retention programme. (CESR), SAS doctors as clinical and When I first joined the AoMRC SAS cross-specialty SAS conference was held Toolkit for implementation. HEE, 2018 and spending time with colleagues from educational supervisors, as well as consider offering yourself – it is a great Committee it was not well attended, and in spring 2018. We have lobbied the (bit.ly/2wwRBLr). other departments whom they don’t leadership training for SAS doctors. personal development opportunity. few Colleges had SAS representatives. government to support the reopening 2 SAS doctor development. Summary normally see during work. This year, I The AoMRC SAS chair is offered a of the Associate Specialist grade in the of resources and further work. NHS have a programme on leadership for The tutor role has brought me in to Confederation, 2017 (bit.ly/2oWBG8Y). co-opted seat at Academy Council, interest of SAS doctors’ professional SAS doctors and there has been great the medical education sphere. To help which brings together all the College and development and wellbeing. Multi- 3 Maximising the Potential: essential measures myself in supporting my colleagues to support SAS doctors. Published by Health demand for places. Faculty presidents to discuss Academy agency work has been carried out Education England and NHS Improvement, I have attended a deanery coaching business. Most of this relates to wider with Health Education England and 2019 (bit.ly/2Zgzmab). course and the National Association of

Revalidation for anaesthetists Enhanced functionality for event providers The Royal College of Anaesthetists has developed a toolkit that offers patients the information they need to prepare for surgery, including the Chris Kennedy important steps they can take to improve health and speed up RCoA CPD and Revalidation Coordinator recovery after an operation. [email protected]

The revalidation article in the ■■ mapping to CPD Skills (what We would like to encourage The Fitter Better Sooner toolkit consists of: previous edition of the Bulletin (Issue was previously the CPD Matrix) event providers to apply for ■ 118, September 2019) described is entirely optional CPD accreditation at least six ■ one main leaflet on preparing for surgery some of the CPD enhancements ■■ there is the option of mapping weeks in advance of the event. ■■ six specific leaflets on preparing for some of the most common which have been introduced into Consideration cannot be given to the Good Medical Practice surgical procedures the Lifelong Learning Platform, domains and also to the to applications received less than including the ability to add ‘realtime Domains for Medical Educators, two weeks before the event date, ■■ an animation which can be shown on tablets, smart phones, laptops and TVs. reflection’ during attendance with the potential to increase or to applications for retrospective at CPD-accredited events. This visibility of your event to the approval. Where a regular event You can view the toolkit here: www.rcoa.ac.uk/fitterbettersooner long-requested development has clinician users of the Lifelong was last accredited more than 12 been particularly well received, Learning Platform months ago, the accreditation We have also created printable posters, flyers and stickers to help you signpost patients to the as has the new functionality does not roll over, and a new ■■ there is a more streamlined toolkit. The animation can be shown on TVs in waiting areas. You can find all these additional that allows assignment of more application will need to be made. payment process for than one personal activity to resources and instructions on how to download the animation in MP4 format (or request a version commercial event providers. We would also like to remind accredited events. in PowerPoint) on our website here: www.rcoa.ac.uk/patientinfo/healthcare-professionals ■■ Other changes based on all users of the existing CPD Event providers seeking CPD stakeholder feedback include a Online Diary that this will be Please share this toolkit with colleagues in both primary and secondary care settings. accreditation had commented free-text ‘Other’ option that can decommissioned during 2020, that the old application form was be selected for the teaching and so we would encourage extremely long to complete and methods that are selected in the everyone to transfer over to the was not intuitive. It had been application form, instantaneous Lifelong Learning Platform as soon spread over three separate screens, uploading of the supporting as possible. and there had been cases where documents, and a more intuitive the form had timed out and all of way of warning of any error the information populated had made during the submission. It has been shown been lost. that people who In response to this feedback, the process for applying for CPD improve their accreditation via the Lifelong Learning Platform has been Further information lifestyle in the run up enhanced and made much is available more user-friendly for event on our website: to surgery are much providers so that: www.rcoa.ac.uk/ cpd-accreditation ■■ the application form appears on more likely to keep or via [email protected] one screen up these changes ■■ it is now possible to add the details of two nominated after surgery. contacts rather than one

Patient perspective A LAY VIEW: the past six years It has been a privilege to be part of the Dr Stuart Burgess and Elspeth Evans joined the Patient Liaison Group, Lay Committee, and hopefully I have as it was then named, in 2014 as part of a cohort of four recruits. They end their term of office early this year, and reflect in this article been able to make a small contribution on their contributions as part of the College’s Lay Committee. Dr Stuart Burgess

Having worked in administration for two anaesthesia in 25 years’ time, which was I was delighted to join the PLG in 2014. ‘Opioids Aware’ has been another hot other Medical Royal Colleges, I felt my aimed at medical students, anaesthetists The committee has changed over the topic. Although I rarely suffer pain, many application was strong and was delighted in training, and foundation year doctors. years, not only in name but also in of my friends have to endure severe pain. to be recruited. My heart sank when a This meant reading 47 entries in total. My the contribution it makes. I think it has Opioids are often used to help particular change of committee name appeared favourite statement was that a celebrity become more focused and engaged people in a carefully prescribed way. on an agenda for discussion, but I soon chef was now Minister of Health. I also with the issues. I have served as the However, it seems to me that it is possible understood that the reason for the went to the Barbican to see the film lay representative on the Professional that the professionals, ie the FPM, could name change was that some applicants Green for Danger (first released in 1946), Standards Committee and on the Faculty be sidelined in the ongoing discussion. mistakenly thought they would be dealing which featured a dastardly anaesthetist, of Pain Medicine (FPM). The FPM would, The media have picked up this topic in with and speaking to patients. It took us and I marvelled at how people smoked in I imagine, be an independent College if a big way, and recently The Times had about ten minutes to decide on ‘the Lay hospital premises in those days. it had a larger membership. It took me a full-page article describing how easy Committee’. I am the lay representative a while to get used to its agenda and its it is to obtain the drugs and also gave The late president, J-P van Besouw, on the Education and Professional way of working. In most committees I am examples of the dangers that are there in referred to us as the ‘Scrutiny Committee’. Development Committee, the Public used to working through the agenda quite terms of dependency. I think this was fair because our remit is to Sector Equality and Diversity Compliance quickly. I learned that on FPM agendas put the view of the patient and the public, My hope would be that the professional Elspeth Evans Group, the Quality Improvement Working Dr Stuart Burgess many items were really discussion issues. and this often means suggesting plain- voice can be heard. Member, Lay Committee, Group, the Communications and External Member, Lay Committee, Two fascinating issues have been the use English explanations for medical terms. Buckinghamshire Affairs Board and, until it was disbanded London of cannabis and opiates, and both are hot I have thoroughly enjoyed taking part [email protected] in 2019, the Revalidation Committee. I was privileged to attend the 2018 [email protected] topics. On the medical use of cannabis, in the Anaesthesia Clinical Services Last year, I contributed to the revision of Summer Reception and be introduced to the FPM board has taken, quite rightly in Accreditation (ACSA) visits. It has been the Audit Recipe Book and joined the Her Royal Highness, The Princess Royal. my opinion, a conservative approach, as good to be part of a team and to be Patient Improvement Group, which is there are so many unknowns and indeed well supported by our hard-working highly regarded within the College. This My legacy? Naming the ‘ARIES’ side effects. However, any discussion administrative colleagues. has given me a good overview of College talks (bit.ly/RCoA-ARIES). Aware that has to be aware of the shifting of public activities and an appreciation of the we couldn’t keep referring to these as opinion, both in this country and beyond. enormous changes introduced in recent ‘TED-style talks’, as we did when they A number of countries have legalised years – the five-year strategy, rebranding, were first suggested, I sat down with a the medical use of cannabis, and two and the reorganisation of staff directorates. piece of blank paper and tried to think countries have legalised the consumption of a suitable acronym. ‘Anaesthetics’ or of recreational cannabis. I was invited to join the 25th Anniversary ‘anaesthesia’ had to be the provider of organising committee set up to make the first letter, and the rest followed from plans for celebrating the College’s 25th there. The committee loved it, although year of holding its Royal Charter. I was it changed one or two of the words. very flattered to be asked to join the My second suggestion? ‘Red Lion talks’ judging panel for the essay competition although I admit that does sound a bit inviting foresights of the position of like a pub quiz.

Methods The free-text themes are summarised to history, there are other means of An email containing a link below. ensuring that only the intended drug at the intended concentration is delivered (bit.ly/2n2taUM) to an online Human factors: questionnaire was sent to all the to the patient, and we call on TIVA pump ■■ distractions while programming anaesthetists (n=525) at eight hospitals manufacturers to prioritise safety, in ■■ time pressures in the Wessex deanery. The questions addition to flexibility, in their design. Dr Hugh Cutler ■■ fatigue related to incorrect pump programming, ST6 Anaesthesia, Royal Hampshire ■■ haste This could include: County Hospital, Winchester drug concentrations, and errors when ■■ miscommunication between mixing opioid with propofol – with an anaesthetists ■■ different screen appearances for opportunity to add free text. ■■ unfamiliar technique. propofol and opiate infusions (this could be as simple as inverting the Results Drug factors: whole screen colour) ■■ different drug concentrations used We received 186 responses – ■■ a drug-specific, whole-screen prompt, within and between trusts a response rate of 35%. While this confirming each drug immediately ■■ incorrect propofol concentration appears low, in the context of the UK prior to the start of infusion ■■ incorrect remifentanil concentration rate for TIVA at approximately 10% of (including 0 ng/ml) ■■ a drug-specific auditory prompt all anaesthetics, this represents a good ■■ lack of double-checking during drug confirming each drug immediately Dr Tom Peck* return. Indeed 89% of responders preparation prior to the start of infusion considered their TIVA experience level to ■■ Consultant Anaesthetist, Royal lack of familiarity with dilutions for ■■ a connection (wired or wireless) drug regime. Hampshire County Hospital, be moderate or confident, while less than preventing the same drug being Winchester 3% considered themselves TIVA novices. Equipment factors: selected in adjacent pumps ■ Wrong drug errors, ie remifentanil ■■ different arrangement of syringes ■ ultimately, ‘smart’ detection of syringe programmed as propofol or ■■ deviation from normal process, eg propofol and non-propofol vice versa – 26% (48) of responders different consumables containing syringes, more akin to the had observed this, of whom 17% (eight) ■■ different pump default remifentanil ‘key-fill’ system used in vaporisers. Reducing drug errors in total indicated that this had occurred within concentration between hospitals the previous year and 60% (29) that it ■■ unfamiliar TCI pump. Conflict of interest had been recognised after induction. declaration Discussion intravenous anaesthesia Two cases had immediate adverse Courses run by Dr Tom Peck have been physiological changes. This survey demonstrates that drug errors sponsored by Carefusion. For as long as healthcare professionals have been administering drugs associated with TIVA are common and Wrong concentration errors – 17% (31) occur despite seniority and experience. R eferences to patients they have been making errors. Numerous systems have been had observed this, of whom 58%(18) The free-text responses reveal the 1 Jelacic S et al. A System for Anesthesia Drug developed to reduce the frequency of such errors, from the universal syringe- indicated that this had occurred within human factors, variability and equipment Administration Using Barcode Technology: the previous year and 61% (19) that it issues involved. History teaches us The Codonics Safe Label System and 1 Smart Anesthesia Manager.™ Anesth Analg labelling system to the more sophisticated barcode systems. In addition, a had been recognised after induction. that education and tighter operating 2015;121(2):410–421. Four cases reported immediate adverse policies are only partially effective in more open culture of learning, double-checking and standardisation have all 2 Nimmo et al. Guidelines for the safe practice physiological changes. reducing medical error, so that, as TIVA 2 of total intravenous anaesthesia (TIVA). been advocated for the prevention of errors. use increases, associated programming Anaesth 2018;74(2):211–224.

Wrong propofol/opioid mixing error – errors will also increase unless other Total intravenous anaesthesia (TIVA) were the cost of branded propofol and the ‘wrong drug’ and ‘wrong concentration’ 5% (nine) indicated that they delivered factors, such as pump design, are *Corresponding author: is most commonly administered using (perceived) restriction to a single algorithm. errors that were previously not possible. TIVA exclusively with a propofol/opioid [email protected] improved. Although the ‘chipped’ sophisticated algorithms to drive syringe mixture, while 47% (87) reported that In 2002, generic propofol entered Following two such errors at our hospital, Diprivan syringe is largely consigned pumps, a system described as target- they never use drug mixtures. Overall, the market, followed closely by a and hearing of other experienced controlled infusion (TCI). The Diprifusor seven individuals had experienced second generation of more agile TCI anaesthetists (within Wessex and beyond) TCI system was the first such available errors associated with the mixing of pumps (open TCI systems) that were who had also made similar errors, we set system, and could only administer drugs, with three recognising this after programmed with additional algorithms out to assess the scale of the problem Diprivan-branded propofol syringes by induction and three reporting it to have Authors’ example of for a range of drugs and with targeting and review any themes by means of a different coloured means of a computer chip in the syringe occurred in the previous year. This type screens, acting as options. Progress indeed, but at a time survey sent to all anaesthetists in Wessex, flange. In this form, it was only able to of error did not lead to any adverse visual prompt when there is rightly an increasing having first trialled it at the Wessex administer the intended drug at the physiological consequences. spotlight on medical error, these ‘open TIVA Training Day. intended concentration. The downsides TCI systems’ have opened the door to

THE MILK OF HUMAN KINDNESS: the importance of supporting each other in the workplace

As a junior trainee, the majority of my ‘bandwidth’ was consumed with trying to meet the clinical challenges of my job, and to disguise the frequent moments when my knowledge was insufficient, my clinical skills inadequate, or my previous experience too meagre, to manage the But in the current climate of to remind myself that patients appreciate giving a break to anyone stuck in theatre Dr Oliver Boney immediate scenario I faced. unprecedented NHS workforce pressures a doctor who’s nice to them, smiles and by themselves; asking about people’s ST7 Anaesthesia, and belated recognition of the prevalence gives them the time of day far more than holiday plans, and so on. I even try to Royal London Moreover, my perceived shortcomings were picked up, I experienced the same feelings of of burnout and low morale among junior they appreciate a cardiovascularly stable be nice to the surgeons sometimes doctors, I am actively trying not only anaesthetic induction or a first-attempt (though not too often: where I work, that Hospital compounded on the not infrequent occasions clinical inadequacy as before. Only this time, to remedy my ongoing (alas) clinical intubation using the C-MAC. Patients can be fatal…). [email protected] I found myself in theatres with another trainee my ID badge said ‘ST6’ instead of ‘CT2’, which shortcomings and knowledge deficits, quite rightly expect to receive good whose knowledge was superior, whose must have made my ignorance and apparent In a nutshell, I’m trying to remember but also to focus on what I can offer quality clinical care, but they also want to clinical skills were slicker, and who asked more anaesthetic ineptitude all the more perplexing that a doctor is judged not just on their as a supportive team member. While I be treated as human beings, with kindness, intelligent questions than I did. to the consultants who had the pleasure of my clinical finesse, but also for spreading may not yet inspire my colleagues as a compassion and empathy – buzzwords company in theatres. love in the workplace. In a world of However, as this sense of inadequacy gradually clinically brilliant anaesthetist, I certainly which you’ll find in many an NHS trust’s information overload and ever-changing became my default workplace state of mind, I Now in my final year of training, I’m starting can do more to support them in lots of ‘values’, but which need to be delivered best evidence, maybe I’d prefer to be reminded myself that I was still at an early stage to realise two things. First, the ‘mastery’ of simple but important ways. Seemingly by a friendly face, not by an institution. remembered simply as a nice colleague of training, and generally tried to knuckle down, anaesthesia which I had hoped to attain by small acts of kindness and minor efforts to So – although my efforts to earn the rather than as a brilliant clinician. do my best, and seek help or advice from those oil the wheels of human interaction can now (and which is so frequently referred to in respect of colleagues for my clinical And while I can’t quote you the latest with more wisdom and experience than me. make the difference between someone the advanced training curriculum) has proved acumen continue undiminished – I’m evidence on the subject, I’d hazard a And whenever I failed to hit cerebrospinal fluid having a good or bad day, between a extremely elusive, and will, I fear, remain so also trying to remember the importance guess that a little more kindness and a with my spinal needle, or struggled with a tricky team that works well and one that doesn’t, until I (hopefully) settle down to a consultant of the little things in my interactions with little less clinical governance would do arterial line, I’d console myself with the thought and – ultimately – colleagues who enjoy post doing the same lists regularly over colleagues and patients alike: smiling wonders for workforce morale. that once I’d passed my exams and seen coming to work and those that don’t. several years. Second, almost everyone apart more; being quicker to offer praise, everything that anaesthetic training had to throw from the pathologically self-confident, or the The same philosophy applies to patient encouragement or reassurance; bringing at me, I too might achieve Anaesthetic Nirvana. so-irredeemably-inept-they-don’t-even-notice- care as well. While I strive to provide in cakes when I’m on call (not for the Three years later, I took a break from training to their-own-failings, often feels this way. It’s safe, high-quality clinical care, I also try patients, of course); lending a hand or try my hand at health services research. A year’s one manifestation of imposter syndrome, and perioperative research fellowship mushroomed sometimes there’s a healthy stimulus in wanting into three years, and when I finally re-entered to improve yourself and being inspired by your the training programme, having long forgotten colleagues, as long as your perceived failings Seemingly small acts of kindness can anything from FRCA and (or so it felt) most don’t crush your self-esteem and push you into of the anaesthetic know-how I’d previously a downward spiral of burnout. make the difference between someone having a good or bad day

CPET testing setup at Torbay Hospital It was sent to the lead clinician for perioperative medicine in each Dr Tim Warrener* trust to complete. ST7 Anaesthesia, Royal Devon and Exeter Hospital Results Of the four trusts which currently offer a perioperative CPET service in the south- west peninsula, compliance with the Dr Anne-Marie Bougeard, RCoA Perioperative Medicine Fellow and ST7 Anaesthesia, University POETTS consensus guidelines ranged Hospitals Plymouth from 66 per cent to 93 per cent. Three Dr Mike Swart, RCoA Perioperative Medicine National Clinical Lead and Consultant in Anaesthesia trusts achieved at least 85 per cent compliance, and one 66 per cent. and Perioperative Medicine, Torbay Hospital The results demonstrated several patterns of ‘non-compliance’: Perioperative cardiopulmonary ■■ in one trust, non-compliance with regard to service structure and supervision appeared to stem from exercise testing in the non-clinicians performing CPET. There was no quality control in place for test implementation and supervision was South West from designated consultants working in a nearby, but separate, theatre

1 2 complex. This supervision was not European and American guidelines advise assessment of preoperative necessarily always achieved cardiopulmonary fitness, or functional capacity, to help estimate a patient’s ■■ the survey also revealed that individual risk for major morbidity or mortality after surgery. In the UK, there has appropriate resuscitation equipment from this regional survey, one example R eferences was not always immediately available is to develop a protocol for regular 1 Kristensen SD et al. Guidelines on non- been an expansion of cardiopulmonary exercise testing to do this objectively. ■■ two sites indicated that they do not biological control testing. cardiac surgery: cardiovascular assessment routinely measure non-invasive blood and management: the Joint Task Force The recent METS (Measurement of society published their consensus clinical We initially benchmarked practice at We feel that this exercise has on non-cardiac surgery: cardiovascular pressure, with one commenting that Exercise Tolerance before Surgery) study guidelines on indications, organisation, Torbay Hospital, one of the first centres in demonstrated that the POETTS assessment and management of the due to artefact the value of this was European Society of Cardiology (ESC) and concluded: ‘Preoperative subjective conduct, and physiological interpretation the UK to regularly perform perioperative guidelines are achievable. Results have felt to be low the European Society of Anaesthesiology assessment neither accurately identified of perioperative CPET.4 The guidelines CPET, and later extended a survey out subsequently been disseminated to (ESA). Eur Heart J 2014;35:2383–2431. ■■ no site was fully compliant with patients with poor cardiopulmonary fitness represent best practice by expert across the south-west peninsula. This individual departments with one trust 2 Fleisher LA et al. Guideline on perioperative the performance of gas-exchange cardiovascular evaluation and management nor predicted postoperative morbidity consensus and set a standard for all included six different trusts, four of which already starting to look at how they algorithms – two sites performed of patients undergoing noncardiac surgery: and mortality.’ However, a more formal those who perform perioperative CPET. currently have a perioperative CPET might improve their service. regular biological control, but this had a report of the American College of assessment of cardiopulmonary fitness, service, and two that do not. Cardiology/American Heart Association yet to be formalised; one site used a This has been a useful exercise for us in specifically peak oxygen consumption In the South West, we decided to Task Force on Practice Guidelines. The survey included six different sections: dynamic torque meter annually; one the South West. Circulation 2014;130:e278–333. during cardiopulmonary exercise testing benchmark our practice with the ■ site was unsure of specific details 3 Wijeysundera DN et al. Assessment of (CPET), improved prediction of moderate aim of helping departments achieve ■ perioperative CPET service structure Our next step is to review the survey functional capacity before major non-cardiac and supervision ■■ no sites were regularly recording the or severe postoperative complications.3 compliance if this was thought to be questionnaire with a broader group surgery: an international, prospective cohort Borg score to evaluate subjective effort. of benefit to patients and medical ■■ preparation for the exercise test who perform CPET. Then we will extend study. Lancet 2018;391:2631–2640. In 2016, the Perioperative Exercise staff. If the POETTS standards were ■■ conduct of the exercise test In summary, overall compliance with the the survey to all UK sites that perform 4 Levett DZH et al. Perioperative Testing and Training Society (POETTS) cardiopulmonary exercise testing found to be unachievable, we would ■■ indications for stopping the test POETTS guidelines is high, and non- perioperative CPET. This can then lead to was developed to promote standardised (CPET): consensus clinical guidelines on highlight this. compliance appears to be clustered a review of the POETTS guidelines. indications, organization, conduct, and ■■ interpretation of the exercise test practice, training and education in around a few specific domains. This could physiological interpretation. Br J Anaesth ■ perioperative CPET. In early 2018, the ■ the perioperative CPET report. reflect a deficit in process at individual 2018;120(3):484–500. sites or a need for more pragmatic *Corresponding author: guidance. In terms of suggested action [email protected]

Dr Lucy Corbett Clinical Fellow, Royal United Hospitals (RUH) Bath NHS Foundation Trust

Dr Amelia Davies Clinical Fellow, Royal United Hospitals (RUH) Bath NHS Foundation Trust

Dr Melanie McDonald, Dr Fiona Kelly* and Dr Lesley Jordan, Consultant Anaesthetists, Royal United Hospitals (RUH) Bath NHS Foundation Trust

‘Bath tea trolley’ training is a novel method of providing multidisciplinary team training in the workplace. Short, succinct ‘bite-sized’ teaching sessions are brought to staff during their normal working day, optimising educational opportunities and allowing them to train together as a team during their shifts.

How did it start? How does it work? Advantages The idea came to one consultant A team of anaesthetic trainers travel ‘Bath tea trolley’ training compliments – it works well for student nurses and team. Trainees who have planned and Prize 2014, was highly commended anaesthetist during a busy theatre list around the theatre suite armed with a and reinforces existing training sessions professors alike. Handouts allow for delivered training programmes have in the BMJ Awards 2018 (Education back in 2014: by 3.00 pm, the last trolley with educational materials on the and workshops, giving staff the reflective learning. We have consistently enjoyed the process of teaching. Trainer and Training category), and was a patient on her list was anaesthetised top and a pot of tea and homemade opportunity to practise infrequently used seen improvements in both participants’ satisfaction is high, the clinical skills finalist in the Health Education England and stable on the operating table and cakes on the bottom. One trainer looks skills and preventing ‘skill decay’. It allows self-rated confidence scores following of many have improved as a result of Healthcare Education and Training she was desperate for a ‘nice cup of after the patient in theatre for 15 minutes, rapid dissemination of new guidelines training3 and in knowledge test scores training others, and many trainees have ‘Inspiring Educator’ Award 2019. tea in the anaesthetic room’. She then enabling the listed anaesthetist to and techniques to the whole team and one month later.3 Improved patient safety been inspired to run similar teaching imagined two colleagues arriving in attend a short teaching session in their an opportunity to refresh knowledge of results were seen following maternal programmes in other hospitals. R eferences her anaesthetic room, providing a five- anaesthetic room delivered by a second existing ones. This method of training is sepsis teaching, with the percentage 1 O’Farrell G, McDonald M, Kelly FE. ‘Tea In Bath, we have run 38 tea trolley minute teaching session and refreshments trainer, followed by refreshments!2 There quick and easy to organise with minimal of mothers screened for sepsis rising trolley’ difficult airway training. Anaesth programmes to date, with more than 2014;70:104. for her and her anaesthetic assistant, is a film on the RUH website that shows associated cost: all the equipment is from 40 per cent to 100 per cent and 100 staff members involved in the 2 Bassher et al. Never too busy to learn. RCP, and told two anaesthetic trainees us in action: bit.ly/310kegy already present in the department, there the percentage of mothers receiving teaching and more than 1,800 staff 2018 (bit.ly/2MrDOwP). about this idea later that afternoon. are no course fees, no need for study antibiotics within an hour rising from ‘mini training episodes’ taking place. 3 Kerton MCS et al. Paediatric anaphylaxis The three of them piloted the idea the Projects to date leave and all the cakes are homemade! 50 per cent to 100 per cent. management: training staff to actually draw This teaching method has been used following week, teaching emergency The method works well for practical skills, up the correct dose of adrenaline. Br J Training members of staff in this way Maybe the biggest advantage is that in more than 24 other UK hospitals front of neck airway techniques to protocols and guidelines and has been Anaesth 2018;120:881–882. has many educational benefits: it is a it is fun! By training together as a that we know of, as well as hospitals in anaesthetists and anaesthetic assistants.1 used in theatres, intensive care units, *Corresponding author: non-threatening teaching method, and team, we have seen real benefits for France, Canada and Australia. Our team It was a huge success and the idea has delivery suites and wards (see our full article [email protected] teaching can be adjusted to suit different morale, communication, teamwork and won the Association of Anaesthetists/ snowballed since.2 online: bit.ly/Bath-Part1).1,2,3 @fionafionakel learning styles and levels of knowledge hierarchy-flattening within the theatre Medical Protection Society Patient Safety #bathteatrolley #teatrolleytraining

Dr David Bogod Dr Naomi Freeman* RCoA Council Member and ST5 Anaesthetist, East Midlands Consultant Anaesthetist, ‘YES, YOUR HONOUR…’ School of Anaesthesia Nottingham University Hospitals

Regulatory (GMC) and ■■ aspiration Some complaints brought by patients or disciplinary cases ■■ anaphylaxis relatives arise from dissatisfaction with the manner and attitude of their anaesthetist. The MPS supported members in both ■■ hypotension and/or hypoxaemia We must be aware of how we may clinical and non-clinical concerns. These following induction of anaesthesia be perceived during discussions, and were raised by patients and relatives, and ■■ chest-drain complications ensure that time is taken to offer suitable by both junior and senior colleagues. ■■ placement of nasogastric tube in the explanations and answer any questions. Some related to more than one concern bronchial tree. We should strive to demonstrate empathy or to a series of clinical incidents. Perioperative deaths involved and show our patients that they are the Common themes were: haemorrhage (including postpartum focus of our attention. ■■ performance – poor technical skills haemorrhage), sepsis, stroke, pulmonary In private practice, patients should be (including airway management), embolism, and myocardial infarction. given clear information about any costs clinical judgement and involved and what their rights are to Part two communication The anaesthetist can also be the subject of claims when they are not the primary refunds/return of deposits if they change ■■ probity – leaving anaesthetised patients clinician involved. For example, claims their mind. unattended; not reviewing patients prior In our previous article we outlined the Medical Protection Society’s (MPS) relating to resuscitation techniques to a theatre list; prescribing for family These are not ‘rocket science’ revelations. throughout the hospital, CT scanning analysis of their involvement in more than 3,000 anaesthetic-related cases members, colleagues or self; being They are based on common sense, rooms and emergency departments. In unavailable when on call or refusing courtesy, respect and communication. between 2008 and 2017 (RCoA Bulletin 116, July 2019), and we focused on some cases, statements were requested to attend when requested; conducting Unfortunately, the best-laid plans and by the coroner months or even years negligence claims. In this second article, we will delve into medical report writing, private practice when on NHS time; most beneficent of intentions can after the event, highlighting the false information on job applications sometimes be misconstrued: so please complaints, local investigations, regulatory (GMC) investigations, and inquests. importance of good record keeping. forms or appraisals ensure you take out full indemnity cover to undertake the entire range of your Common complaints involved when neuraxial blockade ■■ health – alcohol or drug misuse, theft Minimising risk of drugs from hospitals practice in the UK. Complaints covering the whole spectrum featured. Other themes included The analysis from the MPS highlights of anaesthesia, in the NHS and private inadequate sedation, cancellation of ■■ behaviour – inappropriate comments some common topics of complaint, all of And here’s hoping you’ll never need it. sector, accounted for 16.5 per cent surgery, post-anaesthesia-aspiration made to patients, bullying and which are grounded in the foundations Cases Further reading of the anaesthetic cases analysed pneumonia, and failure to obtain harassment of colleagues of good medical practice. The majority ■■ More information regarding opened by the MPS. informed consent for a procedure, ■■ delegation – leaving inexperienced of doctors have the patient at the medicolegal aspects of our 2008–2017 – for example, nerve block. juniors alone centre of their endeavours, but in a busy practice can be found at: Anaesthesia ■■ non-clinical – assault, drink-driving, specialty it can sometimes be easy to by type Critical care medicine www.medicalprotection.org Non-clinical themes included poor shoplifting. forget, however transiently, that these manner and attitude, rudeness, and In Intensive Care, there were allegations are fellow humans putting their trust ■■ RCoA safety, standards and quality: inappropriate comments to patients of poor communication with relatives, Inquests (and lives) in our hands. We should try www.rcoa.ac.uk/ both at preoperative assessment and in including some with respect to treatment An inquest is held to ascertain the who, to understand our patients’ concerns safety-standards-quality the anaesthetic room. Complaints were withdrawal. when, what, where, and how of a death. and expectations and address any ■ 7.5% Claim/preclaim 0.6% Ethics ■ Jolly J, Mounsey H. Learning from also made by colleagues relating to the It is a fact-finding procedure conducted queries they may have. This is particularly UK Anaesthetic cases – an analysis 6.1% Regulatory 15.4% Inquest Pain medicine clinician’s attitude towards co-workers. by a coroner, sometimes in front of a pertinent to pain medicine, where a of Medical Protection data. From Complaints in this field centred 6.1% Disciplinary 29.1% Report jury. The MPS identified the following patient may have an unrealistic belief as a letter to the Royal College of Clinical complaints arose from insufficient around lack of empathy shown during to the outcome that can be achieved. 16.5% Complaint 16.6% Advice recurring scenarios from their experience Anaesthetists, 2019. postoperative analgesia, and painful consultations, including inappropriate of providing assistance at inquests: Risk assessment should be personalised 1.1% Criminal 1.0% Other and/or repeated cannulation attempts. comments by the anaesthetist. There were – discuss and explain frequent and *Corresponding author: Inadequate anaesthesia, post-dural- alleged delays in providing treatment, of ■■ failure or disconnection of anaesthetic serious complications, how these could [email protected] puncture headache, haematoma, misdiagnosis of the source of pain, and of equipment impact upon that individual patient, and infection, and neural damage were persistent post-treatment pain. ■■ delayed or failed intubation how they would be managed.

www.rcoa.ac.uk/ The exciting news is, that within our Table 1 Global warming effects of anaesthetic gases5,6 environment-sustainability professional lives we can make simple changes to the way we work that will CO /kg/hour Distance/ Tropospheric 2 have significant effects on reducing the GWP 100 equivalent hour in a Cost Agent Lifetime years at low petrol car (£) environmental impact of healthcare. It is (years) important that we go back to basics. flow (1 L/hr) (km)

Sevoflurane 130 1.1 1.3 8 £1.81 ‘Primum non nocere’ (first, do no harm) Isoflurane 510 3.2 3.5 22 £0.19 The principle of non-maleficence is not Desflurane 2,540 14 61.1 382 £6.43 a relic from the time of Hippocrates but Nitrous Oxide 290 110 16 (N O/O 100 £0.07 an ever-present principle of bioethics. 2 2 0.5/0.5 mix) In modern-day practice it is essential that we expand the scope of potential abundant when it comes to reducing support, be it with setting up projects, harm from the end of our needle to the our carbon footprint in theatre: turning education, or tackling industry. wider populace. In September 2019, off the anaesthetic-gas-scavenging the international Non-Govermental system (AGSS) when not in use We have a duty of care to patients, and Organisation, Health Care Without (this is equivalent to more than half in order to do that justice we need to Harm, published their first green paper the average anaesthesia-related acknowledge that we have a duty of care looking at how the global health sector energy consumption), switching from to our planet as well. It’s time we cleaned contributes to the climate crisis. It found convective to conductive patient up our practice, and we want to help that healthcare’s climate footprint is warming systems, reducing product you do it. Join our movement and get equivalent to 4.4 per cent of global use (one yankauer sucker per patient), involved in this incredible opportunity net emissions, while in the UK the improving recycling... The list goes on. to implement effective, essential and Dr Jonny Groome NHS is responsible for 5.4 per cent of We can and must do more. meaningful change. ST5 Anaesthetist, Barts Health NHS Trust and total net emissions (the equivalent to Co-founder of the Greener Anaesthesia and the greenhouse gas emissions from With these incredible opportunities www.gaspanaesthesia.com Sustainability Project (GASP) 11 coal-fired power stations). If the in mind and the strong desire to [email protected] global health sector were a country, implement change, in 2018 we set @GASPanaesthesia it would be the fifth-largest emitting up GASP – the Greener Anaesthesia 3 R eferences country on the plane. and Sustainability Project. We are a grass-roots, non-profit, multidisciplinary 1 Masson-Delmotte et al. IPCC 2018: Summary In the UK, anaesthetic gases make up for Policymakers. In: Global Warming of 1.5°C organisation with one mission: to take 1.7 per cent of NHS total CO emissions (bit.ly/2q3tRyo). 2 immediate collective action to reduce (5 per cent of acute hospital emissions).4 2 Vardoulakis S, Heaviside C. Health effects the environmental impact of healthcare In looking at their impact we need to of climate change in the UK 2012 – current in the UK and beyond. We do this evidence, recommendations, and research take into account two factors: their through education, improvement, gaps. HPA, 2012 (bit.ly/2BWwcO9). Greener Anaesthesia ability as greenhouse gases to trap influencing, and knowledge sharing. 3 Karliner J et al. Health Care’s Climate heat, and the time they remain in the Working alongside the College, the Footprint. How the health sector contributes troposphere. Warming comparisons are to the global climate crisis and opportunities Association of Anaesthetists and the and Sustainability Project made using ‘Global Warming Potential for action. ARUP, 2019 (bit.ly/2BTwrJJ). Centre for Sustainable Healthcare, we 100’ (GWP 100), which compares 4 Carbon Footprint from Anaesthestic want to help people set up and run 1 agents’ energy absorption to that of CO Gases. Sustainable Development Unit, 2013 Our climate is changing fast, and it will be healthcare workers who are 2 projects based around our mission (bit.ly/2C1CbkF). over 100 years. By definition, CO has a 2 statement. We aid the continuation 5 Campbell M, Pierce TJM. Atmospheric going to be on the front line, dealing with the increased disease burden and GWP 100 of 1. and promotion of sustainability projects science, anaesthesia, and the Environment. 2 CEACCP 2015;15(4):173–179. socioeconomic consequences. While our planet is febrile and in need of It is clear, some agents have significantly for trainees moving though the 6 Pierce TJM. The Anaesthetic Impact less environmental impact than others, programme, and reach out to medical urgent treatment, we are not at the point of withdrawing care. We are in fact Calculator (bit.ly/AnaesCalc). and life-cycle analyses suggest that schools, allied health professionals 7 Sherman J et al. Life Cycle Greenhouse Gas 7 at a crucial point where time matters. TIVA is better still. The exciting fact is and other specialties, providing them Emissions of Anesthetic Drugs. Anesth Analg that low-hanging fruit is with easily accessible information and 2012;114(5):1086–1090.

Module title Learning outcomes Dr Cathy Lawson* Background Atmospheric structure and science. science Intergovernmental Panel on Climate Change (IPCC). Association of Anaesthetists and Dr Tom Pierce World Meteorological Organisation (WMO). Centre for Sustainable Healthcare RCoA Environmental Advisor Climate change summits (COP). Fellow in Environmentally Climate change and global warming – definitions of carbon dioxide equivalents (CO e), global warming potential to the President 2 Sustainable Anaesthesia, (GWP), ozone depleting potential (ODP), radiative forcing. Newcastle Health and Health implications of climate change and global warming. climate change Air pollution and cardiorespiratory disease. The role of public health and population-based health. Social sustainability, social inequalities, and civility in healthcare. Healthcare within the agreements below. A CALL TO ARMS International Montreal, Kyoto, Kigali, Paris, Osaka, Glasgow 2020. agreements Healthcare without harm. Over the last 10 years concern for the environment and increasing evidence Greenhouse gas protocol. for climate change have moved, quite rightly, from fringe thinking to everyday Climate Change Act. Other government Acts and policies, as well as UK and global strategies for climate change. discussion. In many ways our own specialty has been able to reflect this sea change Sustainable Definitions (sustainability and sustainable healthcare). of opinion, driven by both the Association of Anaesthetists and the College in their healthcare Value in healthcare – triple bottom line.

Proportion of CO2e attributable to healthcare (UK and worldwide). strategies and guidelines for practice. Add in Greta Thunberg, Extinction Rebellion, Targets for emissions reduction and UK wide organisations (Sustainable Development Unit and Centre for Sustainable and school strikes and the mood has changed from what could be done to what Healthcare Principles of sustainable quality improvement. can I do to minimise the environmental impact of my anaesthetic practice? Procurement Overview of procurement process and NHS supply chain. and carbon Scope 1, 2 and 3 emissions (see the Greenhouse Gas protocol). costing Carbon analyses – life cycle, cradle-to-gate and cradle-to-grave. The 2020 College curriculum for training recognise that to meet any form of If you are keen and enthusiastic Whole-life-cycle costing. is in its final stages of preparation. It climate change obligations requires a to join us on our journey to a Current supply chain and procurement models vs ideal sustainable system. has been written as a series of learning fundamental shift in almost all areas of more sustainable specialty and Medical gases Greenhouse gas effect and CO e. outcomes, and it importantly includes life. To embed the need for change, we healthcare system, then please email 2 Main areas of use and Control of Substances Hazardous to Health Regulations (COSHH). domains that incorporate sustainable feel that anaesthetists need to own it [email protected], and let Actions to mitigate their environmental impact, including innovations such as capture (volatiles) and cracking (N2O). practice, efficient use of healthcare and be responsible for it. And so, we are us know which module you’d like to write. Lower-carbon alternatives to their use. resources and the environmental impact searching for volunteers to take on the If you feel that a whole module is too National strategies and initiatives to measure and audit medical gas use and their environmental impact. of healthcare delivery. Such subjects authorship and a team of editors who will much for you, then team up with a friend Intravenous Carbon emissions – inhalational vs intravenous vs regional (CO2e). are not currently included in any of the work with the authors to format it. We and co-write. This is a truly fantastic and local Pharmaceutical water course contamination – implications and strategies to minimise. standard textbooks on anaesthesia, nor propose that none of the sections will be opportunity that will allow you to help anaesthetic Limitations of current evidence base and areas that future research should focus on. will they be for the foreseeable future. too large an undertaking or too daunting, change the direction of anaesthetic agents Role and responsibility that industry has to play in sustainable healthcare. and help will be on hand throughout the training and learning. We look forward to Processes, Increasing efficiencies and minimising waste (Muda principles, and SUSQI – the Centre for Sustainable Healthcare’s The e-learning platform not only presents process. We have included a brief outline hearing from you soon. pathways and ‘Sustainability in Quality Improvement’ framework). us with the opportunity to populate the of the modules and their associated *Corresponding author: journeys Cutting waste in clinical care (lean patient pathways) and choosing wisely. learning outcomes scientifically, but learning outcomes in the table opposite. [email protected] Healthcare related transport – contribution to climate change and chronic disease. it also has a dynamism that permits a Active transport, low-carbon transport and positive health benefits for patients, relatives and staff. wider, faster dissemination. Furthermore, Energy use Carbon intensities of electricity – grid vs combined heat and power (CHP). this format allows changes to be made and water Reduction of carbon intensity – renewable sources, grid decarbonisation. in the light of new data. We propose consumption Operating theatre and ICU as high-intensity energy areas – initiatives to reduce waste and increase efficiency. to use this platform to respond to both Water consumption – areas of high use and potential waste. the need and the desire to publish a Water-reuse management and how pharmaceutical pollution may impact on this. series on environmentally sustainable Waste – what Waste regulations summarised, including specifics for pharmaceuticals disposal. anaesthetic practice. happens to it? Department for Environment, Food and Rural Affairs’ waste hierarchy. Waste streams, including specialist recycling. We could, of course, sit down and Please see the College’s Waste segregation (benefits and pitfalls). write all the material ourselves, but Sustainability Strategy How we can reduce our waste. online at: this, we feel, might be construed as www.rcoa.ac.uk/ The Education and promotion on a departmental level, including embedding SUSQI. imposing top-down demands. We all sustainability- anaesthetist as Wider opportunities extending beyond the operating theatre. strategy-2019-2022 an educator Patient engagement and health promotion, making environmentally preferable choices. Sustainable Development Management Plan – what is it, and how does it relate to anaesthesia? National promotion of sustainability – College, Association, General Medical Council, and other professional bodies.

HOW STANDARDS ARE CHANGING THE FUTURE The PRSB is working closely with health and care professionals and patients to develop OF CARE clinical standards for patient care records Professor Maureen Baker CBE Chair, Professional Record Standards Body (PRSB) summaries, which is helping them to offer involved in a person’s care, including records that could help to improve care. [email protected] continued support services to patients. the patient, carer, and guardian, will The PRSB has been asked to develop In addition to gaining positive feedback have access to relevant data. As a result, guidance on what information should from patients, the service has led to people won’t have to repeatedly restate be shared and with whom, and when The College’s ground-breaking Centre for Perioperative Care better medications compliance and their care history and services will be able to support prescribing. One of the key is an exciting initiative that promises not only to improve care waste reduction. If a person has been to deliver tailored, personalised care. It areas of focus will be pain medication and outcomes for patients but also to drive closer collaboration discharged after surgery, they will have also means that patients will be able to and how to alert clinicians to relevant the support they need to better manage take better control of their own health, genetic information that could affect between health and care professionals and their patients. their own aftercare. which will be important for those who this. For anaesthetists who manage are preparing for surgery or receiving pain control, these alerts will better The key to improving cross-specialty working is better By joining up just two cogwheels, postoperative care. For anaesthetists and support them in managing care. If this information sharing between members of the healthcare team, we have already seen the benefits. other professionals, this information will information could be shared digitally and for the 10 million patients who undergo surgery every year However, we are aware that there is be invaluable, increasing efficiency and between different care providers, it there is an equally powerful opportunity to communicate more further work to be done so that different allowing them to better support patients. will better enable doctors and other effectively and to empower people to take greater control of services are more easily able to work professionals to tailor medical care to We are exploring a number of new ideas their health and wellbeing. together in order to provide the best individual needs. personalised care for patients. As part to ensure that the standard can be put For anaesthetists, having access to high-quality digital patient records of this, PRSB is currently spearheading a into practice, including that of a working In the past, standardisation has been is the key to delivery of safe and effective clinical care. Before collaboration with local health and care group to support different regions to get considered a compliance issue, but in surgery, good information sharing supports treatment planning record programmes to drive adoption started. The first regions that have been reality information is the backbone of selected to pilot the standard are Greater safe and effective care. The driving of and helps the patient and clinical team optimise the chances of a of the new standard for shared care Manchester, Thames Valley and Surrey, innovation, and the maintenance of good recovery. Following surgery, it can ensure that a person gets records (bit.ly/2rgvl95). This will support Wessex, One London, and Yorkshire accurate digital records that can be exactly the right follow-up care, improving their recovery in the the sharing of vital information about community and reducing the chances of re-admission and wastage and Humber. Earlier this year we shared between care providers are the a person between health and care of medications. published a core-information standard key to activating real cultural change systems so that care is safer, timely, (bit.ly/2rgvl95), which determines the across health and care. By directly and more effective. The standard The PRSB is working closely with health and care professionals and information that should appear in a engaging clinicians and patients with the includes a wide range of information patients to develop clinical standards for patient care records. Once shared care record. process, we can create a digital system from different services, including GPs, implemented, these standards will allow health and care professionals that works for all and leads to more hospitals, social care services, and At the same time, we are working on to share and access information digitally between different services. efficient services. As part of our work, we have delivered a series of standards to mental health services among others. It standards in new areas of emerging support transfers of care, which will make sure that people in different will incorporate an ‘About me’ section, research which will have an impact on The PRSB is seeking the support of services have access to the information they need at the right time. which outlines what people want the future of care. By autumn 2019, the anaesthetists, among other professionals, For example, our eDischarge Summary Standard (bit.ly/32dvmqV) professionals to know about their care, as amount of genomic information available to both develop and implement is already being implemented across the UK, and is leading to well as other crucial information such as will increase significantly. Currently, data standards. To get involved with our work improvements in care. In Wales, community pharmacies have allergies, medications and alerts. Once shows that there are findings of practical or for more information, please contact been receiving key information about medication from discharge implemented, it will mean that everyone significance in up to 85% of genomic [email protected]

36 | | 37 Bulletin | Issue 119 | January 2020

Dr Hilary Swales* Dr Poppy Mackie Consultant Anaesthetist, Consultant Anaesthetist, University Hospital University Hospital Southampton NHS Foundation Southampton NHS Foundation Trust and Lead for Exam Trust and Lead for Exam Support HEE Wessex Support HEE Wessex

Please see the EXAM PREPARATION College website for exam resources for Myths and tips candidates: Over the last three years we have identified some common themes from our www.rcoa.ac.uk/ work for the Wessex Deanery Professional Support Unit, where we coach examinations trainees from all specialties struggling with postgraduate exams. We felt it and our revision would be useful to share some of these points, as it may help trainees plan a courses: successful journey as they prepare for the exam. www.rcoa.ac.uk/ Exams are costly in terms of physical is important. It is worth considering what to aid your memory, such as the use of and emotional energy, as well as time, other events are going on in your life – if mind-maps and mnemonics, adding events relationships and finances. It is worth you are rebuilding your house, getting colour to your notes, labelling lists and considering your plan from the outset of married and having a baby, this may not drawing diagrams, and the use of Post- your revision. be the time to attempt the exam! it Notes (especially by sticking them in strategic places!). Podcasts can be a help than making it your primary resource. Plan during the weeks and months of revision, Exam technique When at school and university, your We have identified the following key to those with long commutes. All these out a timetable by dividing the time you and there is nothing like a boost of Practice questions for all parts of the raison d’être was to pass exams. You had areas to consider when planning your will help you to build your knowledge and have available into the number of syllabus endorphins to make you feel better. exam are an essential part of preparation. the luxury of being able to indulge your approach to the exam. understanding, organise your ideas and areas you have to cover. Concentrate Sleep is another essential consideration. As mentioned before, it is a helpful way full focus on exams and not worry about build a lasting memory of the knowledge on those areas you find tricky, as well as You continue to lay down memory while of testing your recall but you also need too much else. Postgraduate exams Study skills required for the exam (and beyond!). areas that come up more frequently. asleep and learning requires good sleep, to refine your techniques. Practice is are challenging because you are now Reflect on your learning style. What so beware of burning too much of the the key to this. Answering MCQs is very working; you have rota duties to fulfil and study methods worked well for you in the Time management Motivation midnight oil and of too much caffeine, different to giving answers in a structured are often commuting to work, and you past? You will have refined your revision You are relatively time poor, so make This is a key ingredient of good revision. and switch off your screen an hour oral exam, and each requires a different also have other personal commitments. techniques significantly over the years, every revision session count – short, You can boost your motivation by setting before bed. set of skills which require practice. If you Sadly, there are no shortcuts, but there but go back and review your previous focused sessions are likely to be more yourself achievable goals and targets and are finding yourself struggling to finish are certainly ways to make the best use good habits. Spending time with family and friends productive. The optimum concentration giving yourself rewards (such as a coffee exams because you read slowly, consider of the time you have. can help you relax and take your mind There are no short cuts, and relying purely time period is, on average, about 40 with friends, time with your children) for whether you could have dyslexia. off the exam. Obviously, this has to be Be prepared! We have heard from on practising multiple choice questions minutes. Test your recall of the topic at achieving these. Peer support has been Doctors are bright and develop many balanced with work and revision, but it many trainees who attempted their (MCQs) is not going to give you the firm the end of the session and plan ahead to shown to make a tremendous difference coping strategies, so it’s worth checking is helpful to factor small doses of all of exams on at least one occasion without knowledge base you require for the FRCA, future sessions. Balance reading sessions to revision, and will certainly help boost it out. Likewise, seek support if your proper preparation ‘just to see what it although this is a common myth passed with practice-question sessions, making motivation. Keeping a positive mind-set these things into your plan to help you communication skills (verbal and non- was like’. This is a costly approach for down through generations of trainees. sure the emphasis is on learning from towards the exam and feeling in control keep feeling positive. Exam nerves can verbal) are letting you down. many reasons – don’t underestimate the books and testing your recall with of your plan will help. sometimes get the better of candidates. Reading is the key, and ensuring you are So…good luck! But remember… the potential effect of failure on your actively engaged with your reading and the questions. You will undoubtedly add It is worth considering in advance how the better your preparation, the morale. There is a maximum number challenging yourself in the process to further knowledge through answering Wellbeing you may best manage this. There are luckier you will be! of attempts you are allowed and also check your ability to recall the knowledge. the questions, particularly with the Wellbeing is also an essential ingredient some very helpful mindfulness exercises a degree of time pressure within the Writing notes can help, and there are helpful model answers, but use this to for maintaining motivation. Exercise that you can practise for this. It is worth *Corresponding author: training programmes, so planning ahead a range of other methods you can use supplement your understanding rather can really help boost your wellbeing trying these out in advance of the exam. [email protected]

Professor William Harrop-Griffiths RCoA Council Member and Professor of Practice The difference is not immediately ■■ The insertion of a CSE with the others. It is almost always incredibly (Anaesthesia), Imperial College Healthcare NHS Trust, London evident, so I will explain. My realisation patient in the sitting position followed simple to insert spinals, epidurals, or a that obstetric anaesthetists are a separate by lying them onto their side before combination of the two, into women [email protected] species started in 1982 when I was the epidural is secured. This too is of child-bearing age. The great skill told by one that ‘pregnant women can illogical. The argument advanced is of the obstetric anaesthetist is not in be difficult to intubate because their that the intrathecal heavy bupivacaine performing these tasks but in doing so breasts are enlarged and can obstruct will spread better if the patient is lying in a human-factors environment that #4 the laryngoscope handle’. I pointed out down. So why not lie her down for can only, on occasion, be described ANAESTHETIC SOAPBOX to my teacher that, even in pregnant the whole CSE and thereby avoid the as mind-bogglingly hideous. When women, breasts tend not to be midline manoeuvring? I have spent 37 years things go wrong in obstetrics you structures, whereas the handle of a inserting spinals and epidurals into quickly become the main focus of the laryngoscope tends always to be in the women in the lateral position, and intense anxiety of all those around you In praise of obstetric midline. He was displeased, for I had not my success rates are no worse than – obstetricians, midwives, paediatricians, accepted as sacred truth the wisdom of anyone else. The argument that ‘it is patients, partners, and anyone else in the obstetric anaesthetic community. easier to identify the midline in the theatre. To perform a faultless neuraxial anaesthetists sitting patient’ holds increasingly less block in those circumstances and to do Such devotion to outmoded tenets water in an age in which ultrasound so reliably, swiftly, cheerfully and with an still exists. There are some obstetric In four decades of regular obstetric anaesthetic practice, I have inserted machines are both widely available air of competent and almost nonchalant anaesthetists who hold on to the and easily capable of identifying the professionalism, is something that is very, thousands of epidurals and spinals for pain relief in labour and for caesarean unshakable view that the ideal dura mater itself, let alone the midline. very special indeed. induction agents for caesarean section ■■ An insistence on overcomplicating section. However, I would never call myself an ‘obstetric anaesthetist’. Rather, I under general anaesthesia are two Obstetric anaesthetists, I call on you block height testing. At first it was ‘museum’ drugs called thiopental and to celebrate your remarkable skills. just the cold sensation provided self-identify as ‘an anaesthetist who does obstetric anaesthesia’. suxamethonium. Why a trainee who In setting myself apart from you by by ethyl chloride. Then it was the has only ever known propofol and calling myself an ‘anaesthetist who differentiation between touch and rocuronium should be obliged to use two does obstetric anaesthesia’, I seek not cold. Now, obstetric anaesthetists unfamiliar drugs for an urgent section to alienate you but to point out to you ask their patients to ‘touch yourself is a mystery to me and a nightmare for that although almost all of what you do and tell me whether you can feel the trainee. One can only hope that the is absolutely wonderful, some of it is just yourself touching yourself’, a concept obstetric anaesthetic community will downright potty. that few native English speakers can ease itself into the pharmacological 21st fully grasp and which leaves others I’ll get my coat… century some time soon. completely befuddled. The latest However, that which makes the obstetric in my list of strange block-testing anaesthetist ‘special’ (as in Nemo’s fin) rituals was added recently when my goes deeper than this, manifesting itself trainee asked our patient whether A RESPONSE FROM as bizarre rituals that permeate the rite of she could ‘feel herself clenching her THE EDITOR neuraxial block insertion: pelvic floor’. Our non-native English speaking patient was nonplussed and Dr David Bogod, Proud Obstetric ■■ Injection of lidocaine into the back I was reduced to giggles. Anaesthetist, Nottingham with an orange (25G) needle that is replaced by a green (21G) needle for I could go on, but as I suspect that I have the greatest respect for William further injection. This is both illogical by now I have already alienated all Harrop-Griffiths. We have been through and a waste of time. Although obstetric anaesthetists, let me redress the fires of academic and political there are parts of the body that can the situation by offering a compliment. anaesthesia together, and have come differentiate between these two Obstetric anaesthetists number among out stronger and wiser for it (well, I needles (think homunculus), the skin the finest anaesthetists with whom I have, anyway). His clinical skill is second over the lumbar spine is not one of have ever worked. However, they should to none; if I were having a caesarean them. If you do not believe this, try it never try to convince themselves (or section, he is the man I would choose to at home with a friend. indeed anyone else) that their mastery stab me in the back, or in the neck for a of the technical complexity of obstetric rotator-cuff repair. anaesthesia is what sets them apart from

But he has always had a bit of a downer a large probe down the oesophagus, on obstetric anaesthesia, so his diatribe upper-limb anaesthetists at directing does not surprise me. Sometimes I ever-smaller doses of local anaesthetic wonder if it’s jealousy, frankly. In any ever closer to a large bundle of nerves. event, I don’t want to spoil the fun by All of these are highly technical skills, being too anal, but let’s just look at the but all can be learnt by any intelligent midline breasts question, seeing as how and well motivated non-medical PERIOPERATIVE JOURNAL WATCH he brings it up. Here’s what actually individual with a couple of days of Dr Katie Samuel, ST7 and Dr Chris Sadler, Clinical Fellow, Bristol School of Anaesthesia happens. The presence of the breasts intensive training. Perioperative Journal Watch is written by TRIPOM (trainees with an interest in perioperative medicine – means that the arm applying cricoid Obstetrics is challenging because of its www.tripom.org), and is a brief distillation of recent important papers and articles on perioperative medicine from pressure has to be disposed much more unpredictability, the non-serial nature across the spectrum of medical publications. vertically than in the flat-chested male. of the workload, the need for excellent The handle of the laryngoscope, pointing Screening for delirium A randomised trial of Effects of depth of Warming strategies for teamwork with a very disparate group sharply down towards the neck as the after surgery: validation non-invasive cardiac neuromuscular block on preventing hypothermia of professionals, the intensity of the blade is manipulated over the tongue, of the four A’s test (4AT) output monitoring to postoperative pain during and shivering during emotions surrounding childbirth, the impacts the cricoid arm and, voila! There in the post-anaesthesia guide haemodynamic laparoscopic gastrectomy caesarean section: a politics, the ethical dilemmas – and the are ways around this, of course, but they care unit optimisation in high-risk systematic review with occasional total mayhem. Obstetric Choi et al. Euro J Anaesthesiol are only known to the cognoscenti… anaesthetists are a very special breed. Saller et al. Anaesth patients undergoing 2019;36(11):863–870. network meta-analysis of 2019;74:1260–1266. urgent surgical repair of randomised clinical trials Will’s other arguments can be disposed Plus, we’ve got the second-biggest Few studies have investigated proximal femoral fractures Chen et al. Intern J Surg of by similar application of common specialist society, so there! This German study evaluated deep neuromuscular 2019; :21–28. sense and nit-picking, or alternatively by the accuracy of a common Davies et al. Periop Med 71 PS The difficult-airway bunch are bigger, blockade (NMB) and its gently pointing out that some of the stuff postoperative delirium 2019;8:8. but that’s another story… influence on postoperative Shivering and hypothermia he sees is not just London-centric but screening tool, the four This blinded randomised pain. This randomised trial are very common and often also London-eccentric. Lying patients A’s test (4AT), in tertiary control trial studied high- from South Korea studied upsetting complications down after a CSE before the catheter is post-anaesthesia care units. risk hip-fracture patients the effect of depth of NMB that occur during caesarean secured? Asking patients if they can feel This tool uses Alertness, (Nottingham Hip Fracture on pain after laparoscopic section. This meta-analysis themselves touching themselves? As for Abbreviated Mental Test Score ≥5) to see whether gastrectomy. reviewed randomised being in touch with your pelvic floor – in 4 (AMT4), Attention, and optimised intraoperative control trials with primary Nottingham you could be arrested for 100 patients received deep Acute Change parameters blood pressure and fluid outcomes relating to that sort of thing. (post-tetanic count 1–2) or to assess delirium, and was management reduced warming strategies. compared with standard postoperative complications. moderate (train of four count What we do agree on, though, is the assessment by experienced 1–2) levels of NMB and were 1,953 women undergoing pre-eminent importance of the non- psychiatric clinicians. 240 patients received either asked to rate their pain in caesarean section from 18 technical stuff, the communications skills, standard care or specific recovery postoperatively. All trials were included, with the human factors, the steadiness of 543 patients were examined, fluid and vasopressor received oxycodone until 11 active warming methods nerve that lets you keep your head when and of the 4.1 per cent management based on an adequate pain control was considered. Quantitative all around are losing theirs. Of course it’s that were deemed to have algorithm using non-invasive achieved, so allowing the synthesis was performed, and not the ability to cleanly and elegantly delirium, the 4AT and the technology. There was no minimum effective analgesia suggested a combination put in an epidural when a woman is standard assessment had a significant difference in dose to be ascertained. of a warmed gown, fluids writhing in pain that separates us from sensitivity and specificity of complication rate, and only and forced air as the the common herd – it’s the ability to Although this was an 95.5 per cent and 99.2 per a very modest reduction in optimal method to reduce calm and reassure her and her partner interesting attempt to cent respectively. The authors hospital length of stay in the shivering, although without in that very tense environment. But the suggest a way to improve therefore encourage the use intervention group. significance. Conduction same point applies to any subspecialty postoperative pain, there of the 4AT as an easy-to- mattress warming or a in our field. Ophthalmic anaesthetists The authors suggest that was no causal relationship use and robust tool for the combination of conduction get very good at sticking needles behind the lack of difference could described between either detection of delirium in the mattress and fluids warming the eye, cardiac anaesthetists at pushing be due to confounders of group in the endpoints postoperative period. were found to be the best in co-morbidities and poor measured. The use of simpler reducing hypothermia. cardiac function within the analgesic adjuncts was population of the study. encouraged instead.

Dr Ruwanmali De Silva* Dr Manisha Shah Consultant Anaesthetist Consultant Anaesthetist and and Member, RCoA MTI Simulation Lead, Medway Leadership Group, Medway Maritime NHS Foundation Trust Maritime NHS Foundation Trust

I was left scratching my head, trying to Foundation Trust (MMFT) to support for all MTI doctors. The first pilot figure out what on earth these words IMGs in internal medicine. This was programme will be in December 2019 had meant, to have them explained to in response to a realisation that IMGs at the Medway Maritime Foundation me later on by a giggling consultant. were lacking the confidence to step Trust in Kent. She had never imagined that I would up to registrar posts for the underfilled not understand such a simple comment medical rota. The programme included As already noted, integration of IMG but, having just arrived from Sri Lanka, a resilience workshop featuring a doctors into the NHS comes with the ‘lingo’ was beyond me – despite consultant psychiatrist, one-to-one skills unique challenges which need a tailored having passed the IELTS (International training and two days of high-fidelity approach. We have used our existing English Language Testing System) at simulation training. This was followed by knowledge and skills as a simulation my first attempt! a second resilience workshop to tie up faculty, as well as experience from any loose ends. The pre- and post-course other training courses, to develop In 2005, I arrived in the UK as questionnaire showed improvements this induction programme for MTI an overseas doctor to complete in competence and confidence; it also trainees, making it widely available and postgraduate training. As a senior highlighted those areas in which trainees sustainable. The cost savings by cutting registrar, I was very confident of needed further support. down the use of agency staff make it my clinical skills but still completely financially viable, and patient safety is unfamiliar with the UK’s NHS systems. The financial cost of the course was improved by enhancing continuity of I have now progressed far enough to offset by about 50 per cent as a result care. Such training for MTI doctors at be selected as a College Final FRCA of the reduction in the cost of agency the commencement of their placement examiner, but I have never forgotten cover. The avoidable cardiac arrest calls speeds up their integration and enhances INTEGRATE... AND how I felt back then, or how my skills were reduced by 53 per cent, GMC the experience provided by placements were doubted simply because I stood survey was positive for workload and the in the NHS. As a result, it is expected to back awaiting orders from the consultant improvements were reflected in the Care have a positive impact on the healthcare GET THE BEST OF BOTH because that was how I had been Quality Commission visit report. systems of the doctors’ native countries expected to practise in Sri Lanka. when they return and share the lessons. The programme was highly commended Support and understanding in the in the British Medical Journal Awards Acknowledgements WORLDS! integration of overseas doctors for 2019 and shortlisted for the Health provides the most effective way to Service Journal Value Awards. David Calderon-Prada in the College’s ease them into a new and unfamiliar Global Partnerships team for invaluable Trying to get my head around a system I did not Having the privilege and honour to be working environment and build up their help and coordination for all MTI a member of the College’s Medical understand, I was observing a consultant on my very first day confidence. The generic trust inductions activity. Gemma Wrighton, Simulation Training Initiative (MTI) Leadership working in the NHS. are not tailored for International Medical Centre Manager at MMFT, for Group, and having worked closely to Graduates’ (IMGs) needs.1 Experiential facilitating the course. Garry Knowels facilitate MTI training with our brilliant learning simulation can be an invaluable for technical support. ‘What would you want to dream about when you are asleep?’ Global Partnerships team, we have help for the alignment of their existing introduced such a programme for R eferences the consultant asked the patient who was about to be anaesthetised. skills with an unfamiliar environment and participants across the UK. The aim 1 Bhat M, Ajaz A, Zaman N. Difficulties for for supporting them and developing ‘Having a big fry up!’ the patient answered with a big grin. international medical graduates working in 2 of this is to have a uniform two-day their confidence. the NHS. BMJ 2014;348:g3120. simulation programme exclusively for 2 Victor J et al. Effects of an experiential Our simulation faculty led a very MTI doctors, held twice a year in four learning simulation design on clinical nursing *Corresponding author: successful five-day simulation-based selected UK centres with a geographical judgment development. Nurse Educator [email protected] induction at Medway Maritime NHS coverage that will make it accessible 2015;40(5):228–232.

44 | | 45 Bulletin | Issue 119 | January 2020

The Quality Improvement Compendium COMING SOON!

Dr Maria Chereshneva*, Dr Carolyn Johnston, Professor Carol Peden and Dr John Colvin, who continuously support the writers This edition places more emphasis and the other editors to ensure that high- on QI, and we in the editorial team Editors of the RCoA Quality Improvement Compendium quality content is being delivered. have aimed to make sure that QI methodology, habits and values The new edition of Raising the standard: a compendium of audit recipes is It is the intended purpose of this QI were clearly visible and accessible to currently with our proofreaders and is being prepared for publication. We Compendium to facilitate and strengthen anyone interested in practising this at delivery of continuous improvement their institution. Easy-to-follow recipes want to take this opportunity to tell you a little bit about what to expect in and safety programmes that are aligned and ‘real life’ examples should make it the new edition. with College professional standards easier both to start your improvement and accreditation. It is aimed at project and to continue the introduction supporting departments in the making of We are confident that this edition The titles of the recipes for each chapter experts, committee members of of improvements. continuous improvement in a way that will be the ‘go-to’ resource for all in section B were decided with the specialist societies, GPAS contributors, provides opportunities for trainees and The draft Compendium has been the quality improvement (QI) needs help of experts in their topic area such and trainees. We have been very impressed and consultants to participate and to learn reviewed by a range of interested parties of trainees, trainers and others who as specialist societies, the Faculty of profoundly grateful for the contributions As well as the individual authors who QI methodology. Each recipe is linked to ensure it will meet the needs of all want to undertake improvement work Intensive Care Medicine, Guidelines for of our fellow anaesthetists to this project wrote the recipes, each chapter has an to the relevant GPAS and Anaesthesia our readers. We have consulted with within anaesthesia, intensive care and the Provision of Anaesthetic Services – giving their time freely to produce editor who is responsible for the clinical Clinical Services Accreditation (ACSA) the trainee committees of the College perioperative medicine. (GPAS) chapter editors and perioperative content that will hopefully be of benefit content. The chapter editors are current standards, and these are listed alongside and the Association of Anaesthetists, leads, and include wider national health to our specialty for years to come. We The new edition will be similar to the or previous GPAS contributors for that the recipe. For trainees in particular, and with the Safe Anaesthesia Liaison priorities. Each recipe is written to a hope you will find it a useful resource. particular subject area. This ensures that each recipe will link with the relevant Group, the College’s Lay Committee previous edition, and will contain two template that describes why this project content is up to date. Each chapter also QI and safety training requirements in and Professional Standards Advisory *Corresponding author: sections. Section A is dedicated to should be done, provides background has a QI editor. The QI editors are a the new anaesthesia curriculum. The Group and the Health Services Research [email protected] the background of QI methodology information, and identifies where the new addition to the editorial team for Compendium will therefore provide a Centre to ensure that the Compendium’s and resources; section B will contain standards in that recipe come from, this edition of the Compendium, and unique link between training, clinical content is in line with our brief. chapters covering a whole spectrum and the best-practice publications their role is to ensure that each recipe standards and delivery of care to of anaesthesia and the provision of relating to that subject The last section offers suitable QI methodology or ‘real guide anaesthetic departments in a perioperative medicine, intensive care of each recipe is the QI section, where life’ examples that will be ‘workable’ practical way in the development of and pain medicine, including a new suggestions are put forward as to how We will be formally launching the for anaesthetists aiming to make their QI strategies. chapter on cardiothoracic anaesthesia. improvements may be achieved and improvements. The overall editorial some steps that can be taken. The fourth edition of the Compendium responsibility lies with the main editors, authors of the recipes include subject at Anaesthesia 2020 in May

before long I was being entrusted with large hospitals that I had secretly hoped Medical Training more responsibilities and trust by my for, I became acutely aware of how consultants and colleagues. fortunate I was to have started off in the Initiative NHS at such a ‘small’ hospital, because In contrast to the largely hierarchical A government authorised I had integrated faster (and with more system (with ‘bosses’ who call all the scheme allowing doctors ease) into the system than many of shots and dictate the daily course of those colleagues. from low- and middle-income events) where I had been trained and countries to undertake schooled all my life prior to taking up my If I had to advise prospective or new anaesthesia training within MTI post, the NHS is a largely egalitarian MTIs, I would urge them (in the face system where everyone chips in their of the new challenges they are about the NHS for a maximum of 24 bit and participates actively in making to face while adjusting to the NHS) months. For more information, decisions and carrying out plans. This to never discountenance or take for please see our website: stark contrast was a rude shock to me granted the clinical experience they (and I must confess still catches me off have gained over the years, because www.rcoa.ac.uk/ guard regularly) and took quite some this is usually what sets them apart from medical-training-initiative getting used to. Learning to address other UK trainees. They should also at consultants and colleagues by their the same time be open to gaining new first names, adjusting to the several experiences and embracing the learning Coming towards the end of my training programme in my home country, ‘dialects’ of English as well as a totally opportunities that abound in the NHS. Nigeria, I had started to question the scope of my anaesthetic practice and foreign language (Welsh), the very ‘open’ yearn for something more – more satisfaction in making a positive difference and frank conversations with virtually everyone, the new food/diet, learning to Be open to gaining new in the patient’s experience of anaesthesia and improving the statistics. drive on the ‘other’ side of the road, the keen sense of adventure among trainees, experiences and embracing It was about this point that I learned who helped with advice and information part of the adjustment process the very friendly banter in theatres and about the Medical Training Initiative on some of what to expect and how to was the ‘paperwork’ (filling out camaraderie among staff, the regular the learning opportunities that (MTI) scheme and decided to apply for prepare for the change. forms, GP and National Insurance coffee breaks, etc, all constituted part of the opportunity to gain experience of Number registration, induction, the ‘culture shock’ that I was faced with I arrived in Bangor on 4 November abound in the NHS working in the NHS. writing postoperative orders, and needed to adjust to. 2018 and was greeted by the winter documenting cases and completing After successfully obtaining an MTI chill. Thanks to the support of a the initial assessment of competencies, While making my application for the Be aware that others have trodden this post and concluding most of my very dear friend and a warm and understanding the appraisal and MTI scheme, I had covertly hoped to path before you, so you can learn from travel arrangements, I was faced with welcoming anaesthetic department, revalidation system, reflections, etc) get a post at one the large hospitals in their experiences as well. Never hesitate the stark reality of an abrupt change I started to gradually settle in and and it took a while getting used to this. one of the popular large cities that I had to ask for clarifications or to request in environment, weather, etc, and adjust to the rigours and demands of Having worked at a more senior level read and heard about for years. So I was assistance, nor to ask for what you separation from family and friends. I had my new role in the NHS. back at home, adjusting to initially sort of disappointed when I secured a think is your due but which may have so many questions in my head – ‘What being treated as an SHO and having to post in some seemingly obscure district been overlooked. There will be ‘good’ if this doesn’t work?’, ‘What if this is Anaesthetic practice is quite similar ‘shadow’ the first-on-call before going general hospital in a ‘little-known’ place. and ‘bad’ moments and experiences, some huge mistake?’, ‘Will I fit in?’, etc. in most parts of the world, so it was on the rota took some getting used to. Fast-forward a few months, and after but it always gets better with time, so Fortunately, I had a small network of fairly easy settling into the routine However, I accepted this as just a phase comparing notes and experiences with be patient and allow yourself some friends who were living in the UK and of clinical work. The most difficult and did my best to ‘go with the flow’, and fellow ‘more fortunate’ MTIs in those time to learn/adjust.

appraisal and/or assessment’. All ■ Trainees and trainers should work The Cappuccini test: trainees should have access to within the parameters relating to these an audit of supervision supervision at all times, with the activities outlined in the GMC’s Good The College has produced an audit tool degree of supervision tailored to Medical Practice (bit.ly/2p8GWq3). (www.rcoa.ac.uk/cappuccini-test) to pick their competence, confidence Trainees will have increasing up issues in relation to the supervision and experience. Within a given autonomy as they advance through of trainees and non-consultant, career- training placement, and for each training, from full clinical supervision grade doctors (NASG) who do not fit trainee, such arrangements may of all practice at entry to foundation the description in Guidelines for the be the responsibility of a named training, up to independent practice provision of anaesthesia services (GPAS) ‘clinical supervisor’. at completion of training. However, (www.rcoa.ac.uk/gpas). We would it is a fundamental principle that recommend using this simple audit tool The GMC also defines a named all trainees working in all situations in your department to monitor levels of clinical supervisor as ‘…a trainer will receive an appropriate level of clinical supervision. who is responsible for overseeing supervision from a consultant or a specified trainee’s clinical work specifically approved SAS doctor. for a placement in a clinical Further reading ■ The profile of ‘safe supervision of environment and is appropriately Job roles and descriptions: clinical care’ will change from close trained to do so. He or she will Education and Clinical Supervisor and proximate supervision (for provide constructive feedback ■ 2 example, for core trainees), through Educational Supervisor; NACT. during that placement and inform clinical supervision by staff within the ■ Recognition and approval of Trainers; the decision about whether the Dr Claire Mallinson same hospital (for specialty trainees), GMC.3 trainee should progress to the Consultant Anaesthetist, to remote clinical supervision by ■ 4 Supervision of safe next stage of their training at the Named Clinical Supervisor; NACT. Guy's and St Thomas' staff outside the trust (for example, end of that placement and/or NHS Foundation Trust, from consultants elsewhere for more Further guidance series of placements’.1 London and RCoA clinical care senior trainees). ■ Proposed best practice guidance for supervision of safe clinical care. Council Member Supervision of safe clinical A clear description of the agreed NACT.5 Dr Roopa McCrossan As the professional bodies responsible for the care in practice: principles standards for supervision can be found ■ Recognition and approval of trainers: ST7 Anaesthesia, Medical care in the NHS is consultant on the College and Association websites. development and promotion of standards in anaesthesia implementation plan. GMC.1 Northern School directed. All trainees work under They can be found at: ■ Multisource feedback for Educational of Anaesthesia and in the UK and Ireland, the College and the Association of supervision. This supervision may be ■ rcoa.ac.uk/safety-standards-quality/ 6 immediate (supervisor in the room), local Supervisors. London Deanery. Honorary Secretary, Anaesthetists jointly recognise the importance of good guidance-resources Association of (supervisor in the hospital), or distant. clinical supervision in the workplace to maintain safe ■ rcoa.ac.uk/training-careers/training- References Anaesthetists Trainee ■ Trainers and experienced, competent anaesthesia 1 Recognising and approving trainers: the implementation plan. GMC, 2012 Committee clinical care. clinical staff have a role in ensuring (bit.ly/34znz8m). that patients are safe and treated Russell Ampofo* To ensure patient safety, clinical work by trainees needs to be carefully supervised by 2 Job description for Educational Supervisor. according to best practice. RCoA Director of experienced and competent clinical staff, who are trained for the role and who recognise Monitoring NACT, 2018 (bit.ly/36JYqdk). Education, Training and and discharge their responsibility to trainees. This should improve quality of patient care and ■ Trainees will vary in their need A mechanism to monitor these standards 3 Recognition and approval of trainers. GMC, 2012 (bit.ly/2JO16wn). Examinations reduce clinical risk. for ongoing supervision of their should be developed and maintained clinical care depending on their 4 Roles and Responsibilities of a Named by all departments. Lapses or failures in Clinical Supervisor. NACT, 2018 Both organisations agreed to develop a set of principles to this effect and to develop a resource seniority, experience and individual *Corresponding author: clinical supervision should be identified (bit.ly/2PNo9eI). that signposts to the various existing documents and standards. Both organisations agree circumstances. [email protected] and addressed promptly and clearly. 5 Proposed Best Practice Guidance for that setting out policies and procedures will be helpful to guide departments in their clinical ■ There is a duty on trainees to Records should be kept. Ongoing Clinical Supervision. NACT, 2012 supervision of trainees, enabling anaesthetists to provide safe clinical care to their patients. seek appropriate ongoing clinical (bit.ly/2PKXfEl). While trainees are the initial focus of the guidance, the principles throughout are applicable for supervision, especially when they Monitoring of departmental 6 Multisource Feedback for Supervisors. The London Deanery, 2012 (bit.ly/2Cfxfce). good supervision for any healthcare professional. approach the limits of their clinical performance, including adherence to skills and competence. the principles and practice of clinical The General Medical Council (GMC) defines a trainer as one who: ‘provides supervision supervision, should occur (approximately) ■ The level of clinical supervision is appropriate to the competence and experience of the student or trainee and training monthly. Feedback on problems should ultimately decided by the consultant environment. He or she is involved in and contributes to the learning culture and be given to trainees and trainers. environment, provides feedback for learning and may have specific responsibility for and not the trainee.

New website. New look. Better service

Gavin Dallas RCoA Head of Communications [email protected]

The College launched its new website1 in November 2019 following two years of close work with members, staff, external suppliers and the public. Not only do we now have a great new website, but are working to further develop the a content strategy was developed, integration, the College plans to provide I’d like to thank the College staff, content and integrate additional member services and benefits. audiences identified, tone of voice members a self-service member portal members Council and Lay Committee guidelines produced, writing and style on the website. Here you will be able for working with us over the past two Borne out of the College’s Technology In May 2018, and making use of how our brand should be reflected guidelines communicated and numerous to update personal details, specify years and for the valued input which Strategy Programme (TSP), the project the discovery phase report, the through the design, the College was editor workshops held. communication preferences, subscribe has led to us launching these three sites (led by the College’s Communication College issued a public request involved in every step of the process. to specific e-newsletters, collate under budget. That’s a great thing to be and External Affairs Directorate) has for proposal for design and was Benefits and future website content around categories able to say and is testament to the hard successfully delivered not one, not two, pleased to receive responses from In addition to developing a visually enhancements and, if you’re in training, review past work from teams across the College and attractive and more advanced platform, examination results and see what the financial diligence of our TSP team. but three brand new websites for the digital agencies across the UK. Through a streamlined content strategy 2 the College was also keen to ensure exams you have coming up. College, the Faculty of Pain Medicine Four agencies, including Manifesto, and improved design and layout, and the Centre for Perioperative Care.3 were shortlisted. the content of the new website was Let us know what you think members will find it easier to search Another membership benefit being optimised. Enter Wardour,5 a London- If you like our three new websites as for, find and read information sought. worked on is single sign-on across our In line with the aims of the TSP, the After a rigorous interview process, based specialist marketing and content much as we do, or if you have comments The different formats of how content is academic publications and College development of these three new Manifesto was chosen to move the agency. Their content specialists had or suggestions on how we can make displayed across the site has enabled IT systems. Once logged into the websites is just one step towards project forward into the design and the unenviable task of undertaking a improvements, please use the website content editors to extract information member portal, the plan is to be able improving the College’s online build phase. This work commenced content audit of the thousands of pages feedback form6 at the base of the from cumbersome PDFs and present this to link directly to the BJA, BJAEd, technology offering to fellows, in October 2018. on our old website, reporting detailed homepage of the College website. as web page content, making it easier for events booking and the Lifelong members and external stakeholders. analytics for each. We’d love to hear what you think. Design and content searched content to be displayed. Learning Platform without the need While the College’s Communications to log in repeatedly. R eferences Background After securing the project and through Developing our three new websites to be In late 2017, the College hired the digital multiple workshops with College Team knew certain pages performed 1 www.rcoa.ac.uk. mobile and tablet-friendly, was another Access to our website content is key agency Manifesto4 to undertake a review members, staff and Lay Committee consistently well in terms of page visits, 2 www.fpm.ac.uk. crucially important task for the College and therefore reading support through of our website at that time. Known as the representatives, Manifesto began the results from the content audit confirmed 3 www.cpoc.org.uk. as we know our members predominantly the industry standard Browsealoud discovery phase, this included scrutinising detailed task of identifying what our that visitors to those pages were not 4 www.manifesto.co.uk. visit our sites on their mobile devices. system has been provided. This assistive our website technology, design, content website needed to address, solve, moving to other areas of the website. 5 www.wardour.co.uk. technology software adds text-to-speech and accessibility. Manifesto also held represent and look like. Working with With this issue not isolated to these two Work within the TSP to implement a 6 bit.ly/RCoAWebFeedback. functionality for those hard-of-hearing workshops to understand what was Manifesto through the identification and areas of the website, it was important for new customer relationship management and highlights and magnifies sections of needed from our new website in terms development of audience personas and web content editors across the College (CRM) software this year will again text for visitors who are hard-of-sight. of navigation, content, technology related content types, brainstorming to know where content improvements provide significant enhancements to and system integrations. proposed navigation and discussing should be made. To address this, the website. Through the CRM/website

Dr Janet Barrie Consultant Anaesthetist, Pennine Acute NHS Trust [email protected]

Tell us a bit about yourself. Can you share any experiences, The most important attributes of an Did you have any assessor professional and personal assessor are to be dispassionate in applying the assessment criteria, experience before you started? learning, or skill sets that you irrespective of the prestige or reputation I have been a district general hospital have gained through your work of the requesting team, and to be consultant anaesthetist for more than with the College? honest in the assessment returns 20 years and have always had an I hope that seeing the assessment process in describing reasons for refusing interest in anaesthetic education. I am from the other side has helped me design recognition. The College feed these the immediate past president of the or deliver courses locally. It has sharpened back to the requesting team, and courses Society for Education in Anaesthesia UK my focus in ensuring the teaching are modified in the light of assessors’ (SEAUK). I am interested in teaching and methods are suitable for the learning feedback. Hopefully this leads to better learning (‘What happens when people objectives and that these are delivered experiences for the learners. learn?’ ‘How can we help encourage by suitable people. The College provides that to happen?’) and how we can use training for new assessors to help with learning theories to help make teaching Can you share your most this and an assessors’ day when particular events better for the learners. I had interesting experience from your issues are discussed. no experience in course assessment time as a CPD Assessor so far? as such but have been responsible for It has also led to invitations to consider The most interesting was refusing to grant putting together a number of study participating in other aspects of the recognition to an event sponsored by days and workshops and reflecting/ College’s work, particularly the new CPD a national body until some substantial acting on feedback. wing of the Lifelong Learning Platform, changes were made to the content. Such for which many CPD Assessors also discussions are conducted through a third Why did you put yourself acted as road testers. party. The assessor knows the identity of AN INSIDER’S VIEW forward for a role as a CPD the course organisers and faculty (to help Assessor at the College? What are the important consider whether the faculty have the experience and credibility to deliver the In my role with SEAUK I had to submit qualities a CPD Assessor course against the learning objectives) details of our Annual Scientific Meeting should have? but the organisers don’t know the identity Being a CPD Assessor to the College for CPD approval, and Timewise, the role isn’t onerous. Most of the assessor. I wondered what happened to these assessors look at one or two events per More than 1,700 of our fellows and members selflessly contribute their applications behind the scenes and the month and each takes about 30 minutes If you could give one piece of time, energy and skills enthusiastically to the work of the College, through process by which they were assessed. I with a two-week turnaround time. understood that the College was wishing advice to someone thinking roles ranging from examiners and committee members, to Anaesthesia Assessors can specify the subspecialties to recruit CPD Assessors and saw this as they are comfortable working within. about becoming a CPD Clinical Services Accreditation (ACSA) leads and Advisory Appointments an opportunity to contribute. Having a wide range of assessors Assessor what would it be? Committee (AAC) Assessors. enables the College to choose an Contact Chris Kennedy at the College assessor with an appropriate interest, so ([email protected]) to discuss further Our 2018 membership survey results showed that many more of our fellows and members would also like to get involved in the that it is very rare to be asked to assess if you have any questions. Alternatively work the College undertakes. To highlight these roles further and to provide you with a true taste of what they involve, we started If you would like to outside the assessor’s areas of interest. give it a go! regular ‘Insider’s View’ interviews for the Bulletin last year. find out more about being a

This year’s first interview from the series is with Dr Janet Barrie, one of the College’s CPD Assessors. The College welcomes CPD Assessor, or to see what applications from doctors interested in acting as a CPD Assessor. Full support is provided by the College CPD team, and the other possible involvement www www.rcoa.ac.uk/ team also sends each CPD Assessor an annual report detailing the event reviews they have completed for use in their own your-membership/get-involved CPD portfolios. We would like to thank Dr Barrie for her participation in this interview. you can have with the College, please go to ‘Get involved’ pages on our website. 54 | | 55 Bulletin | Issue 119 | January 2020

Dr William F S Sellers Locum Anaesthetist, University Hospital Coventry and Warwickshire [email protected] If any fellow or member has an interest in the history of anaesthesia and the College, AS WE WERE... the College’s Heritage and Archives Committee welcome any expressions of interest for The obstetric flying squad new committee members. Professor Michael Rosen in Cardiff did not like ‘chair’ dental general Please contact Flying Squad Anaesthetic Box; anaesthetics or small isolated obstetric units. The latter used to be attended by ex Kettering General Hospital [email protected] emergency obstetric services (flying squads), as proposed by Professor E Farquar for more information Murray in 1929 and started in Bellshill, Lanarkshire by H J Tomson in 1933.

These flying squad attended home revealed that an anaesthetist was taken replacement by a paramedical deliveries in which the patients’ on 32 (89 per cent) general practice ambulance team with extended training. complications made them ‘so desperately calls and 26 (58 per cent) home calls. A A commentary was written by Geoffrey ill that removal to hospital might have paediatrician went on only two calls, both Chamberlain and Malcolm Pearce.4 Our fatal results’. The enterprise was so from GP units. Patient home calls were Bulletin editor may wish to comment on distress. I checked their ancient Boyle’s and added the Trilene. The Manley Cambridge had told me Trilene was a † successful that almost every maternity mostly for antepartum haemorrhage, whether they should be believed. machine, found only trichloroethylene ventilator was going bananas with the great amnesic, so I, my patient, Jenson hospital introduced a flying squad and in GP units they were mostly for and filled the Boyle’s bottle. I had used high flows, so I used the Mapleson A Button,6 Patrick Viera, Trinny Woodall capable of bringing to patients’ homes retained placenta.2 Suggestions began Case report a Boyle’s and Trilene when I started reservoir bag to ventilate. Baby came and Richard Hammond if gassed by this obstetric aid and resuscitation by means to be made that emergency obstetric Stroud Maternity hospital called in Cambridge, where I discovered out pdq (pretty damn quick), flat as a agent, hopefully forgot everything. Flying of blood transfusion. Dr Dame Hilda patients would fare better if they were our Gloucester flying squad to a that it has little anaesthetic efficacy if pancake so the midwife took it to the squad and Professor Rosen; RIP. Nora Lloyd was the first female president brought immediately to hospital rather case of obstructed labour with fetal passed through a circle absorber to resuscitation table and I went to have a of the Royal College of Obstetricians than waiting for the arrival of the flying distress. In the wee small hours, we the patient (it also produces the nerve look. As I was completing intubation the R eferences and Gynaecologists, and in her time the squad. Anaesthetists Dr Chris Callendar assembled inside the ambulance but poison dichloracetylene). To check the registrar and the scrub midwife shouted 1 Lloyd HN. Emergency obstetric service (flying squad). Dame Hilda’s Flying squad letter squad consisted of an obstetrician, a and Professor Peter Hutton reviewed the the paediatrician didn’t turn up. Our oxygen, I opened both cylinders and for my attention. The patient was (bit.ly/2nTKQln). nurse and a medical student. Equipment demand on Bristol’s flying squad from competent Egyptian obstetric registrar twiddled the white knob, but the bobbin sitting up and the surgeon was shoving 2 James DK. Obstetric flying squad service – a carried comprised a hold-all containing 1971 to 1984 and noted a reduction in asked if I could resuscitate; I’d done an got stuck sideways at the top above escaping bowel back. The midwife defence. BMJ 1977;1:217–219. blankets and hot water bottles, three anaesthetics in general practice units obstetric job, had sucked out plenty of the five-litre mark and wouldn’t drop took over baby ventilation, I gave more 3 Callander CC, Hutton P. The anaesthetist leather bags each containing two sterile from 41 in 1974 to zero in 1983/1984, meconium through a Cole5 tube (do down even with me thumping it. I had suxamethonium and thiopentone and and the obstetric flying squad. Anaesth drums of instruments, two boxes of blood, with only one or two at patients’ homes. wear a surgical face mask), and had suxamethonium and thiopentone with gently returned the patient to supine. 1986;41:721–725. an oxygen cylinder, a light source and a Retained placenta was at 84 per cent done all these when an anaesthetic me. The midwife who had come with Phew! The high flows had made the 4 Chamberlain G, Pearce JM. The flying squad. Br J Obs Gynae 1991;98:1067–1069. tin of biscuits for personnel – the last of the commonest reason for a general SHO and registrar. Newborns are us did the cricoid pressure, and after nitrous run out, the Trilene in the Boyle’s 5 Cole F. A new endotracheal tube for infants. 3 these because ‘…frequently attendance anaesthetic. The death knell of obstetric extremely slippery. I arrived in Stroud a intubation I thought I’d better put the bottle had vanished. Stability returned, Anesthesiol 1945;6:87–88 and 627–628. 1 is required for long periods’. A ‘defence’ flying squads was sounded by their tad nauseous; the decision was made nitrous oxide at maximum (10 litres plus?) we returned to Gloucester with everyone 6 Sellers WFS. Was Button gassed? Br J Anaes to retain a West Berkshire service in 1977 Royal College which in 1991 suggested to perform emergency section for fetal to give approximately a 50:50 mixture fine. I remembered that John Farman in 2016;116:559 (doi:10.1093/bja/aew040).

†The Editor well remembers the events leading up to the disgrace of Malcolm Pearce and the collateral damage suffered – some might say thoroughly deserved – by Geoffrey Chamberlain. Interested readers are directed to the BMJ News article at the time: bit.ly/2oQTnGX

West Midlands Imperial South East Warwickshire Thomas Carter Andrew Al-Rais NEW TO THE Dr Carol Downs (George Eliot Hospital) Oliver Keane Kent, Surrey & Sussex In succession to Dr Das Gupta Shital Patel Olubukola Akindele Dr Llewellyn Fenton-May (Heartlands Jenny Cheung South East Scotland COLLEGE Hospital) in succession to Dr Nicky Merle Cohen Laura Armstrong Osborn Robert Guy Thomas Bloomfield The following appointments/ Sadia Ghaffar Y orkshire and the Humber Mersey re-appointments were approved Samantha Warnakulasuriya South Yorkshire Angela Deeley (re-appointments marked with Pre-Hospital Emergency Medicine South Yorkshire *Dr James Stevenson (Scarborough Sarah Fadden Dual ICM an asterisk). General Hospital) David Whitmore Joel Perfitt

Regional Advisors Anaesthesia *Dr Madhuvanti Achawal (Hull University N orth Central London Wales Saba Al Sulttan Anthony Byford-Brooks East of England Teaching Hospitals Trust) Claire Frith-Keyes Thomas Kitchen Dr Emily Simpson in succession to Dr Nicola Barber Certificate of Completion Paavan Gorur David Inglis Warwickshire Northern of Training Asher Lewinsohn Sunita Balla Dr Kathryn Bell in succession to Dr Michael Tremlett To note recommendations made to Anna Poon the GMC for approval, that CCTs/ Wessex Tom Salih Oxford CESR (CP)s be awarded to those set out Honor Hinxman Joint ICM Andrew Wood Pre-Hospital Emergency Medicine Dr Stephen Snyders in succession to Dr Anne Gregg below, who have satisfactorily completed Alexander Stewart Dual ICM the full period of higher specialist training N orth West Christopher Watts College Tutors in Anaesthesia, or Anaesthesia with Archana Awsare West Yorkshire Intensive Care Medicine or Pre-Hospital Carla Gould N orthern Ireland Muhammad Laklouk Emergency Medicine where highlighted. Lorna Sissons Dr A Jane Turner in succession to Dr Esther Davis Craig Montgomery Nicholas Truman Dual ICM August 2019 Scotland Mei Yeoh Barts & The London South East Scotland Louise Frost Northern Dr Rachel Harvey (Borders General Hospital) in succession Dassen Ragavan Dual ICM David Buckley to Dr Sweyn Garrioch Amieth Yogarajah Robert Lyons Iain Walker West of Scotland Birmingham *Dr Ross Junkin (University Hospital Crosshouse) Mohammed Arshad Dual ICM Oxford *Dr Kenneth Kerr (University Hospital Ayr) Colette Augre Pre-Hospital Emergency Medicine Timothy Davies *Dr Stephen Wilson (Dumfries & Galloway Royal Infirmary) James Hudgell Pre-Hospital Emergency Medicine Henry Jefferson Sarah Milton-White Dual ICM Anika Sud Wales Harsha Mistry Dr Susmita Oomman (Withybush General Hospital) in Peninsula Claire Moody succession to Dr Ilona Schmidt Carlen Reed-Poysden Philip Pemberton Severn England East Midlands Samuel Howell East Midlands Juneenath Karattuparambil Dr Elaine M Hart (Leicester General Hospital) in succession Rishie Sinha to Dr Aditi Kelkar Lail U Mah Zaheer *Dr Bridget Cagney (Leicester Royal Infirmary)

APPOINTMENT OF MEMBERS, ASSOCIATE MEMBERS AND ASSOCIATE FELLOWS

August 2019 September/October 2019 Dr Mohammed Hassan Eid Associate Members Associate Fellow Abdelmonem Dr Weththimuni Damith Tharanga Dr Andras Victor Kelecsenyi Dr Tarique Aziz Qureshi BRITISH OXYGEN COMPANY Silva Dr Zahid Furqan Dr Golam Ferdous Alaml Associate Members Dr Harriet Emily Kent CHAIR OF ANAESTHESIA Dr Ilona Ladd Dr Ella Mirielle Quintela Dr Lynda Marcelle Abengue Dr Alizeh Haider Dr Nitya Lizbeth George Dr Eleanor Stanger R esearch Grant 2020 Dr Amr Mohamed Soliman Hassan Dr Manekar Avinash Dr Mina Amirhom Khella Amirhom Elmosalamy Dr Tharuka Kalhari Sikuradipathi Dr Nairita Das In 1958, the British Oxygen Company (BOC), made Dr Vjeran Leventic Dr Zakiya Maryam Dr Ahmed A A M Metwally Alkhatip a charitable donation in support of anaesthesia Dr Benjamin Edward John Perkins Dr Snigdha Sunil Paddalwar Dr Kugan Kishur Xavier Rajan research. The BOC Chair of Anaesthesia Fund GLOBAL ANAESTHESIA: Dr Victoria Van Der Schyff Dr Eyad Talal Mhamad Abdeljawad Dr Ahmed Mohamed Mohamed was created using this donation and is a subsidiary Towards Health Dr David James Ritchie Dr Muditha Chathuranganie Aboughazy charity of the Royal College of Anaesthetists. The Dr Mehul Mange Dhanapala Mawathage Dr Kavisha Premasinghe Dissanayake object of the charity is the endowment of a research Equity Dr Pei Jean Ong Dr Caroline Lalramnghaki Dr Emad Azer Ibrahim Iskander fellowship in a department of anaesthesia. On behalf Dr Isuru Viraja Bandara Vidana Dr Nishita Shah Dr Mubeen Salik of the Royal College of Anaesthetists, the National 24 March 2020 Arachchige Edirisinghe Dr Mohammed Hasan Mohammed Dr Edward Peter Andree Wiltens Institute of Academic Anaesthesia (NIAA) is inviting Dr Piotr Krzysztof Sadowski Ahmed Shaimaa Dr Magde Kayed Sa’de AlBarade applications for this grant. We will be running our next Global Anaesthesia themed Dr Maeve Elizabeth Henry Dr Pawan Kumar Jain Dr Robin Mathew Michael event in partnership with the World Anaesthesia Society Dr Christine Biela Dr Basil Okechukwu Ezenkwel Dr Nithin Jayan The College is utilising these funds in support on Tuesday 24 March 2020. Dr Prajwal Shetty Dr Niranjala Sanjeewani Abeyratne Dr George Mathew of those working towards a senior fellowship or Dr Ana C Hipólito De Borba Monteiro Wickramasinghe Dr Tara Dilini Kachchakaduge developing a credible application for a Chair in Global Anaesthesia: Towards Health Equity will cover a Dr Dale Wesley Thorne Dr Rashi Sardana Fernando number of key topics affecting the delivery of equitable Anaesthesia (or related specialties) within the next Dr Grace Elizabeth Illingworth Dr Eleanor Amanda Ganpatsingh Dr Priyanka Ramakrishnan anaesthesia healthcare across the world, and will include five years. Applications are welcomed from clinicians Dr Paul Bernard Traynor Dr Mahmoud E M A Nassar Dr Parag Jyoti Duarah sessions on climate change, inequality in healthcare and from basic scientists with a similar ambition. Dr Mark Peter Oakey Dr Manu Kumar Dr Sangeet Tanwar access and its effects on migrant population health and Dr Belal Yahia Mohammed Yasin Dr Rajeev Kumar Sharma Dr Shilpee Kumari Funding of £80,000 per annum is available. This corruption and its impact on health equity. Dr Naomi Rose Cynthia Adey Dr Muhamed Samir Bassiony Wanas Dr Swapnil Ganesh Aswar can support the costs of research sessions, projects Dr Abhishek Kumar Sharma Dr Rishabh Sethi Dr Bintang Pramodana or infrastructure. The grant is available for four years Confirmed speakers include: Dr Rafiu Alade Adedayo Ojo Dr Ritu Bansal Dr Ahmed Nahed Aly Elsaid Aiyad (reviewed after two years), and annual progress ■■ Dr Jannicke Mellin-Olsen Dr Deborah Roxanne Douglas Dr Ruwaida Khan reports must be submitted to the NIAA. Dr Alexander Lee Pereira De Lima Dr Ahmed Mohamed A A Yousef ■■ Professor Farai Madzimbamuto For more Dr Atef Kamel Salama Salem Dr Deepa Sannakki Applicants must demonstrate an existing research ■■ Dr Vatshalan Santhriapala information and to Dr Sarah Olohijie Beckley Dr Pavithra Ramamurthi record, the support of a senior mentor/supervisor, ■■ Professor Sir Any Haines. book your place, Dr Priyadarshini Nagaraj Dr Eyad Ibrahim Abdulsalam Ali a credible research proposal and evidence of a please go to Dr Darshana Sawant Dhaka Dr Javear Kimberley Williams supportive research environment. bit.ly/RCoAGA Dr Gregory Thomas Dr Neha Sharma The application form is available to download from Conf2020 Dr Mohamed Khalaf Mady Morsy Dr Chandrakanth Koganti the NIAA website (bit.ly/2WNexSU). Dr Ahmed Mohamed Ibrahim Ahemd Dr Mostafa Kamal Abdellatif Asr Affiliates Applications should be submitted to the NIAA Dr Motsim Sheraz Ms Emma Molyneux (Anaesthesia Coordinator Ms Pamela Hines via email to: Dr Piermauro Castino Associate) [email protected] by the deadline of 5.00pm on Dr Amal Gouda Elsayed Gouda Safan Ms Katie Hubbard (Anaesthesia Associate) Friday 31 January 2020. Dr Declean Corr Dr Vikas Kumar Dr Robyn Anne Lee

CONSULTATIONS The following is a list of consultations which the College has responded to in the last two months. LETTERS TO THE EDITOR If you would like to submit a letter to the editor please email [email protected] Originator Consultation

Professional Record Standards Dr David Bogod Core information standard Sir, Body (PRSB) Problems ventilating? Remember the valve Association of Anaesthetists Suicide amongst anaesthetists During a challenging trauma thoracotomy the patient began to desaturate so lung UK Clinical Pharmacy Association Syntocinon and syntometrine advisory paper recruitment manouvers were employed. The resevoir bag however would not remain inflated despite increasing flows, applying higher pressure to the APL (adjustable pressure-limiting) valve and oxygen saturations continued to drop. The bag was Academy of Medical Royal Colleges High level principles remote prescribing changed suspecting a hole however this didn’t help and so patient was quickly changed onto a Water’s circuit and recruited while anaesthesia was maintained intravenously. The National Institute for Health and Consultation on a proposed Service Specification for specialist oesophageal and patient was then transferred back onto the ventilator and remained stable. Care Excellence gastric cancer services for Welsh residents The eagle-eyed operating department practitioner discovered the problem; the carbon Public Health England Adult Critical Care Influenza guidance 2019 dioxide sampling line had become caught under the APL valve, so that although the

valve appeared to be displaying 20 cm H2O, it was actually completely open, causing Management of glucocorticoids during the perioperative period for patients with the ventilated oxygen to escape via the open valve. Association of Anaesthetists adrenal insufficiency Dr Hannah Mulgrew Clinical Fellow in Anaesthesia, Merseyside DEATHS APPOINTMENT OF FELLOWS TO CONSULTANT AND SIMILAR POSTS With regret, we record the death of The College congratulates the following fellows on their consultant those listed below. appointments:

Dr William J Glover, London Dr Mark Children, Blackpool Teaching Hospitals Dr Annabel J M Mason, Suffolk Dr Robert Hart, Queen Elizabeth University Hospital, Glasgow Dr David A Nightingale, Somerset Dr Siobhane Holden, Royal Preston Hospital Dr Joseph C Stoddart, Newcastle Professor Sir Keith Sykes, Devon Dr Carol Kenyon, Liverpool Women’s Hospital and The Royal Liverpool Dr John R Stoneham, Godalming University Hospital (joint post)

Please submit obituaries of Dr Stuart Knowles, Stockport NHS Foundation Trust no more than 500 words to: Dr Julia Niewiarowski, Oxford University Hospitals [email protected] Dr Kieran Oglesby, University Hospitals Bristol NHS Foundation Trust Obituaries will be published on the Dr Rita Saha, East Surrey Hospital College website. Dr Shiny Sivanandan, Peterborough City Hospital

Dr Andrew Wood, Royal London Hospital

| 64 | 65

Bulletin | Issue 119 | January 2020

RCoA Events Anaesthetists as Educators: Airway Train the Trainer % Anaesthetists’ Non-Technical 12 June 2020 JULY www.rcoa.ac.uk/events Skills (ANTS) RCoA, London 27 April 2020 Final FRCA Revision Course [email protected] 6–10 July 2020 RCoA, London GASAgain (Giving Anaesthesia Safely Again) RCoA, London @ RCoANews GASagain (Giving anaesthesia 24 June 2020 safely again) Bournemouth 29 April 2020 RCoA, London Primary FRCA Revision Course Anaesthetists as Educators: Leadership and Management: 30 June to 3 July 2020 JANUARY 2020 % Teaching and Training in the % Personal Effectiveness RCoA, London Workplace 19 March 2020 MAY Tracheostomy Masterclass 10–11 February 2020 RCoA, London % 10 January 2020 RCoA, London Introduction to Leadership and Ultrasound Workshop RCoA, London Developing World Anaesthesia % Management: The Essentials Patient Safety in Perioperative 23 March 2020 5–6 May 2020 13 March 2020 RCoA, London Primary FRCA Revision Course % Practice RCoA, London RCoA, London 14–17 January 2020 13 February 2020 RCoA, London RCoA, London Global Anaesthesia Airway workshop 24 March 2020 13 May 2020 GASagain (Giving Anaesthesia Anaesthetic Updates RCoA, London Brighton Safely Again) % 25–27 February 2020 15 January 2020 RCoA, London Anaesthesia 2020 Bradford Royal Infirmary APRIL 18–20 May 2020 Old Trafford, Manchester Final FRCA Revision Course MARCH Anaesthetists as Educators: 20–24 January 2020 % Teaching and Training in the RCoA, London Introduction to Leadership and Workplace % Management: The Essentials 2–3 April 2020 ww.rcoa.ac.uk/events Anaesthetists as Educators: JUNE 2020 3–4 March 2020 Edinburgh % Advanced Educational Supervision Mecure Sheffield, St Paul’s Hotel 28 January 2020 After the final FRCA: Making the Anaesthetists as Educators: Airway Leads % Introduction The Studio, Leeds most of training years 5 to 7 Co-badged with: 5 March 2020 3 April 2020 3 June 2020 Anaesthetic Updates RCoA, London The Studio, Birmingham RCoA, London % 31 January 2020 Nottingham Ethics and Law UK Training in Emergency Airway % 11 March 2020 Cardiac Symposium Management (TEAM) RCoA, London 23–24 April 2020 4–5 June 2020 FEBRUARY RCoA, London Bath Ultrasound Workshop FPM Study days: Acute/ % 13 March 2020 Airway Workshop SAVE 10% 18–20 May 2020 UK Training in Emergency Airway in-hospital Pain Management RCoA, London 9 June 2020 Limited early bird Old Trafford, the Home of Manchester United Management (TEAM) – Hot Topics and Updates RCoA, London places available until Anaesthetic Updates 23–24 April 2020 3–4 February 2020 31 January 2020 – BOOK YOUR PLACE AT: % 17–18 March 2020 Wrexham Anaesthetic Updates quote RCoA, London EARLY10 www.rcoa.ac.uk/events/anaesthesia-2020 RCoA, London % 9 June 2020 when booking Clinical Directors Airway Workshop Bristol 27 April 2020 4 February 2020 Birmingham RCoA, London

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

Leadership and Cardiac Disease and BOOK Management Anaesthesia Symposium NOW! 23–24 April 2020 RCoA, London Courses

An Introduction: The Essentials 3–4 March 2020 Topics include Sheffield 31 January 2020 5–6 May 2020 ■■ Awake airway management. London Nottingham ■■ Anaesthesia for pheochromocytoma.

■■ Anaesthesia and anaphylaxis. Personal effectiveness 19 March 2020 London

BOOK EARLY TO AVOID DISAPPOINTMENT

CPD % approved

25–27 February 2020 17–18 March 2020 London London Topics include Topics include

■■ Regional anaesthesia. ■■ Paediatric anaesthesia. ■■ Hot topics in chronic pain. ■■ Difficult airway. ■■ Obstetric anaesthesia. ■■ Burnout and resilience in Patient Safety in anaesthesia and intensive care. Perioperative Practice www.rcoa.ac.uk/events 13 February 2020 RCoA, London

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

January 2020 Greener Anaesthesia and Sustainability Project

How standards are changing the future of care

The Quality Improvement Compendium – coming soon!

‘ Winter has come’ Assessing the impact of pensions tax on workforce and service delivery in a large department Page 12